a—M i HP LIBRARY OF CONGRESS. | ©^.-^..-^ng^^a Shelf .Mfe - \%h% UNITED STATES OF AMERICA. Plate I Neevus Lipoirtatod.es . ( From, a Photograph of one of the author's patients.) (Front ispiece .) A PRACTICAL TREATISE DISEASES OF THE SKIN, FOR THE USE OF STUDENTS AND PRACTITIONERS. SECOND EDITION, THOROUGHLY REVISED AND ENLARGED. JAMES NEVINS HYDE, A.M., M.D., PROFESSOR OP SKIN AND VENEREAL DISEASES, RUSH MEDICAL COLLEGE, CHICAGO ; DERMATOLOGIST TO THE MICHAEL REESE HOSPITAL, CHICAGO ; AND ONE OF THE PHYSICIANS FOR i") DISEASES OF THE SKIN TO THE PRESBYTERIAN HOSPITAL, CHICAGO. if' <\ jAPfi 12 1888 "tV PHILADELPHIA LEA BROTHERS 1888. CO. Entered according to the Act of Congress, in the year 1888, by LEA BROTHERS & CO., in the Office of the Librarian of Congress, at Washington. All rights reserv* DORNAN, PRINTER, PHILADELPHIA. r~ MORIZ KAPOSI PROFESSOR OP DERMATOLOGY IN THE UNIVERSITY OF VIENNA, AUSTRIA, THESE PAGES ARE, WITH HIS GENEROUS CONSENT, jftesjjccifullji Inscribed THE AUTHOR. PREFACE TO THE SECOND EDITION. The work of revision, required by exhaustion of the first and the demand for a second edition of this treatise, has been carefully conducted with results that are declared upon every page here pre- sented to the reader. There have been added new chapters devoted to the description of several cutaneous maladies whose names were a few years ago unknown ; others have been wholly rewritten ; none has been left untouched. The need of conforming to the classi- fication and nomenclature of diseases of the skin adopted by the American Dermatological Association, has involved a labor which it is believed has largely added to the practical worth of the book. Personal observation of more than ten thousand cases of cutaneous diseases in both public and private practice, has furnished an experi- ence which has been made to serve here as far as was practicable in the illumination of the teaching embodied in almost every para- graph. Nearly one hundred pages have thus been added, together with a number of new wood cuts and two portraits of rare diseases of the skin in colored plates. The author is anxious to express his sense of gratitude to the profession for the favorable reception accorded to the first edition of the treatise; and desires to acknowledge his great obligation in the preparation of its successor, to the later authors especially, in cutaneous medicine, whose works are named in the brief but selected bibliography appended at the close of the volume. He has also to extend his thanks to Dr. Frederick W. Mercer, and to Dr. Albert J. Ochsner of the Pathological Laboratory of the College, for aid in the preparation of specimens and drawings ; as also to his assistant, Dr. Frank H. Montgomery, for services ren- dered while the work has been passing through the press. Chicago, March, 1888. PREFACE TO THE FIRST EDITION. The increasing recognition of the gravity of many cutaneous dis- orders, and of the importance of their accurate study, is shown by the rapidly augmenting number of observers in this department of medicine, and by the numerous valuable contributions constantly made to it, both in this country and abroad. For the convenience of the general practitioner it therefore becomes necessary at shortly recurring intervals that some one should attempt the task of pre- senting in a comprehensive form the results of the latest observation and experience. The author is aware of the degree to which he must claim indul- gence in the present effort to perform this duty. The extent of the subject and the limitations of a single volume, require the omis- sion of much detail of secondary importance. With regard to that which it has seemed proper to include, he has endeavored to write concisely, to set forth only what can be held as the truth, to be frank in the admission of the weakness with which the most skilful physi- cian stands in the presence of many grave and not a few benign dis- orders, and to cultivate a wholesome doubt of that which has not been shown to be worthy of trust. How far he may have fallen short of attaining this end these pages will declare. He has to express his indebtedness to the standard w T orks on dermatology of foreign authorship, especially the exhaustive and- invaluable work of Hebra, and the Lectures on the Diseases of the Skin lately given to the profession by Professor Kaposi, which con- tain the mature conclusions of his vast experience. With these should be named the writings of Sir Erasmus Wilson, Dr. Tilbury Fox, Dr. Neumann, Dr. McCall Anderson, Dr. Behrend, and the syphilographers, to whose works special reference is made in the chapter devoted to their theme. Among the books of American authorship, he is under special obligation to the sterling work of Dr. Duhring, of Philadelphia, and to the excellent treatises of Drs. Piffard, Fox, and Bulkley, of New York. All these are named by title in the brief and selected bibliography Vlll PREFACE TO THE FIRST EDITION. appended at the close of the volume. No less valuable aid has been obtained by consulting the papers of American and foreign authors contained in the journals specially devoted to diseases of the skin, among which, as t he representatives of the English tongue, the Archives of Dermatology, lately edited by Dr. Bulkley, and the current Journal of Cutaneous and Venereal Diseases, edited by Drs. Piffard and Morrow, deserve special mention. The author is also very greatly indebted to Dr. Charles Heitzmann, <»f New York, not merely for the information gathered from the study of his original researches in pathology, but particularly for his kindness in furnishing advanced sheets of the chapter on the skin, in his work on Microscopic Morphology, which has just issued from the press. From this work, with Dr. Heitzmann's permission, several illustrations have been borrowed, which appear in the chapter on anatomy, the details of which subject are also very largely drawn from the same rich store. The first of the drawings representing sections of the skin, is from the faithful peucil of Dr. H. D. Schmidt, of New Orleaus, who, iu order to produce it, interrupted, without hesitation, his arduous labors in connection with the subject of pathology. To his colleague, also, Dr. Frederick W. Mercer, of Chicago, the author is glad to express his indebtedness for the skill with which a number of pathological specimens have been prepared and mounted for special study, and original drawings produced for the first and several subsequent chapters of the book. To Dr. Duhring, of Philadelphia, he is further indebted for valuable sugges- tions made during the course of preparation of the manuscript. Medicinal measures are, in these pages, expressed in terms of both the apothecaries' scale and the metric system. It is to be noted, how- ever, that the latter are not in all cases literal translations of the terms of the former, many of the formulae, especially those for preparations designed to be topically employed, being metrically composed, the relative proportions of the ingredients remaining unchanged. The changes which it has been advisable to make, in the matter of nomenclature, classification, and other equally important subjects, are concisely explained in the chapters devoted to each. Chicago, No. 240 Wabash Avenue, February, 1883. CONTENTS. Anatomy and physiology of the skin 17 General symptomatology 48 General etiology 60 General diagnosis ........... 66 General prognosis . . . . . . . . . . .71 General therapeutics . . . .73 Classification 90 DISEASES OF THE SKIN. CLASS I. DISOEDERS OF THE GLANDS. 1. Of the Sweat Glands 95 Hyperidrosis .95 Sudamen 99 Miliary fever 100 Anidrosis • 101 Bromidrosis 102 Chromidrosis ........... 103 Uridrosis 105 Dysidrosis 105 Hsematidrosis 106 2. Of the Sebaceous Glands 107 Seborrhcea 107 Comedo 118 Cyst ■ 124 (A.) Milium 124 (B.) Steatoma 126 Asteatosis 128 CLASS II. INFLAMMATION'S. Exanthemata 129 Morbilli (measles) 130 Rotheln (German measles) 133 Scarlatina (scarlet fever) ........ 134 X CONTENTS. PAGE Variola (smallpox) 139 Varioloid 142 Varicella (chicken-pox) 146 Vaccinia (cow-pox) 149 Erythema simplex 153 Erythema intertrigo 156 Erythema multiforme ......... 159 Urticaria 163 Urticaria pigmentosa ......... 164 Dermatitis 171 (A.) Traumatica 172 (B. ) Venenata . 172 (C.) Calorica 175 Congelatio 177 (D.) Medicamentosa 178 (E.) Gangrenosa 187 Erysipelas 188 Furunculus 195 Anthrax 198 Pustules from cadaveric infection ....... 201 Pustules and other lesions resulting from wounds inflicted by rep- tiles and insects .......... 202 Delhi boil, Aleppo evil, Biskra bouton 202 Phlegmona diffusa 204 Pustula maligna 205 Herpes . 208 Herpes iris 211 Herpes gestationis 212 Herpes zoster 212 Dermatitis herpetiformis 218 Psoriasis 221 Pityriasis maculata et circinata ........ 239 Dermatitis exfoliativa 240 Dermatitis exfoliativa infantum 242 Pityriasis rubra ........... 243 Lichen planus ............ 246 Lichen ruber ............ 250 Eczema 253 The local varieties of eczema 291 Eczema of the scalp 2!il Eczema of the face 2i»4 Eczema of the lips 2!H5 Eczema of the nostrils 297 Eczema of the ears 298 Eczema of the lids 299 Eczema of the beard 300 Eczema of the genital organs 302 Eczema of the anus and anal region ..... 305 CONTENTS. XI PAGE Eczema of the nipple and breast of women .... 307 Eczema of the umbilicus 308 Eczema of the superior and inferior extremities . . . 308 Eczema of the hands and feet 310 Eczema as it affects the nails ....... 313 Eczema of the tropics (prickly heat) 314 Prurigo 316 Acne 319 Acne Rosacea 329 Sycosis 334 Dermatitis papillaris capillitii ........ 338 Impetigo 340 Impetigo contagiosa 342 Impetigo herpetiformis 344 Ecthyma 345 Pemphigus 348 CLASS III. HEMORRHAGES. Cutaneous haemorrhages .......... 353 Purpura ............. 354 (A.) Simplex 354 Purpura urticans ......... 355 Purpura rheumatica (peliosis rheumatica) .... 355 (B.) Heemorrhagica (morbus maculosus Werlhofii) .... 356 Purpura scorbutica (scurvy) . . . . . . 357 Purpura pulicosa 357 Haemophilia ......... 357 CLASS IV. HYPERTROPHIES. 1. Of Pigment 360 Lentigo 360 Chloasma . 361 Melanoderma, chloasma cachecticorum ..... 362 Addison's disease 362 Argyria '..... 363 2. Of Epidermal and Papillary Layers 366 Keratosis 366 (A.) Pilaris 366 (B.) Senilis 368 Molluscum epitheliale 369 Callositas 374 Callositas of hands with unusual complication .... 375 Perforating ulcer of the foot (mal perforant du pied) . . 375 Clavus 378 Xll CONTENTS. PAKE Cornu cutaneum 379 Verruca 381 Multiple cutaneous tumor, accompanied by intense pruritus . 385 Papilloma 385 Verruca necrogenica ......... 386 Nanus pigmentosus .......... 387 Xerosis 388 Ichthyosis 390 Simplex . . 390 Hystrix 390 Ichthyosis congenita 392 Onychauxis 385 Hypertrichosis 398 3. Of Connective Tissue 404 Sclerema neonatorum ......... 404 Scleroderma ........... 405 Morphcea 409 Elephantiasis ........... 412 Lymph scrotum . . . . . . . . . .417 Rosacea 417 (A.) Erythematosa 417 (B.) Hypertrophica 418 Framboesia ... 419 Parangi ............ 421 Donda ndugu 421 CLASS V. ATROPHIES. 1. Of Pigment 422 Leucoderma ........... 422 Albinismus 423 Vitiligo 424 Canities 427 2. Of Hair 429 Alopecia 429 ( iongenital 429 Senile 430 Premature 430 Alopecia furfuracea .......... 433 Alopecia areata 435 Neurotica ........... 440 Atrophia pilorum propria 440 Trichorexis nodosa 441 Nodose swellings of shaft of hair 422 Piedra 443 3. Of Naii 443 Atrophia unguis .......... 443 CONTENTS. Xlll PAGE 4. Of Cutis 444 Atrophia cutis 444 Atrophia senilis .......... 444 Atrophia maculosa et striata ........ 445 Blanching atrophy of the skin 446 Glossy fingers 446 CLASS VI. NEW GrEOWTHS. 1. Of Connective Tissue 447 Keloid 447 Cicatrix . . . 449 Fibroma 452 Neuroma 456 Xanthoma ............ 458 Adenoma 461 2. Of Muscular, Tissue . . .462 Myoma 462 3. Of Vessels . .464 Angioma 464 Naevus vasculosus 464 Telangiectasis 465 Angioma pigmentosum et atrophicum ...... 466 Angioma cavernosum ......... 467 Lymphangioma . . . . . . . ... . . 470 4. Rhinoscleroma 471 Lupus erythematosus 473 Lupus vulgaris ........... 479 Scrofuloderma . . . . . . . ... . . 489 The papular scrofuloderm (lichen scrofulosorum) . . . 491 The small pustular scrofuloderm 492 The large pustular scrofuloderm 493 Tuberculosis of the skin . 494 Ainhum 495 Podelcoma 495 Synovial lesions of the skin 496 The Sartian disease . . . . . . . . . 597 Syphiloderma 497 Chancre 498 Syphiloderma maculosum 504 Papulosum 507 Vesiculosum 513 Pustulosum 514 Bullosum 517 Tuberculosum 517 Tuberculosum serpiginosum 517 Gummatosum •. . . . . 519 Xiv CONTENTS. PAGE Erythanthema syphiliticum ....... 521 Syphiloderma infantile, acquisituin et hsereditarium . . . 521 Chancroid 544 Lepra 549 (A.) Lepra tuberosa 549 (B.) Lepra maculosa 552 (C.) Lepra ansesthetica 553 Pellagra 560 Actinomycosis 561 Carcinoma ............ 561 Epithelioma ........... 562 Superficial ........... 562 Deep, or tubercular ......... 563 Papillary 563 Cancer of the head ......... 564 Cancer of the lower lip 565 Cancer of the genital organs 565 Cancer of the extremities 566 Paget's disease of the nipple 566 Cancer of the connective tissue ....... 573 Tuberose carcinoma ......... 573 Melanotic, or pigmented carcinoma ...... 574 Sarcoma ............. 575 Melanotic sarcoma (melano-sarcoma) 577 Mycosis fungoides 578 CLASS VII. NEUBOSES. Hyperesthesia 581 (A.) Pruritus 581 Pruritus narium ......... 583 Pruritus genitalium 583 Pruritus ani 583 Pruritus hiemalis (prurigo hyemalis, etc.) .... 588 Prairie itch, etc 589 (B.) Dermatalgia 590 Anaesthesia 591 Vasomotor and trophic neuroses 592 Myxoedema 595 CLASS VIII. PARASITIC AFFECTIONS. 1. Vegetable 597 Tinea favosa 597 Tinea trichophytina 603 CONTENTS. XV PAGE (A.) Tinea circinata 604 Onychomycosis 606 Tinea imbricata (Tokelau ringworm, etc.) . . 611 (B.) Tinea tonsurans 611 Tinea kerion 617 (C.) Tinea sycosis 618 Precautions to be observed in managing tinea favosa and tinea trichophytina ...... 624 Tinea versicolor ......... 625 Myringomycosis . 629 Erythrasma 629 La Perleche 631 2. Animal 631 Scabies 631 Demodex folliculorum 642 Pulex penetrans (sand flea) 643 Filaria medinensis (guinea worm) 643 Cysticercus cellulosse 644 Echinococcus . . » . . . . . . . . 645 Distoma hepaticum 645 Leptus (harvest bug) 645 Kriptoptes monunguiculosis 646 Dipterous larvae in the human skin 647 Ixodes (wood-tick) 648 Pediculosis 649 Pediculosis capillitii ......... 649 Pediculosis corporis 652 Pediculosis pubis ......... 655 Pediculi and acari transferred to man from the lower animals .......... 657 Cimex lectularius ........ 657 Pulex iritans (flea) . ... . . . . .659 Culex pipiens (mosquito) . 659 LIST OF ILLUSTRATIONS. Plate I. Case of naevus lipomatodes, from a colored photograj)h of one of the author's patients {frontispiece). Plate II. Xanthoma of elbows and knees, from a photograph of one of the author's patients (page 458). FIG. PAGE 1. Vertical section of the skin of the thumb ...... 18 2. Subcutaneous fat-tissue, after extraction of fat by turpentine . . 20 3. Columnae adiposse 21 4. Vertical section of the skin, after injection from beneath with Berlin blue 22 5. Vascular and nervous papillae 23 6. Horizontal section of the scalp of a negro ..... 24 7. Prickle-cells of the mucous layer ....... 25 8. (a) Pacinian body after staining with silver, showing superim- posed endothelial layers; (b) Section of the same from a duck's bill 30 9. Section of hair-follicle during the formation of a new hair . . 34 10. Hair-follicle in longitudinal section 34 11. Lower portion of hair-pouch from the lip of a kitten ... 36 12. Transverse section of hair and follicle 37 13. Sebaceous glands of the second class from the alae of the nose . . 40 14. Coil-gland . . . ' . .41 15. Sweat-pore, traversing the epithelial layers of the skin ... 42 16. Vertical section of one-half of nail and matrix . . . . *46 17. Implantation of the nail at its border . . . . . .47 18. Irido-platinum needle . . . - . . . . . .89 19. Milium needle 89 20. Scarifying spud 89 21. Epilating forceps 89 22. Grappling forceps 89 23. Skin-grafting scissors 89 24. Cutisector 89 25. Dermal curettes 90 26. Glass pleximeter 90 27. Comedo-extractor 90 XV111 LIST OF ILLUSTRATIONS. I l«;. PAGE 28. Cutaneous punch 90 29. Section of a comedo 120 30. Cysts of the scalp, one of them laid open to exhibit the contents . 127 31. Microphotograph of the bacillus scarlatiuae 138 32. Vertical section of pustule at the beginning of pustulation in variola 144 33. Vertical section of one-half of an undeveloped pustule . . . 145 34. Vertical section of anthrax ........ 200 35. Section of anthrax 200 36. Bacilli of malignant pustule 207 37. Longitudinal section of the third spinal ganglion of the right lumbar region, from a case of zoster 216 3-v Vertical section of skin in psoriasis 226 39. Vertical section of the skin of the forearm, from a case of chronic eczema 265 40. Molluscum epitheliale 370 41. Molluscous corpuscles 371 42. The author's case of molluscum verrucosum 373 ' [ Varieties of cutaneous horns 380 44. J 45. Vertical section of a pointed wart 383 46. Verruca necrogenica 386 47. Ichthyosis hystrix, vertical section 393 48. The Russian " dog-faced man " 399 49. Elephantiasis of foot and leg 412 50. Elephantiasis of the scrotum ........ 413 51. Vitiligo in a negro boy 425 52. Trichorexis nodosa 441 53. Keloid 448 54. Multiple fibromata 452 55. Large single fibroma 452 56. Neuroma of the skin 457 57. Microscopic structure of neuroma of skin 457 58. Lupus erythematosus of the face, from a photograph of one of the author's patients . . . 474 59. Lupus vulgaris of the face, from a photograph of one of the author's patients 480 60.. Section of a lupus nodule 482 61. Section of lupus of the face ....*... 483 62. Facial cicatrices of tubercular syphilodermata, from a photograph of one of the author's patients ....... 503 63. Syphiloderma papillosum 508 64. Vegetating condylomata of the vulva 511 65. Palmar syphiloderm 512 66. Ulcerative tubercular syphiloderm 518 67. Syphilitic gummata of head and face 520 68. Lee's lamp for fumigation 538 69. Lepra tuberculosa 550 LIST OF ILLUSTRATIONS. XIX FIG. PAGE 70. Tubercular leprosy, from a photograph of a leper in the Sandwich Islands 551 71. Anaesthetic leprosy, with mutilating results, from a photograph of a leper in the Sandwich Islands ....... 553 72. Larynx of a leper, with lepra tuberculosa 554 73. ) 74 y Larynges of lepers, with tubercular leprosy 555 75. Bacilli of leprosy, from one of the author's patients . . . 556 76. Epithelioma, vertical section 567 77. Sarcoma, microscopical appearances in section of nodule removed from one of the author's patients ....... 576 78. Mycosis fungoides, drawn from an oil painting of one of the author's patients 578 79. Achorion Schoenleinii 600 80. Epidermis invaded by the trichophyton ...... 607 81. Hair invaded by the trichophyton 614 82. Filaments and spores of the trichophyton from the beard . . 621 83. Microsporon furfur 627 84. Microsporon minutissimum ........ 630 85. Female acarus, fecundated 634 86. Acarian furrow 635 87. Demodex folliculorum 642 88. Leptus . 646 89. Leptus autumnalis 646 90. Acarus hordei 646 91. (Estrus (larva?) 647 92. Larva? removed from body of child ....... 647 93. Pediculus capillitii (male) 649 94. Ova of head-louse, attached to hair 650 95. Pediculus corporis (female) 652 96. Pediculus pubis 656 I. AN ATOMY AND PHYSIOLOGY OF THE SKIN. The skin of the human body is its living envelope, intimately associated with underlying structures, and by its situation brought into intimate relation also with the external world. It is a complex, elastic, and sensitive organ, varying greatly in different conditions of climate, age, sex, health, and race ; and differing also in the charac- teristics exhibited in different localities upon the same individual. Thus, in color there is a wide range between the fair skin of the blonde and the black of the negro, betweeen the rosy pink of the infant's palm and the dark brown hue of the genital region of the aged. The skin varies also in pliability and thickness, being delicate and lax over the lids, the lips, and the prepuce ; and much thicker and more firmly attached over the palms and the soles. It is important to note that the appearance of the skin, even in conditions of health, also changes within appreciable limits. It is the exposed parts, such as the face, which the eye of the physician. most frequently searches, and which betray evidence of mental emotions, physiological fluxes, sedentary or active habits of life, and fatigue or unusual conditions of vigor. Viewed externally, the skin is seen to be traversed by superficial and deeper furrows, dotted by numerous depressions representing the mouths of its follicles, and provided very generally with coarse or fine downy hairs which are in some parts represented by a growth sufficient to conceal the skin from view. This pilary growth serves not merely as an ornament of the body, but also as a protection to some of- its regions most sensitive to thermal changes. By its extraordinary sensitiveness to different degrees of temperature and to the physical properties of the bodies with which it is brought into contact, the skin becomes, even when unaided by the eye, a valuable means of preserving the human frame from external injury. This protective function is, in part, related to the horny character of its outer layer, as a consequenceof which the loss of essential fluids and the ingress of noxious substances are equally restricted. One of the most important functions of the skin is the part which it plays in the regulation of the bodily temperature. The temperature variations at its surface, modified naturally by the character and quantity of the clothing, when such is worn, produce corresponding variations in the smooth muscles and contractile bloodvessels of the skin. By enlargement or diminution of the lumen of these vessels, whether resulting directly from the action of heat or cold at the is ANATOMY AND PHYSIOLOGY OF THE SKIN. surface, or indirectly through an effect upon the vasomotor centres, large quantities of Mood are brought to or removed from the super- ficies of the body. In the one case, the blood is cooled by evaporation Fig. 1. 38 d . Vertical section of the skin of the thumb, partly diagrammatic. «, stratum corneum, traversed by ducts of two glands ; b, rete mucosum with prolongations extending between papillae beneath ; between a and b is seen the stratum lucidum ; c, papillary layer of coriuin. Near the centre of the figure is seen a nervous papilla ; d, reticular layer of cor in m with vascular plexus, nucleated connective tissue and interspaces ; e, four coil-glands ; /, fat-globules in the meshes of the connective tissue. at the surface; in the other, the loss of heat by such evaporation is greatly restricted. This process is materially influenced by accelera- tion or retardation of the heart's action, whether produced by moral SUBCUTANEOUS TISSUE. 19 or physical causes. It is also modified by the occurrence of sweating, as a result of which heat iu varying amounts is rendered latent ; and either watery vapor escapes from the surface or sweat is exuded in drops, the aggregate of which may be several pounds in weight in the course of twenty-four hours. In a limited degree, the skin is capable of acting as a respiratory agent, eliminating carbonic acid gas with watery vapor, and possibly also absorbing oxygen in small amount. Its power of absorbing aliments, medicaments, and toxic substances, in either gaseous or liquid state, is greatly restricted so long as its horny external covering is intact. Such absorption, when it occurs, is probably effected through the portal of the ducts of the cutaneous glands. Gaseous and volatile substances, as well as several of the oils and fats, may at times penetrate the skin through these avenues. The skin is provided with a natural unguent, by which, in a state of health, it is constantly anointed. The fatty and oily secretions of the skin are concerned, not merely in the anointing of the general surface and of the hairs, but also in the regulation of the bodily temperature, by preventing the maceration of the tissues by the sweat. The complex organ which is called the skin is essential to the life of the individual. The sexual, and possibly other organs of the human body, may have their functions arrested, or be even obliterated by destructive processes, and life still continue ; but if the functions of the skin were all suspended for a sufficient period of time, the result would be fatal. In its important relations alone to the compli- cated processes by which the heat of the body is maintained at a relatively fixed standard, the skin exhibits its importance to the general economy. It is thus seen to be, not an isolated membrane stretched mechanically over an artificial machine, but one of several living and potential systems of the body, each of which is in inti- mate union with all others. The integument of the body, when studied by the aid of the microscope, is found to be composed of several organic parts. These are : the subcutaneous connective tissue resting on the deeper struc- tures of the body; then, more externally, the corium, or true skin; lastly, an outermost coat, the epidermis, or cuticle. Beside these, the skin contains coil-glands, sebaceous glands, hairs, nails, blood- and lymph- vessels, muscles, pigment, and nerves. It will be instructive to study the deeper parts before those more superficially disposed, as their mutual relations are thus made clearer. Subcutaneous Tissue. The subcutaneous tissue is differentiated from the corium between the third and fourth months of foetal life. It is a structure serving a mechanical purpose as a receptacle for fat, and for the support of vessels and nerves passing from the tissues beneath to the corium, which lies next above it. It contains, also, coil-glands, some of the 20 ANATOMY AND PHYSIOLOGY OF TIIE SKIN hair- follicles more deeply seated than their fellows, and Pacinian corpuscles. There is no distinct boundary line between its upper limits and the overlying corium, to which it projects columnar masses of fat, extending obliquely to the coil-glands and the hair-follicles above, often with lateral, horizontally disposed prolongations of similar shape. It is built up of loose connective-tissue bundles, pro- longed from the aponeuroses, fascia?, and the membranes lying beneath. It is firmly attached to the skin over the extensor surfaces of the articulations, the palms, the soles, and the groins by short and coarse bundles, between which are single or multilocular spaces lined with endothelia, secreting a mucoid fluid. These are the bursa? mucosa?. Elsewhere, as in the eyelids, the penis, the scrotum, and the auricle of the ear, the attachment to the skin is by loose, delicate connective tissue, containing no fat-globules. All other fibrous tracts are arranged obliquely, admit, by their extension, of various degrees of pliability, and inclose rhomboidal spaces containing more or less numerous fat-globules. These are lobulated, bounded by a delicate, fibrous connective tissue, and abundantly supplied with bloodvessels. This is termed the panniculus adiposus. Fig. 2. Subcutaneous fat tissue, the fat ha tive tissue, carrying injected bluodvi 51111 diameters. (After IIkitzmann.) bundles of fibrous connec- b oblong nuclei. Magnified The deposit of fat in the body is greatly reduced in all diseases productive of emaciation, but never wholly disappears in life. In cases of obesity, fat is deposited in excess of normal limits, and may then be concerned in the production or aggravation of disease. It is THE CORIUM. Fig. 3. 21 Columnse adipose, a, epidermis ; b, erector pill muscle ; p horizontal prolongations of the column ; c, coil-gland suspended in the latter ; /, fibrous bundles of corium ; g, panniculus adiposus ; 7c, band of fibrous tissue extending to the latter. (After Warren.) largely due to the greater or less volume of the panniculus adiposus, that the natural outlines of the body are made graceful and attractive to the eye, or the reverse. The Corium. The Corium, Derma, Cutis Vera, or True Skin, is composed of bundles of fibres of connective tissue, whose decussations produce a dense felt-work, coarsest toward the subcutaneous tissue, upon which it rests inferiorly, and finest superiorly in the outermost portion, which is in contact with the epidermis above. Its general character- istics are well described by Heitzmann as follows : " The bundles are bounded in many instances by a very dense basis-substance, repre- senting the elastic fibres, and separated from each other by narrow layers of a cement-substance (Thomsa), which, in its chemical features, is kindred to the glue-giving basis-substance of the fibrous connective tissue in general. In this cement-substance there are imbedded deli- cate formations of protoplasm, greatly varying in amount in the derma of persons of different age. They represent formations analo- gous to nuclei, formerly called l connective-tissue cells/ at present considered as compact masses, or delicate reticular layers of living matter, which, with a power of five hundred diameters of the micro- scope, look finely granular. The whole glue-giving basis-substance of the bundles is traversed by a delicate reticulum of living matter, in direct union with all protoplasmic formations between the bundles, with all blood- and lymph-vessels, with all nerves, and with the 22 ANATOMY AND PHYSIOLOGY OF THE SKIX. columnar epithelia, nearest to the capillary layer. Only the meshes of the network of the living matter contain the glue-giving basis- substance, which, as the history of development of the connective tissue demonstrates, is produced by a chemical alteration of the life- PiO. 4. Vortical section of skin afiei injection, from beneath, of areolar tissue with Berlin blue. a, epidermis; /, curium; y, panuicuius adiposus. (After Warren.) less' protoplasmic fluid itself. The bundles of the connective tissue of the derma accompany all elongations of an epithelial character. They produce the follicles around the root-sheaths of the hair, the capsules around the coil-glands, and the layers which surround their duets. The bundles of connective tissue are traversed in an oblique direction by bundles of smooth muscular fibres, by relatively scanty bloodvessels in the derma, by numerous capillaries in the papillary layer, by a system of lymphatics, and by numerous medullated and non-medullated nerves." Pars Reticularis. — The reticular layer of the corium is made up, as has been seen, of interlacing connective-tissue bundles, with interspaces increasingly larger from without inward. The fineness of the bundles increases, on the contrary, from within outward, being finest where the minute papilhe of the corium project into the rete, and coarsest near the subcutaneous tissue. Pars Papillaris. — The papillary layer of the corium lies in contact with the rete above, and is connected below with the deeper reticular portion of the true skin. Between the rete and the papilla? of the derma a hyaline substance is interposed which Unna believes may be identical with the so-called cement-substance described as separating the fibrillar of the corium. The basal membrane once THE CORIUM, 23 thought to be stretched between the rete ruucosum of the epidermis and the papillary layer of the corium, cannot be demonstrated to exist. Fig. 5. Yascular and nervous papillce. a, vessel ; b, nervous papilla ; c, vessel ; d, nerve-libre ; e, cor- pusculum tactus; /, transversely divided nervous filaments ; g, epithelia of rete. (After Biksiadecki.) The name of this portion of the derma is intended to describe its chief characteristic, the existence of numerous digital prolongations of the corium, made up of delicate fibres of connective tissue, which do not interlace, and are abundantly provided with nuclei. The papillae spring each from a single, or several from a common, ovoid base ; their bulbous, conical, or blunt apices reaching into the rete, which also dips down between them. They differ in size in different parts of the body, and also in their disposition and shape, being in places arranged in linear series, and in others in concentric whorls, with definite centres, producing thus crossing furrows, visible to the naked eye as markings upon the outer surface of the epidermis. In horizontal sections of the skin, the papillae, being transversely divided, appear as circular or ovoid areas, in which can be recognized centrally a transversely or obliquely divided capillary loop. Between these areas the inter-papillary reticulum of the mucous layer is seen. According to Unna, who bases his statements upon the wide varia- tion between the largest sized papillae and their entire absence in some regions, the papillary layer of the corium represents merely " an ex- tremely variable border-phenomenon." Certain it is that the growth of the rete downward and of the corium upward results in mutual effects of pressure and counter -pressure whose equilibrium is con- stantly adjusted by the mechanical and vital necessities of such union. 24 ANATOMY AND PHYSIOLOGY OF THE SKIN. When the papillae are completely exposed, after the removal of the overlying so-called cement-substance and of the epidermis above, their exterior surface is seen to be uniformly marked with series after scries of alternating furrows and ridges of exceeding delicacy, more or less concentrically disposed. These are supposed by Unna to be grooves with ridges on either side, into which are admitted corre- sponding dentations to be recognized on the under surface of the layer of epithelial cells next to the corium. Fig. 6. Wmm D Scalp of a colored man — horizontal section. B, rete mucosum ; Pi, row of columnar epifhelia, cut obliquely, supplied with dark-brown pigment-granules; Pa, papilla, cut transversely; D, derma. Magnified 500 diameters. (After Heitzmann.) Two varieties of papilla? are distinguished — the vascular and the nervous ; the former containing the terminal loops of a minute artery and vein ; and the latter, the ultimate filamentous termination of a non-medullated nerve-fibre. The greater number of papilla? are of the vascular variety, being traversed by a vertically disposed loop of vessels, consisting of an arterial and venous capillary. Their office is evidently not merely to supply nutriment for the epidermis above, but also to provide for the cooling of the blood when brought in large quantities to the sur- face of the body. Occasionally, two or more of such loops can be recognized in a single papilla. The nervous papillae contain the tactile corpuscles, which subserve an important purpose in providing for the insensibility of the integu- ment. These are described in connection with the nerves of the skin. It is to be noted that ultimate terminations of nerves can be recognized in the vascular papillae, and that at times minute vascular loops can be seen in the papilla? largely occupied with the corpuscles of touch. The Epidermis. The Epidermis, Scarf-skin, or Cuticle, is the most external of the several membranes of the body, being in close contact on one side with the corium, or true skin, and exposed on the other to the THE EPIDERMIS. 25 atmosphere by which it is surrounded. The latter surface is there- fore relatively drier, while the former is constantly moistened by fluids from the vessels which ramify beneath it. No genetic relation can be established between the epidermis and the corium, intimate as is their union and mutual relationship. The former is developed from the ectoderm, the latter from a superficial layer of the mesoblast. Their behavior both in health and disease is marked by the widest difference. The epidermis differs greatly in thickness in different portions of the body, that, for example, of the palms and soles exceeding, in vertical section, that which covers the dorsum of these same organs, and that protecting such sensitive parts as the lids, lips, temples, and prepuce. The epidermis is composed of the following layers, named in order from within outward : the stratum mucosum, the stratum granulosum, the stratum lucidum, and the stratum corneum. All of these several strata, or layers, are histogenetically derived from the one which is deepest in situation. The Stratum Mucosum, Mucous Layer, Prickle-layer, Eete Mucosum, Rete Malpighii or Malpighianum, is the deepest of the epidermal layers, and rests upon the corium below. The latter is intimately united with it by a series of interdigitations which are commonly described as prolongations of the derma into the sub- stance of the rete, but it is equally true that the rete sends down prolongations into the derma. The two, for reasons which doubtless originate in the need of an intimate union to resist friction and to insure vascular supply, are thus closely locked together. The stratum mucosum is built up of nucleated epithelia, epithelial cells, or corpuscles, polyhedral in outline and diffusely colored. These are masses of granular protoplasm., living matter, which by their relations to Fig. 7. each other form a protoplasmic network en- veloping the entire surface of the body and lining all channels and cavities which are in direct or indirect connection with the surface. These elements are flattened by reason of their apposition, and separated from each other by an intercellular substance, which has been de- scribed as a " cement-substance." There is, without question, a system of channels be- tween the epithelia, by which the fluids of nutrition are conveyed from cell to cell. All are, however, uninterruptedly united to each other by means of delicate spokes, known as Priokle ' cel,s la ^ r _ the mucous prickles, spines, or thorns. The living mat- ter, which produces a delicate reticulum within each protoplasmic body, its points of intersection being termed nuclei, nucleoli, and granules, furnishes the filaments already described, which thus pro- 26* ANATOMY AND PHYSIOLOGY OF THE SKIN. duce continuity through all the living layers of the epithelial elements, as well as through the underlying layers of the connective tissue. The epithelia are unprovided with either blood- or lymph-vessels ; hut. when living, are supplied with a large number of nerves, which, in the shape of very minute beaded fibres, traverse the intercellular substance, and are in direct communication with the reticulum of living matter within the protoplasmic bodies themselves. The living masses of protoplasm, just described, play the most important part in all the pathological and physiological proa observed in the skin. It is probable that, in the embryo, all the appendages of the skin are firmed directly by their assimilative and reproductive processes ; and it is certain that, in health and disease, they furnish the organic matter of all secretions. The epithelia next the corium are columnar in form, of a diffuse brownish hue, and arranged with their long axes nearly at right angles to the plane of that portion of the corium upon which they are superimposed. More externally they have pronounced poly- hedral outlines, and the cell nucleus of each is large and distinct. Above this columnar-shaped pavement, irregularly rounded and cubical epithelia, with large, single or multiple, spherical nuclei, are packed between the papillae of the corium, rising from below; and horizontally flattened bodies of the same general appearance lie in strata above the level of the conical apices of the papillae. Here the threads of protoplasm between the cells are voluminous, forming thick and broad strands connecting the elements. Between these, outwandered leucocytes may at times be recognized. In the more externally disposed rows of epithelia the prickles become shorter and the cells flatter, till finally they lie in a uniformly horizontal plane. The Stratum Granulosum, or Granular Layer of the epi- dermis, is built up of one or two, rarely more, rows of horizontally disposed granular bodies, united to each other by short and broad threads. Between these, the intercellular spaces are so contracted that nutritive fluids cannot filter easily outward ; and the nuclei of the cells are usually shrunken in size. These have been carefully studied by Ranvier, Kolliker, Waldeyer, and others. According to these observers, the roundish granules which give this layer of epi- thelium its peculiar name and appearance, consist of eleidin, or kerato-hvalin, a substance essential to the process of cornification in the elements miking up the horny layer of the skin, nails, etc. These granules begin to appear in the neighborhood of the nuclei of some of the large prickle-cells in the rete, but are best studied in the granular layer, whose cells are often completely filled with them. According to Unna, the color of the skin in the white races depends upon this layer alone. The Stratum Luoidum, or Septum Lucidum, of Oehl, lies im- mediately above the stratum granulosum, and appears under the microscope as a delicate, brightly colored line, consisting of two or BLOODVESSELS. 27 three rows of transversely disposed, glistening epithelia, differing in translucency from those situated on" either side. It thus marks with tolerable distinctness the boundary lines of the rows of cells above and below it. Its epithelial bodies have suddenly lost the refractive, shining granules of kerato-hyalin, conspicuous in the stratum granu- losum below. These granules are generally supposed to have disap- peared in consequence of their solution in the protoplasm of the cell- body, which has thus acquired an added brilliancy and clearness. The Stratum Corneum, or Horny Layer of the epidermis, is its outermost aud widest layer, extending from the stratum lucidum below to the external environments of the body. In its lower por- tion, the polygonal plates of which it is composed indicate very clearly their relationship to the cells in the prickle-layer. The nuclei appear in places, only, as shrivelled and inconspicuous relics of the protoplasmic threads. Occasionally, on the edges, rudiments of the prickle-threads may still be recognized. Still more externally, the dried, lifeless, and horn-like plates of which this layer is composed, become mere cornified shells, generally lying in horizontal strata, more curled and wrinkled as the surface of the skin is reached, often imbricated, but preserving the polygonal outlines of epithelia relieved of the forces of pressure and counter-pressure exerted in the deeper parts of the epidermis. These elements are rarely pigmented, save in the case of the negro, where the intense staining of the deepest parts of the mucous layer is to a degree spread to the external strata. Such staining in the colored races is produced by granules of pigment arranged about an unaffected nucleus in the prickle-cells. According to Unna, after digestion with pepsin and trypsin, it is seen that the horny cells are connected by more or less persistent threads, visible after more prolonged digestion as a large-meshed reticulum, with strands formed from a double row of cornified fila- ments united by short horny bridges. Bloodvessels. The Arteries and Veins supplying the skin spring from sub- cutaneous branches which penetrate the fascia? beneath, and proceed by subdivision to be distributed to all portions of the integument below the epidermis, the distribution being especially abundant about the glands and follicles of the skin, and the inferior and superior parts of the corium. They are always more abundant upon the flexor than the extensor faces of the extremities. Just beneath the papil- lary layer of the corium there is a minutely ramifying plexus of fine capillaries, whose loops extend into the papillae above, as already de- scribed. This and the coarser plexus in the deeper portion of the derma are so well defined that they might well be designated as supe- rior and inferior partes vasculares of the corium. Still a third vas- cular district is found in the subcutaneous connective tissue where the vessels are numerous. 28 ANATOMY AND PHYSIOLOGY OF THE SKIN. The arterioles which supply the sweat-glands surround the coils of the latter in a delicate basket-like plexus, and terminate in two or three veinlets, one of which always accompanies the duct of the gland upward as far as the papillary layer, where it anastomoses with the vessels of that part of the skin. The ascending arterioles supply also the .sebaceous glands and hair-follicles; and, finally, breaking up into smaller and yet smaller branches, furnish a single or double capillary loop to each papilla. The capillaries of the papillary layer anastomose freely with those transversely arranged in the upper portion of the hair-follicle, loops from which also pass to the seba- ceous glands. The hair-papilla has a vascular supply similar to that of the other papilla of the corium. Unna divides the vessels distributed to the skin into the papillary system, and the system of the coil-glands and fat tissue. The former includes the ascending loops which traverse the vascular papillae, and the branches supplying lower portions of the corium. The latter embraces the vessels running upward to the coil-glands and down- ward to the fat tissue. In the papillary vascular system, the arteries are narrow and the veins wide. The vessels consist merely of an endo- thelial tube augmented, as the subcutaneous tissue is reached, by both media and adventitia. According to Hover, there is a singular duplex arrangement of vessels in the distal phalanges of both fingers and toes, in consequence of which there is a direct communication between the arteries and veins. Vasomotor nerves are twined around these vessels in all their ramifications. The whole vascular system, as thus arranged, plays a most important part in all the healthy and morbid processes which occur in the skin, as well as in the sudden physiological changes dis- tinguishable to the eye in the phenomena of blanching and blushing. Lymphatic Vessels. The skin in all its parts is provided with a system of lymphatic channels, designed to subserve the necessities of the important pro- cesses of absorption, and traversed by lymph whose currents are continuously directed to the large vessels of the structures beneath the skin. Unna divides these channels into : first, juice-spaces, pro- vided or not with independent walls, usually the latter, and not freely communicating with the endothelium-lined vessels; second, lymphatic vessels proper, which communicate directly with the bloodvessels. The juice- or lymph-spaces separate the epithelial bodies that make up the stratum mucosum of the epidermis, and also extend between the protoplasmic threads or prickles that unite them. Such conduits may be regarded either as delicate excavations in the so-called cement- substance between the epithelia, or as irregular chanuels in a softish, viscid, albuminoid, and readily coagulable substance existing between the protoplasmic threads. In the latter event, these spaces would be comparable to the impression's made by thrusting at random a pencil into a mass of soft putty. At times, this intercellular substance NERVES. 29 seems capable of obstructing the conduits by which it is tunnelled. These same juice-spaces exist in the papillae of the corium, and encircle the different glands, hair-follicles, and nail-beds of the skin. They also sheathe the connective-tissue fibrillse of the corium and surround the fat-cells. The lymphatic vessels are relatively few, but form a continuous mesh work with transversely and vertically disposed branches sup- plying all parts of the skin below the epidermis. The juice-spaces communicate with these vessels in the papillary portion of the corium through minute orifices in the vascular walls, the vessels themselves being here represented by blind terminal loops. As they pass to the deeper portions of the corium and below it, these vessels increase in size. The current of the lymph is from the papillary apices in every direction to all parts of the rete, like the currents in the delta of a river, a reflux occurring at the lower limit of the interpapillary depressions of the rete downward, possibly through the sweat-pores which traverse the epidermis at these points. Thence the current flows freely downward to the lymphatic vessels in the corium, but the stream from the juice-spaces about the coil-glands and fat tissue is retarded by reason of a more restricted communication with the lymphatic vessels below. In consequence of the retardation due to this anatomical peculiarity, the formation of fat by filtration is facilitated. Nerves. Non-medullated and medullated nerve-fibres, each in places being substituted for the other, are supplied to the skin from horizontally disposed bundles of nervous twigs iu the subcutaneous tissue. These traverse the corium in connection with the bloodvessels, and become finer as they ascend, till they form a subepithelial plexus just below the epidermis. Exceedingly delicate Nox-medullated Fibres penetrate to the epidermis between the epithelia in great abundance. Here, traversing the intercellular substance by the side of the juice-spaces, they either terminate between the prickle cells as ultimate bulbous terminations of finely beaded fibrillse, or they penetrate the epithelia themselves in pairs. Each prickle-cell is supplied with a pair of these beaded filaments, which may be either applied to the nucleus of the cell, or be seen to encircle the nucleus more or less completely. Above the stratum granulosum these nervous threads cannot be recognized. Similar nervous filaments are supplied to the sheaths of the hairs and the ducts of the coil-glands. It is by means of these numerous and delicate fibres that the perception of sensation in the skin is accomplished. Motor filaments, discovered by Thomsa, are also distributed to the sheaths of the bloodvessels, in which they are finally lost. Other motor filaments supply the muscles, and trophic nerves are distributed 30 ANATOMY AND PHYSIOLOGY OF THE SKIN to all the secreting organs of the skin, and to all its protoplasmic fori nations. The Medullated Nerve-fibres of the skin have been care- fully studied by Dr. A. R. Robinson, 1 of New York. According to the latter, one or several loops of such fibres pass upward into the papillae, and then turn backward to the subpapillary region. Some of these, alter such reversion, again ascend to an adjacent papilla. Yet others are supplied to the Pacinian and tactile corpuscles. The Pacinian Corpuscles, named from the anatomist Pacini, also called Corpuscles of Vater, exist subcutaneously only upon nerves intended for cutaneous supply, and are small, oval bodies, two or more millimetres in diameter. Each consists of a series of con- centric, nucleated, and vascular capsules, arranged after the manner of the capsules of the onion, more closely united at the periphery Pacinian body, after silver staining, showing sui>c'i'iiii]iuseil endothelial lay- ers. (After Renaot.) Section of Pacinian body, from a duck's bill. g.L, lamellar envelope ; y.h, hyaline zone of the lamel- lar envelope ; bt, terminal bull) of the nerve ; y.p, u.g.p, layer investing the cavity of the body. (After Renaut.) than at the centre, and surrounding a protoplasmic core. The medul- lated nerve to which the body is attached gradually loses its myeline envelope, and terminates in the centre of this core, after traversing the greater part of its axis, in one or several, minutely club-shaped, nervous filaments. The myeline sheath is lost in the tissue of the concentric capsules. According to Ranvier, the nerve may, after of Dermatology, by A. K. Robinson, M.B., etc New York, 1884. JSTEKVES. 31 supplying one capsule, subsequently penetrate a second, or even a third. In such cases the nerve regaius its sheath as it issues from the corpuscle at its opposite pole. Robinson believes that the nerve forms a plexus or loop within the corpuscle, and again leaves it at one of its poles. The precise function of the Pacinian corpuscle is unknown. Its connection with the tactile sense is suggested by its location, since these bodies are most numerous in the subcutaneous tissue of the nipple, the penis, the digits, and parts similarly sensitive. It bears an evident analogy to the organ of vision, each body having a cap- sular character ; each being provided with a special nerve-filament, which enters the corpuscle at one pole ; each also receiving its im- pressions at the extremity of the capsule opposite that where it receives its nervous supply. According to Krause, the Pacinian corpuscles are concerned in the appreciation of impressions produced by pressure and traction. Whether specially concerned in the distinguishing of sensations originating in heat, cold, moisture, pressure, traction, or weight, it is evident that they contribute but little, if at all, to the reception of ordinary impressions upon the skin, and, at this date, they are not known to play any part in cutaneous diseases. The Tactile Coepuscles (Corpuscles of Meissner, or Wagner) (see Fig. 5) are other oval-shaped bodies found in about one of four of the papilla? in the pars papillaris of the corium. They are com- posed of from one to three capsules, each receiving a medullated nerve-fibre and made up of closely compressed, flat, connective-tissue fibres with minute nuclei, which are so packed together as to form a spindle-shaped mass, occupying the greater part of the papilla in which each is found. A somewhat denser connective-tissue capsule encloses each. The myeline sheath of the nerve-fibre is lost in the fibrous tissue of the corpuscle. Externally viewed, they seem to be transversely striated. The axis-cylinder of the nerve-filament distributed to each divides into numerous delicate nervous threads which in part encircle the corpuscle and also penetrate within. According to Dr. Robinson, each corpuscle is provided with an afferent and efferent nerve, the former approaching the corpuscle from the subpapillary region and entering at or near its base. Occasionally the afferent fibre is fur- nished by an adjacent papilla. As the filament that enters the corpuscle frequently divides, two or more efferent fibres may then escape from it. The discovery of nervous filaments in and among the epithelia of the epidermis in such abundance as to provide fully for tactile sensa- tion in the skin, leaves the exact function of these corpuscles in partial obscurity. There can be little doubt, however, as to their association with the perception of certain qualities of foreign bodies with which the skin may be brought into contact. 32 AX ATOMY AND PHYSIOLOGY OF THE SKIN Pigment. The hue of the living integument is due in part to the degree of vascularity and distention of the vessels in the coriura, and in part also to pigmentation of the epidermis. Tin's pigmentation depends upon a distinct and uniform coloration of the epithelia, chiefly those found in the lower strata of the epidermis, and also to minute granules of pigment entangled in the reticulum of living matter in the same parr. Extreme variation in the distribution of pigment is noticeable both in health and disease, and in individuals and races, being, at times certainly, proportioned to climatic and similar influ- ences. This is well illustrated by the wide range between the flaxen- haired and pink-eyed albino, and the blackest specimens of the negro, each with small exception of African descent. It has been already noted that in the colored races the pigment may stain the epithelial cells and their nuclei, as high as the granular layer; and that to this layer only the peculiar color of the skin of the white races is due. Pigment is not found normally either in the horny layer of the skin or in the subepithelial tissues. Waldeyer alone claims to have recognized it in normal connective tissue. The relation existing between the two sources of skin coloration, viz., the blood and the pigment, is interesting and suggestive. The eye unaided, looking at the outer surface of the body, makes no dis- tinction between these two color sources. It is indeed probable that the pigment originates from the coloring matters of the blood. It is certain that solar heat exerts a manifest influence upon both, and that in extravasations of blood into the substance of the skin, every shade of color which can be detected in the spectrum can be at times distinguished. Muscles. Striated Muscular Fibres extend from the subcutaneous tissue into the derma, and in the case of man are found chiefly upon the face and neck, where they are the analogues of more powerful skiu- moving muscles possessed by several of the lower animals. Some, as those in the region of the face, serve to give expression to mental emotion by the production of movements in the features. Non-striated Muscular Fibres exist either as minute oblique fasciculi in connection with glands and follicles of the skin; or as annular bands, such as those which surround the uipple; or as radiating and more or less parallel rods, such as antagonize the orbicu- laris in the lids. The Arrectores, or Erectores, Pilorum are muscles usually found in connection with the hair-follicles. They originate by several minute fasciculi from the papillary portion of the corium, and are inserted at several points into the outer layer of several adjacent HAIRS. 33 hair-follicles, just above the plane of the apex of the hair-papilla. Their general direction is oblique, and their muscle-bundles are both embraced and traversed by elastic fibres which form a dense network about them. Elastic threads also connect them intimately with the connective-tissue bundles of the corium, and serve as tendons at either extremity of each muscular fasciculus. The oblique direction and mode of attachment of these muscles result in their inclusion of the sebaceous glands connected with the hair- follicles in the angle subtended by their muscular fibres. It follows, therefore, that by their contraction they can aid in the expulsion of the sebaceous secretion formed in the gland. But their intimate union with the elastic tissue, which is evenly and generally distributed throughout the framework of the corium, results in their discharge of a still more important function in connection with the regulation of the bodily temperature. Their anatomical connections are such that contraction of the arrectores pilorum serves to approxi- mate several of the papilla? of the corium, the hair-papilla being in this view regarded as one of such cones. Thus, by their contraction the sebaceous secretion may be extruded, or, as more particularly exhibited in the lower animals, such hairs may be erected as the bristles of the boar. But by virtue of direct compression exerted upon the skin, the blood may be driven from the surface in a centri- petal direction and its cooling to a great degree prevented, as in the well-known phenomena resulting in the production of the cutis anserina or " goose flesh." The reverse of this naturally follows when the muscles expand under the influence of external heat. Hairs. Hairs are cylindrical, elongated, and pointed epithelial filaments, derived from the epidermis, and obliquely implanted in depressions in the rete and corium, known as hair-sacs, or hair-follicles. They are found in all portions of the body except the palms and soles, the dorsum of the distal phalanges of the hands and feet, and the skin of the penis. Hairs occur in three tolerably distinct classes. There are the fine downy hairs, or lanugo, covering the face, trunk, and limbs ; the long and soft hairs, such as are implanted upon the scalp, pubes, and axillae ; and the short hairs, including the soft varieties seen upon the brow, and the stiff hairs of the lids. The hairs are first developed in the third month of foetal life, when a short epithelial cone is formed, whose base is gradually surrounded by connective-tissue cells, and finally indented from below by a rudimentary hair-papilla. Gradually the tip of the rudimentary hair perforates the primitive hair-cone, and becomes a mature filament. At about the period of birth, sometimes earlier, occasionally later, the bed-hairs, as they are called by Unna, are replaced by papillary hairs. The term bed-hair is applied to primary hairs unprovided with papilla?, and implanted in shallow follicles from 34 ANATOMY AND PHYSIOLOGY OF THE SKIN. the sides of which productive epithelial offshoots have been sent out. Usually at the end of foetal life these bed-hairs have been Fig. 9. Fig. 10. Jv /"I mm v Section of hair-follicle during the formation of a new hair, a, external and middle root- sheaths ; b, vitreous membrane ; c, papilla, with vascular loop ; c/, external root-sheath ; e, in- ternal root-sheath;/, cuticle of hair-follicle; g, cuticle of hair ; h, i, young hair ; /, bulb of old hair ; it, debri6 of external root-sheath of hair recently expelled. (After Ebnee.) Hair-follicle in longitudinal section, a, mouth of follicle ; I, neck ; c, bulb ; d, e, dermic coat ; /, outer root-sheath ; g, inner root-sheath ; h, hair; k, its medulla; 1, hair-knob; m, adipose tissue ; n, hair-muscle ; o, papilla of skin ; p, papilla of hair ; s, rete mucosum, continuous with outer root-sheath ; ep, horny layer ; t, seba- ceous gland. for two months growing out of the hair-bed, or that part of the epithelium found in the central part of the hair-sac. In studying the mature hairs, the parts to be considered are the hair-follicle, and the bulb, shaft, and point of the hair. HAIRS. 35 Hair-follicle. — The hair-follicle is a sac-like depression in the corium, in which the hair-filament is implanted by its bulb, and there firmly secured. The direction or set of this follicle is always at an oblique angle with the plane of the cutaneous surface where it opens; and thus is determined the set of the hairs, which is always fixed, and at a similar angle. Viewed as a whole, the integument of the body over its entire area exhibits determinate whorls of both short and long hairs with definite centres, such as those which may be recognized at the vertex of the scalp, the centres of the lips, the umbilicus, etc. By this disposition the symmetrical appearance of the hairy parts is preserved, and, as a consequence of the same provision, physiological loss of the hair of the head is not productive of deformity, but rather adds dignity to the aspect of the elderly man. The hair-follicle embraces the lower two-thirds of that portion of the hair which is embedded in the skin, together with the envelopes of the latter, termed its sheaths. Above the sebaceous glands the limits of the hair-follicle are lost in the papillary layer. It is con- stituted of the connective tissue of the corium in three layers : an external, longitudinal, fibrous layer; a middle, transverse layer; and an internal, homogeneous, or vitreous layer. At the base of the sac a fibrous pedicle may often be traced as low as the subcutaneous tissue. If the hair-pouch were made artificially by thrusting into the skin from without inward a blunt-pointed pin, before which the tissue was gradually pushed, it is evident that the external layer, the stratum corneum, of the epidermis would be the first depressed, and finally cover the inner surface of the pouch. This represents the inner root-sheath of the hair. Next to this the pin would carry before it the mucous layer of the epidermis, which then would form the outer root-sheath of the hair„ Outside of both would lie the connective tissue of the corium ; this is the hair-follicle. The Outer Root-sheath, or, as Unna prefers to call it, the prickle-layer of the hair-follicle, accompanies the involutions of the stratum corneum, and the stratum granulosum from without, into the funnel-shaped neck of the hair-pouch as far as the openings of the ducts of the sebaceous glands. There, abandoned by the two other layers of the epidermis, it is thinned in proportion as the papilla, which rises from below and which it closely surrounds, increases in size. It thus forms a hollow^ cylinder traversed by the hair and its envelopes, with a relatively wide, external, funnel-shaped opening, only partially filled by the shaft of the hair, and a narrower opening within, which embraces the neck of the hair-papilla. The Inner Root-sheath, or, as Unna prefers to call it, the matrix of the root-sheath, is externally in relation with the outer root-sheath or prickle-layer of the hair-follicle. The protoplasm of the cells of which it is constituted contains kerato-hyalin in varying 36 ANATOMY AND PHYSIOLOGY OF THE SKIN. quantities, the amount being naturally greater in the cells lying Dearest the hair-filament. The part of the sheath formerly termed Henle's layer is the more externally situated, cellular envelope of this interna] root-sheath, most conspicuous in that part ol the hair- FlG. 11. - M> Lower portion of hair-pouch from the lip of akitteu. F, follicle; T, transverse sections of con- nective-tissue bundles of derma ; M, arrector plli muscle ; IS, inner root-sheath ; OS, outer root- sheath ; P, papilla ; C, cuticle ; R, root of hair ; H, hyaline, or so-called structureless membrane. Magnified 500 diameters. (After Heitzmann.) sac which is above the level of the papilla. That part of the sheath formerly called Huxley's layer, is the more internally situated part of the same sheath, somewhat higher in the follicle. Both of these terms are now falling into desuetude as not actually descriptive of distinctly different structures, but only of one structure in different situations. That structure, whether it is termed the internal root- sheath, or matrix of the root-sheath, springs from the neck of the papilla, and rises as high as the neck of the follicle. It contains HAIRS. I 37 kerato-hyalin, which is actively concerned in the cornification of the hair tissue. Between this structure and the cells constituting the cortex of the hair, there is found, according to Unna, the common matrix of the cuticulee, forming respectively the cuticle of the root-sheath, and the cuticle of the hair. The former is composed of cells with their long axes parallel to the circumference of the hair, while those forming the cuticle of the hair are arranged perpendicularly to the surface. These cuticulse are securely locked together by projection of their cell edges, while united in the hair-follicle. The Bulb, or Root, of the hair is that portion which is embedded in the skin, toward which the shaft of the hair gradually increases in thickness as it descends. It is embraced by the hair-follicle, though its root-sheaths are interposed, and implanted below at the base of the sac upon a nipple-shaped prolongation of the corium, which may be regarded as analogous to the vascular papillae of the papillary layer of the corium. The bulb of the hair embraces the papilla, and is constituted of pigmented cells externally, forming what is called the cortex or cortical portion. This is the larger of the two structures of wdiich the hair is composed, and its cells become vertically elongated and narrow as they are pushed outward in the process of growth. The innermost structure of the hair is called its medulla, a tissue composed of non-pigmented, horizontally broadened cells containing kerato-hyalin. It rests directly upon the . apex of the papilla below, and passes Fig. 12. thence through the centre of the shaft of ,-<^~T~^ HH^ the hair like a delicate cylindrical core. / ■••^^^''" ; ^■-■"^ f!? ^^'' : ■. Air-spaces occur between its epithelial . ' - \ . * cells as it rises toward the funnel-shaped , /-- \ ' opening of the hair-sac, but air does not enter the body of the individual cells. ill The Shaft of the Hair is that \ portion which extends from its exit at the I surface of the skin to its extremity. The , \ ; ,4 - latter, when uncut, always tapers to a \ • •.' ' perfectly acuminate point, as is illustrated in the uncut hairs of the lids, and of the lower animals. The shaft is either straight, Tr curled, wavy, or alternately varied in follicle. diameter, producing the peculiar character of the growth seen upon the scalp of the negro, these variations being due to the different degrees of flattening of the shaft in a transverse direction. The color of the hair is dependent upon the pigment it contains, the proper color of the hair-cells, and the quantity of air contained section of hair and 38 ANATOMY AND PHYSIOLOGY OF THE SKIN. iii the medulla. Variation in these three factors produces the wide range between a snowy whiteness and an ebony black. The membrane which invests the shaft of the hair is the cuticle, already described, composed of numerous flattened plates, regularly overlaid so as to resemble fish-scales when viewed under the micro- scope on the Hat side, and the overlapping shingles of the roof of a house when seen on the edge. The Cortical, or main, Substance of the Shaft of the hair is here also enwrapped by the cuticle, and composed of flat, nucleated, fusiform, epidermal cells. The strength, elasticity, and extensibility of the hair are chiefly due to the cortical substance, and in particular to the firmness with which these epidermal cells are attached to each other. The Medullary Substance of the Shaft of the hair is found best developed in the short and strong hairs of the beard and eyelashes, being wanting in the lanugo hairs. It consists of a loosely packed mass of epidermal elements, differing in shape, developed in the centre of the axis of the shaft. This part of the hair contains also the pigment and fatty matters which are here arranged as in the rete of the epidermis. Seen under the microscope,' the medulla appears as a continuous or interrupted longitudinal band, extending from the bulb, or the part implanted in the follicle, to the extremity or point. The purpose of this difference in the constitution of the cortex and medulla of the hair is doubtless to insure, on well-known mechanical principles, a maximum of strength, extensibility, and elasticity, with a minimum of volume. The coloring matter of the hair is stored in both its horny and medullary portions, and is distinct both within and between the epithelial elements of which it is composed. This pigmentation cor- responds, as Heitzmaun has shown, in great part to the amount of pigment distributed to other parts of the integument, and sustains a. close relation to the general nutrition of the body. Its subjection to the influence of the trophic nerves is well demonstrated by the phe- nomena of rapid blanching of the hairs. Excessive sweating, whether physiological or induced by the action of pilocarpine, has also a distinct influence upon the shade of color of the hair. On transverse section hairs present an ovoid or ellipsoidal outline, occasionally suggesting an irregularly compressed circle. The degree of this flattening differs in different races, and, as has been shown, . i> the cause of variability with respect to straightness or curliuess. As hair- are to a marked degree hygroscopic, and not only absorb but can be deprived of a portion of their water, these states of waviness are subject to variation according to the aqueous condition of the media by which an individual is surrounded. Hairs differ from nails not only in their anatomical features, but particularly as to their physiological reproduction. The former are periodically cast off and replaced by new filaments; the latter are so SEBACEOUS GLANDS. 39 shed and reformed only in disease, and in health enjoy a continuous growth during the life of the body. When a hair is about to be shed it separates from its papilla in the hair-follicle and rises in the latter till it reaches above the level of the papillary apex. It is thus for a time held in place with sufficient firmness by the prickle-layer only, and thus forms the bed-hair de- scribed above. Later an epithelial bud is projected either into the vacant follicle below or into the corium on either side, from which a new hair is formed, somewhat as the hair is formed in the primitive cone of foetal life. Later the growth outward of the new papillary . hair pushes the bed-hair from its connection with the prickle-layer, and the latter is shed. Sebaceous Glands. The sebaceous glands are pyriform bodies, usually racemose in development, situated in the corium, never in the subcutaneous tissue, which furnish a more or less consistent and fatty secretion destined to anoint the skin and hairs. They can be usefully distinguished as in three separate classes, though only two of these classes include glands which are in the embryo associated with hairs. The first class, as proposed by Sappey, includes the sebaceous glands, which are, strictly speaking, appendages of the hairs and hair-folli- cles. They are developed early in foetal life from minute, lateral, bud-like prolongations from the outer root-sheath of the hair. From two to six of these spring from the prickle-layer of the hair-follicle ; and the prickle-cells in the axis of each bud speedily undergo fatty metamorphosis. In the mature gland each acinus is formed of a membrana propria, on which are ranged layers of nucleated cuboidal epithelia undergoing fatty metamorphosis. Gradually the fatty cells are pushed outward toward the duct of the gland, where, sooner or later, their rupture releases numerous drops of fat just where the hair emerges from the closely applied follicle below to the funnel-shaped mouth of the hair-pouch above. Externally, each gland is provided with a layer of connective tissue. On account of the clearly defined relations of these bodies, Unna would call them the "glands of the hair-follicles." They are found in connection with the long and soft hairs, as of the scalp and axillae, several grouped around a single hair-sac. The second class includes the large and complex glandular struc- tures to which the lanugo, or rudimentary hairs, seem accessory, the orifice of their ducts opening directly upon the cutaneous surface. These are chiefly found upon the so-called non-hairy portions of the skin, as the face in both sexes, and portions of the trunk and extrem- ities. The third class includes much the smaller number. These are sebaceous glands opening directly upon the surface and unconnected with hairs or hair-follicles. Such are the glandulse odoriferse of the male and female genitalia (glands of Tyson), the Meibomian glands, 40 ANATOMY AND PHYSIOLOGY OF THE SKIN and those existing about the lips and in the areola of the nipple. These might be designated as the "glands of the mucous orifices." Flo. 13. \ r} ,*?&=* *» _JiF '$ •v Sebaceous glands of the second class from the alse of the nose. (After Sappey.) The sebaceous secretion is found to contain, chemically, water, pal- mitic and oleic acids, palmitin and olein, soaps, and the saline constit- uents of the other organic animal compounds, chlorides and phos- phates of the alkalies and earths. It has been already shown that the extrusion of the secreted sebum from the ducts of these glands is greatly favored by the action of the arrectores pilorum muscles, by whose contractions the gland is to a degree compressed. This is the reverse of what occurs in the coil-glands, whose secretion is impeded by the action of these same muscles. Coil-glands. The Coil-glands, also termed Sweat, or Sudoriparous glands, are globular coils situated in the subcutaneous tissues and in the deeper portions of the corium. They appear first in the fifth COIL-GLANDS. -11 month of foetal life as buds projected downward from the prickle- layer of the epidermis. Unna has demonstrated that these projections always form between the papillae of the corium, and spring from the prolongations of the rete between these papillae. Long, thin cones of epithelium thus gradually traverse the corium, and become slightly bulbous at the lower extremity to form later the coil. The lumen, when formed, extends rapidly to the epidermis, and after this is reached, an opening is made from within outward, which becomes the sweat-pore. These glands after birth are found in all parts of the body, but in certain regions, such as the axilla?, the groins, the palms, the soles, and about the anus, they are either numerous, of unusual size, or peculiarly arranged. They are specially numerous in the palms and soles, where, according to Krause, there are between two and three thousand to the square inch. Fig. 14. Coil of the sweat-gland. S, tubule lined by cjiboidal epithelia ; T, central calibre of the tubule ; D, beginning of the duct ; C, connective tissue with injected bloodvessels. Magnified 500 diameters. (After Heitzmann.) The coil is a convoluted tube terminating in a coecal pouch, lined with cubical epithelia of granular appearance which are the secretory cells of the gland. Outside of these are muscular fibres running parallel with, or in a spiral direction about the coil. Surrounding both muscle-bundles and epithelium is a connective-tissue membrane. The glomerulus, or coil, is globular in outline and reddish-yellow in color. In the larger glands irregular dilatations and constrictions of the tube are conspicuous. The excretory duct of the coil-gland passes from the glomerulus below to the epidermis above, in a straight or spiral course. It is -12 ANATOMY AND PHYSIOLOGY OK THE SKIN. lined with a delicate hyaline cuticle discovered by Reynold, beneath which is a double layer of cuboidal epithelium. Externally is a mem- brana propria, unprovided with muscular fibres. Its outermost sheath is the usual connective-tissue layer. When the duct reaches the border-line of the epidermis, its inner cuticle and external connec- tive-tissue sheath are both lost, Here it becomes the sweat-pore. -TL The sweat-pore traversing the epithelial layers of the skin. /;/', papilla wilh injected blood- vessels; F, yuI ley between two papillae: D, duct in the rete mucosum ; E, E, epidermal layer ; PL, coarsely granular epithelia, deeply stained with carmine ; P, duct with corkscrew windings in the epidermal layer. Magnified 200 diameters. (After Heitzmann.) The Sweat-pore is a continuation of the excretory duet of the coil-gland after the loss of its cuticle and connective-tissue sheath. It is the loss of these sheaths and the consequent intimate relation of the canal to the epithelia of the epidermis that furnish the special basis for this distinction. The sweat-pore is merely a wall-less canal or channel, spirally directed or running a straight course from the duct of the coil-gland below to the outermost stratum of the epidermis above. It has no other wall than that formed by the cells of the prickle-layer below and of the other layers of the epidermis, which successively surround this canal, narrow below and funnel-shaped above. Hence the lumen of the sweat-pore, if such a term be per- missible, is in free communication with the juice-spaces of the epi- dermis. The secretion of the coil-glands consists largely of globules of fat and granules of pigment. Their function, therefore, is plainly the lubrication of the skin with unguent, a task performed only in small part by the sebaceous glands, and by them chiefly for the pilary covering of the body. The palm- of the hands an 1 the soles of the feet, where no 3ebaceous gland- exist, are thus lubricated with fat by the coil -glands. COIL-GLANDS. 43 The total number of the coil-glands in the body is estimated to be between two and three millions, and the total length of the uncoiled glands about eight miles. These figures serve to give an approximate idea of their very great physiological importance, and of the extent to which violation of the rules of hygiene possesses interest from the pathological point of view. The function of the sweat-pores, which communicate directly with the excretory duct of the coil-glands, is distinct from that of the coil- glands, since it provides for the transmission outward of the watery fluids of the skin. The channel described as the sweat-pore is in ample and free communication with the intercellular spaces of the epidermis ; and this anatomical peculiarity provides fully for all the needs of evaporation at the surface of the body. The sweat excreted by the body differs under varying conditions of Temperature, humidity of the air, and the amount and character of the articles ingested by the individual, either as food, drink, or medicament. Nearly ninety-eight per cent, of the secretion is pure water, the remaining proportions representing the saline constituents of the other fluids furnished by the animal in life. In all chemical analyses of the sweat, a source of error lies in the difficulty of securing the fluid secretion unmingled with that produced by the sebaceous glands; and the same, it may be said in passing, is true of the chemical analysis of the sebum. According to Duhring, the iodide of potas- sium, benzoin, succinic and tartaric acids may be excreted with the perspiration. Unna, following in the line first indicated by Meissner, asserts that the coil-glands actually produce the subcutaneous fat-cushion ; and the anatomical basis of such a statement is clear. The coil-glands and the fat-cushion appear at the same period of foetal life and develop in the same proportions. At birth the clusters of fat are most con- spicuous where the coil-glands are most numerous. In the adult, the greater number of coil-glands are subcutaneous in situation and are closely surrounded by fat tissue ; while those glands which do not descend below the corium, though not thus surrounded, are regularly met by columns of fat advancing toward them from below. The credit of discovering and naming these fat columns belongs to Dr. J. Collins Warren, of Boston, whose studies were principally directed to the anatomy of the thick cutis vera. 1 The back and shoulders of a vigorous adult furnish an integument much thicker than the hide of many pachydermatous animals. The papilla? are imperfectly formed, and represented by an undulating line. The follicles of the lanugo hairs penetrate only the superficial layers of the cutis. From the bases of the hair-follicles, nearly vertical clefts, or slender, columnar-shaped spaces, extend obliquely to the panniculus adiposus, which were fitly termed by Warren, "fat-columns or fat- canals," as they are entirely occupied bv adipose tissue. (See Figs. 3 and 4.) These columns are about four mm. in length, and are slightly i Satterthwaite's Manual of Histology, p. 420. New York, 1881. 44 ANATOMY AND PHYSIOLOGY OF THE SKIN. wider than the hair-follicles above. Their long axes form a .slight angle with that of the follicle, but they are nearly parallel to that of the erector pili muscle. Two horizontal prolongations arc given off on either side of the mid. lie of this axis, partly fat-filled. Near this point Dr. Warren called attention to -'the coil of a sweat-gland, held in place by a few delicate fibres." The duct of the gland runs to the top of this space, whence it may be traced to the side of the hair- follicle. The connective-tissue fibres seem to terminate abruptly at the edges of these columns. The cleft slightly widens below, and on the side toward which its axis leans the fibres of connective tissue form a bundle penetrating below to the subcutaneous fat. The erector pili muscle is inserted partly into the base of the follicle and partly into the apex of the fat-canal. These columns correspond in number to the hairs. The blood- vessels which they contain, springing from the subcutaneous plexus, bifurcate at the lateral clefts. The later studies of Unna demonstrate very clearly that the fat- columns, first recognized by Warren, invariably advance toward the coil-glands, the latter either singly or in groups; and that the con- nection of the fat-columns with the hair-follicles is a mere incident of that advance. The alternation of muscular fibres with the secretory cells of the duct of the coil-gland is a provision for the extrusion of the gland- secretion onward. The same anatomical arrangement permits free communication between the epithelia and the lymph-spaces which reach into the connective-tissue sheath of the gland. As a result, the lymph Hows freely among the secreting elements of the gland and its duct. This lymph, loaded with fat, streams away from the coils, and before it reaches the lymphatic trunks its fat-globules are filtered away in the subcutaneous tissue. Such is the interpretation of this rela- tionship by an author whose studies of the mutual interdependence of the several component parts of the integument have furnished the most interesting and fruitful results. The Odorous Emanations from the Skin. The skin of the human body in health is the constant source of odorous emanations, which, in pathological conditions, may be greatly increased or otherwise changed. The nature and exact sources of these emanations are as yet imperfectly understood. Were these ex- clusively of a volatile, gaseous, or vaporous composition, even though such fluids were capable of condensation upon external bodies, this could scarcely explain the well-known fact that some of the lower animals are capable of tracing the track of the human being for miles over a wind-swept path, till the soil pressed by the foot is covered with water. There is strong reason to believe that these emanations are the sole sources by which some contagious and infective diseases are communicated from oik 1 individual to another, a fact which suggests that these emanations may at times contain living matter THE NAILS. 45 •derived from the protoplasmic masses of which the body is built up. These emanations are properly regarded as having their origin in the secreting system of the skin, but in what proportion the several secreting glands participate in the product is difficult to establish. The sweat at times, even to human nostrils, exhales a distinct odor, though, as before indicated, to what extent this is due to its admixture with the sebaceous material it is difficult to determine. Peculiarly fetid and disgusting odors occasionally originate in chemically altered sebum, where the influence of the sweat secretion must be, from the locality under examination, partly eliminated. The Nails. Nails are dense, elastic, and translucent concavo-convex plates, or shells of horny tissue, placed upon the dorsum of the terminal extremities of the distal phalanges of the fingers and toes. Each has a free border at the distal portion of the pulp of the digit, with sides and proximal borders let into distinct furrows of the skin. The convex surface of the nail is exposed, the concave regarding the phalanx, and being implanted upon the nail-bed beneath. In the embryo the first change looking to the future formation of a nail consists in a peculiar smoothness and brilliancy of the epidermis covering the dorsum of the distal phalanges. Later, an epithelial ridge or line with a groove in front of it traverses the tip of the finger. Thus, three regious are defined : that behind the ridge, the nail-wall ; that in the groove, the nail-bed ; and that in front of the groove, the pulp of the last phalanx of the digit. A collection of large prickle-cells at the orifice of the nail-fold soon furnishes the first trace of the rudimentary nail. Mature nail-cells finally push forward between the prickle and horny layers of the nail-bed, which, by fan- shaped bundles of follicles, is firmly united to the periosteum of the phalanx. Lastly, a thin plate of horny material with a free edge, is visible externally in the fingers and toes of the newborn child. In the adult, what is termed the matrix of the nail, is the tissue from which the horny plate springs. It is separated, as shown by Hans Hebra, into, first, a posterior part, filled with from three to six rows of papillfe. Next, in advance of this, is a lenticular space with curved borders, the anterior limit of which corresponds to the anterior border of the lunula. The area included in these two divi- sions is provided with papillae grouped in symmetrically converging ridges, decreasing in size as they pass forward. This forms the matrix of the nail. Further forward, the nail-bed proper — in other words, the tissue that supports, rather than produces the horny plate — is composed of higher ridges of papillae whose grooves and summits are covered with prickle-cells, and whose height is uniformly main- tained as they stretch forward toward the pulp of the fiuger. Attention has been already called to the fact that the digital arteries communicate directly with venous spaces and veins in the nail-bed, an anatomical peculiarity demonstrated by Hoyer. This arrangement 46 ANATOMY AND PHYSIOLOGY OF THE SKIN. evidently provides for the safety of these slender and exposed organs in conditions arresting temporarily either the venous or the arterial current. Fig. in. d e .j* Vertical section of one-half of nail and matrix, a, nail substance ; b, horny layer ; <-, mucous layer; ,1. papillae of corlum ; e, nail furrow destitute of papillae ; /, horny layer of the ungual furrow rising above the nail ; g, papilla? of skin of dorsal surface of the finger. The Nail, or, as it is termed by Unna, the true nail or nail-plate, originates only from the floor of the nail-fold as far forward as the anterior edge of the lunula. As to its formation, it may, therefore, be imagined as springing from its matrix vertically in the form of an involuted, shield-shaped plate, its convexity regarding the proximal phalanx. It may then be viewed as pressed downward over its nail- bed in front, with partially unfolded edges enwrapped by the epi- dermis of the sides, the narrowed point of the shield, elongated when untrimmed, projecting at some distance beyond the tip of the finger. "With this conception, it is easy to understand that the nail is con- stituted of horny filaments, or coherent strata of cornified cells, passing from the matrix or floor of the nail-fold. The upper surface of the nail grows, therefore, from the bottom of the nail-fold ; the under surface from the lunula ; and the intermediate layers propor- tionately from the parts between. It is firmly attached to the nail- bed by ridges upon its under surface, which interlock with corre- sponding grooves on the upper face of the bed. The Nail-fold, crescentic in shape, clasps the nail posteriorly and at the sides. It is formed of connective tissue, whose bundles are interpenetrated by numerous coil-glands and fat-columns. The epi- dermis beneath the nail exhibits prickle, granular, and horny layers. As the nail is gradually liberated from its bed, both at the sides and point, the cornification of the horny layer becomes more complete, so that finally, as the nail-plate is pushed forward, it no longer rides over the cells of the rete, but over a completely cornified tissue. If the pulp of any nail-bearing phalanx be pressed with moderate force against any firm object, the naked eye can detect upon the surface of the nail, just behind its free border, a whitish and yellowish band, convex anteriorly and somewhat increasing in width laterally. THE NAILS. 47 This line, described by Unua, is also visible when no pressure is exerted upon the digit, its width varying under the conditions described. ' This border represents the space in which the three layers of the epidermis from the skin of the point of the finger, viz., the horny, the granular, and the prickle-layer, successively come in con- tact with the under surface of the nail. Fro — JV Implantation of the nail at its border. P, papilla; decreasing in size toward the middle line ; B, rete mucosum, which broadens toward the border of the nail, and forms irregular prolongations; R', E, epidermal layer ; N, plate of the nail. Magnified 500 diameters. (After Heitzmann.) The lunula is the relatively light-colored space extending from the middle part of the nail-fold posteriorly to its well-defined convex border in front. After artificial removal of the nail-fold, it is seen to extend to the posterior and enclosed border of the nail-plate. It, therefore, represents that part of the matrix of the nail which is not concealed by the nail-fold. Its color is not due to absence of vascu- larity, but solely to opacity of the keratoginous cells (Ranvier) which are concerned in the production of the horny threads that form the nail. 48 GENERAL SYMPTOMATOLOGY. II. GENERAL SYMPTOMATOLOGY. In cutaneous, as in other diseases, the clinical signs or symptoms of the morbid process are those by which it is recognized alike by the patient and the physician. It is usual to divide these into subjective and objective : the former, those appreciated by the patient alone in consequence of his sensations ; the latter, by the eye and the touch of another who undertakes the investigation of the disease. It should be remembered, however — and this is a matter of some importance in this connection — that many objective signs are made manifest to the eye and touch of the patient himself, and liable to be interpreted or misinterpreted by him, with consequences which should not be ignored. Subjective Symptoms. — The purely subjective symptoms of a disease of the skin are those manifested to the patient by sensations other than those connected with vision and his own sense of touch. They include; sensations of itching, smarting, ting-ling, pricking, and burning; sensations as of increased or diminished susceptibility to the contact of foreign bodies; of increased or diminished tempera- ture ; pain in various grades of severity ; and disordered sensations, as of the crawling of insects over the part, currents of hot or cold vapors or liquids, and compression of portions of the skin by either cords, bands, or closely fitting plates. The character of the subjective sensations experienced by a patient often proves an aid to the phy- sician in recognizing the nature, not merely of a present disease, but of one also which has preceded. Thus the sensation produced by an attack of erysipelas is rarely an itching, while the latter is highly characteristic of eczema and scabies ; the pain of zoster and the ting- ling of urticaria being distinctly different, not only from each other, but from the subjective symptoms named above. Objective Symptoms. — The study of the objective symptoms of a cutaneous disease is of paramount importance. In uo respect does the skilled physician so distinguish himself from one who is inexpert as in the recognition of the typical or atypical objective characters presented in diseases of the skin. The study is one which can be neglected safely by no diagnostician, and its rewards are precious in every department of medical science. These symptoms are spread before the eye, and their legibility increases with every hour of care- ful attention. These signs of skin disease — or, more literally, skin injury — are called lesions, and it is usual to classify them as primary and second- ELEMENTAEY LESIONS. 49 ary. Such a division is, however, open to criticism, since, viewed from the standpoint of time merely, some of the so-called primary lesions of the skin become in' turn secondary and even tertiary. Thus a papule which might at oue moment be called primary, may be transformed wholly or in part into a vesicle, which thus becomes a secondary lesion ; and such vesicle again, in the evolution of a dis- ease, may become a tertiary pustule. The latter finally may result in a quaternary crust. In the following pages these symptoms of skin disease will be distinguished as elementary and consecutive. Elementary Lesions. In describing the average size of cutaneous lesions, it is less con- venient to state their measurement in fractions of a line or millimetre than to convey an approximate idea by a comparison with familiar objects of relatively fixed dimensions. The objects usually selected for this purpose are, beginning with the smallest, the seeds of poppy, mustard, and rape; the coffee-bean; the pea; the bean; the cherry; the finger-nail ; the chestnut ; the horse-chestnut ; the egg of the hen and of the goose ; and the orange. To these may also be added the point and the head of a pin. The student will find it useful to familiarize himself with the size of the small seeds mentioned, that their names may at once suggest to him the relative size of the lesions to which they are compared. Maculae, Spots, or Stains, are generally circumscribed alterations in the color of the integument, differing as to the size, shape, hue, and duration of the dyschromia, and unaccompanied by elevation or depression of the SURFACE. Examples of macula? are to be found in the exanthematous rashes (measles) ; in localized hypersemige of the capillary plexus of the corium, disappearing in various degrees according to the pressure exerted on the part (rosacea) ; in visible acquired development of bloodvessels in the skin (telangiectasis) ; in congenital vascularization of the surface (nsevi) ; in variously colored blood extravasations and stases (purpura) ; in stains produced by contact with dyes (hand- workers in aniline) ; and in pigmentary changes such as those pro- duced by solar heat (freckles), or by leprosy. Extensive non-circumscribed changes in the skin color are seen in the course of several general disturbances of the economy, as in yellow fever, cancer, chlorosis, albinism, Addison's disease, argyria, and icterus. Spots of various color and device are also produced by the inten- tional or accidental introduction of pigmented particles beneath the epi- dermis, as by the process of tattooing, the explosion of gunpowder, etc. Maculae exhibit a wide variation in color from a rosy pink to a chocolate-brown or even a black. This difference has suggested the employment of such descriptive terms as roseola, erythema, and pur- 50 GENERAL SYMPTOMATOLOGY. pura, which have, unfortunately, served to distinguish both features of diseases and diseases themselves. A macula which encircles another lesion, as, for example, the halo around the vaccine vesicle, is called an areola. Linear hemorrhagic streaks are called vibices; punctate and larger extravasations of blood are termed petechia? and ecchymoses. Papulje, or Papules, are solid or compressible, ephem- eral OR PERSISTENT, CIRCUMSCRIBED PROJECTIONS FROM THE SURFACE OF THE SKIN, VARYING IN SIZE FROM A POPPY-SEED TO A COFFEE-BEAN. These exceedingly common skin symptoms vary greatly in their shape, color, location, career, and significance. Thus they may be flattened at the apex, acuminate or pointed, conical, rounded, or depressed at the summit to form an umbilication. They may be pale, rosy, dark or lurid-red, purplish, or even blackish. They may develop in transitory or persistent processes; they may be trans- formed into lesions containing fluids ; may desiccate and furnish scales either at apex or base; may degenerate into ulcers: or enlarge into tubercles or tumors. They may be scratched, torn, or rubbed so as to lose their typical appearance ; they may come and go ; be sensitive to sudden changes in the blood-current, and yet be them- selves persistent. The mixed forms described above are generally named vesico-papnlar or papulo-vesicular, papnlo-squamous, papulo-pustular, lesions, etc. Lesions which simulate the papule and which, though described under that title, really belong to another category, are the small, semi-solid elevations of the surface which form at the orifices of the ducts of the cutaneous glands and follicles. Thus they may consist of little heaps of epidermis about the hair-follicles (lichen pilaris, keratosis pilaris), or of inspissated sebum collected in one or all of the acini of the sebaceous glands (milium, comedo). The concomitants of an eruption of papular type also vary. Thus there may be a febrile process, or extensive infiltration of the skin about and beneath the papules (prurigo) ; or itching of the most in- tolerable character (eczema papillosum) ; or production of trifling sensations of annoyance, as a slight burning without other subjective symptoms (acne, lichen planus). Papules which are transformed into moist lesions become covered with a crust. Papules which are scratched or torn by the finger- nails usually betray the fact in the minute and flat blood-scafe dried upon their surface. Papules which ulcerate may be followed by scars. Papules which have undergone the process of involution may be followed by macular sequelse. Pomphi, Urticje, or Wheals, are more or less transitory, rosy-red and whitish, irregularly shaped and sized eleva- tions of the surface of the skin, produced by blood-stasis in spasm of the vessels, accompanied by a tingling or ELEMENTARY LESIONS. 51 PRICKING SENSATION AND CHARACTERIZED BY RAPIDITY OF EVO- LUTION AND FREQUENCY OF RECURRENCE. The typical wheal is seen in the disease known as nettle-rash (urticaria), where closely packed, shining, roundish and whitish, pea- to finger-nail-sized elevations of the skin are visible, surrounded by a slightly rosy border. They are firm to the touch, and arranged in patches, circles, bands, gyrations or striations, often disappearing in a brief time and recurring with or without a renewal of the cause. They are occasioned by a rapid exudation of serum into the rete or pars papillaris of the corium. This is supposed to be due to clonic vascular spasm, producing irregularities in the lumen of the skin capillaries, under the influence of the vaso-motor nerves which supply a small area of the superior pars vascularis of the derma. The sen- sations produced by the wheal are particularly stinging, burning, pricking, and itching. They are often surrounded by an areola. "Giant" wheals are such as enlarge to the dimensions of an egg or a tomato, or cover extensive areas of integument, as, for example, the entire surface of the buttock or shoulder. Relics of disappeared wheals are usually transitory erythematous macula?, but in rare cases a more or less deep pigmentation is left, which slowly disappears (urticaria pigmentosa). It should be borne in mind that at times the wheal-like condition is assumed by papulae, as also by lesions resulting from such trauma- tism as the bites of insects, reptiles, horses, dogs, etc. TUBERCULA, OR TUBERCLES, ARE CIRCUMSCRIBED, SOLID, GEN- ERALLY INCOMPRESSIBLE, AND PERSISTENT, NODOSITIES OF THE SKIN, VARYING IN SIZE FROM A COFFEE-BEAN TO A CHERRY. They may be largely projected from the free surface of the integu- ment, or be deeply seated in the skin, and but a small portion become evident to the view externally. Their varieties as to shape, color, size, and other features, correspond in great part to those described in connection with papules. They may be attached by a broad base to the skin, or be pedunculated, or even pendulous. Their seat is usually in the deeper portions of the corium or the subcutaneous connective tissue. Degenerating and ulcerating tubercles are followed, as might be supposed in view of their volume, by considerable destruction of tissue, and in cases of repair by correspondingly exten- sive cicatrices. Tubercles are seen in such diseases as fibroma, mol- luscum epitheliale, syphilis, leprosy, sarcoma, and cancer. Tubercles are often described as merely enlarged papules ; but the distinction between these two forms of lesion will be better recog- nized when attention is paid to the particular portion of the skin in which each takes its origin. Papules spring oftenest from the super- ficial layers of the derma ; tubercles, on the other hand, from the deeper. This being remembered, it will be clear that at times a tubercle may project from the surface to a less extent than a papule, though its larger volume is evident as soon as the skin within which it has developed is handled. 52 general symptomatology. Phymata, Tumores, ok Tumors, are masses of solid tissue, or of solid tissue more or less commingled with fluids of variable consistency, differing ix size, shape, color, and in the benignity or malignity of their career, either located within or beneath the skin, or, being 'at- tached to the latter, projecting from it to a variable EXTENT. The mere fact thai a lesion of the skin approaches in dimensions the size of a tumor is in itself an element of gravity. Tumors may- originate in mere hyperplasia of the living matter; may consist of new formations of greater or less danger to the vicinage, or the gen- eral economy ; may be formed of blood or lymphatic vessels, or both in the same lesion; may embody large fluid-containing cysts; may be built up of nervous tissue, fat, bundles of connective-tissue fibres, glandular elements, and indeed of any of the elements which exist physiologically in the human integument. Examples of tumors are seen in fibroma, sarcoma, carcinoma, and rhinoscleroma. A^esiculje, or Vesicles, are elevations of the horny layer of the epidermis with limpid, lactescent, or sanguinolent fluid contents, varying in size from a poppy-seed to a coffee-bean.' Typical vesicles are seen in the minute and transitory lesions occurring in the vesicular form of eczema. They are usually filled with a clear serum. Variations from this type are, however, com- mon. Thus, they may be flattened, acuminate, roundish, umbilicated, or conical ; may be fully distended or partially collapsed upon their contents ; may have a short or long duration ; may be distended with milky, chylous, or a blood-stained fluid ; may be opalescent, yellowish, reddish, or blackish in color ; several may coalesce to form a many-chambered lesion; and a single one or several such may undergo transformation into pustules or bullse. Vesicles may termi- nate by accidental or spontaneous rupture, their contents freely flow- ing forth upon the surface of the peripheral integument ; or they may desiccate to a crust; or may even terminate by one of the ulcera- tive processes. They may or may not be accompanied by pruritus. Minute vesicles, which are merely the external apices of large-cham- bered accumulations of fluid beneath, occasionally form upon the surface of the skin. Such are seen in the course of lymphangiectasis. Pustul.e, or Pustules, are circumscribed cutaneous ab- cesses, covered with an epidermal roof-wall, and varying in size from a millet-seed to a filbert. The typical pustule contains pus, and is colored yellowish, yel- lowish-green, or brownish-green, according to the admixture of its contents with blood. The pus being an inflammatory product, it necessarily indicates the occurrence, at the base of the pustule, of an CONSECUTIVE LESIONS. 53 inflammatory process. Pustules, like vesicles, may be roundish, acuminate, globoid, conical, umbilicated, surrounded by an inflamed or normal integument ; may be superficially or deeply seated ; may terminate by rupture or desiccation ; may or may not be followed by an ulcer and ultimate cicatrix. They may be seated either upon the free surface of the skin, or at an orifice of a follicle, in which case they represent an inflammation with purulent product in the duct or gland beneath. Pustules may originate as such ; or as a consequence of transfor- mation of vesicles; or after a change in a papule, which may thus come to have a purulent apex. According to Auspitz, they invari- ably originate from vesicles. Pustules often result in the formation of crusts, the latter varying in color according as the pustules from which they originated contained a clear serum or blood. Transitional forms between vesicles and pustules are termed vesico- pustules. Pustules of a large size and resting upon an indurated, engorged, and elevated base are often called ecthymatous. Pustules are seen in syphilis, variola, eczema, scabies, acne, and many other cutaneous diseases, including several forms of dermatitis medicamentosa. Bulkze, or Blebs, are superficial or deep-seated eleva- tions OF THE SKIN HAVING FLUID CONTENTS, DIFFERING IN COLOR, SHAPE, AND CAREER, AND VARYING IN SIZE FROM A COFFEE-BEAN TO A GOOSE'S EGG. Blebs have been described as large vesicles ; but this fails to define exactly their pathological character. Like vesicles they may contain serum, lymph, blood, or pus ; and be variously colored in the degrees according to which their contents become visible through a semi- transparent roof-wall. They may be globoid, hemispherical, oval, crescentic, semi-crescentic, conical, and even exhibit angles. They may be seated upon an apparently unaltered or evidently morbid integument ; and may or may not present a peripheral areola. Bulla? may persist or rupture ; may desiccate or degenerate into ulcers ; may collapse after the escape of their contents, and the roof- wall become glued to the base from which it was originally raised. Bullae usually occur in extremely debilitated states of the system, and are, as a rule, of graver portent than other fluid -containing, lesions of the skin. They occur in scalds and burns, in pemphigus, leprosy, erysipelas, syphilis, and moist gangrene. Consecutive Lesions. Squamae, or Scales, are attached or exfoliated epithe- lial LAMELLJ3, WHICH HAVE BECOME APPRECIABLE AT THE SURFACE AS THE RESULT OF SOME MORBID PROCESS IN THE SKIN. A physiological desquamation is constantly in progress over the superficies of the body, whose evidences are not pronounced in skins properly cleansed by ablution. In disease processes, however, des- 54- GENERAL SYMPTOMATOLOGY. qnamatioi] may occur as a distinct symptom in various forms. Thus the scales may be minute, fine, branny, dirty-white, or yellowish ; they may be larger, pearly-white, shining; dry or fatty; aggregated so as to resemble flaky pie-crust ; exfoliating in extensive sheets, as from the entire sole of the fool or palm of the hand; or in glove- finger-like sheaths, as from the surface of a digit. They may be scanty, scarcely perceptible, and so attached as to require force for their removal; they may fall spontaneously in a pulverulent shower, being bo abundant as to iill the garments or bed-clothing of the patient. Furfuraceous desquamation is that form in which fine bran-like scales are shed from the surface. Scales occur in eczema, psoriasis, pityriasis, ichthyosis, syphilis, and in several of the parasitic diseases of the skin. It should not be forgotten that scales are frequently intermingled with other lesions, often they succeed the latter. Thus a papule may scale at its apex, or surround its base with a collarette of loosened epidermal plates, beneath or between which a macular stain is visible. Again, they may develop from the macule, the tubercle, or the tumor. Though generally conceded to be evidences of a dry and non-dis- charging disease of the skin, they are at times accompanied or suc- ceeded by moisture of the part affected. The term "scales" is sometimes applied to the flattened plates of dried sebum which form on the scalp and portions of the trunk in seborrhea sicca. Crust.e, or Crusts, upon the skin, are relics of the desiccation of its pathological products. Crusts never occur as primary symptoms of disease. When formed by the desiccation of serum only they are of a yellowish, straw- yellowish, or reddish-yellow hue ; when composed largely of dried pus they are colored greenish, or greenish-yellow ; and, when there has been an admixture of blood, they are usually brownish or blackish. At times they suggest in appearance gum, honey, or Venice turpen- tine ; in shape they may have the form of the concavo-convex lid of a watch-ease; in color and shape they may resemble the half-shell of the oyster, or the carapace of a small turtle. They may be delicate and thin ; bulky and thick ; friable or mealy ; may be firmly attached to the subjacent tissues, or readily separable ; may cover a sound, though tender and reddened epidermis ; may conceal a superficial, or deeji, foul-based ulcer, by whose secretions from beneath they are raised above the plane of the skin and increased in thickness. They may be circumscribed and no larger than a small finger-nail; may envelop an entire limb or organ, as the leg or the penis ; or, finally, mav be so irregularly disposed among other lesions, papules, pustules, excoriations, and open ulcers, that it is difficult to define their out- line, and even to recognize their identity. Crusts formed of dried sebum are greasy to the touch, dirty-yellowish in shade, and usually seated upon a non-infiltrated base. Crusts are common in eczema, CONSECUTIVE LESIONS. 55 syphilis, leprosy, seborrhcea, and a large number of other diseases of the integument. Excoriations are superficial solutions of continuity, usually involving portions of the skin affected with prukitus, and resulting from mechanical violence. Excoriations, in appearance among the most trivial of skin lesions, possess a value from the diagnostic standpoint which can scarcely be overestimated. They occur as striated, linear, punctate, circular, or irregularly shaped, furrowed wounds, at times involving areas of flat surface, oozing with serum or blood, covered with dried blood or crusts, yellowish or reddish in hue, and for the most part both induced and accompanied by severe pruritus. They may coexist with hyperemia and infiltration of the skin beneath, brought on by the irritative character of the continuous, or, more frequently, interrupted cause by which they were begotten. Excoriations become significant according as they indicate scratch- ing, tearing, or other species of wounding by the finger-nails, and rubbing portions of the integument with foreign bodies. In the former case they are significantly recognized in those portions of the body most accessible to the hands, though in the case of eczematous children and infants they may originate by the rubbing together of the knees ; or the leg of one side by the feet and toes of the other. The loss of tissue may extend deeper than the rete — at times invading the papillse of the corium, which bleed in consequence. Excoriations may occur without the appearance of other lesions, as in the disease called pruritus ; but where itching is severe and induced by a cutaneous exauthem, the lesions constituting the latter may be intermingled with, obscured, or even obliterated by excoriations and the pathological processes to which they give origin. Thus macules, vesicles, pustules, and papules may undergo change ; and the recog- nition of the type of the existing disease be correspondingly difficult. Excoriations are common in skins wounded by lice, bed-bugs, and gnats ; in the subjects of eczema, scabies, intertrigo, and prurigo ; and in individuals with special sensitiveness of the integument to the action of a medicament employed either internally or externally. Rhagades, or Fissures, are linear solutions of con- tinuity, USUALLY OCCURRING IN PREVIOUSLY INFILTRATED PORTIONS OF THE SKIN. They may extend to the derma, and even invade yet deeper structures; may be painful, or the reverse; dry, secretory, or in- crusted ; are often hemorrhagic, and usually formed with sharply cut walls. They are of frequent occurrence in the vicinity of the articu- lations, in which situations they are induced or • aggravated by the joint-movement stretching or tearing tissues whose extensibility has been diminished by any morbid process. Fissures may terminate in ulceration. They vary as to length, curve, and tenderness. They are often exquisitely painful, and greatly complicate the skin disease 5b GENERAL SYMPTOMATOLOGY. in which they occur. They may follow the curve traced by the boundaries of bodily organs near which they occur — as, for example, the line of the posterior junction of the ear with the heat], or of the breast of a woman with the thoracic wall where it rests. Fissures occur iu eczema, syphilis, dermatitis, and lichen ruber. Ulcera, or Ulcers, are losses of substance resulting prom a previous pathological process involving the corium, and, ix cases, the subcutaneous tissue. Cutaneous ulcers differ greatly in size, shape, color, edges, base, career, and, indeed, in all their characteristics. Every ulcer has an outline, base, floor, edges, and secretion. The outline may be cir- cular, crescentic, reniform, ovoid, serpiginous, or with horseshoe-like contour. The base, or underlying tissue, may be .-oft, supple, indu- rated, or in a state of active inflammation, with consequent infiltration. The floor may be glazed, shallow, deep, excavated, cup- or funnel- shaped, " worm-eaten," crateriform, sloughy, covered with a tenacious or readily removed secretion, granular, puriform, or hemorrhagic. The edges may be clean-cut, having a punched appearance, under- mined, everted, ragged, regular, or contracting, with a whitish inner border of advancing cicatrization. The secretion may be scanty, limpid, puriform, profuse, ichorous, and odorless or exhaling an offensive stench. They may be so crust-covered as to be invisible, or so exposed and erosive in action as to render the affected surface in the highest degree unsightly. They may be acute or chronic, insen- sitive or productive of intense pain ; may heal by cicatrization, remain open for a lifetime, or prove fatal by either destruction of parts essential to life, or by exhaustion of the vital forces. Cicatrices, or Scars, are new formed substitutes fop lost connective tissue. Scars never succeed excoriations, fissures, or other solutions of continuity in the skin, which have not penetrated as far as the derma, and resulted in destruction of a portion of the elements of which the latter is built up. They possess the highest importance for the diagnostician, since they point invariably to a pathological process whose career is terminated, the characteristic features of which they frequently embody They may be regarded as the special and per- sistent imprints upon the integument, of the serious disorders from which it has suffered. To a certain extent, as already shown, scars retain traces of the special peculiarities of the lesions, and even of the diseases, which they suc-eed. The identification, however, of the individual prede- cessor in each instance is, in the present state of our knowledge, not always possible from a study of cicatrices alone. The extent of knowledge in this direction is, however, rapidly increasing; and in many cases the certainty thus acquired is of incalculable value to the diagnostician. Scars are remarkable for their tendency to contraction and gradual GENERAL SYMPTOMATOLOGY. 57 decoloration. They may be minute, punctate, extensive in area, attached to underlying tissues, depressed, raised above the plane of the peripheral skin, seamed with furrows, pliable and soft, indurated, traversed by ridges, knotted, and as irregular in contour as the ulcers already described. They may extend in digital, linear, or annular prolongations 'toward contiguous portions of the skin, and by subse- quent contraction induce considerable distortion and deformity. Thus they may drag down an eyelid, and ectropion ensue ; may glue the lobe of the ear to the cheek ; may evert lip or nostril. When recent, they are usually reddish in tint ; when older, be pigmented in centre or circumference ; or, as is common, exhibit a gradual decoloration, centrifugal in its progress. They may be the seat of pain from an entrapped nerve- filament; may reopen to ulceration ; or be accom- panied by no subjective sensation. Not rarely they become the origin of the disease known as cicatricial keloid. Scars are unprovided with hairs, papillae, or the orifices of sweat-pores and sebaceous gland ducts. As implied in the definition given above, scars may result from any disease or injury of the skin which involves loss of connec- tive-tissue elements in the corium. To these lesions Bazin adds, as elementary forms, the mucous patch of syphilis ; the cuniculus, or furrow, produced in the skin by the acarus scabiei ; and the sulphur-colored crusts of favus. These, however, are not general, but special features of individual disorders, and are best studied in connection with the latter. The elementary lesions of the skin are termed by Auspitz, " anthe- mata;" groups of such lesions, "synanthemata;" and, as in accord- ance with common usage, generalized eruptions affecting the entire surface of the body, " exanthemata." The word "erythanthema" is used by this writer to describe groups composed of several of the elementary lesions of the skin, as, for example, of papules, vesicles, and pustules rising from a common, reddened, and hypersemic base. In addition to the names of the lesions of the skin just enumerated, certain peculiarities of cutaneous symptoms are described in qualifying terms, which here require definition. They relate chiefly to the color,, shape, distribution, and method or period of evolution of lesions as they are observed in individual cases. The more important of these terms, as used by modern writers, are arranged below, alphabetically, with a brief explanation appended to each. A much larger list of obsolete adjectives, employed by older authors, is purposely omitted. Abdominalis. Located on the abdominal surface. Acquisitus. Acquired. Acuminatus. Having a pointed apex. Actjtus. Of acute course. Adttltorum. Occurring in adult years. iEsTiVALis. Occurring in the season of summer. Aggregatus. Collected in patches. Agritts. Acute, or angry in appearance. Albidus. Of whitish color. Angiectaticijs. Vascularized. 58 GENERAL SYMPTOMATOLOGY. Annularis, [n the form of a ring. Axsn.ATrs. In the form of a ring. Apyreticus. Unaccompanied by lever. Areatus. ( Iccurring in areas. AetIFICIALIS. Producible artificially. ASYMMETKICALIS. ( >f different distribution on the two lateral halves of the body. Autumnalis. Occurring in the fall of the year. BRACHIALIS. Occurring on the surface of the arm. Cachecticorum. Occurring in debilitated subjects. Capitis. Occurring on the head, usually the seal]). Caverxosus. Large chambered. ChronICUS. Chronic in course. ClRCINATUS. Of circular outline. Circumscriptum. Having a definite contour. Coxfertus. Arranged in close proximity, with coalescence of lesions. Confluens. Arranged in close proximity, with coalescence of lesions. Contagiosus. Capable of communication by contagion. Corporis. Occurring on the surface of the body ; employed usually to designate an eruption upon the trunk, as distinguished from that on the head or extremities. Crustosus. Crusted. ( IrystALLINUS. Of crystalline appearance. DlFFUSUS. Irregularly disposed. DlSCRETUS. Having isolated lesions. Disseminatus. Disseminate, without regularity of distribution. Eruption. Is used of the totality of all patches and lesions upon the person of one individual. Erythematosus. Having a reddish blush. Essextialis. Idiopathic. Exfoliativus. Having a tendency to exfoliation or shedding from the surface of the body. Exulceraxs. Is employed by French writers to designate superficial ulcerations, or lesions with a tendency to such a process. By English and American authors it is sometimes used to designate unusually deep ulcera- tions. Facialis. Located on the face, usually as distinguished from the scalp. Favosa. Displaying crusts of favus. Febrilis. Accompanied by a febrile process. Femoralis. Occurring on the surface of the thigh. Fibrosus. Composed of fibrous tissue. Figuratus. Having a figured appearance. Flavescexs. Of yellowish hue. Foliaceus. Resembling a leaf or leaves. Follicularis. Concerning the cutaneous follicles. Fuxgoides. Resembling a fungus. Furfuraceus. Exhibiting numerous, fine, bran-like scales. Guttatus. Of the size of a drop of water. Gyratus. Having a serpiginous or gyrate outline. This is usually the result of a coalescence of imperfect circles or semicircles. Herpetiformis. Vesicular or herpetic in type. HlEMALIS. Occurring in the winter season. Humidus. Accompanied by moisture. Hypertrophicus. Characterized by hypertrophy. Hystrix. Having lesions projected or erected like quills. Imbricatus. With crusts or scales overlaid like tiles. iMPETKil nodes. Pustular. Infantilis. Occurring in infancy. IXTERTIXCTUs. Distinguished by color. Iris. ( >ccurring in more or less distinctly defined concentric rings. Labialis. Occurring upon the surface of the lip. GENERAL SYMPTOMATOLOGY. 59 Lenticulaeis. Of the size of a small bean. Lividus. Deeply colored. Maculosus. Discolored. Madidans. Characterized by moisture. Marginatus. Having a denned margin. Medicamentosus. Produced by external or (more commonly) internal medication. Melanodes. Of blackish color. Miliaris. Of the size of a millet seed. Mitis. Of mild, benignant type — the reverse of agrius. Multiformis. Exhibiting simultaneously several types of elementary lesions. Neonatorum. Occurring in the newborn. Neuriticus. Having nervous association. Nigricans. Of black or blackish color. Nodosus. With development of nodes or tuberosities of the surface. Nummularis. Of the size of small coins. Oleosus. Accompanied by an oily secretion. Palmaris. Occurring on the palms. Parasitarius. Produced by an animal or vegetable parasite. Parasiticus. Produced by an animal or vegetable parasite. Patch. The aggregation of several isolated or confluent lesions. Phlegmonosus. Accompanied by deep-seated inflammation. Phlyct^enoides. Characterized by groups of small vesicles. Pigmentosus. Accompanied by pigmentation. Pilaris. Belated to the hair. Plantaris. Situated on the soles of the feet. Planus. Flat. Polymorphous. This is the Greek equivalent of the Latin multiform. Pr^eputialis. Situated upon the prepuce. Progenitalis. Situated on the exposed mucous surfaces of the genitalia. Pruriginosus. Accompanied by itching. Pubis. Located upon the skin or hairs of the pubes. Punctatus. Occurring in dots or points. Ehagadiformis. Fissured, or tending to produce fissures. Rosaceus. Having a rosy or pinkish hue. Euber. Red, usually dark red in color. Scutiformis. Having the shape of a shield. Sebaceus. Concerning the sebaceous glands or their secretion. Senilis. Occuring in advanced years. Serpiginosus. Literally, creeping — advancing in irregular gyrations. Siccus. Dry, unaccompanied by moisture. Solitarius. Having an isolated lesion, or with isolated lesions. Symmetricalis. Similarly distributed on the two lateral halves of the body. Toxicus. Poisonous. Uniformis. Exhibiting lesions all of one type. Universalis. Affecting the entire surface of the body. Urticatus. Accompanied by wheals. Uterinus. With association of uterine disorder. Variegatus. Exhibiting several distinct colors. Vasculosus. Accompanied by vascular development. Vernalis. Occurring chiefly in the spring of the year. Versicolor. Exhibiting several shades of the same color. Vulgaris. Of the usual or commonly observed type. 60 GENERAL ETIOLOGY. III. GENERAL ETIOLOGY. Toe study of the causes of diseases of the skin gives us a glimpse of the etiology of diseases in general. In the lowest representatives of life, the greatest dangers to existence originate in exposure to assault from other and stronger representatives in search of their prey, in other terms an external danger. In man, the highest repre- sentative of the animal scale, the perils of existence are complicated by his social necessities and his artificial methods. He can never, however, at any period of his existence, divest himself from the necessity of exposure to external peril. The plan of his organs and the play of his normal activities are perfect, even to the recoverv from all but mortal injury and repair of moderate loss The struggle for existence of the ideal man is intended to be with that which is without; his body meanwhile furnishing him with a com- fortable tenement and a fair fortress. In the purview of nature there should be no internal revolt. When such occurs, it is usually the result of his ignorance, his folly, or his vice. Viewed in this light, the causes of the diseases of his skin will be seen to differ but little from those which induce disease in his other organs. Exposed to cold, he suffers from a pneumonia; to injury, a fracture or a dislocation ; to the contact of poisons, he vomits or purges ; to contagion from his fellow-man, he has the cholera or plague ; all these are capable of producing diseases of his skin. But meantime his organs have a tender care for themselves and each other, compared with which the solicitude of a mother for her child becomes insignificant. The stomach refuses to digest itself; the lung, unwounded, admits no air to the pleura ; the bladder, so long as it is unruptured by violence, permits no drop of urine to pass into the peritoneal sac. In the same proportion, and under the same general law, do the viscera refuse to generate a poison which will injure the integument ; and the fluids of the body, a vicious "humor" which will damage the bones. Reasoning thus from analogy alone, it will be seen that the preva- lent doctrines respecting blood-poisons of internal origin must be greatly restricted. Eczema alone, in its manifold forms, furnishes more than one-half of all the diseases of the skin ; and yet every one of these several forms can be produced at will and artificially upon the integument of man. Again, it is not to be forgotten that the body is really invested with a continuous skin which not only is extended over its outer surface, but is also reflected so as to line all passages by which it is traversed within. This inner investment, called the mucous mem- GENEKAL ETIOLOGY. 61 brane, is as truly a part of the skin as the epidermis and corium of the face or hand. This is clear : first, as shown from the facts of evolution, because representative animals of the lower scale are found capable of complete inversion, by which the outer skin becomes the inner or digestive, and the inner, in turn, the outer or protective organ; second, as shown by histology, the anatomical characters of the skin and mucous membrane being similar ; third, as shown by pathology, the extroverted mucous membrane rapidly undergoing the transformation which causes it to resemble the skin; while the inverted skin, as when the thighs are by disease kept in continuous contact and moistened, assumes the characteristic features ■of mucous membranes. In the study of cutaneous etiology, it is manifestly proper to regard as of external origin all causes which operate from without upon either the outer or the inner skin of the body. This much premised, it can be said that the large proportion of all diseases of the integument originate either from the action of solar heat and light; temperature changes at the surface of the body; contact with various fluid and solid substances with the production •of either factional, traumatic, or toxic effects ; or the development upon and within the skin, of vegetable parasites. It remains merely to consider these causes somewhat in detail, remembering that at times several influences cooperate in the production of a given effect. The action of solar light upon the skin is usually coincident with the operation of another mode of motion called heat. To the former are to be attributed the production of freckles, " tan," and other pigmentations of the surface; to the latter, the erythema, eczema, and, various grades of dermatitis which may follow exposure to the direct rays of the sun. Other temperature effects, including those produced by extremes of both heat and cold, are to be classed in the same category. According to Hebra, exposure of the skin to a temperature over 100° Fahrenheit, produces merely a transient erythema, which under a further elevation of 65° F. will not subside for several days. At a temperature of 212° F., all grades of acute dermatitis are awakened with the production of bullae, up to the point where complete destruction of the integument occurs. The influence of the seasons is of the same general character. Some cutaneous diseases are worse in summer; others in winter. Prickly heat (lichen tropicus) is peculiar to certain warm seasons ; frost-bite and its subsequent hyperemia, exudation, or gangrene, occur in winter; pruritus is common in cold weather; erythema mul- tiforme is most frequent in the autumn and the spring. The questions originating when considering the influence of climate, are so complex that they are differentiated with difficulty. They involve the study of soil, potable water, diet, atmospheric humidity and temperature, and the sociological conditions of a given locality. Pellagra is said to originate in certain coun- tries from the diet of the people. The severe forms of ringworm 62 GENERAL ETIOLOGY. observed in India result probably from exuberance of vegetation in the parasite under the influence of heat and moisture The aggra- vated species of scabies seen in Norway is doubtless the product of filth and eold, with the itch-mite as an exciting cause. It must, however, be admitted that the more extensive the study of diseases claimed to be peculiar i<> given degrees of latitude and longitude, the less they are found to depart from the types recognized in other countries. Frietional effects are perceptible in the action upon the skin, of the clothing. Coarse flannel is known to exeite pruritus, especially when aided by profuse sweat and the muscular movements of the laborer. Trusses, corsets, napkins, "pads," supporters, crutches, orthopaedic apparatus, hat-bands, stockings, garters, and a long list of similar articles, are responsible for many disorders, especially when soiled with physiological or pathological secretions. So in the occu- pation of men, bakers, masons, confectioners, blacksmiths, tailors, and an equally long list of laborers and tradesmen suffer from the results of friction, to which is often added the influence of trauma- tism or the action of chemical irritants. Traumatism plays a most important part in cutaneous etiology. It includes the action in scratching of the nails, the knees, heels, elbows, etc., well illustrated in the case of infants whose hands are confined, as well as the influence of several articles used for the same purpose — pieces of cloth of various kinds, etc. In this way excoria- tions, and even infiltrations of the skin, are induced. Under the head of traumatism should be considered also injuries of the surface produced by animals, occasionally with the added effect of a toxicant. Here are included the wounds produced by lice, fleas, bugs, and acari ; the bites of serpents, horses, dogs, and cats; and the accidents producing traumatism of every kind, not omitting the intentional wounds inflicted by the surgeon and their results. Toxicants operate upon the surface with and without the produc- tion of traumatism. Thus the worker in dyes and the wearer of the dyed garment manufactured, may suffer alike; while vaccination, when it produces a generalized exanthem, operates first in the wound made by the lancet of the vaccinator. Medicaments used upon the outer skin, such as mercury, croton oil, iodine, antimony, and nitrate of silver, are capable of engendering disease ; and those which, being swallowed, operate as irritants to the inner skin or mucous mem- brane, may have a similar effect. Others being swallowed and sub- sequently absorbed from the gastrointestinal tract, produce a toxic effect upon the skin in the effort to eliminate them. Thus the bromide and iodide of potassium, quinine, arsenic, copaiba, and many other articles of the materia mediea, occasion erythematous, vesicular, pustular, and bullous rashes of variable persistence and different external characteristics. To the class of toxicants must be added the articles of food and drink, which under ordinary circumstances, and perhaps to the majority of individuals, serve to nourish the body, but yet operate GENERAL ETIOLOGY. 68 as poisons to the few. Thus alcoholic drinks, shell-fish, preserved meats, certain fruits, cheese, pickles, and many other dietary articles, are known to originate or aggravate pruritus, urticaria, eczema, and acne. Cracked wheat, Graham bread, oatmeal, and buckwheat have been found, in certain susceptible individuals, to induce pruritus, urticaria, and occasionally decided roughness of the skin. It should be remembered in this connection that any undigested or indigesti- ble article of food may excite similar effects at one time and not at another, in the same individual, the resulting difference being due to the varying condition of the alimentary canal. An important list of toxicants is furnished by the poisons either of animal origin or requiring for the mature development of their germs, culture in animal fluids or tissues. All of these are external sources of disease. None is known to be generated de novo in the human body. To this class belong the exanthematous fevers, glanders, farcy, malignant pustule, and syphilis. Some require trau- matism for their introduction into the system ; some do not, and some are capable of introduction both with and without traumatism. This class includes the cutaneous disorders due to the presence of bacteria. In the present state of pathological science, it is impossible to define accurately the etiological import u nee of the microbes which have been demonstrated to exist in a number of diseases of the skin. In some, for example, lepra, these bacteria may be recognized as effi- cient factors of the disease ; in others, as, for example, lupus vulgaris and syphilis, the etiological value of the bacilli which have been recognized in tissues affected with these diseases cannot to-day be irrefutably demonstrated. Some cutaneous diseases are produced by the growth of the vege- table parasites upon and within the skin and hairs, and in the folli- cles. To this class belong ringworm of the scalp, beard, and skin ; tinea versicolor, and favus. Of the causes of diseases named, it may be said that no one of them is necessarily productive of such effects. The majority of men and women expose themselves daily to the action of light and heat, are subjected to friction, suffer from wounds of the integument, and come in contact with toxic agents, without exhibiting a disease of the skin. Often there is a marked degree of sensitiveness of the integu- ment peculiar to the individuals who suffer, which may exhibit itself in several members of one family, or exist in one person for but a brief period of time. Again, an individual idiosyncrasy may be exhibited, in consequence of which an article, harmless to all others, becomes to one person only a source of serious discomfort. The various physiological changes of the human body are never the causes of diseases of the skin, but at times furnish special oppor- tunities for the operation of such causes. Thus in the rapid tissue evolution of early life, eczema and lupus are relatively common — carcinoma and tinea versicolor rare. At puberty the hairs of the beard of the male are liable to the incursions of the trichophyton ; and the nipple and breast of the woman become the seat of eczema <3-± GENERAL ETIOLOGY. from epiphora of milk. The <>1<1 man and the old woman may be- come the victim.- of cancel-, aggravated forms of pruritus, and horny growths. Dentition, menstruation, pregnancy, and the menopause disturb the physiological equilibrium, and at times render the access of other disturbing forces exceptionally facile. The sexual appetite leads t<> excesses which bear fruit in attacks of herpes, pruritus, and syphilis. And the unceasing excretion from the skin surface, with constant deposit thereof effete material, may, when there is prolonged disregard of the laws of cleanliness, induce a liability to disease of the skin, which is especially marked in the case of infants and children. The power to transmit skin disease by heredity is of less impor- tance than is generally supposed. It is most conspicuous in the in- stances of hereditary syphilis; but even here the transmission of the disease is not without singular exceptions, and is limited to certain periods of the disease in the progenitors. The transmitted disease is also most common in the foetus, which is in direct communication with the mother, and rapidly diminishes in frequency with every month of separate existence, till late and very late instances of hered- itary syphilis have come to be received with suspicion. Many of the examples cited of hereditary transmission of cutaneous diseases are, without doubt, cases of coincidence, which, considering the number of patients affected annually with eczema and psoriasis for example, should not be regarded as of very rare occurrence. The list of causes recognized as directly productive of diseases of the skin are, without question, under special circumstances, capable of operating as indirect etiological factors. Temperature changes, contacts with the external world in all harmful degrees, and toxicants are prime agents in the production of diseases of internal organs; and these, in turn, may induce changes in the skin, of the nature of disease. The uterus, the stomach, the liver, the kidney, the heart, the nervous centres, and the intestinal tract may become disordered, and the result be declared not only in disturbance of the function of these organs, but in an attack of urticaria, pruritus, jaundice, or erythema. Without attempting to decide whether the preponderance of evi- dence is in favor of internal or external causes as productive of the greater number of cutaneous maladies, it is certain that disorders of the digestive tract sustain to many of them a most important relation. Thus the several conditions included under the somewhat indefinite term "dyspepsia," habitual constipation due to torpor of the intestinal tract, a portal circulation impeded by functional disturbance of the liver, and many other affections of the alimentary canal may each be productive of cutaneous accidents or complicate the results of the latter. In the same proportion, diseases of the kidneys, suprarenal capsules, spleen, anc] generative organs of both sexes may induce or be complicated by diseases of the skin. The influence of the nervous system, when considered in this con- nection, may be either directly or indirectly exerted. There is scarcely any efflorescence upon the surface of the integument, the arrangement of whose lesion is not in part determined by the nervous fibres whether GENERAL ETIOLOGY. 65 with or without the intervention of an effect upon the bloodvessels. Both vaso-niotor and trophic nerve-fibres are capable of inducing skin changes either after direct lesion or stimulation of the nervous centres, or through the medium of the latter after peripheral acci- dents of the same kind. Passive congestions of the surface, leading to oedema and violaceous blush of the skin, often result from circu- latory changes; and, in fine, any constitutional disease, by impairing general nutrition, arresting repair, hastening waste, or in other direc- tions impoverishing the protoplasm of the body, is capable of inducing disorder in the skin as in other organs. Thus in cancer, chlorosis, ansemia, and cholera there are significant alterations in the hue of the integument which not merely possess a diagnostic value for the clinician, but attest the sympathetic unity of each organ of the body with all others. There are authors who affirm, with eminent French dermatologists, that certain states or diatheses explain the origin of many cutaneous maladies. These diatheses, whether termed " arthritic," " dartrous," u lithsemic/' or "herpetic," cannot be demonstrated as efficient causes for the production of the diseases attributed to them. The chief ex- ponents of these opinions are not agreed among themselves as to the names of such supposed systemic conditions, nor as to the symptoms by which they are betrayed, nor as to the exact method of combating their effects. The claim that these states are of a nature analogous to the tuberculous or syphilitic diathesis, is to-day well nigh deprived of foundation, since the bacterial origin of tuberculosis and syphilis is at least on the road to demonstration. The complexus of symptoms characterized by evolution without demonstrable cause, by frequency of recurrence, by obstinacy under treatment, and by alternation of cutaneous with other maladies, is no proof of a diathesis, but rather of the failure of science to appreciate perfectly all the several condi- tions which produce the result. As to the group of phenomena well described by Dr. Da Costa 1 as characteristic of lithsemia, even with the fullest recognition of such conditions the cutaneous symptoms displayed by those who are the subjects of that state are neither con- stant, uniform, nor peculiar. While no wise physician would hesi- tate to treat patients for the relief of such states when there was coin- cidence of skin disease, he would not be, therefore, justified, even after coincident relief of the entire group of symptoms of disease, in attributing one part of this group to a constant association with the others in the case of all patients. Without attempting fully to discuss or to settle these questions, it is necessary to establish the fact that the eruptive phenomena in any skin are produced by a multitude of ever-shifting and varying com- binations of causes. Even the syphilodermata are influenced from hour to hour by drugs swallowed, by external irritants, and by con- ditions of the general health, such as a transitory diarrhoea, or a fit of coughing. In the light of our present knowledge, it is the part 1 The Nervous Symptoms of Lithasrnia. American Journal of the Medical Sciences, p. 313, 1881. 5 66 GENERAL DIAGNOSIS. of the physician, on the one hand, to neglect consideration of no effi- cient factor in the origin <>r evolution of a cutaneous disorder; and, on the other hand, to refuse to assign to a diathetic state only a group of* symptoms which may occur in persons where no such systemic condition can account for the evidences of disease. IV. (xEXERAL DIAGNOSIS. The establishment of an accurate diagnosis in cutaneous diseases is essential to their successful management. This statement is rendered necessary in this connection by the prevalence of a belief among the uneducated that the disorders of the skin, exhibited for the most part in visible symptoms, can be safely treated on general principles, without a recognition of the nature of the malady. By many prac- titioners the demand for an accurate diagnosis is ignored in conse- quence of a too general impression that the desired end is to be pursued through great and perplexing obscurity. Yet with patience, method, a habit of careful observation (without which no physician is successful), and a reasonable degree of skill, both the practitioner and student can, in the large proportion of all cases, attain their purpose. It is a popular error that the sole requisite for establishing a diag- nosis is the exhibition of the affected portion of the integument to the eve of him who is consulted with a view to its relief. The phy- sician is supposed to inspect this surface attentively for a few moments, and then to pronounce definitely upon the nature of the disease present, and the therapeutic measures to be adopted. But far more than this is requisite, and, indeed, fully as essential here as in the investigation of disease involving any other organ of the body. It is first necessary to secure a history of the physical and mental condition of the patient in the past ; then should follow the special history of the disorders of the skin ; lastly, an examination of the affected integument. For the purpose of methodically arriving at these facts, and of preserving them for future reference, they should be systematically recorded. The following are some of the points upon which it will generally be found useful to secure information : The name, residence, age, sex, occupation, and married or unmarried state of the patient should be known, as also, whenever practicable, the health-history of parents and children. In the case of women it is not only necessary to learn the history of the menstrual function in GENERAL DIAGNOSIS. 67 the past, but of the highest importance to be informed as to the previous occurrence of abortions and miscarriages, and, if such have occurred, the order observed by these with relation to the birth of viable infants. The significance and value of several of these facts have been described in the chapter on etiology. ' With respect to the history of the products of conception, it should never be forgotten that these have a most important bearing upon the question of syphilitic infection; and the absolute exclusion of syphilis in any obscure case is a long step in the direction of an accurate diagnosis. In the case of male patients, questions will usually elicit either admission or denial of the fact of a precedent or present venereal disease, and the answers should be regarded as valueless or trustworthy according as they are or are not substantiated by corroborative clinical facts. Then should follow some record of the habits of the patient, as to active or sedentary employment, bathing, food, and drink, including under the latter term the use of beer, wine, and spirits. The history of any previous disorders, whether of the skin or other organs, should be satisfactorily clear ; and, with respect to the latter, the dates of occurrence, recurrence, and convalescence be at least approximately discovered. The patient should also make known whether he has had refreshing sleep ; whether he has undergone mental anxieties (domestic, financial, etc.) ; whether he has suffered in his digestive, respiratory, circulatory, genito-urinary, or nervous system. This much ascertained, the patient should be encouraged to narrate as succinctly as possible, and as far as may be in his own terms, the history of the present cutaneous disorder. He should give the sub- jective sensations it has produced, as also the objective features presented to his own vision and touch. In the case of infants this information will, of course, have to be obtained from the mother or nurse. The treatment to which the disease has been subjected should then be detailed. This frequently furnishes a key alike to the diag- nosis and therapy of the disorder. In an incredibly large proportion of all cases, ignorantly directed and vicious internal or external medi- cation has either begotten or aggravated the disease of the skin. This much ascertained, the physician is ready to examine the affected surface for himself. During, however, the verbal interrogations which are required for this part of the exploration of the case, the watchful and observant practitioner will probably have secured for himself some useful -information of which the patient is totally unconscious. Much of this is difficult to describe, as it is the rich fruit of a wide experience and careful scrutiny. "With a gentle, courteous, and sympathizing manner, the diagnostician must combine the art of a detective and the skill of a swordsman. Glancing occasionally at the face of his patient while making record of the answers given, he will, of course, have observed any eruption upon that portion of the body. He will have made a mental note of the temperament of the sufferer, or any movement made by the latter indicating a tendency to scratch or rub any portion of the skin. He will have noticed the posture, clothing, 68 GENERAL DIAGNOSIS. and head apparel ; the* existence of hair on the scalp or extensive baldness ; the condition of the exposed hands, as indicating manual labor or the reverse; and. in the absence of facial lesions, will have observed the general tint of the skin of the face, as indicating anaemia, chlorosis, or a general condition of cachexia. The facial expression, as indicative of anxiety or placidity, habits of debauch, sexual excesses, etc., will not have escaped his attention. All this and much more will have possibly enabled the questioner to direct his interrogatories into the channel where they would elicit the most useful responses. The posture, cries, facial expression, and general condition of nutrition of the infant will have been no less carefully noted. Proceeding to the examination of the affected integument, the phy- sician must assure himself of a good light, as colors are best distiu- guished by daylight, and artificial illumination should be reserved for exploration of the cavities of the body. The air of the apart- ment should be sufficiently warm to permit of exposure of the pers< >n without discomfort. Adult males and children of both sexes should have the clothing completely removed, so that all portions of the skin may be inspected. One portion of the body may, however, be exam- ined, and then recovered, if desired, while the examiner proceeds to direct his attention to another. In the case of women the investi- gation should be conducted with all the tact and delicacy to which the sex is entitled. The examination, whenever practicable, should extend over the entire surface of the integument. The importance of this point can scarcely be exaggerated. It must be remembered that the physician should be very much wiser than his patient, and the assurances of the latter are always to be accepted with reserve. Thus, one who exposes his leg merely, stating that this is the only part of his body affected, may have concealed beneath his clothing extensive vari- cosities of the veins of the thigh, a typical syphilitic exanthem over the belly, a significant scar on his elbow, an extensive patch of tinea versicolor on the surface of the chest, or a blennorrhagic discharge from the urethra, the medication of which has induced the rash for which he seeks relief. These are uot the rare, but the common cases of a daily experience. Observation should be had at this time of the general and special features of the eruption. As to the former, the following consider- ations should be borne in mind : A symmetrical eruption, one equally distributed over the two lateral halves of the body, is rarely the result of an etiological factor operating upon the outer skin. It more often points to an efficient cause of; so-called internal origin, one influencing the inner skin or the internal organs. An eruption affecting the covered integument, never creeping out upon the exposed surfaces, suggests the operation of the clothing ; as the latter may chance to prove the nidus or pro- tector of a parasite, the fabric which has been colored by a noxious dye, the recipient of a chemically altered secretion, which has proved GENERAL DIAGNOSIS. 69 irritating to the surface, the instrument of friction, or the source of increased temperature at the surface by its non-conductivity of heat and unseasonable thickness. An eruption, accompanied by excoria- tions and scratch-lines, is that usually most severe in the parts most accessible to the hands, and least developed where the latter have the least play, as over some parts of the back. An eruption limited to the hands is likely to be one induced by an agent to which the hands alone have been exposed, as those originating in the trades and domestic occupations ; while in the latter, an eruption more distinct on the right hand, and especially about the right thumb and index finger, tells its own story when the hand-worker is not ambidextrous or left-handed. Artificially and intentionally produced eruptions, as in malingering, hysteria, mental depravity and insanity, usually occur also in parts to which the right hand finds easy access. Eruptions occurring on the face, hands, and genitalia of men, or face, hands, and mammae of women, point to external contact or contagion (poison-ivy, scabies, crotou-oil, etc.) ; since, next to the face, the hands are more commonly brought in contact with the parts named in the sexes respectively, as the wearing apparel of each suggests. An eruption, limited to the forehead, suggests an inspection of the hat-band, the veil, or the overlying false hair ; to the ears of women, a glimpse at possibly cheap ear-rings ; to the centre of the root of the neck, before or behind, a scrutiny of the collar-buttons and collars ; to the anus of the baby, an inquiry as to the changing of its napkins ; to the wrists of the adult, a question as to the cuffs worn ; to the feet, information respecting gaiters, varicose veins, recently cut corns, and ill-fitting shoes. Eruptions springing from each of these causes have been long and vainly treated as "diseases of the blood." Eruptions markedly asymmetrical are indicative of asymmetrically operating causes — that is, the accidents of environment, or else influ- ences exerted within the- body unequally on its two lateral halves. Thus an orthopsedic apparatus, worn to correct talipes, excites an eczema in the leg only of the affected side; and zoster of the trunk is evident on that side supplied by the intercostal nerve which has been inflamed. The greater stress may be laid on this peculiarity, as the law of symmetry, in eruptions not occasioned by causes operating on the outer skin, is faithfully observed in nature. The earlier syphil- ides, the quinine exanthem, rubeola, and even lupus erythematosus, are remarkable illustrations of this fact. Proceeding next to the special visible characteristics of the erup- tion, the physician will not fail to note an acuteness or chronicity of lesions; their color, size, distribution, tendency to become aggregated in patches, or the reverse; and the evidence presented as to change in type, the sequence or coexistence of several lesions at the same time — that is, the multiformity (polymorphism) or uniformity of the eruption. He will observe whether the limit of the affected skin is well defined against that which is normal, or scarcely to be outlined 70 GENEKAL DIAGNOSIS. ■with ;i pen or pencil. He will rapture a bleb, pustule, or vesicle, should such be found, to discover the nature of its contents. He will remove one <>r several crusts in sight, to expose the surface on which they rest. He will remove a few scales with the dermal curette for a similar reason. He will as carefully inspect the skin where the disease has existed, as that where it does exist. He will pinch up between his thumb and finger a portion of each, in order to deter- mine its infiltrated condition; its atrophy; or its attachment to the tissues beneath. He will pass his hands over the surface to recognize the firmness or softness of the lesions, their dryness or moisture, and the existence of sebaceous or perspiratory secretion. He will look at the mouths of the follicles, where such secretion is retained or abun- dantly exuded. He will discover any lice or ova on the hair; any ascarides at play about the anus; any unnatural formation of the nail, or deformity of its matrix. He will examine for inguinal, post- cervical, axillary, and epitrochlear adenopathy, and will thus be often greatly aided in his task. This done, he will question in turn for himself, and by the methods recognized in medical science, the organs of the body other than the skin. He will inspect the tongue care- fully, and then, if he is through with the mouth, he will be guilty of great error. The gums rarely deceive the questioning eye; the inside of the lips, fauces, and tonsils are all to be searched. A mucous patch here will often echo the story of a palmar or plantar syphiloderrn. The laryngoscope may be called for in syphilis, cancer, lupus, and leprosy. The degree of distention of the belly and the region of hepatic dulness should not be overlooked. The genitalia of men, and of children and infants, can usually be explored. For women unaffected with syphilis or disease limited to these parts, an exception in this particular should usually be made. With the necessary reserve of all very obscure cases, it may be said that the physician who has conscientiously conducted an examination after the manner described above, is in possession of the diagnosis for which he seeks. If the facts thus acquired have been properly recorded, and yet do not spell out such a diagnosis to his eyes, they are probably legible to others with a wider experience or riper judg- ment, to whom such a record is shown. It is not. claimed that this exhaustive method of examination is requisite in every case, as, for example, in order to recognize an acne or to differentiate erysipelas from erythema. But it is certain that few obscure cases of skin dis- ease will remain such under severe scrutiny, and the establishment of a thorough and exhaustive method of examination is important in the earliest experience with disease. Let the student or practitioner conduct such an examination in the first few cases of eruption upon the -ui'face of the body for which his advice is sought, and he will establish a habit of observation in comparison with which his pecu- niary or professional success in the management of the same cases will be indeed of trivial worth. Upon one special point should the inexperienced physician be guarded. It relates to the acceptance of a diagnosis which is not GENERAL PROGNOSIS. 71 based upon such au examination as that given in outline above. A diagnosis by a patient is usually faulty, and the verdict of even skilled practitioners may be founded upon an error. The careful diagnos- tician should commence his task iu a spirit of scepticism, and pro- nounce definitely only upon ascertained facts. The man who says he has an "eczema" may be louse-bitten ; the woman who has been "over- heated" may prove syphilitic. The patient recognized as suffering from ringworm of the beard may not have been infected under the hands of the barber. Finally, the eruptions upon patients unmistak- ably syphilitic, are often of other than syphilitic origin. They are men, women, and children exposed daily to the accidents from which the non-infected suffer. They exhibit acne, physiological alopecia, and dermatitis medicamentosa equally with those who have not sinned sexually. The microscope is an instrument whose aid in establishing a diag- nosis of cutaneous disease can rarely be dispensed with. The con- tributions it has made to the knowledge had on the subject of path- ology are of inestimable value; and as a means of diagnosis it can be used with advantage both at the time of the first examination of a patient, and afterward for the more leisurely examination of hairs, scales, crusts, or portions of tissue. Those unable to secure the cost- lier and elaborate instruments sold by the makers, should take pains to provide themselves with a fairly good student's stand, and a fifth and half inch objective for use in the diagnosis of skin diseases. The diagnosis of special diseases of the skin is described in the chapter devoted to each. Y. GENERAL PROGNOSIS. The prognosis of most diseases of the human body is formulated with a view to the decision of the serious question of life or death. Occasionally this question arises in connection with skin diseases. Many of the latter are trivial ; some are grave ; a few, inevitably fatal in their termination. Thus general exfoliative dermatitis, leprosy, sarcoma, carcinoma, at times lichen ruber, and variola in the unpro- tected, are of grave portent; while the ordinary congestions and exu- dations, the great majority of all cases of acquired syphilis in adults, and the entirely curable diseases induced by parasites do not excite alarm in the breast of the average patient with respect to his longevity. The questions, however, as to his future, which are urgently pressed by the victim of cutaneous disease, are both numerous and important. 72 GENERAL PROGNOSIS. He is anxious as to the time during which he must .suffer; as to the possibility of conveying his disease to his progeny or other members of his family ; as to the disfigurement of his person which might result; as to the scars which he may have to carry for the remainder of his life; as to the possible recurrences of his malady in the future. The responses to these questions will be largely influenced by the prog- nosis of the physician. Some diseases of the skin are acute, rapidly pursue their course, and are then prompt to disappear. Others are chronic, rebellious to treatment of the most energetic and skilful character. Others, again, though not shortening life, are never relieved while life is coutiuued. Some disappear, only to reappear at more or less regular intervals. There arc cutaneous diseases which affect oue individual but once in his lifetime; others which reappear at the instant the patient is again exposed to their exciting cause. There are cutaneous diseases so dis- torting and destructive in their effects, that their victims have com- mitted suicide under the influence of the morbid emotions which they have as a consequence experienced. The mental distress occasioned by even an insignificant cutaneous disorder is often out of all proportion to its excitiug cause; and this should always be regarded in establishing a prognosis. The sexual hypochondriac has been made insane by an acne; and the man or woman affected with syphilis has been made wretched for years by a recurrent erythema. Again, a disease of the skin may coexist with grave lesions of in- ternal organs, and the prognosis of the disease of the one be greatly influenced by that demanded by the other. Thus there is occasional coexistence of syphilis and phthisis. Pruritus may be associated with Bright's disease of the kidneys; and the eczema of an infant starving for want of breast-milk may hasten its marasmus to a fatal termination. Upon the answers given to his patient inquiring as to the prog- nosis of the disease of the latter, will largely depend the professional success of the physician. Scrupulous honesty should be here welded with all the skill that science can command. That a disease does not endanger life, is not an argument in favor of its amenability to treat- ment. The practitioner should never suffer himself to be pushed by his patient to the position that an obstinate disease is readily manage- able. It is the height of folly to estimate lightly that zoster of the forehead, the scars of which the patient w r ill exhibit to all who after- ward look upon his face both in life and death. He who engages to relieve an alopecia areata in the month, may have a year in which to repent his precipitancy. There is no way in which the conscientious physician can so readily secure the confidence of his patient, and with it that willingness to submit to appropriate treatment, which is be- gotten of such confidence, as by demonstrating his ability to forecast the future of a disease; in other words, to describe accurately its prognosis. GENERAL THERAPEUTICS. 73 YI. GENERAL THERAPEUTICS. A consideration of the subject of the methods of treating skin diseases in general, suggests at once the intimate relation which sub- sists between the integument and other organs of the body. The etiology of one, largely explains the causes of the disorders in all. The pathological processes in each are subordinated to the same general laws. The principles of treatment are very similar, in all the disorders of the body. The object to be attained by treating a cutaneous disease is, first, its complete relief; second, where the latter is impossible, such a management of the morbid process as will mitigate its severity and render the victim of the disease more comfortable. A higher aud more scientific achievement than either is the prophylaxis by which man is enabled to escape the disease altogether. He can by his wis- dom largely diminish the danger to which his integument is exposed. He can, to a certain extent, shelter himself from extremes of tem- perature, traumatism, toxic agents, and the contagious diseases. He can, by observing the simple rules of hygiene, fortify his skin against the lesser evils which may befall it. If it be true that "the people perish for the want of knowledge," it is certain that once in posses- sion of it, they can greatly enhance their comfort and prolong exist- ence. Here, however, the subject under consideration involves dis- ease which is actually present and in progress. Like all other diseases of the body, those of the skin may be divided into three classes with relatively fixed limits. The first embraces all the diseases which have a natural tendency to pursue their course to a favorable termination. It embraces all those affections which, either mild or severe, require absolutely no treatment of an active character. It is the duty of the skilful phy- sician to watch the evolution of these maladies, and to discharge a most important part by refraining from all therapeutic measures which in such cases might prove hurtful. By his judicious counsel also, he hinders patients and their friends from pursuing a course which might prove prejudicial to the disease. The second class embraces all those affections of the skin which are either inevitably fatal or hopelessly remediless while life is pro- longed. Fortunately, this includes but a small proportion of the large list. Here the duty of the physician is plain. He should assuage pain, attempt to relieve deformity, administer to the comfort of the afflicted in other ways, and, by his patient courage, inspire confidence and hope. It must not be forgotten that the skill of man has not 74 GENERAL THERAPEUTICS. yet reached the acme of human need. In the presence of many diseases of the body, he stands absolutely helpless; and the speediest way to success in such cases is to begin by an honest admission of the plain fact. The third class of affections naturally embraces all not included in the other two. Here disease may be prolonged or shortened in its course, rendered acute or chronic, made more or less endurable, per- mitted to Income inveterate, or be absolutely relieved, by prompt and energetic measures, according- as it is, or is not, judiciously and skil- fully managed. Here are gained the most brilliant successes of the dermatologist; here also occur his most humiliating failures. In the presence of a cutaneous disease which requires treatment, a question naturally arises as to whether this treatment shall be in- ternal, that is, by medicaments ingested; or external, that is, by local therapeusis; or by combination of the two methods at the same time. With regard to the first question (concerning the Internal treat- ment of skin affections), which is one of pressing importance, it can be safely said that there are no remedies to be given by the mouth which can be described as certainly and specifically curative of the diseases of the skin. The number of medicinal agents employed with this end in view is incredibly large, by far the greater part being obtained from the vegetable kingdom. With few exceptions, for the most part enumerated below, the most esteemed of these exert only an indirect therapeutical effect upon the integument. The larger number of medicaments thus used are, it must be admitted, without value of any kind, but will probably continue to be vaunted as possessing specific virtues so long as credulity on the one hand, and avarice on the other, move the mass of mankind. Arsenic has long stood at the head of the list of remedies as valuable, when ingested, for the relief of cutaneous disorders. It is known to exert its effects almost exclusively upon the epithelia of the skin, and upon these, so far as therapeutic effects are concerned, only when they are in indolent conditions of subacute and chronic exudation. It is known to exert an unfavorable influence upon the epidermis when the latter is in a condition of active inflammation. Operating in this limited class of cases favorably, it also operates slowly, requiring months for the production of its curative effects. Its administration is at all times attended with the hazard of pro- ducing toxic effects, which, however, when the result of the exhibi- tion of the drug in medicinal doses, are usually limited to a mild exanthem upon the skin, moderate coryza, and some redness from congestion of the vessels in the eyes and eyelids. It is used chiefly in psoriasis, acne, squamous eczema, pemphigus, and lichen ruber; its dosage in cases of children being relatively large. It should be invariably administered only after eating, and a mini- mum dose be first employed in order to test the susceptibility of the patient to its action. It should be remembered that the toxic effect of this, as also of several of the other drugs mentioned below, is often speedily noticed after the first exhibition of a relatively small GENERAL THERAPEUTICS. . 75 dose. Toleration ouce established, the dosage may be cautiously increased. The forms in which it is usually administered are the prepara- tions of arsenious acid, such as the liquor potassii arsenitis (Fowler's solution) ; the liquor arsenici et hydragyri iodidi (Donovan's solu- tion) ; the liquor arsenici chloridi ; and the Asiatic pill. Duhring's modification of this pill is obtained by making two grains (0.13) of arsenious acid, and thirty-two grains (2.2) each of black pepper and liquorice powder, into thirty-two pills by the aid of a sufficient quantity of mucilage. Arsenic is also at times advantageously com- bined with other indicated medicinal substances, such as iron and the iodide of potassium. In the first edition of this treatise, it was stated that an unpreju- diced view of its action, even in cases properly selected for its in- ternal administration, would justify the conclusion that arsenic is in diseases of the skin a remedy of uncertain effect, and, in that proportion, disappointing. Subsequent investigation, made particu- larly by American observers, has more than established this position. Dr. G. H. Fox, of New York, 1 after collation of the experience of a number of experts in this country concluded that the common practice of giving, arsenic in many cutaneous diseases was both harmful and irrational, not merely because of its effect in inducing cutaneous congestion and pruritus, but because of the reliance placed upou it to the exclusion of other and better methods of treatment ; and that the beneficial effects supposed to follow its administration were often due to other causes. He also called attention to the striking fact that no series of carefully recorded cases had ever been published in which notable therapeutical results had been shown to result solely from its administration. These conclusions elicited a number of statements from well- known physicians having experience in the management of cutaneous diseases, who, for the most part, assented to Dr. Fox's conclusions. Even in pemphigus, psoriasis, chronic eczema, and lichen ruber, where the remedy has been thought to possess special efficacy, it has in cases conspicuously failed. It is safest to conclude, first, that arsenic, instead of being one of the earliest, should be one of the last remedies selected in the management of cutaneous diseases by the general practitioner ; second, that, when thus selected, its value will probably prove greatest if the eruptive lesion be superficially seated, generalized, diffused, or iu evident association with neurotic symptoms; third, that in any case its failure should not be regarded as definite, if only Fowler's solution has been administered. The value of Mercury in the syphilodermata is incontestable, and its injudicious employment in many cases springs from that precise fact. The vulgar prejudice that many disorders of the skin, really not syphilitic, are obscure manifestations of lues iu a preceding gen- 1 Journal of Cutaneous and Venereal Diseases. June, 1886, p. 179. 76 GENERAL THERAPEUTICS. eration, and amenable to mercurial treatment, is a striking illustra- tion of the uecessity of accurate diagnosis in cutaneous diseases. Few non-syphilitic affections are benefited by continuous courses of mercury, though the value of the metal as an alterative in this small proportion of cases must be admitted. The corrosive sub- limate is often superseded, in consequence of its irritative effects, by the compounds of the metal with iodine. The gray powder is useful chiefly in case of infants and children, though its not infre- quent development of the corrosive chloride has largely limited its favor with Americans. Calomel and the mercurial pill should be employed only for transient effect, as, when administered for long periods, they are much more apt to produce ptyalism than the other preparations mentioned. Iodine and its compounds are also chiefly used by the dermatolo- gist in syphilitic disorders of the skin, but they possess a wider range of value than the mercurials in the treatment of other cutaneous affections. Here, too, the abuse of the drug furnishes a long list of cutaneous disorders either originated or aggravated by its employment. As in the use of arsenic, toleration should be established before large doses are exhibited. The compounds chiefly used are the iodides of potassium, sodium, lithium, and ammonium, and iodoform. It has been administered for the relief of the scrofulo- dermata, lupus, keloid, and syphilitic affections of the skin. As to the latter it may be added that in the earlier symptoms of lues it is often a source of positive injury. Cod-liver Oil is a remedy of special value in diseases of the skin, and was for that reason held in high favor by the distinguished Hebra, though its action is almost exclusively that of a nutrient of the general system. It is employed chiefly for its roborant effects, and these are similar to those of the digestible aliments. Its special value in the treatment of infants and children affected with cutaneous diseases cannot be questioned. It is, however, of great use also in maturer years, and is advantageously exhibited in eczema, lupus, scrofula, syphilis, scleroderma, and in all the disorders of the integument accompanied by wasting. Quinine, administered both as a tonic and antiperiodic, is largely employed in cutaneous medicine for its generally recognized systemic effects. It produces, in certain susceptible individuals, a peculiar smoothness and softness of the skin, which usually disappear when the drug is suspended. Like arsenic and iodine, it is occasionally the cause of a generalized exanthem, and is capable of producing other toxic effects, such as failure of the heart's action, dizziness, and tinnitus aurium, symptoms recognized under the designation of cin- chonism. It will, of course, exhibit its happiest effects in malarial affections with coincidence of cutaneous symptoms in the forms of disease of the skin associated with a neurosis. GENERAL THERAPEUTICS. 77 Ergot, whether by exerting an effect upon the muscle-bundles or vessels of the derma, or upon the uterus, or yet by its influence upon the general economy, is thought to possess some value in the treat- ment of several cutaneous diseases occurring in both sexes. Such are acne, purpura, and a few other disorders. Calx Sulphurata may be regarded as the most efficient of the sulphur compounds for internal use in cutaueous diseases. Its recog- nized value in furunculosis has led to its employment also in eczema, acne, and impetigo. It is given in doses of from one-tenth (0.004) to one-fourth (0.016) of a grain, three or four times daily. Chrysarobin has been administered internally by Stocquart 1 and others in doses of one-sixth (0.01) of a grain for a number of cutaneous disorders. Ichthyol, mentioned later as of some value when externally employed, has also been given by the mouth. Jaborandi and Pilocarpine, probably as the result of the free dia- phoresis which they excite, have unquestionably exerted immediate therapeutical effects in a number of cutaneous disorders. Tar, Carbolic Acid, and Phosphorus are remedies which have been employed internally with appreciable effect in certain cutaneous maladies, but the action of each is uncertain, and at times highly preju- dicial. They have been used with advantage in cases of lupus, eczema, psoriasis, and pruritus ; but their internal administration has been to a great degree a bar to their general employment. The " perles" of phosphorus, and the elegant elixirs of the same drug now in the market, seem to have obviated this difficulty in the instance of at least one of these articles. Unpromising as is confessedly this brief review of the remedial influence which internal medicaments are capable of directly exerting upon the skin, it must not be forgotten that, while the treatment of the patient and the treatment of the patient's skin are practically one, there is some distinction to be drawn between them. No one would claim that castor oil, for example, possessed any efficacy in the frac- ture of a femur, yet such a cathartic is frequently ordered by the surgeon, with the happiest effect upon the condition of his patient in a splint. Such precisely is the inestimable value of a j>roperly con _ ducted internal medication in cases of cutaneous disease. The consideration of this point introduces us at once and properly to the broad field of general medicine. He is totally unfit to treat cutaneous diseases who is not qualified by education and experience for the general practice of medicine. The internal treatment of the patient suffering from a disease of the skin, is that which is in each case indicated by his general condition. Thus the aperients, cathar- tics, diuretics, and occasionally even the anodynes, are demanded, and, when judiciously employed, accomplish beneficial results. Few 1 Ann. de Derm, et de Syph. 1884. 78 GENERAL THERAPEUTICS. practitioners can afford to dispense with the use of the preparations of iron, for example, iu cases of ana?mia. Even the patient affected with a parasitic disease may ncrtl one of the bitter tonics, and the youth with vegetations upon the glans may require first to be rid of his blennorrhagia. Among the medicinal substances indicated by the general condition of the patient affected with a disease of the skin yet not directly acting upon that organ, none are more useful than the diuretics, cathartics, and remedies acting as stimulants to the secretions of the chylopoetic viscera. At this day no educated physician believes in employing medicines with a view to either the so-called "driving out" or " driving in" of a disease of the skin, much less to a use of evacuants with a view to carrying off a supposititious materies morbi. The remedies suggested above are undoubtedly, for the most part, useful in diminishing the congestion of the cutaneous capillaries, an important point not only with respect to the comfort of the patient but to the relief of his ailment. He who accomplishes the largest success will not, finally, neglect consideration of the diet, hygiene, and social surroundings of the patient. The chief value of many of the mineral springs and health resorts of this country lies in the change of the manner of living which they invite and necessitate. Sunshine, pure air, recreation after the care and toil of business, change of climate, of foods and drinks, and even of cooks, often decide the question of speedy recovery. Unfortunately, both in this country and abroad, many of the health resorts are peopled by unscrupulous charlatans, with a myopic tendency to attribute all the benefits to be derived from these sources to the medicinal virtues of this or that particular spring, aided always by treatment according to their own peculiar methods. Many patients affected with disease of the skin are thus made worse by a temporary residence at noted health resorts, and, therefore, it is often the case that a visit to the seashore, the mountains, or any healthful place in the country proves conducive to far greater prac- tical results. This understood, it is admitted that many of the springs of our own country possess a therapeutical value in cutaneous diseases actually dependent upon the constituents of their waters. A new study of this interesting and important subject is demanded by the annual discovery of new sources within the borders of the United States, which give a large promise for the future. Many of those ignorantly recommended as valuable for the entire list of cutaneous disorders are either entitled to no such encomium or maybe usefully employed only in a limited number of skin affections. Large successes are undoubtedly to be credited to the scores of ferruginous, sulphuretted, chlorinated, alkaline, arsenical, purgative, and other springs whose names appear in the lists given by European writers on this subject. Most of these are represented in this country by waters of equal, if not greater value, furnished by the numerous spas of Michigan, Vir- ginia, New York, Colorado, New Mexico, Utah, and other States and GENERAL THERAPEUTICS. 79 Territories of the Union. As these are brought within reach of a larger portion of the population of the country by greater railway facilities, their medicinal value will be better appreciated, and they will be much more systematically employed than at present. They offer a most promising future for the internal treatment of diseases of the skin in this country. In the External treatment of diseases of the skin, the indications are, to hasten repair when this is possible ; to alleviate distress, if palliatives only are admissible ; to destroy absolutely or excise the diseased tissue, when this is justifiable. The following are the prin- cipal substances employed as external applications : Water, either pure or medicated by holding other substances in solution or mechanical suspension, is applied either in baths or lotions. Baths, local or general, may be employed for days contin- uously, or but for a few moments at a time. They are given with water of varying temperature, cold, warm, or hot. Cold baths of short duration are generally followed by a sharp reaction, the skin becoming congested after the normal temperature of the surface is regained. Thus it is that cold sponging of the inflamed skin is usually grateful so long as it is continued ; and is succeeded after- ward by an aggravation of the symptoms which it was intended to relieve. Continued applications of cold water are not open to this objection. Hot baths are followed by a more or less enduring relaxation of the integument, while those given with tepid water are chiefly macerative of the surface. It should be remembered that the appli- cation of watery lotions to the broken surface of the skin, is liable to- be followed by endosmosis, unless the specific gravity of the serum of the blood and that of the fluid of the bath or lotion are nearly the same. This imbibition of fluids by the broken skin is accompanied by slight swelling of the tissues and productive of disagreeable sensations. The most perfect of all methods by which water is applied to the surface of the body, is that which most resembles the water-bath in which the tender skin of the foetus is safely immersed for consecutive months. Here the bath is continuous ; the temperature, that of the viscera of the living animal ; and the delicate skin of the unborn child, anointed with a fatty substance which actually interferes with the macerative action of the surrounding fluid so long as vitality is preserved at the average standard. The comfort and therapeutic value of a bath prepared and administered in approximation to this ideal, can scarcely be overestimated. Were it not for the difficulties with which it is attended, so far as relates to many portions of the surface of the body, it would be possible with this single therapeutic measure to rob the exudative affections of the skin of a great part of their formidable features. In acute inflammations of the skin, the application of pure water, 3"> GENERAL THERAPEUTICS. even when of proper temperature, is often prejudicial to the integu- ment ; and soap and water washings may prove quite harmful. The greatest caution must be exercised in giving instruction to patients as to the washing of the inflamed skin. Water for external application, as in the bath, is medicated by the addition of a large number of substances, such as marine salt, sodic and potassie salts, alum, tannin, the mineral acids, mucilages, gelatin, bran, and, especially in the Southern States of this country, the orange leaf. The alkaline bath, made by adding the bicarbonate or the biborate of sodium to water of the proper temperature in the proportion of twelve ounces of either salt to thirty gallons, is usually grateful to the inflamed skin. Sulphur baths are best prepared by adding an ounce of Vleminckx's solution 1 to the same quantity of water. When employed as a lotion, water is made to produce a sedative effect by the addition, of opium, belladonna, glycerine, carbolic acid, hydrocyanic acid, zinc, bismuth, mercury, lead, and the alkaline bicarbonates with the sodic biborate. It is rendered stimulating by the admixture of alcohol, most of the acids and alkalies in stronger solution than in the soothing or sedative lotions; and by a large number of substances which operate upon the surface either mechani- cally or chemically. It is also rendered astringent when tannin, lead, and similar medicaments are dissolved in it ; and by its union in various degrees with soaps and alkalies a solvent effect is produced, either upon the cuticle itself or upon pathological or foreign products upon its surface. Water is employed also, both in the form of the douche and vapor bath. When evaporation is prevented, by covering the wet surface of the body with an impermeable tissue, such as gutta-percha or rubber cloth, still further macerative effect is produced. The sweat alone is in the same way converted into a macerating agent. Lotions other than those containing water are often serviceable. The fluid in such case may be alcoholic, ethereal, or oleaginous, and medicated to any desired effect. S< »aps are of great value wheu applied to the skin. The hard, or soda, soaps are employed chiefly for the purposes of ablution. The soft, or potash, soap has a wider therapeutic range. In consequence of the small excess of caustic potash which it contains, it not only serves to cleanse the skin of any accumulations upon its surface, native or foreign, but also to exert a mild, destructive effect upon the horny layer of the epidermis. Digested with rectified spirits of wine in the proportion of two parts of the soap to one of the alcohol, it forms the well-known " spiritus saponis kalinus " of Hebra, a prepa- ration which the modern dermatologist employs constantly with admirable results. 1 The formula is : ~fy. Calcis, Sss; 1G Sulphur sublim. gj; 32 Aq. dest. 3x ; 32o| M. Coque ad 3vj ("200] deinde ultra. Sig. " Vleminckx's Solution." GENERAL THERAPEUTICS. 81 Medicated Soaps, containing carbolic acid, glycerine, tar, sulphur, and various oils, are sold in the shops, but contain so small a portion of the individual medicament from which each is named, that they are practically worthless except for purposes of ablution. The author has had such prepared under cold pressure, so as to contain medicinal substances in therapeutic proportions ; but, after experimentation, has concluded that other forms of administration are preferable. Fatty and Oily Substances are applied to the skin either directly by pouring, or by friction, or by the mediation of compresses, bandages, etc., which are saturated or spread with the material to be applied. The oils may be used for either nutritive, soothing, or stimulating effects. To the first and second classes belong cod-liver, lard, olive, almond, linseed, neat's-foot, castor, and similar oils ; to the third class, the oil of tar, of cade, of white birch, of the cashew nut, and of juniper. Fatty substances are also applied in the form of ointments or pomades. They are compounded with various medicinal substances, according to the requirements of each case, such as the salts of mer- cury, zinc, copper, lead, and sulphur ; pyrogallol, chrysarobin, carbolic and hyposulphurous acids; tar, camphor, iodoform, balsam of Peru, hydrate of chloral, the extracts of opium, belladonna, etc. The products of petroleum refinement, known as Vaseline and Cosmollne, though not true fats, are increasingly employed for similar purposes, and continue to enjoy high favor in this country and abroad. They are particularly useful as bases for ointments for application to the hairy portions of the body, such as the scalp, when more con- sistent salves paste the hairs to the surface in an unsightly mass. Glycerine — even the best — is, when applied in its purity to the skin, usually irritating. It is, however, exceedingly useful when diluted or made a component part of lotions and ointments. When combined with starch it makes, in different proportions, a series of combinations known as glyceroles, or glycerolates. These are pasty, semi-solid substances which are capable of varied medication, as in the glycerole of the subacetate of lead proposed by Dr. B. Squire, of London. They are useful chiefly as protectives of the surface. Glycerine, when used in a fluid soap, is an exceedingly valuable agent when a milder effect is desired than that produced by the spirit of soap described above. The Vienna preparation known as Sarg's fluid soap is an admirable substitute of this sort when a soft shampoo is required for the scalp. The Pastes employed for local application in diseases of the skin have been greatly perfected by Lassar and Unna. 1 These pastes are valuable especially in the exudative affections, where salves are often either not well tolerated or actually prove irritating to the skin. The pastes, when applied to such surfaces, form a protective and adhesive dressing, which may be medicated as desired. 1 Monatsh. f. prakt. Derm., February and March, 1884. 6 82 GENERAL THERAPEUTICS. They are prepared with kaolin [terra alba, or Armenian bole of red color, when it is desirable to have the application resemble the color of the skin], gum, lead, dextrine, glycerine, and other substances. Formula' for each are here appended : Kaolin in a pure state, with ecpial parts of vaseline or glycerine, or with almond, olive, or linseed oil, in the proportion of two to one, is readily applied in a thin layer over the skin. When it is desired to add the oxide of zinc, or the plumbic acetate, the kaolin and oil or glycerine are first carefully mixed, in order to prevent the formation of an insoluble compound — e. g., It. Kaolini pur., ol. lini [vel glycerini], aa 30 parts; zinci oxidi, liq. plumb, subacetat., aa 20. M. For making lead pastes, litharge is boiled with twice the quantity of vinegar till the latter has evaporated and a damp but drying paste is left, which may be, on occasion, remoistened with a small quantity of vinegar — e. g., I^j. Lithargyr. subt. pulv. 50 ; aceti, 80. Coque usque ad consistent, pastas : deinde adde ol. lini [v. glycerini, v. ol. olivse], 10. M. In the two forms of pastes above described, the adhesive and desiccative qualities are obtained from the main ingredients, but in those resulting from combinations of gum, starch, and dextrine, these results are for the most part obtained by the addition of other ingredients, such as sulphur, zinc, etc. A good basis, semi-solid, rapidly drying, and fixing its ingredients well upon the surface, is the following: ly. Amyli oryzae, 3; glycerini, 2; aq. dest. 15. M. Coque ad remanent. 15. For convenience, the solid substances are mixed at once with the glycerine, starch, and water, and then heated together. Tfy. Zinci oxid. 50 ; acid, salicylic. 2 ; amyli oryzae, glycerini, aa 15; aq. dest, 75. Coque ad 140. For a sulphur paste : !ty. Sulphur, prsscipit. 40 ; calc. carb. 2 ; zinc. oxid. 20 ; amyl. oryzae, 15; glycerini, 20; aq. dest. 75. Coque ad 120. Here is a formula giving a combination of starch and lead re- sembling cream : ly. Amyli oryzae, 10; glycerin. 30; lithargyr. 30; acet. 60. Evapora ad 80. By adding 10 parts more of litharge, and 20 more of vinegar, and evaporating to 90, a thicker and cement-like paste is formed. To make use of dextrine, the officinal pulverized article is selected, and a simple paste of this forms a good drying base. An added half- weight of glycerine is required if powders are also combined with the paste — e. g., Iy. Zinc. oxid. 40 ; dextrin., aq. dest., aa 20 ; glycerin. 40 ; sulphur, sublim. [vel. sod. sulpho-ichthyol.] 2. Cpq. A mixture of dextrine and lead is thus prepared : 1^. Lithargyr. 30 ; acet. 50. Coque ad remanent, 50; adde dextrin., aq., glycerin., aa 15. Coque. If too consistent, these pastes are made to spread easily by the addi- tion of a few drops of hot water. Such water is not required in making the paste if another fluid be one of the constituents, as, I^i. Dextrin., glycerin., liq. plumb, subacet,, aa 10. M, Coq. ft. pasta. For the gum pastes, gum arabic is used in the proportion of one part of mucilage and glycerine to two of the powder selected, mixed without heat— c. g., jfy. Zinc. oxid. 40; hydrarg. oxid. rub. 2; GENERAL THERAPEUTICS. 83 mncilag. acac., glycerin., aa 20. M. 1^. Cret. prseparat., sulphur, subliru., aa 2 ; picis liquid. 8 ; amyli, 20 ; mucilag. acac, glycerin., aa 15. M. 1^. Acid, salicylic, 20 ; glycerin. 20; mucilag. acac. 30; ol. ricini, 10. M. The author gives the following details respecting the availability of these pastes for different ingredients : Lead is best used as an acetate, either in a simple paste or with dextrine; the carbonate, oleate, and iodide combining well with both. Zinc oxide combines well with kaolin, lead, starch, dextrine, and gum. Sulphur combines well with the three last named, poorly with kaolin, and not at all with lead. Ichthyol suits well with all save the gum pastes. Naphthol, calomel, corrosive sublimate, red and white precipitate, carbolic acid, chloral hydrate, camphor, and salicylic acid can be incorporated with all, the last named in smaller proportion with gum paste. Tar is better united with starch, dextrine, and gum, than with the others. Iodine and iodoform naturally do not suit well with the starch and dextrine pastes. Chrysarobin and pyrogallol are united with kaolin and gum pastes, but acids in general destroy the adhesiveness of the gum pastes and should not be added to them. Fatty and soapy substances, if commingled in large amounts with these pastes, injure their special properties. Powders are mechanically dusted over the surface of the skin for the purpose of protecting it, and occasionally in order, also, to pro- duce an astringent or anti-pruritic effect. In order to be serviceable, they should generally be rendered impalpable by sifting them care- fully through a fine silk bolting-cloth. They are composed of starch, magnesia, lycopodium, bismuth, boric acid, camphor, tannin, oxide of zinc, iodoform, salicylic acid, and similar substances. The articles sold by grocers as "Oswego Gloss Starch" and "Corn Starch Farina" are usually much more finely bolted than the dusting-powders extem- poraneously prepared by chemists. As absorbent powders, the starchy substances are open to the objection of forming little pasty rolls or "cakes," when wet with serum or sweat. Lycopodium, which is seen under the microscope to consist of irregularly globular pollen sporules, never behaves in this way, and is, for that reason, deservedly popular. Dr. Faithful, of Australia, has recently suggested the preparation of medicated powders by first dissolving them in alcohol, ether, or chloroform. The solution is then mixed with starch or French chalk. Evaporation of the menstruum is conducted without artificial heat, and a fine, medicated starch or chalk powder results. Plasters are employed when it is desired to exert a more or less continuous effect upon the skin, and are thus necessarily consistent and desirable. The resin plasters are less useful in skin diseases, because more irritating than the lead plasters. Unna's plaster-mulls are described below. The mercurial plasters are useful, especially in syphilitic lesions of the skin. A valuable addition to the list of methods for applying medicated ointments to the skin has been devised by Unna. His Salve-muslins 84 GENERAL THERAPEUTICS. or salve-mulls are strips or bandages of muslin thoroughly impreg- nated and thickly spread with ointments medicated by almost every desirable substance, from the oxide of zinc to tar, thymol, salicylic acid, and mercury. They are elegantly made, and, when imported to this country, surrounded by impermeable tissue, so as to be quite fresh and sweet when used. They are efficacious, and, as a rule, well liked by patients. The chief objection to their general employment in this country is the expense of importation. The author has used them with great advantage in skin diseases of the exudative class affecting the extremities. Unna's "Plaster-mulls" seem to be less useful. They are plasters thinly spread on gutta-percha cloth, and manufactured with a wide range of medicinal constituents. They serve a good purpose in the protection of parts of the skin exposed to friction. Lanolin, or wool-fat, was first introduced as a salve-base by Dr. Oscar Liebreich, of Berlin. It is a peculiar substance obtained from keratinic tissues, and contains cholesterin fat instead of glycerine, with but thirty per cent, of water. It has a bright yellowish color, a distinct odor of the sheep, and is neutral, never, when pure, acid in reaction. The Berlin specimens that first came to this market required the addition of from ten to twenty per cent, of an ordinary fat in order to overcome the consistency of the lanoline. But, in 1886, Prof. Liebreich called attention to a lanolinum purissimum which he had substituted for the former, and which, being free from cholesterin compounds, required no such fatty addition. This substance seems now to have outlived the period both of extravagant praise and denunciation. It is readily absorbed from the surface of the skin, and, either pure or medicated, may be reo-arded simply as a useful addition to the bases of ointments for employment upon the skin. The Oleates of zinc, mercury, copper, lead, and other metals have been employed with advantage in the topical treatment of disorders of the skin. Of these, the oleates of mercury and lead are decidedly the most valuable. The latter is represented by Hebra's white diachylon ointment. The oleate of mercury is serviceable in syph- ilitic, parasitic, and other disorders. Collodion and Traumaticine are employed for the purpose of applying a remedy to the skin, and at the same time protecting or contracting the surface to which the application is made. Traumati- cine is the name given to a solution of gutta-percha in chloroform, in the proportion of ten per cent. In this way bismuth, cantharides, sulphur, chrysarobin, oxide of zinc, white precipitate, iodine, and other substances may be with advantage applied to the surface, and the action of each definitely limited to the margins of a single patch of disease. The several varieties of Tar, crude and distilled, together with its derivatives, occupy an important place among efficient topical agents. In general, they seem to exert upon the epidermis a local influence, which extends more deeply as the remedy is continuously applied. GENERAL THERAPEUTICS. 85 At times, both irritative and inflammatory effects are thus induced ; and when absorption from the skin occurs, even systemic intoxication. Pix liquida, or the oleum picis, is the favorite article of this group with most American physicians ; but the oleum cadini or oil of juniper, and the oleum rusci or oil of birch, are rather more generally employed by experts. The last-named, found in purity and abun- dance, and to be had at a low price in our own markets, is recom- mended above the others. In Vienna the distilled oil is preferred ; but there is good reason to believe that the crude oil is decidedly more efficacious. The skill of a physician entrusted with the management of a dis- ease of the skin might almost be measured by his success in the use of tar. He who has not had experience in its employment is urgently advised to select one member of the tar family and learn thoroughly how to apply that, singly and in combination, either in lotion or salve. Properly employed, it will favor involution of lesions, less- ening hypersemia, infiltration, scaling, and discharge. It serves admirably as an antipruritic. As indicated above, it may, however, produce severe inflammation of the skin. To produce the benign or emollient effects of tar, it is best mixed with some soothing or astringent powder, and with this end in view nothing is better than chalk. Spender's hints 1 for making such an ointment are admirable. Finely levigated chalk is strewed into melted lard in a stone jar, the whole being stirred till it is cold. Then at first the smallest quantity of tar sufficient to make a brownish smear of color is added to the quantity of salve employed for use. This color can be successively deepened at will. Auspitz advises the use of the tars in a pure state, applied in very small quantities with a strong bristle-brush and well rubbed in. In combination with one of the most valuable of all substances for topical use in cutaneous therapeutics, viz., sulphur, tar enjoys a special reputation. The Wilkinson salve modified (q. v.) represents such a combination. Ichthtol, fish-oil, sulpho-ichthyolate of sodium or ammonium, introduced to the profession by Dr. Unna, is the distillate of a bitu- minous and sulphurous deposit of petrified fishes and marine fossils found in Tyrol. Its chemical formula is C 26 H 36 S 3 ]Sra 2 6 . It has a tarry appearance, odor, and consistency. It is soluble in water, partly so in ether and alcohol, and can be incorporated in any desired proportion with fat, vaseline, and lanolin. It has been used both pure and diluted; and several proprietary articles (plasters, soaps, salves, and medicated cotton) are sold in the market. It has been used both at home and abroad in cases of leprosy, pruritus, acne, sycosis, eczema, psoriasis, and a number of other cutaneous disorders. 2 It is used in solutions and salves of from ten to twenty per cent, strength. As before stated, it is also administered internally, more 1 Practitioner, June, 1883, p. 402. 2 See Baumann and Schotten : Monatsh. f. Prakt. Derm., 1883. Unna : same journal, 1882; Deut. med. Zeit., 1883. Samml. klin. Vort., 1885 ; Lorenz; Deut. med. Wocn., 1885 ; Stehvagon and Pif- fard : Journ of Cut. and Ven.*Dis., 188*5 ; Zeisler: Chicago Med. Journ. and Exam , 1886. 86 GENERAL THERAPEUTICS. particularly in the management of rheumatism, in doses of from fifteen to twenty drops. Ir doc- not seem to have a disturbing effect upon the stomach. This substance has not yet been employed to an extent sufficient to establish its position firmly as a remedial agent in diseases of the skin. Personal employment of it in a series of different cases, the greater Dumber being of eczema and lupus, led to the impression that it was not superior to tar in a therapeutic sense. It will probably secure a place among the useful article- in this list. Unpleasant results have been reported as following its application in a single instance (Sinclair). A four-months old infant sank into a state of stupor two hours after its head and limbs were smeared with a salve composed of one part of ichthyol to five of vaseline. A group of substances which occupy a therapeutical position inferior to the tars, but which serve an important end in the management of cutaneous diseases by the production of similar effects, are, carbolic acid, creasote, salicylic acid, benzol, naphthol, iodol, chrvsarobin, pyrogallol, resorcin, and jequirity. 'Resorcin in ointments of the strength of five to twenty per cent, serves as an antipruritic and alterative. Dr. Stelwagon reports an anodyne effect following its use. This same experimenter has modified Ihle's formula by adding a drachm (4.) of resorcin to one to two drachms (4.-8.) of castor-oil, five minims (0.33) of Peru- vian balsam and four ounces (128.) of alcohol, for use in alopecia and seborrhoea of the scalp. It is a valuable parasiticide in lotions of the strength of from five to ten per cent. Naphthol, or /3 naphthol, as it is termed chemically, first intro- duced by Kaposi, has fairly retained its place in the list of efficient topical remedies. It is chiefly valuable in scabies, but has also been used in the management of eczema, psoriasis, and other exudative affections. Van Harlingen 1 has found it answer well in seborrhoea of the scalp. Xeisser has described renal disorders as resulting from its use in children, but MM. Josias and Nocard 2 report that in ordi- nary medicinal doses it is harmless. The fact that the naphthol preparations are odorless and do not stain the skin is to be set down in their favor. Jequirity (abrus precatorius), employed by ophthalmologists for the purpose of inducing artificial inflammation of the conjunctiva, has been used by Dr. Shoemaker 3 in the management of lupoid and other ulcers. One part of the cleansed, decorticated, and bruised grains, macerated for twenty-four hours, and reduced by rubbing in a mortar to a smooth paste, was added to sufficient water to make four parts. This emulsion was used for local application. Sulphur, employed popularly chiefly as a laxative or for the local treatment of scabies, has also a deserved reputation in cutaneous therapeutics, as an external agent in a wide range of non-parasitic i Amer. Journ. of the Med. Sci., Oct. 1883. - Ann. de Derm, et de Sypu., May, 1885. 3 Lancet, Aug. Is*--), p. 186. » GENERAL THERAPEUTICS. 87 disorders. Hebra once regarded it as valueless in eczema, but his opinions on this point are not now generally accepted. The precipi- tated sulphur is to be preferred to the other compounds of the phar- macopoeia. It may be mechanically incorporated with salve-bases or chemically combined with vaseline and other petroleum products, a process by which experiments have led the author to believe its therapeutic value is not increased. It is also applied after mechani- cal union with various substances as a lotion. It is irritating to the acutely inflamed skin, but much better tolerated in conditions of subacute or chronic exudation than the tars. Mercury and its compounds are of value in the local treatment of many disorders of the skin, syphilitic and not syphilitic. Corrosive sublimate as a parasiticide is of great importance in the treatment of several cutaneous disorders due to the presence of bacteria, as, for example, lupus vulgaris. Calomel, the oxides, iodides, and the ammonio-chloride, are chiefly used in the form of ointments, but the black wash, prepared with the mild chloride, is of great value in eczema. Piffard 1 has called attention to the fact that the officinal ointment of white precipitate is made with pure lard instead of as formerly with lard and wax ; and to this change, tending to hasten the absorption of the mercurial, he attributes some late failures with this admirable salve. Disagreeable dermatitis followed by scaling has been reported to follow its use in the strength of forty grains (2.66) to the ounce (32.) by Mr. W. E. Green, of Londou. 2 Chloral-camphor and Phenol-camphor have value chiefly as antipruritics. The former is obtained by rubbing together the hydrate of chloral and gum-camphor (Bulkley) till they form a clear liquid of pungent odor. Phenol-camphor is made by gradually adding camphor to melted crystals of carbolic acid, a colorless liquid resulting having the fragrant odor of camphor without that of the acid. It is a useful local anaesthetic agent, being insoluble in water, but freely soluble in chloroform, ether, and alcohol. Many Agents are employed upon the surface of the integument to produce in various degrees a Caustic or Destructive effect. Among these may be named the thermo-cautery (Paquelin knife), galvano- caustic apparatus, the mineral acids and alkalies, ethyla^e of sodium, arsenic, chloride of zinc, several mercurial compounds, acid nitrate of mercury, bichloride of mercury, chloride of antimony, sulphate of copper, and nitrate of silver. Several of these substances in weak solution are employed as milder agents for the production of irritative, or even various inflammatory, effects. To the latter class should be added iodine in tincture, chloroform, tartar emetic, croton oil, and cantharides. These destructive effects are of advantage in the treatment of dis- orders of the integument due to parasites, either animal or vegetable. Of those employed for this purpose, and not mentioned above, may be named petroleum and staphysagria, for the destruction of lice ; i Journ. of Cut. and Ven. Dis., Oct. 1866. 2 Brit. Med. Journ., 1885. bo GENERAL THERAPEUTICS. sulphur, styrax, and balsam of Peru, for the destruction of acari; sulphur and its compounds, and a number of derivatives from tar' for the destruction of vegetable parasites. A variety of Surgical and other Appliances are found useful as adjuvants in the treatment of skin diseases. They may be employed to support, protect, or compress the surface, or merely to aid in 'the retention of dressings or external medicaments. Thus the ordinary roller bandage is applicable to many portions of the body; the sus- pender, or suspensory bag, over the scrotum; elastic or inelastic Stockings to the feet and legs; kid, rubber, and thread gloves to the feet and fingers ; and various skull-caps, face-masks, and mittens are employed in the case of infants and children to protect affected surfaces from the dangers of scratching. It is an axiom in dermatology that a salve is worth far more to the patient when it is spread on muslin, and thus retained in contact with the skin, than when it is merely smeared or rubbed over the surface. It is this important feature which has doubtless contributed so largely to the reputation of Unua's salben-mulle, or salve-muslins. In order to secure the retention of such salve-spread muslins in con- tact with the surface, the common muslin roller, which exercises more or less compression, is inferior to the light and more pervious cheese- cloth bandage. This is especially true when the' dressing is made by the patient, who is, in general, far less expert than either the trained nurse or the physician. Apart from the surgical apparatus required for ablation of tumors or other severe operations, a number of instruments are required for the daily use of the dermatologist. Among these may be named : A set of variously sized dermal curettes. These sharp-edged spoons are for erasion of the surface, and should consequently have in each a fenestrum large enough to permit the escape of all collected sub- stances from the floor of the spoon. Epilating forceps with easy springs and smooth blades meeting in perfect apposition. A set of Piffard's comedone extractors, provided at each extremity with a differently sized, minute, spoon-shaped, and perforated bowl, the convex surface of which is pressed over the comedo with the orifice immediately over the black head of the plug. This is a great improvement over the old-fashioned comedo extractor shaped like a watch-key, and the discomfort to the patient is by its use greatly reduced. A set of half-inch and four-inch leuses for examining the surface of the skin. Needle-holders with light handles for firmly grasping needles for use in opening pustules, etc. The latter should be, some of them flat with a double-cutting edge, others rounded neatly on an emery- wheel, and all of them very carefully disiufected if used more than once. Too many precautions cannot be taken in the practice of GENERAL THERAPEUTICS. 89 dermatology, with respect to the disinfection of all instruments made to penetrate the skin. Fig. 18. Irido-platinum needle. Fig. 19. Milium needle. Fig. 20. Scarifying spud. Fig. 21. Epilating forceps. Fig. 22. Piffard's grappling forceps. Fig. 23. Skin grafting scissors. Fig. 24. Piffard's cutisector. 90 CLASSIFICATION Fig. 25. Dermal curettes. Fig. 26. Hess's glass pleximeter. For observing the skin under pressure. Fig. 27. modification of Unna's comedo extractor. Fig. 28. '^4 OF REAL SIZE. Keyes' cutaneous punch. Probes, exploring needles, fine dressing-forceps, delicate straight and curved scissors, and other instruments from the ordinary pocket- case of the surgeon, are indispensable. The instruments required for use in connection with the galvanic battery are enumerated in the chapter on hirsuties. For detection of different degrees of temperature at the surface, the author has employed for several years the thermo-electric differential calorimeter. The thermopiles of this apparatus act upon a galva- nometer needle suspended by a single filament of the cocoon of the silk-worm, and it is thus as sensitive as is required for the most delicate observations. VII. CLASSIFICATION. The numerous attempts which have been made to classify diseases of the skin according to their nature and relations, have been a response to the generally recognized demand for a systematic arrange- ment of all scientific facts. As regards dermatology, not only have CLASSIFICATION. 91 these attempts been numerous and based upon different principles, but the results which they have accomplished have been in the highest degree divergent. No single classification yet devised has hitherto secured general acceptance. While it is certain that no one of them has been perfect and that each has exhibited defects, it is equally true that of the larger number each has possessed some merit of its own. No perfectly satisfactory classification of cutaneous diseases can be generally accepted till the knowledge of diseases of the skin has been greatly enlarged. One of the most satisfactory of the systems thus far proposed is that of Hebra. By it cutaneous disorders are arranged in the following nine classes : Class I. Disorders of Secretion. Class II. Hyperemias. Class III. Exudations. Class IY. Hemorrhages. Class Y. Hypertrophies. Class YI. Atrophies. Class VII. New Growths. Class VIII. Neuroses. Class IX. Parasites. Since this classification was devised by Hebra, none has been pro- posed which compares in ingenuity with the arrangement by Auspitz of the diseases of the skin into natural groups. The principle of this classification is to place together those diseases and groups of diseases which present a clinical unity ; the general pathological process being the predominant characteristic for selection, and individual patho- logical characteristics, such as symptoms, localization, anatomical peculiarities, etc., are only brought thus predominantly forward when coinciding with the real nature of the class, group, or disease in question. 1 Auspitz's nine classes are: 1. Simple Inflammatory Dermatoses ; 2. Angioneurotic Dermatoses ; 3. Neuritic Dermatoses ; 4. Stasis Dermatoses; 5. Hemorrhagic Dermatoses; 6. Idioneuroses ; 7. Epi- dermidoses ; 8. Chorio-Blastoses ; 9. Dermatomycoses. . Under these classes, by the aid of divisions and subdivisions, an elaborate scheme is presented, which embraces fully not only all cutaneous diseases, but all pathological processes recognized in the skin. This system, accepted with modifications by Hans Hebra, 2 has unquestionably been followed by a greater advance in the nosology of cutaneous medicine than any of those which have been proposed since Hebra first offered his. 3 1 System d. Hautkrankheiten. Wien, 1881. 2 Die Krankh. Veranderung. der Haut. Braunschweig, 1884. 3 An exceedingly ingenious and comprehensive scheme of classification of diseases of the skin, embracing most of the principles upon which the best of previous classifications were based, was pre- sented by Dr. E. B. Bronson, of New York, at the meeting of the American Dermatological Association, in August, 1887. 92 CLASSIFICATION. Auspitz's classification is, however, open to various objections on the part of the student of dermatology. It is elaborated to the extent of setting the names of some diseases in more than one family; and is, hence, confusing to the beginner. It is bettor adapted to the needs of the expert than of the young student, for it introduces to the study rather of morbid processes in the skin than of the com- plexus of those processes which are recognized in disease. Whether the principle of classification be anatomical, etiological, or pathological ; whether it be based on the processes actually occur- ring in the skin, or on those deeper factors and forces operating oen- trifugally upon the skin, and on which that organ depends for all its functions and even its existence ; whether it proceed etiologically from the causes which are immediate, or those which are remote, it is easy to see that, as knowledge in each of these directions enlarges, the exact position of any one disease in any given classification must be rendered insecure. Never was this observation more suggestive than at this day, when the pathogeny of numerous skin disorders is revealed in the light thrown on the subject by the discovery of new and hitherto unknown inferior organisms. Indeed, to this last cause, awaking grave doubts as to the precision of much that was once esteemed fact, may be attributed the declining interest in the general subject of classification of diseases of the skin. The earnest discussion of this theme has been practically deferred by common consent to a date when the questions thus suggested can be more satisfactorily answered. Several recent writers have actually contented themselves with an alphabetical arrangement of the names of skin diseases, 1 as an order useful simply for reference. The classification observed in this edition of this work is that adopted by the American Dermatological Association, August 29, 1878, and revised by the same body, August 28, 1884. It is that of Hebra modified. Its claims on American students cannot be ignored. It has been presented and adopted by the recognized expo- nents of Dermatology in America. It has been made for nearly ten years the basis of dermatological study in some of the leading medical schools of this country. It is not claimed for it that it is a perfect system, but one in which the names of many disorders have merely a provisional position. It will, without question, be revised from time to time, by the body which first gave it to the world, and which by its aid has fostered the study of cutaneous medicine in America as it was never fostered before. It is employed here as a valuable, convenient, and accepted nosological scheme, in which, it is distinctly admitted, a rearrangement of many terms is demanded from year to year by the advances of science. 1 Van Harlingen : Handbook of the Diagnosis and Treatment of Skin Diseases. Phila., 1S34. CLASSIFICATION. 98 CLASSIFICATION OF DISEASES OF THE SKIN ADOPTED BY THE AMERICAN DERMATOLOGICAL ASSOCIATION. -Class I. Disorders of the Glands. e. pustulosum. 1. Op the Sweat Glands. /. rubrum. Hyperidrosis. g. squamosum. Sudamen. Prurigo. Anidrosis. Acne. Bromidrosis. Acne rosacea. Chromidrosis. Sycosis. Uridrosis. Impetigo. 2. Of the Sebaceous Glands. Impetigo contagiosa. Seborrhcea : Impetigo herpetiformis. a. oleosa. Ecthyma. b. sicca. Pemphigus. Comedo. Cyst: Olass III. Hemorrhages. a. Milium. Purpura : b. Steatoma. a. simplex. Asteatosis. b. hemorrhagica. Olass II. Inflammations. Exanthemata. Olass IV. Hypertrophies. 1. Of Pigment. Erythema simplex. Erythema multiforme : Lentigo. Chloasma. a. papulosum. b. bullosum. c. nodosum. Urticaria. pigmentosa. 2. Of Epidermal and Papil- lary Layers. Keratosis : a. pilaris. b. senilis. Dermatitis i 1 a. traumatica. b. venenata. c. calorica. d. medicamentosa. Molluscum epitheliale. Callositas. Clavus. Cornu cutaneum. Verruca. e. gangrenosa. Verruca necrogenica. Erysipelas. Furunculus. Anthrax. Phlegmona diffusa. Pustula maligna. Herpes simplex. Herpes zoster. Dermatitis herpetiformis. Psoriasis. Pityriasis maculata et cir- cinata. Dermatitis exfoliativa. Pityriasis rubra. Lichen : Nsevus pigmentosus. Xerosis. Ichthyosis. Onychauxis. Hypertrichosis. 3. Of Connective Tissue. Sclerema neonatorum. Scleroderma. Morphoea. Elephantiasis. Rosacea : a. erythematosa. b. hypertrophica. Frambcesia. a. planus. b. ruber. Eczema : Olass V. Atrophies. 1. Or Pigment. a. erythematosum. Leucoderma. b. papulosum. c. vesiculosum. Albinismus. Vitiligo. Canities. d. madidans. i Indicating affectioDg of this class not properly 2. Of Hair. 'included under other titles. Alopecia. 94 CLASSIFICATION Alopecia furfuracea. Alopecia areata. Atrophia piloram propria. Trichorexis nodosa. 3. Of Nail. Atrophia unguis. 4. Of Cutis. Atrophia senilis. Atrophia maculosa et striata. Class VI. New Growths. 1. Of Connective Tissue. Keloid. Cicatrix. Fibroma. Neuroma. Xanthoma. 2. Of Muscular Tissue. Myoma. .">. OF VEB8ELS. Angioma. Angioma pigmentosum et atrophicum. Angioma cavernosum. Lymphangioma. 4. Rhino-scleroma. Lupus erythematosus. Lupus vulgaris. Scrofuloderma. Syphiloderma : a. erythematosum. b. papillosum. c. pustulosum. d. tuberculosum. e. gummatosum. Lepra : a. tuberosa. b. maculosa. c. amesthetica. Carcinoma. Sarcoma. Class VII. Neuroses. Hyperesthesia: a. pruritus. b. dermatalgia. Anaesthesia. Class VIII. Parasitic Affections. 1. Vegetable. Tinea favosa. Tinea trichophytina : a. circinata. b. tonsurans. c. sycosis. Tinea versicolor. 2. Animal. Scabies. Pediculosis capillitii. Pediculosis corporis. Pediculosis pubis. DISEASES OF THE SKIN. CLASS I. DISORDERS OF THE GLANDS. In this class of disorders are grouped all the functional disorders of the sweat or coil-glands, the sweat pores, and the sebaceous glands. These disorders may be betrayed in quantitative or qualitative changes in the secretion, or in retention of the latter in the whole or in a part of the secretory apparatus. When a disease of the skin ceases to be purely functional in type, and is accompanied by an exudative process, glandular or periglandular in situation, such disease is properly classed with another and in this particular related group of affections. 1. Of the Sweat Glands. Hyperidrosis. Gr. imep, in excess ; vdup, water. Hyperidrosis is an exaggerated quantitative effusion of sweat, the secretion accumulating in visible drops upon the surface of the skin. Symptoms. — This condition, also termed Idrosis, Hydrosis, Ephidrosis, Sudatoria, Polyidrosis, and Hyperhidrosis, may be physiological as the result of active exertion in a medium of high temperature ; or it may be pathological in character, and in the latter case be either general or partial. General sweating to a pathological extent occurs chiefly in the obese, but also in those who are the subjects of constitutional disease (phthisis, the various febrile disorders, etc.). It is the fertile source of the various forms of intertrigo, sudamina, and miliaria. Local hyperi- drosis is the exaggerated quantitative effusion of sweat limited to certain definite portions of the skin, as the palms, soles, dorsa of the hands and feet, the interdigital spaces, the genitals, the axillse, and temples. In such cases the secretion occurs moderately or greatly in excess, varying in this respect somewhat in different degrees of temperature, 96 DISEASES OF THE SKIN. and of rapidity of the circulation ; is occasionally, but not commonly, accompanied by fetor; and always occurs to a marked extent. It may involve one or both sides of the body, being generally symmet- rical at the extremities, and asymmetrical* upon portions of the face. [ts topical expression may be studied in the hands, which are con- tinually moistened, clammy, or dripping with fluid within a brief time after the most careful drying of the parts. In the case of a woman, the instincts of whose sex prompt her to take such precautions, the dress is constantly protected from contact with the macerated palms by a handkerchief or similar article which is always in readi- ness. The disadvantages thus arising in individuals of both sexes who are engaged as tradespeople, artists, hand workers, etc., can be readily estimated. In women of social position, no small coin- plaint is made of the disagreeable result produced after wearing kid gloves for even a short time, the material of which is soon soiled by its complete saturation with the secretion from the skin. With and without this local excess, occurs the hyperidrosis of the feet, aggravated by the mechanical force of gravity and the need of constant covering. The stockings and the leather of the boots, shoes, or gaiters are saturated with the secretion, and become rapidly subject to chemical alteration. There is usually an offensive odor of the region, originating partly in the primary' fetor of the secretions them- selves, and partly in the subsequent chemical decomposition of the latter, rapidly progressing under the influence of the soiled and often stinking investments of the feet. The integument, constantly macerated, may become both painful and tender ; very rarely there is vesiculation or exfoliation of patches of sodden epidermis. When the genitals are involved, especially in the male, erythema and intertrigo are the frequent results. Etiology. — The disease may be in rare cases congenital. In others it is associated in one person with disorders not apparently related to it. The author has at present in hospital a woman, twenty-four years of age, affected with severe tylosis of the feet, from which are exfoliated extensive lamellated casts of the soles. She also has tvpical hyperidrosis of the hands. In no portion of the nervous system has a localized centre for excito-sudoral or inhibitory effects been recognized. Traumatisms, gliomata, gummata, scleroses, and other lesions affecting the cerebrum, medulla, cord, ganglia, and trunks of the sympathetic nervous system have been followed by local and general hyperidrosis, but they have all repeatedly failed to induce such morbid sudoral symptoms, while a fit of anger or sudden fright has been as conspicuously effective as any. In short, the predominant influence of the nervous system in an etiological sense must be admitted here as in physio- logical sweating : and the sympathetic branches of that system must be assigned the greater influence for the most cases. A paralysis or paresis of the sympathetic is held to explain the occasional coincidence of pulmonary and cardiac disorders, with either general or partial HYPERIDROSIS. 97 excessive sweating. Compression of the sympathetic by adenomata, aneurisms, carcinomata, etc., has been followed by marked symptoms of this disorder. The disease is encountered in individuals of both sexes, and in all ages and degrees of general health, as also in those who are and those who are not careful as to cleanliness. There is reason to believe that the facial asymmetrical hyperidroses associated with migraine, neuralgias, hemicrania, etc., are etiologically and pathologically distinct from the similar symmetrical affections of the hands and feet. The latter certainly occur with conspicuous frequency in young women who are the subjects of hysteria, chloro-ansemia, some form of dysmenorrhoea, or cardiac trouble. In one young svoman under the author's observation, there was an habitual pulse of fifty-five to the minute without dicrotism, the patient being in other respects well. Pathology. — Robinson, who has examined a number of sections from the palm of the hand, failed to detect any abnormal feature either in the glands or the epithelium. The disorder is to be regarded as purely functional ; and any anatomical changes in the coil-glands or sweat-pores are probably accidents of such derangement of function. Treatment — When universal, hyperidrosis is to be treated inter- nally by the aid of such remedies as are indicated by the general condition of the patient. The various ferruginous tonics, mineral acids, arsenic, strychnia, quinine (the latter particularly when, as is often the case, a malarial affection is responsible for the disorder), and ergot, with both belladonna and atropine, are all of unquestionable value. Even though but temporarily serviceable, belladonna and atropine are well used at the outset of most cases. Aconite, jabor- andi and pilocarpine, white agaric (agaricine is recommended in doses of one-sixth of a grain (0.01 1), repeated as required), carbolic and salicylic acids may be named as in the second rank. External treatment is often promptly efficacious, and can rarely be neglected in any case. The simplest method , is by wiping, not washing, the surface until it is dry, and applying the dusting- powders, such as lycopodium, talc, salicylic acid, boric acid, bismuth, magnesia, hydrate of chloral one part to five or six of starch, and starch itself, the chief objection to the latter being its tendency to form cakes or rolls after its union with the sweat. Alternately with these, or in lieu of them, baths or lotions' may be employed, aqueous or alcoholic, and medicated with corrosive sublimate, tannic acid, zinc sulphate, alum, permanganate of potassium, or the sea salt now sold in packages for domestic use. Dr. G. H. Fox 1 advises a lotion containing one part of quinine to one hundred of alcohol. Van Harlingen recommends the use of juniper tar or carbolic acid soap with the bath, as alone sufficient to relieve some cases. For hyperidrosis of the feet, the treatment by the method of 1 Journ. of Cutan. and Ven. Dis., 18S5, p. 24 7 98 DISEASES OF THE SKIN Hebra has, deservedly, high repute. It consists in neatly and com- pletely enveloping the entire foot and toes separately, after thorough washing and drying, in strips of cotton cloth over which is spread to the thickness of the blade of a common knife, the unguentum diachyli albi elsewhere described. This latter is made by boiling one part of the best litharge with about four parts of pure olive oil, to which a little water is added while the materials arc stirred together over a slow fire. The parts are well bandaged, and the patient either remains subsequently at rest or pursues his vocation, wearing over the feet, shoes and stockings which have not been previously used. In twenty-four hours, the feet are redressed with- out washing, after dry rubbing with charpie and a dusting powder. This is repeated daily for ten to twenty days, after which a dusting powder may be substituted for the local dressing. A parchment- like desquamation of the epidermis in thick, yellowish-brown lamella? occurs, beneath which an epidermis is formed, new and at first tender, but apparently normal. When the latter has lost its tenderness, the feet are for the first time washed with water. In case of failure, the routine of treatment is, as often as necessary, again carried out. It is scarcely necessary to add that no ill effects are known to have resulted from the therapeutic measures adopted for checking a local hyperidrosis. For the diachylon salve may be substituted tar, ichthyol, or naphthol ointments. Fredericq employs finely jDulverized tartaric acid, applied at first with some caution, and always in small quanti- ties. Stewart first bathes the feet in hot water and then soaks them for a few moments, and once only, in a solution of the permanganate of potassium, four to six grains to the ounce, (0.266-0.4 to 32.), after which, the plaster selected for use may be applied as directed above. Legoux orders pediluvia of tar water twice daily, for three days, followed by a painting of the feet with a solution of the per- chloride of iron. Morrow 1 recommends foot-baths in the extract of pinus canadensis, followed by the application of boric acid, or sali- cylic acid, mixed with lycopodium. Lastly, Brandon, experimenting on the permeability of the skin to ethers and gases, claims to have solved the problem of local treatment with a " liquor anti-hidror- rhoicus," prepared from the chloric ethers. ProcpiOHis. — The future of any case of hyperidrosis is uncertain. The disease, whether local or general, may spontaneously disappear, recur, be promptly amenable to treatment, or prove obstinate to all therapy. Dr. Myrtle 2 reports the case of a male patient, seventy- seven years old, who sweat to death after repeated recurrences of severe hyperidrosis, and after temporary relief from the use of Fowler's solution. 1 See his ivsume of this subject in the Journ. of Cutan. and Ven. Dis., vol. v. p. 68. 2 Medical Press, Feb. 25, 1S86. SUDAMEN. 99 Sudamen. Lat. sudor, sweat. Sudamina are discrete, superficially seated, millet-seed sized and larger, translucent vesicles, resembling seed-pearls. Symptoms. — In this disorder, also termed Miliaria Crystallina, the lesions are thickly agglomerated, but discrete, transitory, and translu- cent, pin-point sized vesicles, resembling dew-drops or seed-pearls, upon the surface of the skin, often requiring the touch to define their real character. They are usually limited to certain regions of the body, as the trunk, and here more generally upon the face and sides of the belly, and the iliac regions, though they may occur upon any part. Their course is rapid, both in evolution and involution, and their sequela? are exceedingly delicate desquamative flakes, the thin roof-wall which originally covered the sweat-drops having been lifted from the superficial stratum of the horny layer of the epidermis. They contain each a droplet of sweat, which is removed by evapora- tion. They are usually preceded by an attack of pruritus, and may follow the hyperidrosis of systemic debility, enteric and continued fevers, phthisis, inflammatory rheumatism, pneumonia, and other asthenic conditions. They may also result from violent exercise, the elevated temperature of the summer season, flannel underclothing, vapor baths, and the application of wet and hot cloths to the surface of the skin. The lesions are the result of the accumulation of sweat between the most superficial layers of the stratum corneum, in high tempera- tures of the body, or of the medium by which it is surrounded, and usually in states of adynamia. They may hence occur at all ages, and in both sexes. Eobinson states that they form rapidly on the face of laundresses, and in women from the thirty-fifth to the fiftieth year of life, where also they are isolated and disappear slowly. Three forms of sudamina have been described: (a), sudamina alba ; (b), sudamina rubra ; and, (c), sudamina crystallina. The last-named is the only form to which the term sudamen is properly applied, since it alone of the three designates a purely functional derangement of the sweat-secreting apparatus. The first term, sudamina alba (miliaria alba), is applied to lesions where there is maceration of the vesicular wall and the contents be- come opalescent. This is rare. The second term, sudamina rubra (miliaria rubra, lichen tropicus, "prickly heat"), is applied to in- flammatory lesions which may accompany profuse sweating. These are numerous pin-point to pin-head sized vesicles surrounded by a reddish halo, or papules of the same dimensions, or the two lesions commingled, almost invariably accompanied by hyperidrosis, though the latter may be absent in high temperatures. The marked tingling, pricking, and burning sensations by which they are accom- 100 DISEASES OF THE SKIN. panied, arc often in the highest degree distressing, and may solicit rubbing of the affected part, though the scratching elicited by severe pruritus is not common. Minute crusts may form after vesicular rupture. The attack may be mild or quite severe, and last for a few days, or for as many weeks or months, as the result of continuous aggravation, or of the production of new crops of lesions after each recurrence of the cause. It is not rarely complicated in obese indi- viduals, by all varieties of intertrigo and eczema, The sudamina crystal Una are, however, the sole lesions which may be properly considered in this class of affections. They are always free from all inflammatory symptoms, presenting a limpid, dew-drop-like aspect that is characteristic. Etiology. — The disease is induced by excessive sweating ; often in consequence of an elevated temperature; also, however, as a result of a systemic asthenia, as indicated above. Pathology. — Dr. Robinson has studied the anatomy of the sudamen with special care. Its contents are pure sweat without admixture of lymphoid corpuscles. The fluid collects between the lamina? of the deeper part of the corneous layer. The author supposes a rupture of the wall of the sweat-duct, but with our present knowledge of the a latomy of this part of the skin, we can see in his illustrations the obliterations merely of the sweat-pore by a sudden effusion of watery fluids toward the epidermis, which pass with moderate pressure through the wall-less sides of the pore into the spaces between the epithelial cells, where a chamber is readily formed. This is made clearer by the author's exact description of actual dilatation of the duct of the coil-gland, where there is "not an escape of sweat into the neighboring tissue," which he recognized in the corium. The sudamina exhibiting this peculiarity appear on the face, chiefly of women. Diagnosis. — No difficulty can arise in making a diagnosis, if the peculiar characters of the sudamen be kept in view. All pustular lesions have different contents; all bullous lesions are larger; or seated on an engorged base; or lack the limpid clearness of the sudamen, because, however transparent the contents, they are mostly covered by a thicker and less transparent roof. The halo about the lesions of miliaria rubra, or their rosy-pinkish shade will determine their character. In varicella the lesions are chambered. Treatment. — Only the simplest treatment is required. The lesions may be dusted with one or several of the dusting powders, such as starch, lycopodium, or boric acid, named in the chapter on General Treatment of Cutaneous Diseases. The general treatment is that indicated by the condition of the patient. Miliary Fever, or the suette miliaire of the French, is an epidemic disorder, accompanied by sweating and a cutaneous exan- them. Pineau 1 gives a description of the disease as it occurred in epidemic form in the island of Oleron, where, of one thousand patients i ArcUiv. Geiu-r. de M<5d., Jan 1882, p. 25, ANIDEOSIS. 101 affected, between one hundred and fifty and two hundred perished. The eruption appeared in the form of hyperaamic maculae, disappearing under pressure, after which there rapidly formed myriads of reddish or whitish, grouped, unequally sized, and acuminate papules, rising from a whitish and macerated surface. Among these were inter- spersed lesions of sudamina. The region of the face was not spared, and the conjunctiva? were occasionally affected. In the course of from two to four days, pin-head to bean-sized, varioliform but non- umbilicated pustules formed in the site of some of the papules, the contents of which disappeared by resorption, the final lesions pre- sented being large, flat, reddish papules, the skin, of the face particu- larly, becoming generally reddened and. swollen. In the course of from ten to twelve days, general desquamation ensued with large palmar and plantar losses. Relapses occurred in some cases with general redness of the surface, or with crops of reddish plaques, or yet again with the occurrence of furuncles. The sensations were those of myriads of needles thrust into the skin. The exanthem was accom- panied in some cases by fever, and in others not. In fatal cases death resulted from exhaustion. Geber, however, and other writers believe that the lesions described are not peculiar to any special disease; and deny the possibility of an independent miliary fever. Anidrosis. Gr. a, privitive ; vdap, water. This name is properly applied to those morbid conditions where no sweat is secreted from the surface of the body. The word Hypohidrosis is more exactly used to designate a relative, general or partial decrease in the quan- tity of the sudoral fluid. The former term is, however, often used to include the latter. Complete anidrosis occurs naturally only when the sudoral appa- ratus has been involved in destructive or other changes in the skin (scars, atrophy, etc.). Diminution in the quantity of sweat excreted, or its complete sup- pression, whether general or local, is a symptom of several disorders, but as a separate cutaneous affection has no existence. It is suffi- ciently common in many cutaneous diseases, as, for example, ichthy- osis, psoriasis, and some forms of eczema. But in these, the symp- tomatic character of the anomaly is illustrated by the well-known fact that when the skin is relieved of these cutaneous troubles, the function of sweat secretion is restored. Similarly, in neuralgias and certain forms of paralysis, a circumscribed and temporary anidrosis may be the local expression of the nervous disturbance, precisely as in the case of the asymmetrical hyperidroses. Lastly, there are indi- viduals exhibiting the idiosyncrasy of sweating either not at all or quite imperceptibly in elevated temperatures, phenomena which 102 DISEASES OF THE SKIN. should be ascribed rather to peculiarities In the equilibrium of the heat- exchanging forces, than to congenital deficiency of the sweat-glands. According to Geber, Strauss and Bloch regard the occurrence of hypohidrosis and anidrosis as differential diagnostic symptoms of dif- fuse myelitis and poliomyelitis as against cerebral paralysis. Treatment. — The measures capable of stimulating the sweat secre- tion are: the ingestion of water in quantity by the mouth, the ex- ternal application of heat in a dry or moist atmosphere, and the use of jaborandi or pilocarpine by the mouth or hypodermatic injection. In the anidrosis accompanying cutaneous disease, the indication is always primarily for the relief of the latter. Bromidrosis. Gr. /3pw ( «or, a stench ; vSup, water. This disorder is also termed Bromhidrosis, Osmidrosis, and fetid or stinking sweat. Symptoms. — Here the perspiration is effused in such a state that it can be immediately perceived to possess an unusual odor, or, as Hebra taught was the case with the majority of patients, to be rapidly changed to that condition. It is often associated with hyperidrosis, or may occur quite independently of the latter, and like the latter also be either general or partial. The odor may be either agreeable or disagreeable, having been in various cases compared to that of several flowers and fruits, as well as to that of various stench-emitting animals. Iu this respect the sweat presents a striking analogy to the urine, with which it sustains a close and well-recognized physiological relation. General bromidrosis may be physiological, as in the case of indi- viduals of the African race, or in those of dark skins who are pro- fusely sweating during labor or in exalted temperatures. General pathological bromidrosis is rare. The odors emanating from the person in ulcerating syphilodermata, smallpox, aud other general dis- orders, may, in certain cases, be associated with the sweat secretion, but in others doubtless are connected with the decomposition of patho- logical products of the inflammatory process. The local varieties of bromidrosis affect the regions in which the sweat is oftenest secreted in excess, and its immediate evaporation prevented, as in the axillae, groins, feet, ano-genital, inter- aud infra- mammary regions. In a qualitative sense, every degree of odorous- ness is noted, from that which is merely slightly agreeable or offen- sive, to the most intolerable stench. When complicated by a seborrhoea in situations where the parts are not only warm, moist, and covered by clothing, but also subjected to friction aud long uncleansed, the most intolerable and nauseous fetor is perceived. Sweat may be effused in a normal condition, upou and within the articles of clothing worn, and subsequently generate a stench by chemical changes both in the clothing, and the fluid by which that CHROMIDROSIS. 103 clothing is saturated. This should never be forgotten in the prac- tical management of any case. Treatment. — The treatment of bromidrosis is, in general, that of hyperidrosis already described. Thin 1 has successfully employed stockings and cork soles dried thoroughly, after saturation for hours in a jar containing a solution of boric acid. The efficacy of this, he ascribes to the fact that the odor is the result of the development in the secretions of the bacterium foetidum. An ointment is also em- ployed by him for similar purposes, produced by making a solution of the acid in glycerine, and incorporating it with a fatty basis of white wax and almond oil, making thus a " glycerated cream of boric acid." Armingaud, of the French Academy, has reported excellent results following the subcutaneous injection of three grains (0.20) of the nitrate of pilocarpine, eight of which operations were successful in reducing the abnormal sweating fetor. Clement Hawkins 2 finely triturates fifteen grains (1.) of the red oxide of lead, and to this adds gradually one ounce (32.) of Goulard's extract. This is used as a lotion following a nightly foot-bath containing an ounce (32.) of alum. Fox (1. c.) advises a one per cent, solution of chloral, or potassium permanganate as a topical application. Internally the sodium salicylate has been employed with success in five grain (0.33) doses. Ohromidrosis. Gr. xptifia, color ; vdup, water. By this terra is indicated the condition in which effused sweat exhibits an abnormal color, yellowish, reddish, greenish, or blackish. The term Cyan- hidrosis has been employed to indicate blue sweating. In these cases there has been usually a copious secretion of fluid. Authors have variously attributed the color to the presence of com- pounds of phosphorus, iron, cyanogen, indican, Prussian blue, hsematin, chromogen, and even to parasitic vegetations upon the surface. Women, much more often than men, exhibit the free deposit of pigment upon the skin, and, in view of the admitted rarity of chromiclrosis, the suspicion arises that in some of the cases reported, there was free pigmentation of the surface by which the fluid exuded was immediately stained or colored. Duhring reports a single case of red sweating in a vigorous male patient. Usually, however, the phenomena occur in persons who betray some evidence of impairment of other organs than the skin, or who are debilitated in general health, thus furnishing an indication for their treatment. Babesiu, 3 of Pesth, reports some interesting cases of this disorder, which appear to have been produced by the presence of bacteria. In four patients, three of them women, there was considerable pruritus with pale red to blood-red sweat ; in one, the skin, and hairs were 1 Practitioner, December, 1881, p. 2101. 2 Brit. Med. Journ., May 7, 1881. 3 Lancet, 1862. 104 DISEASES OF THE SKIN. reddened. The axillae were the source of this colored perspiration. In all the cases microscopical examination revealed similar changes. The hairs of" the axilla' were thin, pale-red, brittle : and surrounded with a colloid-looking, rusty, or bright-red sheath, in places of con- siderable thickness and having a rough surface. It consisted of red masses, presenting a radiating striation, more or less confluent, appa- rently proceeding from fibres of the cortex of the hair, or from some broken part of its Burface. The radiating striation was found to he dm' to the aggregation of round or ovoid bacteria, scarcely a micro- millimetre in diameter, which were united in zoogloea masses by a reddish, intermediate substance. Xodular swellings on the hair were produced by the infiltration of the organism between the separated fibrils. The roots of the hair were free from bacteria. The red tint of the sweat was found to depend upon numerous roundish masses of zoogloea. T. ( '. Fox 1 also has reported two eases in which a deep bluish- black pigment was exuded upon the skin of the circum-orbital region. The amorphous granules were found insoluble in almost all hot or cold reagent.-, but displayed a deep blue color when moistened with glycerine, and a purplish hue when dissolved in hot sulphuric acid. The hypothesis, that certain cases described as chromidrosis are really instances of mechanical washing of pigment to the surface in the profuse sweating of the debilitated, is strengthened by the phe- nomena of simultaneous hair coloration. Thus, Prentiss 2 reports the case of a young woman affected with acute cystitis and passing puru- lent urine, wdiose hair, under the influence of profuse sweating in- duced by the action of pilocarpine, changed speedily from a light blond to a nearly jet-black hue. At the meeting of the American Dermatological Association, in 1881, the author exhibited hairs of a middle-aged man which had changed in a night from a grayish-white to a greenish and yellowish-brown hue; and in commenting upon these, Dr. White, of Boston, stated that he had observed several similar cases of hair coloration as the result of profuse sweats. In the year 1884, this same observer reported to the Association the case of a workman in a sugar refinery whose sweat from the left side of the body was of a bright yellow color for several months, and where, though -ought for, no bacteria were discovered. In a case observed by Bergmann, a mycelium was recognized which was subsequently cultivated on paste. Eberth has recognized bacteria in both normal and yellow sweat. Le Roy de Mericourt, first to name this disorder, 3 has also 4 de- scribed a case of rosy sweating in an infant. Fereol believes that in these cases there is actually an absence of sweat and prefers to call the disorder chromocrinia. In all eases, before accepting statements of patients as to the exi.-t- i Med. Press and Circular, Jan. 1, 1881. - Phila. Med. Tines, July 2, 1881. Arch. gen. de Med., Nov. 1857. * La France Medic, 1884. URIDROSIS. 105 ence of symptoms of this character, it is needful to eliminate the possibilities of deceit and accident. Coloring matters received upon the hands may be, either in wilfulness or ignorance, transferred to the surface of the body. The treatment is that of the general condition of the patient ex- hibiting these symptoms. Uridrosis. Gr. ovpov, urine ; vdup, water. While a small amount of urea is to be recognized in normal sweat,, it may, under peculiar conditions, be increased, and, together with urinary salts, deposited upon the skin suria.ce after evaporation of the exuded fluid. Such symptoms have usually occurred either as the result of grave constitutional affections, such as cholera, or of organic renal disease, accompanied by anaemia ; or of the ingestion of jabo- randi. In a few cases, the symptoms have been presented in indi- viduals who were apparently in good health. The salts of the urine appeared upon the skins of these patients in the form of minute lamellae, or a fine powder of whitish color and crystalline aspect. In some cases reported the symptoms have been noted to precede by a few days a fatal issue. The constantly adjusted equilibrium between the sweat and the urinary excretion would explain, for cases of a mild type, temporary augmentation in the urea formed in the sweat of unusually free dia- phoresis. Geber supposes that decomposition products, such as the carbonate of ammonium, possibly aided by the volatile fatty acids,, may in part account for these conditions. Dysidrosis. — Under the names Dysidrosis and Cheiro-pom- pholyx, Tilbury Fox and Hutchinson, of London, respectively,, described cases in which deeply imbedded, pin-head sized, acuminate,, primarily translucent vesicles occur upon the palmar and inter-digital surfaces. Both in consequence of coalescence and increase in size, bullae may subsequently form an inch or more in height, filled with an alkaline or slightly acid fluid supposed to be sweat, Partial absorp- tion occurs if the lesions be undisturbed, after which desquamation ensues from a reddened non-discharging surface. The cuticle about the lesions may be soddeu, and macerated, or reddened ; it is usually painful and swollen. There is often produced a sensation of prick- ing, burning, or itching. The eruption is most commonly discovered upon the hands, and less frequently upon the feet ; though other por- tions of the body may be involved. No little controversy has arisen respecting the exact nature of this disease, Fox and Crocker, on the one hand, 1 claiming a sudoral origin for the malady ; while llobinson 2 concludes, from a careful 1 The Histology of Dysidrosis, London, 1878, from Trans, of the Path. Soc. of London, vol. xxix., 1878. 2 Pompholyx, Arch, of Derm., 1877, vol. iii. No. 4, p 289. 106 DISEASES OF THE SKIN. study of a single case, that "everything points against its being an affectioD of the sweat-glands." In his treatise this author Dames the disorder pompholyx, classes it where it properly belongs among the exudative affections of the skin, and describes it as a neurosis. The evidence on this point is striking. Fox says: "I never knew any patient who had this disease .... well." He describes a condition of well-marked cachexia in all his cases. Robinson's patient was sickly for years, had twice suffered from fracture of the femur, had lost three of six children, and was " depressed." The severest lesions exhibited by patients observed by the author, were those in a woman who had chronic enlargement of the spleen ; and in a man who was profoundly cachectic, suffered from night sweats, had a sallow hue of the skin, aud subsequently died paraplegic. Geber, however, in studying two cases of this kind iu middle-aged men coming under his observation, believed that the lesions were not pemphigoid. ELematidrosis, or bloody sweat, reported as observed by several authors (Foot, Fbers, Parrot), is a name applied to conditions in which blood has been seen to exude from an unbroken skin. The phenomena described under this title belong properly to the en- semble of symptoms called haemophilia, and may iu some cases be due to direct transudation of red and white blood-corpuscles aud fibrine into the inter-epithelial spaces traversed by the sweat-pores. Geber points to the neuralgic, hypersesthetic, pruritic, or emotional symptoms that are usual precursors to the flow of pale or bright red blood. The fact that the patients thus affected are mostly women, hysterical, dysmenorrhoeic, or near the puberal epoch, also throws light upon these cases. In many of them petechia;, or signs of hemorrhage into other tissues of the body, were observed. In the effort to eliminate certain substances, accidentally or other- wise introduced into the system, the sweat may possibly become charged with iodine, turpentine, tar, arsenic, phosphorus, and other articles. After the ingestion of the last-named substance, the secre- tion is said to have occasionally become luminous. Doubtless several of the eruptions described in the chapter on dermatitis medicamentosa are due to a similar eliminative effort, especially those accompanied by excessive sweating and the production of vesiculation. With equal reason it may be inferred that the sweat is at times charged with excrementitious and other products of the body ; as, for example, the principles of the bile. During the late civil war the author observed several patients affected with yellow fever whose skins exhibited the characteristic hue of that disease, and whose sweat was similarly colored. The so-called " Galactidrosis," from supposed metastasis of milk, does not occur. Cases thus described have been instances of pathological sweat in the puerperal state. SEBORRHEA. 107 2. Of the Sebaceous Glands. The disorders named in this group all depend upon functional ■derangements of the sebaceous glands, whose office, it will be remem- bered, is the supply in part of the physiological unguent of the skin and hairs. What proportional part of this process is borne by the coil-glands, and what part by the sebaceous glands, it is difficult to determine. It should be remembered that the varieties of acne, which is a disorder of the sebaceous glands and their periglandular environment, are described in Class II., among the inflammations of the skin. Seborrhoea. Lat. sebum, tallow ; Gr. peu, to flow. Seborrhoea is a functional disorder of the sebaceous glands, exhibited in an abnormal condition of the secretion as it collects upon the surface of the skin. This disorder is also termed Steatorrhoea, Acne Sebacea, and Dandruff. Symptoms. — Seborrhoea occurs in two forms, according to the con- dition of the excreted product. These are known as seborrhoea sicca and seborrhoea oleosa. The two forms are recognized clinically as of separate occurrence ; and also as existing occasionally at the same time in one person. Either form of the disease may be limited to certain sites of preference, or be generalized so as to extend over all portions of the body provided with sebaceous glands. The most •common seats of the disease are : the scalp, the face, the genital region, the dorsum of the body between the scapulas, and the anterior surface of the chest. It appears at all periods of life, and in both sexes. As the sebaceous glands are mainly appendages of the hair- follicles, the lesions of the disease differ somewhat, according as they occur in the regions covered with long or lanugo hairs. In the same proportion, a difference exists in the career of the disease. At times it is a trivial and short-lived affection ; at others it is persistent and intractable, lasting for years, and possibly for a lifetime. The indi- viduals thus affected exhibit a difference also with respect to the general condition of their health. Some are anaemic, chlorotic, or asthenic ; some are of the sanguine temperament, fleshy, red-faced, and thick-skinned ; others again are absolutely healthy, so far as can be discovered, except for the local sebaceous disorder. This last fact is one of some significance. One may see exaggerated types of seborrhoea in vigorous men who have worn for one month merely, a skullcap, to which was fastened an apparatus for relief of fracture of the lower jaw. The skin affected with a seborrhoea is usually anaemic, and either dry or humid. In such cases the subjective sensations are either slight and limited to a moderate degree of itching, of which the patient does not complain until he is questioned upon the subject, 108 DISEASES OF THE SKIN. or altogether wanting. At other times the glands, or periglandular tissues, are affected with a mild form of inflammation, and then the involved surface may be reddened and become the seat of a consider- able pruritus. Seborrhoea Sicca (or Squamosa) is the most common of all forms of the disease, and occurs upon both the hairy and non-hairy portions of the integument. In the former situation, where it is vulgarly known as "dandruff," it is called — Seborrhcea Capillitii, in consequence of its limitation to the hairy scalp. In its ordinary manifestations, the affection is recog- nized in the adult, by the formation in this region, of greasy, whitish or yellowish pellicles of dried sebaceous matter, which may be freely shed from the surface and cover the shoulders of the indi- vidual whose scalp is involved. At other times these fatty plates are more or less adherent to the scalp surface, or piled up in lamina?, one upon another. These may closely mat the hairs together, per- ceptibly near the exit of the latter from their follicles ; or be abun- dantly disseminated through the mass of the hairs, some of which penetrate a flattened greasy scale, as a twig might be passed through the centre of a leaf. In consequence of their deprivation of unguent, the hairs to which the affected glands are accessory, become dry and lustreless, and fall from their follicles. If the process be not arrested, atrophy of the hair- follicle ensues, and the resulting alopecia is permanent. Fortunately, the seborrhoea is usually symmetrical, and, corre- spondingly, the baldness which it occasions. The disfigurement then resulting is of the character of symmetrical senile alopecia, and is chiefly annoying as the loss of hair is premature. When the loss is asymmetrical, which is decidedly the exception, the disfigurement is- greater. The affection may be circumscribed, and in conspicuously selected patches where thin, mealy, grayish, or whitish scales cover the patch : or thick yellowish masses may paste the hairs firmly to the surface of the scalp. The disease may also extend over the entire surface of the scalp uniformly ; or, as is frequently noticed, fringe the brow at the line of the hairs, and then extend chiefly over the vertex, being conspicuous at the line where the hairs are parted from vertex to brow. Beneath the scales or crusts of dried sebum the scalp is usually lustreless aud of a slate-gray color. As the disease does certainly occur at times in types intermediate between functional and inflam- matory forms, the adjacent tissues may present a hypersemic or even exudative feature, with true epithelial desquamation and con- siderable itching. One group of cases, assignable to this class, deserves attention. In them there is a tolerably well-diffused sebor- rhoea sicca of the scalp, aud, here and there, irregularly distributed SEBOREHGEA. 109 •over the surface, are filbert-sized, generally circular, dark reddish patches, covered with a moist secretion or a friable, granular, reddish and yellowish crust. These are scalp excoriations produced by the finger-nail. They are most common in "nervous" patients, who cannot resist forcibly digging the scalp on slight provocation. Occurring in infancy, the disease is well known as " milk crust," or as crusta lactea. This may be merely persistence of the dried vernix caseosa about the vertex in the newly born, or it may occur in scalps which have been perfectly cleansed after birth. The crust differs somewhat in color with the tint of the child's complexion ; and may vary from a light yellow to a dark brown. It may be thick, greasy, and mat the hairs together ; or be thin, dry, and friable. It is a frequent complication of the eczematous disorders •of this region, and, as a consequence, more often in the adult, every variety of hyperemia and inflammation may affect the tissue beneath the crust. In infants and children, however, the resulting alopecia is never permanent, as the rapidly growing follicles hasten to repro- duce the hair. The disease is also neither contagious nor followed by cicatrices, points upon which mothers are usually solicitous. The regions of the brow, the surface covered by the beard of the male, and the pubic hairs may be involved in the disease. Seborrhoea of the non-hairy portions of the body may exist upon the face (forehead, cheeks, chin, and nose), trunk, and genitals. Seboebhcea Faciei is characterized chiefly by the accumulation of thick, dirty-yellowish, and even yellowish-black, accumulations of sebaceous matter, often adherent to the surface and disfiguring the features by the artificial mask produced. This is exceedingly conspicuous about the nose, where the disease is at time symmetri- cally disposed. There was lately exhibited to the medical class at the author's clinic, a young woman with a complete cast, covering the nose uniformly from root to alas, composed of only yellowish-gray sebum. Such masses once removed, the skin beneath is generally found to be pallid or slightly reddened, with the orifices of the sebaceous ducts patulous ; while the under surface of the separated crust is seen to project downward in corresponding delicate prolongations, which Kaposi compares to stalactites. The crusts are rapidly reformed when the disease is not arrested. They are found in the furrows on either side of the nostrils, on the brows, the cheeks, and the pavilion of the pinna of the ear. They are most common at the puberal epoch in both sexs, when the sebaceous glands of the skin undoubt- edly sympathize with the changes occurring in the beginning of the sexual life. Seboeehcea Teunci is chiefly seen about the clavicles, scapulas, sternum, and umbilicus. Its features are less pronounced than those of some other localities, probably because the friction by the clothing •even in persons who neglect the care of their skins, serves to stimu- 110 DISEASES OF THE SKIX. late to a moderate degree the sebaceous glands of those regions. The disease occurs here in circumscribed or, more frequently, illy defined patches which by confluence may describe irregularly reticulated figures of reddish tint, when, as is usually the case, the few loosened fatty plate- have been removed by friction. According to Duhring, who has carefully studied these features, the chest patches are circular, pale reddish in color, defined in outline, separate or associated in large groups, and covered with withered, greasy, grayish-yellow pellicles, the eruption here much resembling ringworm of the body. About the umbilicus, the fatty matters are remarkable for their tendency to speedy decomposition, with the production of an exceedingly fetid odor, which may prove to be the source of a mild grade of inflamma- tion. In the latter event, a reddish halo surrounds the umbilical depression, which may be the source of a thin, sero-purulent discharge. Seborrhcea Genitalium is usually located in men in the sulcus behind the corona glandis, though in individuals with a tight or redundant prepuce it may be more extended. In women, the accumulation occurs about the clitoris and vestibulum, though the external labia may be covered with the secretion in various degrees of fluidity. The smegma preputii supplied by the glands of Tyson may be thus the source of trouble either by its retention, or secretion in abnormal quantity or quality. In either event the tendency, as in umbilical seborrhcea, is to decomposition, fetid odor, and subsequent irritation, which may provoke inflammation of severe grade. The retention of this smegma beneath a tight prepuce in the male may provoke a long list of reflex symptoms, such as incoordination of movements in the lower extremities, nocturnal enuresis and pollu- tions, hernia, and irritability of the testis. In some cases the secre- tion forms a ring as hard as the rind of cheese encircling the glans. It should be remembered that the young of both sexes as well as adults are liable to be thus affected ; and that in young female chil- dren these symptoms may have a medico-legal interest in connection with suspicion of criminal attempts. Seborrhcea Generalis, affecting the entire surface of the body, is an exceedingly rare disorder. It has been described by authors as Ichthyosis Sebacea, Cutis Testacea, and Pityriasis Tabescentium. In the infant, the skin is universally spread with a greasy layer, rapidly renewed after removal, beneath which the skin seems to be varnished in reddish-brown shades. The consequent stiffening of the integu- ment produces painful fissures, inability to take the nipple, and con- sequent marasmus. In adults, there is noticed the same marasmus ; with greenish to blackish crusts covering the trunk and extremities, and desquamation of lamella? of the sebaceous accumulation, corre- sponding, for the most part, to regions of the skin mapped out by its normal furrows and folds. SEBORRHCEA. Ill Seborrhcea Oleosa is in its pronounced features rarer than seborrhoea sicca ; but to a less distinct degree is a condition sufficiently common in many forms of the disease. Here the sebaceous secretion is poured out as an oily fluid upon the surface both of the hairy and so-called non-hairy parts of the skin. In the former situation, both iu adults and infants, the free oily substance is seen to cover as a coating both skin and hairs, and, especially in bald adults, to produce a glistening and shining appear- ance of the scalp. It often concretes into masses which are described above as the crusts of seborrhoea sicca. The same greasy layer can be seen in the non-hairy portions of the skin, especially about the nose, forehead, and cheeks. Free drops of oil can be occasionally wiped from such surfaces with a handkerchief. The ducts of the sebaceous follicles are here either patulous or plugged with come- dones; the surface may be reddened or pallid, but is usually cold to the touch. The oily substance serves to entrap particles of dust, soot, etc., floating in the air, and often thus a peculiarly dirty or even blackish hue of the face is produced. Some of the forms of seborrhoea described above in connection with the umbilicus and genitalia, are of this variety. In the negro, where the sebaceous glands are usually well developed and active, the oily forms of seborrhoea are common ;. and the flux, at times, almost physiological. Even in the absence of their frequent anointing with palm-oil, one can see the naked blacks in Africa with exposed skins shining from exuded grease. Etiology. — Seborrhoea may be due to local or general causes. This is a point which should be clearly understood, as Hebra, with his superb powers of observation, noticed that the majority of his cases occurred in young male and female subjects affected with chlorosis or conditions analogous to that state. It is a clinical fact of ready veri- fication ; but it is clear that many cases are essentially of local origin ; and, as before indicated, a seborrhoea can be artificially produced in a healthy individual in the course of a few weeks by very simple local measures without interference with the general economy. Women with long hair are usually disposed to take special care of the scalp, upon which it grows. Men with short hair are more apt to attend chiefly to its disposition upon the head, and to neglect the care of the scalp. For the seborrhoea sicca of the hairy parts, neglect of the scalp is a frequent cause ; for the same disease of the non-hairy portions of the skin, in by far the greater number of all cases, chlo- rosis, struma, malnutrition, obstinate constipation, disorders of diges- tion and menstruation, and sedentary habits of life, are unquestion- ably responsible. The exanthematous and other fevers are often followed by asthenic states in which the same condition prevails. Hebra has pointed out the fact that the sebum of individuals who have fatty livers from chronic alcoholism, is peculiarly fluid and oily; and it will be observed that few of all the disorders of the 112 DISEASES OF THE SKIN. sebaceous glands characterized by inspissation of the secretion occur in such persons. Pathology. — It will be remembered that the sebaceous secretion is produced in consequence of a fatty transformation of the epithelia lining the acini of the sebaceous glands; it is, therefore, directly de- rived from the living- matter of the protoplasmic elements of the rete. A seborrhoea is, therefore, strictly speaking-, a catarrh of the epi- dermis; and the name is in this connection properly used, since most of the so-called catarrhs of the skin are in reality not such, the effused fluids being furnished by the bloodvessels. Typical forms of sebor- rhcea are strictly anomalies of secretion only, unaccompauied by in- flammatory processes in either the glands or periglandular tissues. While other exceptional forms are without question thus complicated, the variations in the sebaceous product as to quantity, inspissation, fluidity, tendency to rapid decomposition and exhalation of fetid odors, may be due to variability in the transformation of the epithelia into fat under the influence of the trophic nerves, but this is a matter of conjecture. It is certain that these conditions are largely under the influence of external agents, such as friction, temperature, and air currents. In many cases the product of the disorder is composed, for the greater part, of epithelial masses mingled with a relatively small quantity of sebum, thus justifying further the view explained above regarding its catarrhal nature. The unguents naturally found in excess upon the body or parts of it, such as the vernix caseosa, are, of course, physiological in character. Diagnosis. — Seborrhoea is to be distinguished from : Eczema. — The objective points of difference between eczema and seborrhoea depend upon the inflammatory character of the first named disease, easily recognized, whether upon the face or scalp, by the reddened, infiltrated, or discharging skin, and the considerable degree of itching which it occasions. In squamous eczema, the scales are rarely so abundant as to be shed freely from the surface, and are not greasy. It should be remembered, however, that the two diseases may and do coexist. Eczema of the scalp in infants is especially apt to be accompanied by a seborrhoea, a fact which clearly shows that the technical distinctions between many diseases, useful though they be for analytical study, are not always capable of clinical demonstra- tion. Ichthyosis. — This is a congenital disease, usually involving the entire surface of the body, while seborrhoea is generally acquired, and rarely universal. The distinction between ichthyosis and the rare generalized forms of seborrhoea, described above, might involve a difficulty. But in the latter, the greasy charactei of the crusts, their color, and the marasmic condition of the subject of the disease, would sufficiently distinguish the two disorders. Impetigo and Impetigo Contagiosa. — Here the only possibility of error would originate in the discovery of either of the two diseases SEBORRHEA. 118 named, in the stage of crusting, especially upon the scalp. But both are acute disorders, with crusts much bulkier than the sebaceous matters formed in seborrhoea, and beneath such crusts the integument is reddened and evidently the seat of an exudation. Keratosis Pilaris. — In this disease, also, there is a chronic accumulation of matters, partly sebaceous, on the hairy and non-hairy portions of the skin. But, unlike seborrhoea, the sebo-epithelial heaps are here aggregated in pin-head sized masses about the hair- follicles only, and never accumulate in such quantities as to paste the hairs to the surface. The disease is also most common on the extensor surfaces of the extremities. Lupus Erythematosus. — Hebra, in 1845, described a Seborrhoea Congestiva, which it would be indeed difficult to distinguish from lupus erythematosus, as the two are practically identical. Typical cases of the two diseases are widely different and readily distinguished ; the atypical forms might lead to confusion. But lupus erythematosus, though occurring on the face, is rare on the scalp ; it is accompanied by infiltration and the production of a new growth ; and is followed by a characteristic scar. Its lesions are darker red than the conges- tive patches beneath certain seborrhoeas of the non-hairy parts. The scales of lupus are tenacious and dry, and require scraping for their removal; those of seborrhoea are readily detached, greasy, and often cover the shoulders of the patient. The contour of the sebor- rhoeic patch is ill defined, while that of lupus is very distinct, excep- tion being made of the mask-like crusts seen in certain of the facial seborrhoeas, when the greasy character of the layer is very evident. Lastly, seborrhoea is a disease of puberty chiefly, while lupus erythem- atosus is likely to be first seen in the earlier years of childhood, when facial seborrhoea is rare. Psoriasis. — Psoriasis of the scalp may resemble seborrhoea sicca. But the latter is rarely developed in such a universal exanthem as is frequent in the former. Few doubtful cases will come under obser- vation, in which a psoriasic patch on the elbow, knee, leg, or sacrum, will not point to the nature of the disease. The scales of psoriasis are lustrous, larger, and not greasy, unless fatty applications have been made to soften them ; and they cover, moreover, a reddened and exuding patch of integument. Psoriasis of the scalp and face prefers the areas of the forehead adjacent to the hairs of the scalp, and rarely departs boldly to the nose and the furrows beside the nostrils, favorite sites of a seborrhoea. Syphilis. — Some forms of the pustular syphilodermata located upon the scalp and face, if observed only in the stage of crusting, might be confounded with seborrhoea. Here the history of the case, the discovery of other signs of syphilis (adenopathy, mucous patches, etc.), and the puriform character of the secretion beneath the crust, 114 DISEASES OF THE SKIX. should point to the identity of the disease. In syphilitic crusts about the angles of the nostrils, there is often a peculiar reddish-brown tint of the skin at the edge of the patch, the so-called "copper" color, which is significant. ( Irusts of the hairy scalp in syphilis are very often accompanied by post-cervical adenopathy, and especially by in- durated enlargement of the occipital glands. Tinea Circinata and Tinea Tonsurans. — In ringworm of the hairy parts, as also of the body, the microscopical discovery of the parasite will always point to the nature of the disease. Upon the seal]), the affected patches are seldom as diffuse as in seborrhoea; are usually circular; are often accompanied by fragility of the hairs; and, in the latter case, the discovery of stumps of hairs is significant. There is also a history of contagion and absence of the greasy condi- tions of the .-eales characteristic of seborrhoea. Treatment. — The internal treatment of seborrhoea is often of the highest importance. The preparations most often indicated are: Iron in anremic young women; cathartics in sluggishness of the bowels; aud cod-liver oil when there is impairment of nutrition. Duhring recommends the sulphide of calcium iu doses of from one-tenth (0.0066) to one-fifth (0.0133) of a grain. Arsenic, employed iu the manner suggested by Sir Erasmus Wilson, is praised by Hebra : R. Vin. ferri foj^s; 50 Syrup, simpl. ) Liq. potass, arsenit. j f3ij ; 8 128 M. Aq. destill. fgij; 60 M. S. A teaspoonful to be taken three times daily with the meal. Iu many cases, the acid iron mixture of Startin, or some modifi- cation of it, admirably meets the indications present : R. Magnes. sulph. ,fij ; 64] Ferri sulphat. 9>s-BJ ; 0.66-1.33 Acid, sulph. dilut. f3ij-foiv; 8-16 Infus. quassia? adf^iv; 128 S. A teaspoonful in water, through a tube, after eating. The preparations of malt aud maltine, uow largely employed in the treatment of wasting diseases, will be found available in cases where the cod-liver oil canuot be well taken. Lastly, the bitter tonics may be needed. Throughout the treatment, the physician should insure a careful observance of the laws of hygiene. Sunlight, nutritious food, and open air exercise are not to be disregarded. In the large cities of this country, many young women of indolent habits are greatly benefited by sending them to the riding-schools for an hour's equitation daily. The indications to be met by local treatment in seborrhoea are: first, the removal of the crusts and the fatty matters accumulated upon the surface; second, the restoration of the deranged function of the glands. SEBORRHOEA. 115 Upon the scalp, it is always well to warn patients, especially if the disorder is aggravated, and occurs in young women with apparently luxuriant tresses, that a coDsiderable loss of hair will result. Many of the filaments are so impoverished by the chronic course of the disease, and so loosened in their follicles, that a complete cleansing of the scalp surface will bring them away in quantities sufficient to threaten a speedy baldness ; aud it is not rarely the case that patients attribute this to the treatment rather than to the disease. The fatty accumula- tions are first to be soaked in some oily fluid to facilitate their removal ; and for this purpose olive oil, cod-liver oil, vaseline, cold cream, almond oil, glycerine, or lard is usually employed. The article selected should be used in excess, and in quantity sufficient to permeate all crusts. It may be poured over or rubbed into the scalp several times in the twenty-four hours ; and at night a flannel or other cap be worn to insure still further success. In the case of children and infants, considerable gentleness is required in thus treating the scalp, especially in the subsequent washings, lest the surface be irritated. In young women it is rarely necessary to cut the hairs. As soon as the soaking with oil is insured, the crusts are to be removed by washing with soap and water, though when the accumulations are bulky, masses may be gently removed with fingers or comb. When the scalp is quite tender, ordinary toilet, or Sarg's glycerine soap, may be applied with warm water ; but it is usual, in the case of adults, to employ the spiritus saponis kalinus of Hebra, two ounces (64.) of green soap digested in one (32.) of alcohol, filtered and flavored with lavender or bergamot. The surface should be thoroughly sponged with the spirit, and then warm water added till the foam of the lather is abundantly produced over the scalp, when an excess of water is finally used to cleanse the part of both crusts, oil, and soap. The scalp and hairs are then thoroughly dried, and anointed with some bland, fatty substance, if the surface exposed is tender and irritable ; if not, with some stimulating pomade. The last-named precaution is an important one. However exten- sive the seborrhoeic crusts, it is possible to remove these completely by the measures described above, in every case ; and with the first experiment patients are often delighted. Their disappointment is correspondingly great when they discover that the seborrhoea is not yet at end, and that, in the course of a few days, the fatty plates are as freely as ever deposited on the scalp, disseminated through the hairs, and showered upon the shoulders. Some will even declare that the soapy applications aggravate the disorder by increasing the seborrhoea. It should, therefore, never be forgotten that, having got rid of the extraneous matters accumulated upon the surface, there is still to be remedied a functional disorder of the sebaceous glands of the part. In every case, then, after the use of the soap and water, which may be repeated as often as need be, daily, at intervals of several days, or once in the week, the scalp is to be thoroughly anointed. For this purpose olive oil, cod-liver oil properly scented, almond oil, vaseline, 116 DISEASES OF THE SKIN. or glycerine and water, may be used. In the course of a few days, in most instances, a more stimulating plan of treatment may be adopted ; and, in that event, alcohol may be combined, for example, with the oil of' sweet almonds, half an ounee (10.) of the latter to five ounces (160.) of the former, to which half a drachm (2.) of carbolic acid may he added, the whole flavored with the oil of bergamot. A r an Harlingen recommends the oleum moringae nucis, or oil of benne, as a substitute for others, since it does not dry and elog, as do the latter. An ounce (32.) of this rubbed up with five grains (0.33) of powdered benzoin, and digested for three hours over a water-bath, with the addition of three drops of absolute alcohol, and filtered, furnishes an excellent basis for oily mixtures to be used on the scalp. Dr. Morison, 1 of Baltimore, has devised an ingenious instrument for the application of oily fluids to the seal]). The latter are retained in a small reservoir, to which is connected a comb with perforated teeth. Through the latter the article selected for medication of the scalp readily passes down to the surface between the hairs. In the place of oils after these ablutions the ointments are often used with more advantage. For this purpose the beuzoated oxide of zinc ointment, cold cream, or salves containing ten per cent, of tannin may be applied. In cases where milder effects are required, the seal]) may be washed in water containing such alkaline substances as borax, ammonia, and the carbonate of potassium. The popular prejudice against these articles is based upon the abuse of strong alkaline lotions in the hands of inexperienced persons. Such lotions may be readily tested by the tongue for the degree of softness required for the scalp. They should, in the management of all cases, be followed by an oiling or greasing of the surface. Women solicitous about their personal appearance are apt to object to such inunctions, preferring greatly the drier conditions of the scalp and hair, a prejudice often respon- sible for the disease in question. Veiel recommends the following formula : R. Extr. cinch, frig. par. ^j ; 1 Bals. peruv. gtts. xv ; 1 Cantharid. tinct. gtts. xxiv-3ss ; 1.5-2 Succ. citri n\,xv ; l Ungt. poinat. 5Jss ; 50 M. S. To be rubbed into tbe scalp once or twice daily. The tars are useful in many obstinate cases. Tar soap may be employed in the washing; or the oleum rusci added in the strength of one to ten parts to the other salves recommended above. Ichthyol in ointment- of the strength of five to ten per cent., and resorcin in spirit lotions of ten grains (0.66) to the ounce (32.) have also proved efficacious. Repeated applications and patient care of the seal]) are necessary to secure complete relief in the case of a disease as essentially chronic as seborrhoea. At times the local treatment may be changed with 1 Maryland Med. Journ., January, 1885. SEBOKRHffiA. 117 advantage. Sulphur enjoys a high reputation in the treatment of all sebaceous gland disorders ; and in the form of an ointment, one to two drachms (4.-8.) to the ounce (32.) of cold cream, it is often of service. The author has used with success the hypochlorite of sulphur, which has lately come into our markets from the English laboratories. But it is open to objection on account of its odor, which can scarcely be disguised. Beside these, the tinctures of cantharides, capsicum, and nux vomica are frequently incorporated with advantage into lotions and pomades for use upon the scalp. Most of the latter can be made sufficiently fluent for use in this situation, by adding a drachm (4.) or two (8.) of glycerine to the ounce (32.) of lard or cold cream. The alterative effect of the mercurials is also as evident here as in many other cutaneous disorders. At the head of the list, for this special purpose, stands the red oxide of mercury in the strength of from two to four grains (0.133-0.266) to the ounce (32.) of ointment; but the white precipitate, the ammoniated mercury, and calomel, in the pro- portion of five to ten grains (0.333-0.666) to the ounce (32.) may be often substituted for the former with advantage. Solutions of cor- rosive sublimate, in the strength of two to four grains (0.133-0.266) to the ounce (32.) of fluid, may prove of use in obstinate cases. Hil- lairet recommends a lotion containing from two to four fluidrachms (8.-16.) of sulphuric ether and two to four drachms (8.-16.) of borax dissolved in eight fluidounces (256.) of distilled water. Viguier advises the following lotion for use in seborrhoea of the scalp, in those cases more particularly where loss of hair is threatened : R. Santal. ess. ) Eosar. ess. Y aa tt^v ; 30 Chimaphil. umbell. es S.J Pilocarpin. muriat. gr. vijss; 50 Spts. vin. rectif. liij; 100 Camphor, spts. ] Glycerin. > aa 3j gr. xv; 5 Cantharid. tinct. ) Dissolve the pilocarpine in the alcohol, and then add the other ingre- dients. The treatment described in outline above, may be used with success also for the relief of seborrhoea of the non-hairy portions of the body, especially the face. Here, it will be observed, the crusts have a singular tendency to re-form, and the most persistent care is necessary to secure permanent relief. Occasionally, after cleansing the surface by soap and spirit lotions, according to the indications of each case, it is of advantage to apply the ointment selected for subse- quent application, not only by gently smearing it on the part with the tips of the fingers (always the most effective method), but also by spreading it on a compress, which, for the night at least, may be fixed in contact with the part. Unna's lead-plaster mulls, used for this purpose in Germany, may be fairly well imitated by drawing strips of cheese-cloth through heated diachylon ointment and then smoothly smearing them w T ith the same material. 118 DISEASES OF THE SKIN. When this tendency to reformation of the crust is abated, one or more of the dusting powder- may be at times employed with advantage for the purpose of protecting the skin or exercising upon it an astringent effect. The local treatment of seborrhoea of the genitals is somewhat different. Ointments rarely answer well in disorders of the mucous surfaces ; and the green soap is too irritating for similar employment. Here washing with a good toilet soap and warm water is sufficient for the purposes of cleanliness, and diluted lotions containing alcohol, in the form of whiskey, brandy, or aromatic wine, suffice to procure relief. These can be made astringent with tannin, alum, or the zinc sulphate, and, when there is pain or tenderness, opium can be added. In this form of the disease, as also in seborrheas of the umbilicus, carbolic acid or the chlorinated soda may be necessary to correct fetor. In the generalized varieties of the disease the surface is to be thoroughly anointed with oil. The body, especially that of infants, is to be swathed in flannel or other good non-conductor of heat ; and a roborant treatment directed to the general adynamia. In the grave forms of seborrhcea of infants described as keratosis sebacea, ichthyosis sebacea, etc., the body must be kept anointed with oils or fats. Artificial feeding is demanded by the condition of the mouth. Prof/noxi*. — In forming a prognosis in cases of seborrhcea, it must be remembered that the disease is frequently an obstinate one ; and the resulting loss of hair, if symmetrical, may be remediless. Much may be done in the way of saving that which is left. Facial sebor- rhoea is much more amenable to treatment ; and seborrhcea of the genitals and umbilicus is an entirely manageable disease. When the affection is generalized, the prognosis is in the highest degree unfavorable. Comedo. Lat. comedo, a spendthrift. Comedo is a disease in which an inspissated secretion, lodged in the excretory- ducts of the sebaceous glands, becomes visible upon the surface in yellowish- white or brownish-black points. Symptoms. — Comedones occur exclusively in the ducts of the sebaceous glands, and consist of a whitish fatty plug formed by the inspissation of the secretion of these glauds, one extremity of which i- visible at the surface when the plug is in situ. Occasionally they project to an appreciable distance above the general level of the integument ; but often the extremity of the plug is slightly depressed below that level. There may be but two or three upou the face, which is their most common seat; or the nose, forehead, cheeks, chin, the front and back of the neck, and the back of the trunk, aud the penis may be thickly studded with them. The visible extremity of the comedo varies in size from a needle-point to a pin-head. They are readily expressed from the follicles in which they are lodged, and comedo. liy when thus examined are seen to be whitish moulds of inspissated sebum, one to two Hues in length, the exposed extremities of which have become blackened by the dust and dirt entrapped at that point. In consequence of this suggestive appearance of the mass, the disease has been vulgarly known as " black heads" and " skin worms." The deformity produced in the face when these lesions exist there in large numbers, is strikingly conspicuous ; and it is for the relief of this chiefly, that the practitioner is consulted. The subjective symptoms awakened are of trifling moment. The disorder is essentially chronic in its course. Isolated comedones may be observed for years in one situation without apparent change or modification of any sort, and without producing the slightest local or constitutional derangement. Others appear, only to disappear under the influence of the usual hygienic regimen of the skin of the face. Others, again, serve to irritate the skin in which they are implanted, precisely as though they were foreign bodies ; and the sebaceous glands and peri-glandular tissues, with and without the operation of such cause, exhibit grades of hyperemia and inflammation. Comedones may occur as the sole lesions of the skin, even to the extent of very great multiplicity; or they may coexist with other diseases of the glands, chiefly acne. They may occur at any period of life, but, like seborrhoea, are most fre- quently observed at the puberal epoch in both sexes. According to Kaposi, the disease tends to disappear in women earlier than in men, in whose case it may be prolonged to the twentieth or thirtieth year. Crocker 1 has called attention to the occurrence of comedones in children, with a special tendency to grouping in places subjected to heat and moisture, and also to occurrence upon the hairy scalp. Occasionally a so-called " double " comedo is formed, a plug of inspissated sebum being expressed from the skin, each extremity of which is discolored. Whether this be due to a duplicity of efferent ducts in a single gland, or to an artificial or pathological connection between two adjacent glands, is not clear. 2 Etiology. — Much has been written with reference to the improper care of the skin as a cause of comedo, the neglect of soap in washing the face, and the influence of the trades, as in the case of those who work in metals, dust, and tar. But observation shows that these are exceptional causes. Very obstinate and generalized lesions occur in the skin of intelligent youug men and women of the upper social classes, who regularly wash their faces with toilet soap, are rarely exposed to dust, and whose habits and recreations are of the most healthful character. On the other hand, observing the grimy faces of coal heavers, machinists, masons, and ink manufacturers, one is impressed with the singular rarity of the disease in such laborers. The cause of the constipation of the gland is unquestionably to be sought for elsewhere, in the most of cases. It is true that chlorotic 1 Lancet, April 19, 1884. 2 A. H Ohniann-Dumesnil : Journ. of Cutan. and Yen. Dis., February, 1886. 120 DISEASES OF THE SKIN. young women, affected also with dyspepsia and torpor of the bowels, may exhibit the disease; and equally certain that many cases occur in peculiarly thick-skinned bruuettes, or men with a characteristic reddish-brown and greasy-looking complexion. But for all this, many such never suffer from comedones, while often a perfectly healthy, fair-skinned girl will be greatly mortified by the disfigure- menl of her lace. Fig. 29. ■■ b a. Section of a comedo, a, excretory duct of a sebaceous gland filled with a comedo ; it contains also two small hairs with brush-like inferior extremities; into it opens a small hair-follicle, o, whose contained hair, d, after touching the opposite wall of the duct, curves downward at/. (After Kaposi.) In vet other patients there is unmistakable connection between this disorder and chlorosis, scrofulosis, dyspepsia, habitual constipation of the bowels, menstrual derangements, and cachexia. This connection is demonstrated by the remarkable improvement manifested in the untreated skin when improvement of the general health is assured. Pathology. — The mass termed the comedo is a collection of con- centrically packed epithelial plates mingled with masses of cholesterine, fragments of epithelia undergone fatty transformation, minute lanugo hairs, and, occasionally, upon the exterior, the aearus foUirulormn. This little mite, first detected by Henle, in the ceruminous glands, was bv Simon and others once thought to be the cause of the comedo, COMEDO. 121 a view which is now abandoned by all dermatologists. The parasite, in persons upon whose skin it exists, can be detected in masses of commingled sebum and epithelial plates scraped from the free surface of the integument, as also upon the surface of those who do not exhibit any disorder of the sebaceous glands. The comedo plug is located either in the excretory duct of the sebaceous gland or in the pouch-shaped canal common to the sebaceous gland and the hair- follicle. It will be remembered that in the class of sebaceous glands chiefly involved in the comedo, the hair-follicle is rather an appendage to the former, the relation between the two, evident upon the scalp for example, being here reversed. According to Biesiadecki, the hair-follicle often forms here an obtuse or even a right angle with the duct of the gland, and the point of the hair being thus projected against the wall of the duct, is occasionally curved downward upon itself, exciting thus an irritation at the point of impact and subsequent multiplication of the protoplasmic elements lining the canal. Thus he explains the epithelial character of the outer envelope of the plug; the special occurrence of the disease at the puberal epoch, when, as is well known, there is an especially active growth of the hairs ; and, lastly, the frequent discovery of lanugo filaments in the expressed contents of the common excretory duct. Diagnosis. — The recognition of the disorder is attended with no difficulty, patients themselves being usually sufficiently observant to identify the affection, though frequently misled as to the character of the " skin worm." It is, as might be expected, a frequent coincident of acne ; its lesions, when commingled with those of the disease last named, being either in preponderance or so infrequent as scarcely to attract the attention of the patient. A condition somewhat resembling the comedo may be produced upon the face when tar, or ointments of mercury and sulphur are applied to it at the same time, the resulting black sulphuret appearing conspicuously at various points upon the skin, often at the orifices of the sebaceous glands. Curiously atypical cases, however, are occasionally observed, and these might confuse one unfamiliar with the singular variations dis- played in almost all sebaceous gland disorders. Thus Cauty 1 reports a remarkable case in a boy ten years of age, who was somewhat im- becile but well nourished. The upper part of the back, both shoulders, and the outside of both arms were covered with short bristles, of a clear, darkish brown-yellow color, and acuminated apices. These bristles were, at the edges of the group, gradually shortened from their full length of three thirty-seconds of an inch, until they joined the skin, which was at the junction raised into polygonal, flat disks, finally graduating to the sound integument of the hands, chest, and back. The feeling communicated to the hand on passing it over the shoulders was exactly similar to that of touching a coarse brush, and the bristles gave way under the touch, resuming an upright position 1 Medical and Surgical Journal, March 4, 1882, p. 237. 1-- DISEASES OF THE SKIN. afterward. There were a few pink maculae over the body, and con- siderable scaly thickening on and around the patellas. The bristles were expelled comedones, containing very few immature hairs and very little sel 1. drying up into a horny substance. They were firmly attached, requiring more force to remove them than to 'extract a well-rooted hair; and when removed they left a .-mall, central depression, surrounded by a circle of torn epithelium, which retained them in position. They averaged one hundred to the square inch, and had existed over three months. A somewhat similar ca.^e was exhibited by Dr. Warren, before the New York Dermatological Society, January 26, 1886, and described as keratosis follicularis. Treatment. — The internal treatment of the patient affected with comedo is largely that described in connection with the subject of seborrhoea. God-liver oil, iron, the bitter tonics, and preparations indicated by any special condition of the patient's health, are not to be omitted. Open-air exercise, bathing, and the avoidance of all medicinal and dietary articles which might tend to aggravate the disorder, are also imperative. Even aggravated cases of comedo are completely relieved by natural processes in the course of time. These processes are, however, slow, and may require years for their completion. The rarity of come- dones in middle life and advanced years sufficiently attests this fact. Presumably this natural cure i's due to the more vigorous growth of lanugo hairs with the increment of age, which thus push forward slowly to the surface the excrementitious mass, until it is gradually removed by ordinary friction and ablution. Absence of comedones from the scalp, where the hair is vigorous, is certainly a significant fact. Comedones are removed artificially by the aid of an extractor. The instrument formerly employed for this purpose was shaped like a watch-key, the cylinder of which had a smooth bore and bevelled extremity. This clumsy tool is far surpassed by the exceedingly convenient comedo-extractor designed by Unna and modified "by Piffard (see Fig. 27). Each end has a convex bowl-like surface, with apertures cut to gauge and the orifices slightly counter-sunk. It is pro- ductive of for less pain to the patient than other instruments, and can be wielded, on account of its long shank, with greater precision and ease by the physician. The surface to be operated upon is best previ- ously moistened by spraying it with a thymol and glycerine, or euca- lyptol and glycerine solution. Often a sharp-edged 'or well-rounded needle, firmly held in a needle-holder, may be advantageouslv em- ployed, alternately with the extractor, in opening certain follicles or somewhat loosening the plug of others. All of these instruments should be scrupulously disinfected before use. With the present knowledge had on the subject of transmission of disease, the danger of such manipulations as these with uncleansed instruments should never be overlooked. Wigglesworth suggests the performance of COMEDO. 123 the operation at night; and there are good reasons for selecting the hour before retiring as the time for all vigorous topical applications to the face. Ointments then applied can be left in contact with the skin during the hours of sleep; aud the patient be at liberty to resume his usual vocation in the daytime with his face free from conspicuous evidence of local treatment. An ordinary watch-key, the thumb-nail, or a spatula may also, on occasion, be used in the extraction of comedones, which may be, if few, removed at one sitting, or, if numerous, on separate occasions. Repetition of the process is usually required by the reformation of the plugs. Once they are removed, the skin should be sponged and bathed with hot water, then thoroughly dried, and anointed with an ointment which may be medicated to suit the indications of each case. Sulphur, as in all the functional disorders of the sebaceous glands, enjoys here also the highest reputation. In the strength of one-half to one drachm (2.-4.) to the ounce (32.) of cold cream or vaseline, it may be applied as an ointment ; or as a lotion, in combination with spirits of wine, glycerine, etc. The author has frequently used with advantage the mild application suggested by Piffard in acne, equal parts of sub- limed sulphur, alcohol, compound tincture of lavender, glycerine, and camphor water. Mercurials are also of some advantage locally, and, as before indi- cated, should not be employed at the same time with preparations of sulphur. The use at night, especially in obstinate cases, of the white precipitate ointment, or one compounded of two grains (0.133) of the red oxide to the ounce (32.) of cold cream will often prove of benefit. One to two grains (0.066 to 0.133) of corrosive sublimate to the ounce (32.) of glycerine and rose-water may be substituted for the latter in coarser skins. When the extraction of the plug is not attempted nor permitted, something may yet be done to remove the inspissated mass. Repeated sponging every third night with one ounce (32.) of the green soap, digested in an equal quantity of Cologne water, will, at first certainly, seem to render the comedo more conspicuous, but will slowly operate to dissolve the sebaceous secretion. Unna has lately observed that the blackish discoloration of the comedo extends to a certain degree below the external extremity of the plug, a circumstance, in his opinion, militating against the dust and dirt theory, by which the hue of the comedo point has been ex- plained. He concludes that this is the result of pigmentation, such as that producing the coloration of the hair, nails, and skin in several other anomalous conditions. Having this in view, he prescribes an ointment containing four parts of kaolin, three of glycerine, and two of acetic acid, with or without the addition of a small quantity of ethereal oil. This is applied at night, the eyes being carefully closed, for a few nights in succession, when the black points of the lesions are removed, and the comedones then readily extracted. Citric or dilute hydrochloric acid is employed, with the same end in view. 124 DISEASES OF THE SKIN. The author has employed this formula in about fifteen cases, with varying results. It cannot be considered as efficient in every form of comedo. Actors, actresses, and women of fashion will occasionally persist in using variously colored toilet powders while under treatment, the injurious ingredients of which are often the cause of the disease. The practitioner may then either refuse to be responsible for the care of the case; substitute a harmless for a noxious powder; or gently anoint the face after his treatment of it with a bland ointment, upon the surface of which the theatrical effects are subsequently produced. In such cases the use of soap and water with each dressing i> even more than usually imperative. Comedones of the penis need not he treated. This injunction is suggested by the occasional demand made upon the physician by the sexual hypochondriac, who regards these lesions with a degree of alarm which he can best appreciate who has been confronted with these cases. Prognosis. — As the disease tends naturally to a spontaneous, though occasionally long-deferred resolution, the prognosis is favorable. Treatment in many cases will accomplish much in hastening the re- sult. The most obstinate forms are those in which the face, back of the ears, inside of the auricle, neck, and shoulders are studded with relatively small, indolent comedo points, about which the orifice of the duct rises in a whitish rim. This, when felt with the finger, produces the impression of hyperplasia of the wall of the duct. Such eases, however, are nearly allied to the forms of acne described else- where. With exceeding rarity, the comedo is merely the first step of a more serious local affection. In early life a single prominent lesion is formed, and though the plug be frequently removed and finally be no longer reproduced, the orifice of the duct remains patulous in middle life. Slowly thereafter its walls undergo a metamorphosis and a warty epithelioma results. Cyst. Gr. h'ictlq, a bladder. Sebaceous cysts are millet-seed to egg sized and larger, milky-whitish, or yellowish-white, encysted tumors of the sebaceous glands, occasionally having the color externally of the normal integument, either imbedded within the skin or projecting above it. The term sebaceous cyst is applied by some authors to one merely of the two disorder- of the skin to which it properly belongs, viz., the wen. In these pages it includes both milium and steatoma. I A] Milium. Lat. milium, a millet-seed. Symptoms. — Milia, also called Grata, occur upon and about the eyelids, the cheeks, the temples ; the penis, scrotum, and corona CYST. 125 glandis of men ; and the internal face of the labia minora of woman. They are millet-seed to pin-head sized, globoid masses, rarely at- taining the dimensions of a coffee-bean, showing within the epidermis as though kernels of rice were lying there immediately beneath a translucent layer of tissue. They occasionally project from the surface to such an extent as to resemble small-sized vesicles filled with milky contents. In color they are yellowish and whitish. They are often congenital ; and can be recognized about the lids and temples of the newly born infant ; they are also seen, however, in middle life, when they develop very slowly, and sometimes persist for years. They are often observed in the neighborhood of cica- trices, which latter in such cases have usually been effective in their production. They occasion no subjective sensation, and are usually so insignificant as to induce no deformity. They never degenerate by ulcerative processes, but when not artificially removed are, in the course of years, exfoliated in the natural processes of physiological desquamation. Etiology. — Milia are at times produced mechanically, the stroke of a knife-blade, accidentally or by the processes of surgery, separating one or more of the acini of a sebaceous gland from the main body. The contracting bands of a cicatrix, after the destruction of tissue from any cause, may operate in a similar way with a precisely similar result. Having this in view, it may be said generally that milium is always the result of a cause which prevents the transform- ation of the epithelium lining the gland into fat, and the subsequent excretion of this upon the free surface of the skin. These causes are thus, for the most part, obscure, but all are probably of purely local significance. Pathology. — When a milium is incised externally, a spherical body of nearly corresponding. size may be expressed, though it may require tearing from a minute pedicle below, which represents the attach- ment to the hair-follicle. The small mass thus extracted is then seen to be composed of several thin envelopes suggesting the capsules of the onion, and representing cornified epithelia not undergone fatty metamorphosis, in the centre of which is a fatty nucleus. This mass represents the contents of one or more acini of a superficially situated sebaceous gland, cut off from the main body of the follicle in the manner described above, and always covered when in situ, as Kaposi has shown, by a delicate layer of the superimposed corium containing papilla?. Usually the orifice of the excretory duct cannot be appreci- ated in milia, though occasionally these lesions are developed when the orifice is patulous. These singular bodies do not always represent conditions of mechanically pent-up sebum, as the epithelia from which their con- tents are produced seem at times indisposed to fatty transformation and particularly apt to develop into horny or other formations. Thus Foster, of Boston, describes one where the process of calcification had been apparently complete ; Wagner has observed colloid contents in certain opalescent lesions which appeared in the cheeks and temples 126 DISEASES OF THE SKIN. of a woman ; Barensprung and Hebra report numbers of acutely pro- duced niilia following pemphigus and erysipelas; and Virchow and Rindfleisch describe milia of the hair-sac and similar lesions accom- panied by cysl of the hair-follicle adjacent. It would seem rational to conclude that, in cases, the cause of milia is to besought in obscure changes by which the epitnelia of the gland are primarily a fleeted. Robinson believes that milia originate from miscarried embryonic epithelia from a hair-follicle or from the mucous layer of the epi- dermis. Diagnosis. — Milia might be mistaken for minute vesicles contain- ing a milky fluid, but puncture of the lesion, with expulsion of its contents, would at once disclose the character of each. Comedones with blackish external points, surrounded by the patulous orifice of the excretory duet and prolonged more deeply into the substance of the skin, could scarcely be confounded with milia. The most minute of the lesions of xanthoma have a yellowish color and cannot be as readily scraped away from the subjacent tissue as can milia. Treatment. — Milia rarely require treatment, as they are usually relatively few in number, and produce neither subjective sensation nor deformity. If desired, they may be opened with a fine milium needle, and their contents turned out. To insure their non-recurrence, the little sac left after the operation may be entered with a needle dipped in a fifty per cent, solution of chromic acid. This operation may have to be repeated in the rare cases where the lesions exhibit a special tendency to recur. The simplest and most elegant method of removing these and many similar-sized lesions of the skin is by the galvanic battery. With from four to six cells in the current, the negative pole is connected with a fine needle which is introduced within and beneath the lesion, Avhile the moistened sponge of the positive pole is in contact with the skin of the patient. The operation is bloodless and effectual; insig- nificant or no scars resulting. The prognosis is always favorable. [B.] Steatoma. Gr. G-Edp, fat. This form of sebaceous cyst is also called Wen, and Atheroma. Symptoms. — The history of the development and career of wens does not greatly differ from that of milia, already described. They are usually slow of growth; unattended by subjective sensation; occur as single or multiple tumors on the head, trunk, or genitals; and, being larger than milia, may attain the size of a hen's egg. They are situated beneath, within, or upon the skin; are usually un- attached to the deeper contiguous tissues ; and develop into irregularly globular, occasionally large button-shaped, masses, covered by an integument usually unprovided with hairs. This envelope may be quite normal in hue; or unnaturally whitish from pressure; Or,, CYST. 127 especially upon the bald scalp of certain fleshy men of middle years, reddened, shining, and greasy in appearance. At times they are to be distinguished only by passing the fingers through the long hairs, of the scalp beneath which they are hidden ; at others, they are so con- Fig. 30 - spicuous in consequence of physio- logical alopecia as to occasion consid- erable disfigurement. They vary greatly in consistency, but usually produce to the touch a certain feeling of elasticity, especially if the cyst be •! ---.■■ Union Med., March 25, 1882. DERMATITIS. 183 the ingestion of the iodide of potassium. The patient died, and the post-mortem appearances are reported in full. The eruption occurred chiefly about the head, neck, and the upper extremities. The author has called attention to the significant rarity of vesicular and bullous lesions in acquired syphilis, and suggested that at least some of the cases on record were those of rashes induced by the remedy given for relief of the disease. A careful analysis of these bullous rashes leads to their division into three categories : first, those occurring often with fatal results in cachectic adult patients; second, those occurring as part of the erup- tive lesions in a polymorphic group ; third, those occurring in well nourished children, taking on the appearance of molluscum epitheliale and condyloma lesions, usually compounded of papulo-vesicles and pustules. Erythanthemata of a similar type have been also recognized in infants after the ingestion of bromide of potassium. The pustules induced by the administration of iodine compounds are seen chiefly upon the face, neck, trunk, and arms. They are usually seated upon a firm base, and may be followed by cicatrices. Duhring has seen an annular patch upon the forehead, made up of minute vesico-pustules, which eventually developed into a globular violaceous mass, nearly two inches in diameter. On several occasions the author has observed large cherry-sized, tubercular elevations abruptly rising from the surface of the integument, and presenting a cribriform appearance, which showed the open ducts of several sup- purating follicles (chin, cheek, nose). The purpuric rash occurs in petechial macules, discrete and miliary, situated chiefly on the lower extremities. In a case reported by Dr. Mackenzie (quoted by Van Harlingen) a single dose of two and a half grains (0.166) in an infant, was followed by a fatal result after the petechias appeared. Jaborandi and Pilocarpine are capable, when ingested, of inducing free diaphoresis, and erythematous macules, wheals, and pin- head sized papules have been seen upon the surface as a result. Mercury. — The statement that mercury when ingested is capable of producing an erythematous rash upon the surface of the skiu, is made by several authors of reputation. In view of the fact that the metal has been, in its various compounds, administered for so long a period of time, and for so many various diseases without the produc- tion of cutaneous symptoms, it is a fair hypothesis that the few reported cases are those in which there was coincidence rather than causation. The author has had the opportunity of observing a large number of individuals in whom the drug had been both properly and very injudiciously employed for long periods of time, and has not been able in a single instance to discover any evidences upon which to base a belief in its power to produce a cutaneous exanthem. A similar statement was made by Dr. White, of Boston, when this subject was under discussion in the American Dermatological Associa- 184 DISEASES OF THE SKIN. tion. Mercurials, when applied to the external surface of the body are, as is well known, capable of exciting, in various degrees, cuta- neous irritation and inflammation. Opium am> era Alkaloids. — Erythema, wheals, and occasion- ally intense pruritus, with oedema, and subsequent desquamation, have followed the ingestion of opium and several of its alkaloids, notably morphia. In its mildest expression this cutaneous effect is limited to a characteristic itching about the nostrils, which can be perceived in a large proportion of all patients as soon as the general effect of the opiate becomes apparent. In several cases the author has observed an intense and distressing general pruritus without efflor- escence; and in some instances has been certain that the subsequent urticarial efflorescence was induced by the free diaphoresis which the medicament induced. This is a matter of some practical moment, as the use of an anodyne for the purpose of procuring sleep for a patient tormented with a nocturnal pruritus, would seem to be occasionally indicated. Inasmuch as chloral, the bromide of potas- sium, and the opiates are all capable of aggravating such distress, great caution is in such emergencies needful. In general, it may be said that the employment of these and similar remedies for such a purpose, should be interpreted as a confession of weakness on the part of the physician, who ought to be able to alleviate the distress of his patient by a judicious employment of topical remedies. Phosphorus. — Hasse (quoted by Van Harlingen) cites the case of a youug girl who exhibited a pemphigoid rash after the ingestion of phosphoric acid ; and, according to Farquharson, 1 phosphorus itself is occasionally responsible for purpura with gastro-intestinal derangement and jaundice preceding a fatal issue. Podophyllin. — Winterburn 2 reports that those who work in resinoid podophyllin, are liable to suffer, as a consequence of this exposure, from a cutaneous disease of the scrotum. Quinine, Cinchona, and its Alkaloids. — Morrow 3 has col- lected in an interesting' paper, the record of over sixty eases of quinine exanthem, and shows that its prevailing type is exanthe- matous, the rash being of a bright vivid hue, disappearing on pressure, and resembling scarlatina. Other lesions produced are wheals, papules, vesicles, petechia*, hemorrhagic purpura, bulla?, and, in one instance, an intense localized dermatitis with commencing gangrene of the scrotum. In some cases the rash reappeared on repetition of the dose,' and even after recourse to the other alkaloids. The subjects were mostly women. As with most of the other exan- them-producing drugs, small doses, where the idiosyncrasy existed, sufficed for the effect. The author has seen the rash in an adult male, i Loc. cit - Louisville Med. News, April 21, 1882. •■'■ N. Y. Med. Jouru.. March, 1880, p. 244. DERMATITIS. 185 who, after taking two grains (0.133), of the sulphate of quinia for the first time in six years, exhibited an efflorescence over the entire surface of the body, of discrete, finger-nail sized, salmon- and pinkish-tinted, scarcely elevated patches, accompanied by a moderate pruritus. A repetition of the dose was followed by a recurrence of the exanthem. In several cases desquamation is reported as resulting from the rash. As to the occurrence of the general symptoms recognized under the title of cinchonism (tinnitus aurinm, etc.), these may and may not accompany the lesions. Morrow makes the pertinent sug- gestion, in view of the frequent similarity of the rash to that exhibited in scarlatina, that many cases hitherto recorded as recur- rent attacks of that disease and measles, with other anomalous cuta- neous eruptions, may have been instances of the quinine exanthem. Salicylic Acid and the Salicylates. — Reports of cases where these substances after ingestion have produced cutaneous symptoms, have been made by Heinlein, Wheeler, and Freudenberg, all cited by Van Harlingen. The symptoms were diffused redness, urticarial lesions, vesicles, pustules, petechia?, and vibices, accom- panied by intense pruritus, and followed by desquamation. Santonine. — A generalized eruption of urticarial lesions seated upon a reddened surface, and accompanied by oedema, is reported by Sieveking as occurring in a child to whom santonine had been admin- istered as a vermifuge. 1 Sodium Benzoate — Rohe 2 reports two cases in which an erythem- atous rash, with well-defined border, accompanied by itching and slight desquamation, occurred during the use of the benzoate of sodium. The patients were a woman, aged thirty-five, and a boy with diphtheria. The eruption disappeared on the discontinuance of the remedy, and was made successively to appear and disappear by its alternate use and disuse. Sodium Biborate. — Gowers 3 reports the occurrence, especially on the arms, but also over the trunk and legs, of an eruption resembling psoriasis, after the ingestion of the biborate of sodium. Some of the resulting patches were one inch and a half in diameter. Three cases in all are collated. In two the eruption faded when a solution of arsenic was added to the sodium salt. Stramonium. — Deschamps (cited by Duhring) reports an erythem- atous rash after the administration of the thorn-apple. Strychnia. — Skinner (cited by Van Harlingen) reports a case where an eruption of six weeks' duration ensued upon the adminis- 1 British Medical Journal, February 18, 1871. 2 Maryland Medical Journal, June 15, 1881, p. 91. 3 Lancet, September 24, 1881. 186 DISEASES OF THE SKIN. tration of quinine and strychnia together; the former in the dose of one and a half grains (0.10), the latter in the dose of one-twenty- fourth of a grain (0.0025). Tanacetum. — A varioliform eruption produced by the ingestion of a drachm and a hall* (6.) of the oil of tansy, administered for abortifacient purposes, is reported by Porter. 1 There were antecedent clonic convulsions. The result was not fatal. Tab and Turpentine. — Erythematous, vesicular, and papular rashes arc reported as resulting from the ingestion of these substances. The diagnosis of the various medicinal rashes described above does not, fortunately, demand a recognition of the essential peculiarities impressed upon each by the exciting cause, since in many cases such peculiarities do not exist. The urticaria? resulting from the ingestion of "head-cheese," quinine, and chloral, may be absolutely indistin- guishable. But to establish the fact that a medicamentous eruption is present in any given case, is a long step in the direction of reaching the precise cause that has been in that case effective. This fact must often be obtained from the lips of the patient. The medicinal rashes are in general remarkable for their sudden appearance, their symmetry, their diffusion over large areas of the integument, the presence of pruritus, the absence of fever, and their existence alike upon exposed and protected surfaces of the skin, hinting thus at the action of some cause not operating externally. Excluding syphilis and the exanthematous fevers, a generalized rash of sudden occurrence should always raise the suspicion of a dermatitis medicamentosa. Similarly in cases of preexisting cutaneous disease, syphilis, eczema, or psoriasis, the sudden occurrence of lesions of a new type widely diffused, or of rapid aggravation in situ, or of speedy extension as to area of those already in existence, should awaken the suspicion, if there be fever, of the exanthemata ; and, without a febrile process, of the medicinal rashes. Thus the author has seen two patients with eczema exhibit rapid rise in temperature, and subsequently develop a generalized variolous rash ; and it is a matter of common experience to examine patients on the eve of a macular syphiloderm, or even long past the eruptive stage of that disease, showing their faces, necks, and shoulders covered with an acneiform rash produced by the potassium iodide. The practitioner cannot be too strongly urged to view with exceeding watchfulness the skin of any patient affected with either of the common disorders, eczema, acne, and psoriasis, when the eruption in any instance becomes anomalous as to type, distribution, or symp- toms. An illustrative example has come under my observation since the first paragraph of this chapter was written. A physician, on a trip from Colorado to Chicago, with a long standing eczema of the scrotum aud thigh, suddenly exhibited tumefaction of both hands with small 1 New England Medical Journal, October 15, 1881. DERMATITIS. 187 egg-sized, discrete, dull red plaques over the palms and dorsa ; and in the centre of nearly all such lesions a firm, whitish, elevated wheal accompanied by severe burning, tingling, and pricking sensations. He had been swallowing "bromidia," a proprietary preparation con- taining the bromide of potassium, the hydrate of chloral, and cannabis indica, each single drug being capable of inducing an exanthem, and yet he had not the slightest suspicion of the real nature of his symp- toms, having been questioned by a brother physician, to whom he exhibited his hands, as to the possibility of syphilis. The medicamentous rashes, as a rule, disappear rapidly after the withdrawal of the exciting cause, and require no further manage- ment. In some cases the soothing lotions, baths, and dusting powders employed in the treatment of acute eczema may be required. It should not be forgotten that the patient who exhibits these lesions is usually one who has been suffering from the real or fancied disease for relief of which the drug was taken, and that condition may require recognition and management. In Morrow's contribution to this subject, it is clearly shown that the same drug may produce a variety of eruptive phenomena, and that the same eruptive features may result from the ingestion of different drugs. He points to what he concludes to be the neurotic origin of many of these rashes, and believes that the proof is incon- clusive that these are, to any considerable degree, brought about by elimination through the cutaneous glands, of the noxious element introduced with the drug. Tilden, 1 however, calls attention to the fact that many of these eruptive phenomena are of the nature of angioneuroses, similar to Trousseau's " tache cerebrate," requiring often increase in the irritability of the cutaneous vessels, with exuda- tion of serum, outwandering of cells, aud, in case of heemorrhagic lesions, some change in the vascular walls themselves. [E.] Dermatitis Gangrenosa. Idiopathic and symptomatic cases of dermatitis terminating in gangrene, where no history of external violence or caustic application has been obtained, are reported by several authors. In most of these, single or multiple, circumscribed, erythematous or hemorrhagic macules have been followed by superficial gangrene with sloughing, the process being in some instances attended with constitutional symptoms of such gravity as to result fatally. In certain other cases the affected patches presented at an early period the mummified and alabaster white aspect, noted at times in dermatitis calorica. In establishing a diagnosis in such cases, care should be taken to exclude the forms of senile gangrene occurring in the lower extremities as the result of vascular calcification, when the skin and deeper tissues are alike invaded ; as also the cases of simulated eruption produced by caustics upon the skin with a view to deception. In the latter 1 Pathogenesis of Certain Affections of the Skin, June 9, 1885. 188 DISEASES OF THE SKIN. class, a distinguishing feature of the lesions is their occurrence chiefly upon those part- of the body most accessible to the hands: and, in persons not ambidextrous, upon those parts which the hand pre- dominantly employed can most readily reach. Ca>c~ of "symmetrical dry gangrene of the fingers and to multiple ulceration terminating in gangrene, "asphyxia of the extremities," and others described under similar titles, are annually recorded. Some of them appear to have a neurotic or angio-neurotic origin : some are peripheral symptoms of diseases of internal organs or of the vessels ; some are cases of locomotor ataxia, the shrivelled or gangrenous spots on. the hands and feet being merely early symp- toms of the perverted nutrition due to the spinal sclerosis. Atkin- son's case, 1 and that of Eichoff and C. Boeck, assigned by this author to the group of affections termed by Simon " multiple cachectic gan- grene," seem to belong to this same category which includes the " symmetrical gangrene" of Raynaud, or, as it is often termed, ''Raynaud's disease." Mr. Hutchinson has reported instances where the tendency to this disorder appeared to be transmitted through three generations, the lesions not progressing in some indi- viduals of the group beyond the "asphyxiated" condition to that of gangrene. Terrillon 2 reports perforations of the hand as preceding symptoms of a disease of the central nervous system supposed to be locomotor ataxia, which resemble the similar lesions of the feet reported by Atkin 3 in a case of undoubted ataxia. Petit and Verneuil 4 have referred these disorders to a malarial origin. Drs. Flynn and Clark, of New York, 5 have also reported sym- metrical gangrene of the extremities in men of advanced years. In many of these cases the preliminary stages of the process either did not exist, or were too transitory for observation. The first appreciable external symptoms were the perforating ulcer, the shrivelling phalanx, the gangrenous patch, or the completely "asphyx- iated " tissue. For the relations of these to a large group of tropho- neurotic affections of the skin, the reader is referred to the chapter devoted to the neuroses. Erysipelas. Gr. ipvdpog, red ; irkKha, the skin. Erysipelas is an acute and specific inflammation of the skin and subcutaneous tissue, characterized by diffuse, shining redness, pain, swelling, and elevated temperature of the affected part, terminating in desquamation, and usually accompanied by fever. Symptoms. — The disease is usually preceded by a prodromic period of malaise, lasting for twenty-four hour- or less, which may be 1 Multiple Cutaneous ("lceration. Amer. Journ. of the Med. Sci., 18S4. 2 Rev. Medic*!, Jim.- !:'.. 1>S".. :i Brit. Med. Journ., Julv 24, 1886, * i;.v. d.- Chtfurg., Nob. 1, 3, 6, and 9, 1883. 6 \. y. Med. Record, 1886. ERYSIPELAS. 189 ushered in by one or several chills followed by febrile symptoms. The latter are accompanied by anorexia and often by vomiting with general depression and headache. The eruptive symptoms are generally first displayed at a given point, from which the disease progresses. It is commonly first noticed in a nut- or egg-sized patch, the integument of which is tumid, slightly elevated, irregular in contour, distinctly circumscribed, and presents a rosy or crimson-reddish color with a peculiarly smooth and characteristic shining or glazed appearance. The sensations awakened may be those of moderate pruritus, pain, heat, or burning. To the touch, the affected part is tender, moderately firm, and per- ceptibly hotter than normal. The color fades under pressure to a yellowish- white. In typical cases, the erysipelatous blush and swelling spread over an area which may be of the size of the palm, or may even cover the surface of an entire limb or region of the body. In cases of moderate grade, the inflammation attains a maximum of extent and severity within a week, remains apparently unaltered for a day or more, and then begins to abate, with amelioration of all the concomitant symptoms. The fever which often precedes the eruption, continues unabated during its progress, the temperature rising to 105° or 106° F., with nocturnal exacerbation, cephalic and lumbar pain, dryness of the tongue, gastric distress, and occasional delirium. As invo- lution of the disorder is accomplished, the redness is replaced by the brownish, bluish-red, and dirty-white shades often seen after the disappearance of erythema multiforme, the epidermis finally desquam- ating in various degrees according to the extent of the preceding inflammation. In other cases, where the exudation of serum beneath the epidermis has been rapid, the latter is raised iu the form of vesicles, pustules, or bullae, more often the latter ; and, precisely as in the severe forms of dermatitis calorica, with which erysipelas presents a certain analogy, gangrene of the skin may result in the part affected. This is particularly apt to follow the disorder when it attacks the seat of surgical wounds and injuries. Erysipelas Ambulajsts is a term used to describe that form of the affection in which the erysipelatous blush, after involving a given area, spreads with greater or less rapidity to the parts in the vicinage, either by direct extension and uniform advancement in one direction, of the tumid and distinctly circumscribed border ; or by linear, digital, or irregular prolongations radiating from the inflammatory focus. As the blush and swelling advance in one direction, there is usually correspondingly rapid disappearance on the other. At other times, the disease, while extending to a new area and abandoning the old, is relighted in the latter, and thus an irregularly involved and irregularly extending erysipelatous surface presents for weeks the varying phenomena of the disease. In yet other cases again, chiefly those in which there has been a history of traumatism, a long erysipelatous linear streak or band may spread from the site of the 190 DISEASES OF THE SKIN. traumatism in one direction or another, suggesting the indurated lines observed in lymphangitis. In severe eases, the febrile, nervous, and other symptoms are grave, including coma, delirium, meningitis, and the signs of serious involvement of the lungs, pericardium, pleura, and bowels. Metastatic abscesses may also occur in the cutaneous and subcutaneous tissues, the joints, peritoneal cavity, and even in the viscera. Death may result from these complications, or from shock, exhaustion, or pyaemia. Surgical accidents aside, the face is the most common seat of the disease, where it may be first seen upon one side of the nose, one cheek, the lips, or the eyelid. It often attacks the lobe of the ear after the operation of piercing the lobule for the insertion of ear-rings in women. Thence it may extend over the whole face, inclusive of the mucous linings of the mouth and nose, which present a dry, tumid, and glazed appearance, suggestive of the symptoms displayed upon the skin. The inflammation may extend to the hairy parts, but in many cases it exhibits a species of reluctance to transgress the limits there pre- sented. It may be noticed in cases of mild grade where no applications have been made to arrest a local progress, that the elevated border spreads symmetrically to within a few lines of the male beard or the hairs at the edge of the forehead, and there spontaneously rests. In severer grades these limits are readily surpassed; and then, as a rule, the extension is rapid and formidable. In this way the entire head may become enormously swollen, suggesting to a casual observer that it is fully twice its normal size. The patient may then be greatly disfigured; his scarlet lips, swollen, parted, and permitting the escape of saliva; the ears, as usual when greatly enlarged, projecting in a marked degree from the side of the head ; the lids cedematous and incapable of separation ; the face, disfigured by bulla? or crusts; and the mind disordered by violence of the fever or the accesses of delirium. When recovery ensues, the hairs are apt to fall. All other regions of the body may be invaded, as the vaccinated arm, the leg whose skin is involved in venous varicosities, the scrotum or umbilicus of the infant, the genitalia of the newly deliv- ered woman, the breast of the nursing mother, and every surface which has been the seat of punctured, incised, contused, or poisoned wounds, or other accidents of the integument. Several authors describe habitually recurrent and Chronic forms of ERYSIPELAS, whose identity with the disease here described, it is difficult to establish. The diagnostician is sufficiently often consulted in cases where an erythematous eczema of the face, an acne rosacea, or asymptomatic erythema, is described by a patient as chronic or recur- rent "erysipelas." The lesions to which such terms, however, are restricted by careful writers, are often forms of chronic dermatitis, such, for example, as occasionally follow dermatitis calorica. In- stances occur in which the face, or parts of it, are the seat of a low grade of inflammation with local heat, swelling, redness, consid- ERYSIPELAS. 191 erable infiltration, and some tenderness, the part being irritable and worse after exposure to a high wind or after excesses at the table. But the most of such cases fail to exhibit the distinct imprint of erysipelas ; they are not only chronic in course, but exceedingly indo- lent, lasting for years ; they are unaccompanied by fever; they are distinctly limited in all accesses of aggravation to the same part of the face ; they are never characterized by a bullous efflorescence ; they never completely disappear ; many occurr in the subjects of chronic alcoholism. The febrile symptoms are, throughout, persistent and characteristic of a specific toxaemia. The temperature, as has been seen, may reach 105°-107° F., with vespertine exacerbations and remissions; it may also become subnormal. If not relieved in the course of seven or eight days, complications may be expected. These are oedema, abscess, phlegmonous inflammation, gangrene, and inflammatory acci- dents involving the membranes of the brain, lungs, heart, bowels,, kidneys, peritoneum, and joints. Etiology. — The modern view of the invariable origin of erysipelas from some point, however insignificant as to size, where a morbid germ has secured access to the economy, is generally accepted and adds interest to the study of the local manifestation of the disease. Whether it be the slightest or severest traumatism, an erosion, a torn pustule, or a puncture by a pin, such lesions are now interrogated whenever erysipelas occurs in any part of the body or in the course of auy other disease. In the face, catarrhal and ulcerative processes involving the mucous membrane of the mouth, ears, and nose, are often the cause of an erysipelas, these processes occurring in a wide range of disorders from syphilis of the nasal bones to caries of the teeth. Injuries of, and surgical operations upon the scalp not conducted with antiseptic precautions, and the common piercing of the lobe of the ear in women and female children for the insertion of ear-rings, may be followed by the appearance of the disease upon the scalp, as a' result of which the hair often falls. Fistulse, vaccination, lesions of the tender umbilicus of the newly born infant, and railroad accidents may be named as common causes of the disease in other regions. Predisposing causes of this disease are to be sought for in cachexia, epidemic influences, traumatism, violation of hygienic rules, and occa- sionally, the recurrence of previous attacks. Besides these, it is alleged that constitutional predisposition and particular articles of diet may be responsible for the disease (mussels). If the disease be invariably the result of infection due to the presence of a micrococcus, the essential cause lies in the specific germ, in the absence of which none of the predisposing causes named can be effective. It is clear, however, that the predisposing causes suggested are those in which the multiplication of such germs and their entrance to the general economy are most facilitated. The infectious nature of erysipelas has been demonstrated by clin- ical proof, and the experiments of many, observers, including H liter, 192 DISEASES OF THE SKIN. Nepveu, Wahlberg, Lukomsky, Koch, Orth, Fehleisen, 1 and others. The micrococci recognized by them were seen in great abundance, often arranged in chains, in the curium, subcutaneous tissue, and lymph spaces of erysipelatous skin, never in the bloodvessels. Other views as to the etiology of the disease have been advanced. Hebra and Kaposi believed it to be due to the secondary products of local inflammation ; others have held to a "malarial" origin (Cohnheim). Among later observers, Tillmans concludes that the infection of the disease may be transmitted by fluids both containing micrococci and without them. The conclusion is irresistible that the disease is always the result of the admission of specific bacteria to the human body by the avenue of a lesion of the surface, however insignificant in size. Women are rather more subject to the disease than men. The disorder is also apt to occur in spring and autumn. Pathology. — Under the microscope, the skin and subcutaneous tissues are seen to be infiltrated, the exudate being more serous and less rich iu protoplasm than that observed in ordinary phlegmonous inflammation of the skin. The bulla? represent rapid exudation of this same serosity to the congested epidermis, aud the elevation of the latter in consequence. The elements of the rete and connective tissue are for the same reason swollen, the lymphatic and bloodvessels enlarged, and the cutaneous follicles engorged, the root-sheaths of the hairs being occasionally separated, necessitating thus the temporary loss of the pilary growth. In proportion to the severity of the exudative process, pus corpuscles may appear and represent, for the most part, degenerative changes iu the subcutaueous tissues resulting in abscess. The phenomena are, in short, those of superficial or deep-spreading dermatitis. After death, the skin which has been the seat of the disease cannot be distinguished microscopically from that of another body. Diagnosis. — Erysipelas is to be distinguished from the ervthemata, from dermatitis of various grades, from eczema, and from scarlatina. As a rule, its recognition from all is readily effected, when the presence of the fever in erysipelas is had in view, as also the peculiar shining, swolleu, and rosy-reddish to damask hue of the affected parts. The redness is never produced as in scarlatina by multiplicity of reddish puncta, nor is it so widely diffused as in that disease. Erysipelas may be at times accompanied by a pruritic sensation, but the patch which it affects is never by any possibility scratched. By this simple test alone one may often distinguish an erysipelas of the face from an eczema of the same region in a child. From a chronic dermatitis with thickening of the affected tissues and redness of the surface, erysipelas is to be distinguished by its tendency to spread, by its acute career, by its frequent association with bullous or vesicular lesions, and by the color, outline, and raised border of the affected patch.- However, it must be understood that to these localized patches of chronic dermatitis several authors have given the name, 1 Die Aetiologiu iles Erysipelas. Berlin, 1883. ERYSIPELAS. 193 chronic erysipelas, the difference between the views held on this point being chiefly one of terms. Treatment. — Upon the continent of Europe, the therapeutic man- agement of erysipelas is in general limited to the employment of such systemic and topical measures as are specially required in each case. Quinine is administered whenever indicated by the temperature record ; and the erysipelatous surface is either left exposed to the air, covered by dry compresses, moistened by eold or hot aqueous lotions, or anointed with unguents, simple, mercurial, or anodyne, as suggested in each case. Occasionally cataplasms are applied over the inflamed surface. Abscesses, whether subcutaneous or connected with a carious tooth, are opened ; the contents of all pustules evacuated ; and crusts carefully removed. Kaposi lays stress upon freeing the nasal cavities of all inflammatory products, whenever the face is attacked. The method of treating erysipelas by the administration of the tincture of iron internally has long been popularized among American practitioners. This preparation is given in full doses, from twenty to fifty drops, day and night every two to three hours, irrespective of the febrile state. When the erysipelatous blush has a distinctly circumscribed outline, the annular zone extending for an inch or more in width upon the sound and affected skin is either covered with the tincture of iodine, pencilled with a crayon of nitrate of silver, or painted with a saturated solution of the same salt. This is done with a view to limit the extension of the disease. It is true that these measures will not always succeed, but it is erroneous to assert with some authors that they always fail. Certain it is that, whether effective or not in the production of the result, the advancing border of the disease will often fail to surpass the limits thus artifi- cially described. Collodion has been employed for a similar purpose, and lately Darlin 1 has written in advocacy of the revival of this method of treating the disorder, basing its claim on the fact that it diminishes the temperature of the part thus protected, and that, by the compression excited, it interferes with septic absorption. Heppel 2 recommends the painting over the surface of a ten per cent, solution of carbolic acid in alcohol, as an abortive treatment, for which Braithwaite 3 substitutes a similar solution of tannin. Excellent results are occasionally reached in the local treatment of erysipelas, first by attempting to limit the extension of the disease by the application of the tincture of iodine over the peripheral zone ; and, secondly, by retaining over the entire surface affected, neatly applied compresses saturated with a solution of the hyposulphite of n sodium in the strength of about one drachm (4.) to the ounce (32.). Dr. Spencer, of the United States Army, has frequently seen the disorder upon the face entirely relieved in this way in forty-eight hours. 1 Bull. Gen. de Ther., 1881, vol. ii. p. 239. 2 Arch, of Derm., April, 1881. 3 Brit. Med. Journ., April, 1881. 13 19-i DISEASES OF THE SKIN. With many judicious practitioners all attempts to limit the exten- sion of the disease by local applications of an irritating sort(corrosive sublimate, nitrate of silver, carbolic acid, tar, turpentine, etc.) are condemned as positively injurious. Dry heat is applied by the aid of cotton or wool ; or cold compresses are laid over the part; or iced lead lotions with intermissions of application ; or salicylic acid, boric acid, iodol, or iodoform, in powder, llesorcin in solution has been followed in some eases by excellent results. Erysipelas rarely attacks a patient in vigorous health. The large majority of all the subjects of the disease are either those who have previously suffered from manifest general ill-health, or who have been complaining of local ailments, trifling wounds, nasal catarrh, or surgical accidents. It is these precedent conditions which often demand the special attention of the physician or surgeon. It is needless to add that all surgical indications are to be fully met when these are present : pus is to be evacuated, crusts removed, and drainage secured. The physician and surgeon alike should never forget that the disease is infectious, that the patient is to be isolated, and to be supplied with an abundance of pure air; and that fomites, surgical instruments, and even the uon-disinfected hands of the attendants are capable of transmitting the disease. Finally, there are forms of erysipelas which are remediless. These are usually septic in character. The scarlet blush spreading from an irreparable injury of long duration, is often the last protest of nature against the damage which even her final resort of gangrene will not avail to repair. Prognosis. — Under favorable circumstances, erysipelas, even of severe grade aud extensive invasion, terminates in complete resolu- tion. Reserve should be made, however, in every case, as a serious complication has often transformed the simplest into the gravest forms of the disease. The author has seen an erysipelas of mild grade originating in the irritation of the lobe of the ear by an ear ring, trans- mitted to a child who died with gangrene of the entire mucous lining of the oral cavity. The very young, the cachectic, the victims of drink, the aged, the inmates of hospital wards depressed by other illness, aud those mentally distressed by destitution and neglect, are particularly liable to suffer from grave and fatal forms of the malady. The patients who fill the beds in most lying-in hospitals are young women, either unmarried or deserted by their husbands, and unpro- vided with the necessities of life by those upon whom such a respon- sibility rests. The mental depression thus originating in connection with the septicemic influences too common in all large charities, is responsible for much of the relation which erysipelas often seems to sustain to the puerperal state, as also for the appalling mortality which it may exhibit under these circumstances. FURUNCULUS. 195 Furunculus. Lat. furunculus, a petty knave. Furunculosis is a disease characterized by the occurrence of one or more circumscribed, cutaneous or subcutaneous abscesses called furuncles, which usually terminate by necrosis of tissue in the centre of the phlegmon, its expulsion in the form of pus or a core, and a resulting cicatrix. Symptoms. — Furuncles, or Boils, commonly begin as both tender and painful indurations in the skin or its subjacent tissues, the sum- mit of which soon becomes visible in the epidermis as a reddish punctum. It is the result of an active inflammatory process, limited to a definite area, and of greatest intensity at the centre of the in- volved mass. This centre is often represented by a hair-follicle, the pustule that forms subsequently being perforated by a hair. More or less rapidly thereafter these symptoms are succeeded by increased redness, heat, and tumefaction, the latter producing a nut- or egg-sized tuberosity, well projected from the surface, or fairly imbedded within or beneath the derma. A yellowish point in the centre of the erythematous swelling soon announces the occurrence of suppuration. When accidentally or artificially opened at this summit, exit is given to a thick yellowish pus which may be com- miugled with blood from the traumatism of the neighboring capil- laries. The small abscess may then, after discharging its purulent contents for a few days, gradually close by granulation, or may also expel from its cavity a tenacious, pus-covered, yellowish-green slough, known as the " core." This evacuation is usually followed by relief of the tense and throbbing pain which is the well-known subjective characteristic of the furuncle. The length of time requisite for the completion of this process varies, with the exteut of tissue involved, from a few days to several weeks. Boils may occur in any part of the body, but are most common about the face, the auricular region, the neck, the armpits, the ano-genital region, the hips, the buttocks, the breast, and the extremities. They may occur as single or multiple lesions, or may succeed each other in crops, especially about the buttocks, trunk, and thighs, for a period of several mouths. It is this succession of boils to which the term furunculosis is specially applied. The disease of the skin, in such cases, may produce a constitutional effect manifested in pyrexia. This is usually encountered when the furuncles are few and short-lived, only in individuals of irritable constitutions. There is also a decided chloro-ansemia due to the pain, fever, purulent drain, derangement of the nervous centres, inappetence, and consequent perversion of nutrition. The sequelae of boils are maculations of a violaceous tint, often perceptible in the skin for weeks and even months after their disap- pearance ; and cicatrices, pin-head to coin-sized, which are permanent. Etiology. — The causes of furunculosis, as also of a single furuncle, 196 DISEASES OF THE SKIN. are often exceedingly obscure; and it must be admitted that the sub- ject requires more extended study. It is true that both conditions are encountered in typical subjects of " hospitalism," where anaemia, asthenia, marasmus, malnutrition, and exhaustion resulting from excesses, from grave general disease, from low fevers, and from ner- vous strain, play a prominent part. But the reverse is also true. The author has recently, for example, had under his care a gentleman of superb physique, active habits of life, and large -wealth, who availed himself of all the resources of medical skill, and who had yet suffered for six months from a persistent furunculosis. Few actively engaged practitioners have foiled to see similar eases. On the other hand, scratching, eczema, scabies and. other cutaneous diseases, lice, and external irritants of various sorts are responsible for nmny boils, especially those that are few and not followed by similar lesions. When, however, such sequence occurs, it should never be forgotten that the furuncles, if sufficiently numerous and large, are amply capable of disturbing the general economy. The collar-button at the back of the neck; the edges of an unyielding corset, for one unaccustomed to it ; a hard bench; the saddle-tree; and many similar articles, may be the exciting cause of furuncles. Account should always be had, in cases of persistent furunculosis, of externally operating poisons. In this category must be included sewer-gas emanations, arsenical wall-papers, and the poisons handled in the trades, e. r/., by dyers, lead-manufacturers, etc. Lastly, it is exceedingly common for patients thus affected to apply to practitioners for remedies intended to " purify the blood ;" and, inasmuch as the iodide of potassium is often mischievously prescribed in response to this demand, the original trouble is thus enhanced to a manifold extent. Many cases of furunculosis are instances of boils resulting originally from external irritation, which have greatly mul- tiplied and finally profoundly affected the system under the impulse of the so-called "blood-purifying" process. Patholoyy, — Authors have attempted to explain the phenomena of furuncle by supposing the process to be due to inflammation attack- ing a sebaceous follicle in the derma ; or a pilary follicle or sweat- gland beneath the skin ; or the peri-follicular tissues ; or the con- nective tissue pedicle which passes downward from the fundus of the hair-follicle to the subcutaneous tissue ; or the blood and lymphatic vessels which surround the sac. It is reasonable to suppose that they are all in the right. No one of these component parts of the skin is known to be exempt from the changes which are induced by the inflammatory process. It is difficult to discover in the furuncular lesion any symptoms which set it apart from the other results of localized inflammation, its phenomena differing from those of ecthyma, acne, pustular eczema, anthrax, etc., only by the seat and extent of the inflammation. The core of the furuncle represents a necrosis induced by the violence of the exudation, and so does the gangrenous slough which falls after a severe dermatitis calorica. The core of the furuncle is moist, yellowish, and puriform, because it is FURUNCULUS. 197 completely immeshed beueath the epidermis, and pus-soaked. The core or slough of a gangrenous dermatitis may be as dry as a crust, from desiccation in consequence of exposure to the air, or be in various degrees moistened by the fluids escaping from the tissues beneath. Where there is no core in furuuculus, this absence is prob- ably due to the fact that the purulent products of the inflammation pass with readiness from the peripheral to the central parts of the phlegmon without having to leak through or between, or to be pressed against, masses of centrally disposed elements, whose vitality is thus the more readily lost. Inflammation of tissue in a practically closed chamber, under tense pressure, under slight pressure, exposed freely to the air, or in all grades protected from it, will always differ in its phenomena. It is wiser to attribute these diifereuces to the circumstances under which it is displayed than to any peculiarities in the nature of the process itself. The contagious character and parasitic origin of furuncles have been studied by a number of observers. Giugeot, 1 Startin, Trastour, Lowenberg, Pick, Pasteur, and others have, with varying success, reproduced these lesions by experimental inoculation. The name torula pyogenica has been given to a vegetable parasite recognized in furuncular products, which, however, in development, is to a marked degree modified by the nature of the site in which it is implanted. It is with these demonstrations in view that Gingeot suggests the employment of parasiticides in the treatment of furunculosis, the acid nitrate of mercury, iodine in tincture, carbolic acid, and borated alcohol. Internally sulphur and the hyposulphite of sodium in large dilution are administered. Diagnosis. — Boils are to be distinguished from carbuncles by the exaggerated symptoms of the latter, described below. Circumscribed furuncular abscesses of the groins and axilla? are not to be con- founded with suppurating, sympathetic, or virulent buboes of these regions, associated with genital or extra-genital, contagious, venereal sores. This goes without saying ; but many such errors have been made. Furuncles of the anal and genital region may be significant of surgical affections of the neighboring parts (perineal, peri-prostatic, peri-urethral, and scrotal abscesses in men ; suppuration of the vulvo-vaginal gland in women, etc.). Treatment. — The debilitated constitution of many patients affected with boils indicates clearly the need of a tonic regimen, including the administration of iron, quinine, and strychnine, the mineral acids, and, contrary to the generally accepted opinion of the laity, a gene- rous diet of milk, cream, eggs, and fresh meats. To these, wines and malt liquors may be at times added with advantage. Change of climate, of diet, of cooks, and of the habits of life is most service- able in cases of prolonged furunculosis. The mineral waters, at some of our health resorts, prove especially valuable for the debility which often results from these disorders. The internal remedies which i Bulletin gen de Therap., Jan., Feb., and Mar. 1885. 198 DISEASES OF THE SKIN. possess reputation in this complaint are arsenic, sulphur, and the sodic sulphites, the alkalies, tar, phosphorus, and the sulphide of calcium. The last-named is probably more highly esteemed by the larger number of practitioners than all other internal remedies, and is given in doses of one-fifth to one-tenth of a grain (0.0133-0.0066) every three or four hours in the day. In lithsemia, the aeetate or citrate of potassium is given in large dilution ; in gouty states, col- chicum and the alkalies, including the sodie salicylate. No one of these articles, however, may be deseribed as an efficient and certain remedy tor the complaint; many eases will progress without hin- drance from any or all of them. Attempts in the direction of aborting a furuncle may occasionally l»e made by the topical application of the stronger alkalies (aqua ammonia') or acids; caustics or cautery ; ice, or premature complete incision with the scalpel. These measures will occasionally succeed ; more often they fail. Frequent renewal of hot poultices of powdered slippery elm or flaxseed, to which an opiate may be added for the relief of the acute pain, should be practised till suppuration is estab- lished, and exit given to the pus or core. For a brief time after- ward, they may lie continued. Subsequently the treatment is by carbolated lotions and simple ointments. Prognosis. — The future of the patient affected with a prolonged furunculosis is that only of which there can be question. Eventually the worst cases are relieved when unaccompanied by systemic or visceral disorders, and where the circumstances of the sufferer permit him to pursue the most advantageous course (travel, diet, abstraction from business, etc.). The resulting cicatrices depend upon the severity of the process. Often they are small, and in the course of years scarcely distinguishable. In exceptional cases they are large, persistent, and disfiguring. Anthrax. Gr. avdpa^, a live. coal. Anthrax is a circumscribed, cutaneous and subcutaneous abscess, usually larger than a furuncle, characterized by dense induration and sloughing, and terminating, in favorable cases, by the production of a persistent cicatrix. The term anthrax is employed by several foreign authors to desig- nate the disease known among the English as murrain, splenic fever, or malignant pustule, the charbon of the French. It is here employed solely in the description of the non-specific carbuncle. The malignant carbuncles clue to the presence of bacteria will be described under the title, Malignant Pustule. Symptoms. — Carbuncles are often preceded by malaise, chill, and pyrexia of severe grades. In cases where the anthrax is formidable and seated upon or near the head, alarming symptoms of prostration, stupor, somnolence, and even coma, may be noted. With and with- ANTHRAX. 199 out these concomitants, a dense, dull-red, indurated, and painful phlegmon soon appears, varying in size from a small hen's egg to an orange and even much larger, involving not only the skin, but the tissues beneath. Suppuration finally occurs ; but the pus is not con- fined to a single sac. It undermines the integument, and often, through several apertures, leaks out indolently to the free surface. The fenestrated or cribriform appearance of the skin covering the carbuncle constitutes, in this stage, one of its most striking features. Through these apertures may be distinguished the whitish or yel- lowish pus-soaked sloughs, or portions of a single slough, which can be at times extracted through the orifice. Often the entire mass separ- ates in a single slough, involving the skin and subcutaneous tissues, leaving a crateriform ulcer of formidable size, which, in favorable cases, proceeds to heal by granulation. The resulting cicatrix is at first of a deep violaceous tint, and later becomes blanched. It is indelible. The fever which usually accompanies this process may be mild or severe, or, more commonly in dangerous cases, of a typhoid character. It results unquestionably from sepsis due to unli berated pus and necrotic tissue, and is naturally most grave in consequences where the patients are weakened by previous asthenic disorders. Under these unfavorable circumstances, the carbuncle may spread at the periphery, with islands of necrotic tissue and ill-conditioned pus ( separated by bridges of empurpled, infiltrated, and yielding skin. The peculiar lesions of this disease most often appear upon the back of the neck, the back of the trunk, and the lateral aspect of the hips and thighs, usually in single development, though occasion- ally two or even three carbuncles of small or medium size may co- exist. The reason for their appearance in the localities named is clear. It is here that the skin is most thick and resisting, and, as a consequence, purulent foci when formed are covered in by the most voluminous layers of the connective tissue of the corium. Etiology. — Anthrax is produced by the obscure causes to which reference has already been made as probably effective in the produc- tion of boils. The two may coexist; or the one follow the other; and intermediate forms occur which might be assigned to either class. The disease is encountered more often in men than in women, and in later than in earlier life, simply because the tissues constituting its sites of preference offer in these individuals, and at these ages, a greater resistance to the exit of pus. The bacilli which may be recog- nized in many cases may sustain an etiological or purely accidental relation to the lesion. Pathology. — The pathological anatomy of carbuncle is well described by Warren, 1 whose observations conclusively show that the inflammatory process here is one with that seen in the simplest pustule. The peculiar symptoms of carbuncle are due solely to the formation of the phlegmon beneath the dense and extremely thick masses of fibrous tissue found in the back " for the protection of 1 The Tathology of Carbuncle, or Anthrax, Cambridge, 1881, p. 15. 200 DISK A S ES F T HE S K I X . that comparatively defenceless portion of the body." The elements, multiplying with the intensity of the inflammatory process, first in the subcutaneous adipose tissue, pass upward along the fat columns described by Warren as columnse adiposae, crowd these, push along their horizontal clefts branching from either side, infiltrating the derma, pass along the edges of the hair-follicles, till the papilla? till the latter ''balloon" with pus, ooze to the surface through the cribri- form apertures in the undermined epidermis, and soak the bundles of fibrous tissue, relatively intact, which constitute the undetached mass of sloughing tissue. It cannot lie doubted that the general symptoms in anthrax, pyemic, septicemic, sympathetic, are due solely to pus imprisonment. Frr,. 34. Vertical section of anthrax. Dense network of fibrous bundles, with interspaces communicating and extending to the subcutaneous tissue. (After Warrex ) Fig. 35. Section of anthrax. Infiltrated papilla? are seen at I, distended in balloon-shaped figures, between which the rete is compressed ; at p and mp columnae adiposae are seen ; /, division of elements, the fibrous bundles resolving into protoplasm. (After Warrex.) Diagnosis. — It follows from what has preceded that carbuncle and furuncle differ solely in consequence of the depth of the starting- point of the phlegmon, and the density and resisting power of over- lying tissue. The former is therefore flatter, denser, less rapidly de- veloped, larger, less tender, and more painful, opens by many rather than by one or two apertures, and is followed by larger sloughs, ulcers, and cicatrices, and occasionally by fatal results. ANTHRAX. 201 Treatment. — Crucial and other deep incisions in the local treat- ment of carbuncle are certainly inferior in results to the method advocated by Wood 1 and Talor, 2 which are employed in cases with complete success. A saturated solution of pure carbolic acid is injected through the several apertures in every direction into the sloughing tissues by the aid of an hypodermatic syringe. When the orifices are not sufficiently numerous, the point of the needle is thrust through the thinned integument at the summit of the swelling in several points. The pain is severe, but short-lived ; the tissues are blanched, indurated, and destroyed ; the slough in a few days is readily separated after division of its slender fibrous attachments; and the ulcer rapidly contracts with the sequel of a smaller scar. It is necessary to use pure acid in saturated solution to prevent absorption of the injected fluid and resulting toxic effects. Relief is afforded in many cases by opiated hot cataplasms and fomentations, with the requisite skill in the surgical dressing of the parts by carbolated lotions, extraction of the slough wholly or in portions by the forceps, and the subsequent employment of simple or carbolated unguents during the reparative process. An excellent method of withdrawing the purulent and sloughing contents of the carbuncle is to apply over it, at the proper period, an exhausted receiver, such as a common cupping-glass. In many cases the antiseptic treatment of a carbuncle furnishes decidedly the best results as regards the comfort of the patient and limitation of the disease. Here there is absolutely no surgical inter- ference with the lesion, beyond the incisions made for the evacuation of pus. The violent squeezing and manipulation of the carbuncle are interdicted. It is freely powdered with iodoform, and on it is laid soft, felt cloth, thickly spread with any emollient and antiseptic salve. Bulkley 3 advises the use of the ordinary zinc salve for this purpose. Boric acid in powder, or iodol, thickly dusted over the carbuncle and covered with antiseptic wool will also be found a useful dressing. Iuternally calx sulphurata should be administered in full doses. It has an unquestionable effect in diminishing the pus-formation. Other constitutional treatment is that demanded in the case of furunculosis, including the liberal employment of tonics, a generous diet, a strict observance of the rules of hygiene, and stimulants when indicated. Pyrexic, septicemic, pysemic, and adynamic states require the special management of such complications, including cold sponging of the surface in fever, and the use of quinine and stimu- lants, with artificially applied heat in the algid condition. Prognosis. — A serious issue need be anticipated only when the complications described above are grave in character, or occur in asthenic constitutions. Pustules from Cadaveric Infection. — The lesions generally known as dissection-wounds usually occur upon the hands of those 1 Toledo Medical and Surgical Journal, Dec. 1880. - Austral. Medical Gazette, Dec. 1, 1881. 8 Journ. of the Amer. Med. Assoc, May 16, 1885. 202 DISEASES OF THE SKIN. exposed td the danger of post-mortem examinations and dissections. At the point of inoculation, which may be either the site of a former abrasion, rent, or the month of an open follicle, a painful vesico-pustule, papule, tubercle, wart, furuncle, or hemorrhagic bulla rises rapidly from an angry and indurated base, with hypersemic areola in dull red shades. Suppuration, crusting, or ulceration may follow, limited to the seat of the lesion ; or lymphangitis in various grades with consequent pysemic or septicemic involvement of the system. Suppurative and non-suppurative axillary buboes are common. Gangrene and necrosis of the soft parts and bones, especi- ally the phalanges, may ensue, as also a fatal result from the systemic disorders named. In a few cases a chronic marasmus is induced. Prophylaxis, by proper protection of the hands and the immediate cleansing and disinfection of any accidentally wounded point, is of the highest importance. The treatment is to be conducted in accord- ance with the principles already described. There is reason to believe that accidents of this kind may be pro- duced by absorption of the alkaloids engendered in the cadaver by the decomposition of proteid substances, called ptomaines. These were first isolated and named by the late Professor Selmi, of Bologna, subsequent investigation seeming to prove that in chemical constitu- tion they do not differ from the alkaloids produced by albuminous decomposition in vegetables. Brieger has identified neuridine, cada- verine, putrescene, and saprine in the dead body, and, with these a peculiarly toxic alkaloid to which he has given the name mydalein. All these are capable, after ingestion or admission by other avenues to the circulation, of inducing salivation, vomiting, diarrhoea, dysp- noea, paralysis, and death. The lethal issue in the case of lesions of the character here designated, is probably due to the fact that, at the site of the pustule of irritation or traumatism, one or more of these toxic alkaloids has gained admission to the lymphatic circulation. For further reference to this subject, the reader may consult the chapter on Verruca Necrogenica. Pustules and Other Lesions resulting from Wounds In- flicted by Reptiles and Insects are often of an insignificant character. Such are the trivial results of the bites and stings of flies, fleas, mosquitoes, ants, bees, hornets, etc. At other times, however, serious and even fatal consequences have been recorded. The wounds produced by the tarantula and scorpion (which frequently lurk in the clusters of tropical fruits now imported to almost every part of this country), as also of the venomous reptiles, may prove to be grave. Urticarial, vesicular, pustular, papular, bullous, and petechial lesions may thus originate and be the cause of a more or less severe dermatitis with toxic symptoms. In the latter event, it is common in this country to administer as remedial agents, alcoholic stimulants as freely as they can be ingested. Delhi Boil, Aleppo Evil, and Biskra Bouton. — These are chronic endemic disorders characterized, for the most part, by the ANTHRAX. 203 occurrence of painful nodosities upon the face, hands, and other portions of the body. The lesions are often multiple papules, which subsequently become purulent and ulcerate indolently ; or become covered with scales. They are often grouped iu patches and followed by cicatrices. The exact nature of the maladies thus named, is unknown. They are quite fully described by Fox, Farquhar, Pollack, Willemin, and other authors, as occurring in India, the region about the Euphrates and Tigris Rivers, and along the northern coast of Africa, especially Algeria and Morocco. The descriptions given of these diseases certainly suggest that, in some instances at least, several different disorders have been included under these titles, such as the lesions of lupus, syphilis, and the frequently formidable symptoms produced in the skin by the vegetable parasites in tropical countries. The author has personally journeyed from Arabia in the East, along the coast to six degrees below the line in South Africa, and thus enjoyed a fair opportunity of observing the symptoms of many of the endemic disorders of that region. In no single instance has the author been able to persuade himself that the numerous furuncular, papular, and pustular affections encountered, differed from the similar lesions observed in temperate climates, except in that they were greatly aggravated by filth, meagre diet, intense heat of climate, ignorant and vicious medication, and the syphilitic diathesis. Laveran 1 has lately described afresh the Biskra bouton. It occurs not only in Biskra, but also in the adjoining oasis, and is plainly identical with the Aleppo boil. It shows itself as an endemic only in the months of September and October, and continues till Decem- ber. No new cases appear in January and February. All ages, both sexes, the strong and weak, are liable to it. The eruption affects the face and extremities by preference, sometimes also the trunk. It ordinarily attacks the same person but once, yet may recur. So long as the disease prevails, the least excoriation has a tendency to become Biskra button. At first there is a reddish, pain- less elevation of the skin, the size of a pin's head ; the centre of this soon dries, and a brownish crust forms, easily removable. Beneath this, there is a small round ulcer. The papules may occur in patches, bearing thick crusts which long resist. The crusts are remarkably dry. When the latter are removed and the ulcer left undressed, a new, less firm crust forms ; when dressed, the crust- formation is pre- vented and an ulcer of an obstinate character remains, which in the leg is not unlike a varicose ulcer. If the original crusts be not disturbed, these eventually fall and leave no scar. Should, on the contrary, the crust be removed at the beginning of cicatrization, this is accom- plished slowly, and a permanent scar remains. Lymphangitis, erysipelas, and phlebitis, occur as complications. There are no peculiarities in the crusts. Epidermic cells, pus corpuscles, and bacteria, are commonly recognized by the microscope. An expectant treatment is the best. Should the crusts be removed or fall off, it is advisable to powder the ulcer with henna, which favors the procluc- 1 Aimal. de Derm, et de Syph., 1881, t. i. p. 173. 204: DISEASES OF THE SKIN. tion of fresh crusts and cicatrization. As regards its pathogenesis, the author holds Weber's view, that the disease is contagious and inoculable, and perhaps auto-inoculable. The virus exists in the crusts, but its nature is not established. Carter's opinion as to its parasitic nature is uot tenable. Dr. Altounyan, of Turkey, 1 protests against the view, given above, entertained by Geber and others that the Aleppo button is a term applied indefinitely to various cutaneous disorders. In his view it is a specific disease beginning, independently of the hair-follicles, as a small acne-form papule, disappearing on pressure and pinkish in color. Afterward it grows deeper, larger, and harder, and becomes more adherent and more vascular. Still it is livid, sensitive, smooth, and boggy to the touch. Pus forms centrally and dries into grayish- brown crusts which are rupioid in character. Beneath is a spongy ulcer, with ragged margin, ovoid contour, and ichorous discharge. Healing is by the production of a permanent and deforming scar, the entire course of the disease lasting one year. Dr. G. R. Eliott, of New York, who made a microscopical exami- nation of some specimens furnished him by Altouuyau, reports that the disease was limited to the epidermis and corium, and its area occupied by small round inflammatory or formative cells and epithelial elements. There was a distinct line of separation between the healthy and diseased tissue. No cryptogams or other micro- organisms were recognized. The hair-follicles and other glandular structures were intact. Altouuyau found the best treatment to be the painting of the button with the tincture of iodine ; and that one attack furnished immunity against a second. He believes the disease to result from the bite or stinsr of an insect. Phlegmona Diffusa. Gr. fyleyfxovf], an inflamed tumor. Phlegmona Diffusa is a grave form of non-circumscribed inflammation of the skin, in which the integument becomes livid, hot, swollen, painful, and apt for necrosis, this process occurring in one or many places to a considerable depth, and accompanied by fever and systemic disturbance. The word phlegmon is employed by most English and American writers to indicate a circumscribed inflammation of the skin, ter- minating naturally in suppuration, and, as to the tissues involved, larger than an ecthymatous pustule, and yet not large enough to be termed an abscess. Circumscribed phlegmons are represented by most furuncles, and, at one stage certainly of their career, also by carbuncles. In the disorder, however, under consideration, the symptoms, both local and general, are far more serious. The first evidence of trouble may be a severe chill, followed by high fever and deep-seated ham- 1 Journ. of Cutan. and Ven. Dig., viii , No. 6. June, 1885. PUSTULA MALIGNA. 205 mering pain, felt in the part which is the seat of the disease. This is soon recognized as an oedematous area, of dull red or livid hue, tensely infiltrated, of the familiar brawny type and indeterminate outline. All of these symptoms rapidly increase as resolution is very rarely attained, and are followed by suppuration at one or more points. In diffuse phlegmon, however, the brawny tenseness of the inflamed skin has been so great that vascular thrombosis occurs, and the circulation is greatly impeded, as a consequence, between the points where pus forms, or about a single point. The tissues then become more or less necrotic, both during and after the formation and evacuation of pus. The fever meantime may abate or entirely remit, or, in grave cases, steadily persist. In the latter event, the subcutaneous tissue, fascia, periosteum, bones, joints, and ligaments may be involved. But in all favorable cases the systemic condition is greatly improved when pus is no longer deeply or extensively formed, and when the gangrenous shreds and sloughs are well loosened or entirely removed. The "Acute Purulent (Edema " of English authors and the Gan- grene Foudroyante of the French may be regarded as severe types of diffuse phlegmon. In most of such cases the patients die septicemic before the complete evolution of the cutaneous inflammation has been reached. In others, the affected part, suddenly losing its tense brawny hardness, becomes emphysematous, or crepitates with bubbles of gas produced by decomposition. The patient may then become somnolent or delirious, or be the victim of an intercurrent and fatal involvement of the kidneys, lungs, liver, spleen, or bowels. The treatment of diffuse phlegmon is largely surgical, and in this day simple. Incision, drainage, and disinfection are the three essen- tial requirements. These thoroughly assured, the systemic treatment is by quinine, stimulants when indicated, and the accepted remedies for the typhoid condition generally, including rest in the recumbent posture and a proper supply of wholesome air and food. Amputation of limbs may be necessitated in order to save life. The prognosis rests almost entirely upon the extent, diffusion, and severity of the local inflammation, and the systemic condition of the patient. In a previously healthy subject, with good hygienic environ- ment and the absence of thrombosis, pyaemia, septicaemia, and ery- sipelas, the results will generally be favorable. With the reverse of these conditions, the outcome may be serious as regards the loss of a limb, deformity, or a. fatal issue. Pustula Maligna. Malignant pustule is a grave carbuncular lesion occurring usually upon exposed portions of the body, which may result in gangrene, accompanied by a specific fever, and usually resulting from inoculation with a virus obtained from some of the lower animals. This disease in man is fortunately rare of occurrence, and is usually derived from some animal affected with the specific malady variously 206 DISEASES OF THE SKIN. termed "Anthrax," " Charbori," "Splenic Fever," "Splenic Apo- plexy." or "Texan Fever." The lesion under consideration is also termed Splenic Fever Carbuncle. After inoculation with the disease from any infected animal, the human subject may (a) perish from systemic poisoning- wholly septicemic in character with few external symptoms; or, (/>) when life is sufficiently prolonged, suffer from visceral symptoms, and exhibit subcutaneous tumors; or (c) exhibit the symptoms of the disease now under consideration. In from twelve to eighteen hours after inoculation, a painless macule is first manifested, usually upon the dorsum or other parts of the hands or face to which the virus has had access. This is followed by an inflammatory and pruritic papule, which is rapidly transformed into a flaccid vesicle filled with a bloody serum and surmounting a firm indurated "nucleus," or a larger blood-filled bleb reposing upon a somewhat painful, engorged, and ofteu densely indurated base. Oue or more similar lesions may follow in the sur- rounding integument, coalescence of which produces a large, angry, (edematous, and ofteu gangrenous ulcer. The involved skin may be as large as. a small coin, or of the size of the palm of the hand. The lymphatic vessels and ganglia enlarge, and often suppurate ; metastatic- abscesses form; and the constitutional symptoms super- vening are those described in connection with equinia. If recovery ensues, the grangrenous mass is sloughed off as iu favorable eases of carbuncle ; if the result is to be fatal, the process is rapidly aggravated by ^edematous infiltration extending to a wider area and by larger quantities of tissue falling into necrosis. In some cases the accompanying fever is high, with marked delirium ; in others, it is of a typhoid character. Death results from shock, septicemia, or exhaustion, though in cases where the lesion is circumscribed and unattended by constitutional symptoms, recovery may ensue. 1 Etiology. — The disease is commonly induced by infection from one of the lower animals, usually horned cattle, who suffer from charbon or splenic fever, and are in relation to herders, ranchmen, etc. The susceptibility of the carnivora to the disease is very much less than that of the herbivora. It is claimed that not only direct inoculation may produce the disease, but that it may be extended by the medium of flies and other insects. More recently it is claimed that food, drink, and even inspired air may be the medium by which the disease is conveyed. Pathology. — Since the first investigations reported by Davaine to the French Academy in 1864, Pasteur, Klebs, Koch, Carneviu, aud others have fully demonstrated that splenic fever is solely due to the multiplication in the blood and tissues of a rod-shaped bacillus, the bacillus anthracis, which is always motionless. Under culture the bacilli may develop long filaments, many times larger than the 1 A chromolithograph exhibiting the peculiar features of the malignant pustule in the neck, will be found in the British Med. Journ. of June l:i, 1SS4, illustrating a paper by Mr. Morrant Baker. PUSTULA MALIGNA. 207 original rods, with a distinct sheath about a protoplasmic cylinder, which after segmentation furnishes oval and shining spores. These have been cultivated again and again, with re- sulting germs that have produced the disease FlG - 3C - artificially in the lower animals. The pathological anatomy of the malignant «$ . ^ pustule is that of carbuncle with the added V ««»«os) fact that specific bacilli and spores are abun- (i ^^Ai #?'? dantly present in the blood and debris of / t$\ ^'# . tissue. *..*», ^ &%t^ In establishing a diagnosis, care must be {JfJL*^ $%# taken to avoid one source of error. Malig- #'*■*■ " ftao<> nant pustule in man is not of frequent occur- rence in this country, but occasionally various Malignant *™ tul ° bacim and " ' . - . J . pus corpuscles. About X 300. cutaneous eruptions are induced upon the hands, after contact with animals or hides upon which chemical solu- tions have been applied for the destruction of lice. These solutions usually contain arsenic, corrosive sublimate, or other substances capa- ble of exciting a localized dermatitis. The treatment is to be conducted on the principles of general thera- peutics. Popper, 1 an Hungarian physician with a large experience in malignant pustule, reports success by deep excision of the lesion, extending the operation to the subcutaneous connective tissue. This has always proved successful when practised before the occurrence of general symptoms. A number of other authors have had similar successful results after excision. Pitts, for example (Brit. Med. Journ., March 19, 1887), reports two successful excisions of malignant pustule in the case of brothers. Hebra was not in favor of the early cauterization of the malignant pustule, and it may be considered as a questionable method of procedure. A grave case of malignant pustule is recorded, 2 in which recovery ensued after the hypodermatic injection of the tincture of iodine. Three syringefuls of the pure tincture were deposited beneath the skin at the periphery of the diseased surface, and lint soaked in the same was applied over the slough. Internally, fourteen drops of the tincture (1.) with three grains (0.26) of the iodide of potassium, were also administered. Normal cicatrization followed in this and six other cases recorded. Crucial incisions with the free application afterward of pure car- bolic acid have been followed by good results. Mr. Baker, of London, reports rapid and complete relief after excision, and the free use of iodoform. Internally, the hyposulphite of sodium and quinine are successfully employed. The febrile, typhoid, and adynamic features of the disease are to be treated in accordance with the recog- nized principles of general medicine. i Ctbt. f. Chir., 1881, No. 33. 2 Arch. gen. de Med., Feb. 1883. 208 DISEASES OF THE SKIX. Herpes. Gr. kprreiv, to creep. Herpes is an affection of the skin characterized by the occurrence of one or more vesicles rilled with a clear serum, disposed in groups, limited to a certain region of the body, and pursuing a definite career within a relatively brief period of time. The term herpes is unquestionably responsible for a great deal of the confusion which has existed with respect to contagious disease. By the ancients it was employed, as its etymology suggests, to desig- nate a disease creeping or extending gradually over the surface or within the substance of the skin. By several more modern authors the term has been employed in a generic sense in a futile attempt to distinguish a series of so-called " herpetic diseases," and even her- petic diatheses from those of a different complexion. The significance which attaches to the word in the minds of the dermatologieal authors of this day, is exceedingly simple, and is limited to the features conveyed in the definition given above. It will be seen that the description thus embodied is largely that of herpes' zoster, an affection which is in this work considered separately. Symptoms. — The disease is declared by the occurrence of millet- seed to coffee-bean sized vesicles, single or relatively few in number, and in the latter case grouped, occurring as epiphenomena of a general febrile process, or as symptoms of an idiopathic disease. The lesions are usually short-lived, surviving but for a few days, and are filled with a clear, serous fluid which may become lactescent. After accidental or spontaneous rupture, there is left a slightly tumid, superficial excoriation, which at times is characterized by a circumscribed hyperemia, slight infiltration, or oedema of the base and periphery. The subjective sensations are not usually severe, varying between moderate pain, itching, and heat. There are occa- sionally precedeut chill and pyrexia, but no persistent lesiou-relics result from complete involution. Herpes Facialis. — About the lips, mouth, and alas of the nose, rarely upon any other portions of the face, lesions occur singly, or iu a group, possessing the characters described above. Their frequency about the lips has determined the title Herpes Labialis, under which they are described by several authors. The tongue, buccal membrane, palate, and larynx may participate in the morbid process; and the lesions in such moist situations are represented by isolated or grouped, dark-grayish patches of epithelium, which are sensitive and exfoliate. The functions of the mouth in articulation and mastication are thus rendered painful. The disease is common in acute pneu- monia, malarial and enteric fevers. In these cases, as Kaposi has HEEPES. 209 shown, the occurrence of the eruption by no means augurs favorably in every instance, as a fatal result may nevertheless follow. Often the lesions coalesce, forming a pea-sized bleb in an irregular line of elevated epidermis, spreading along the vermilion border of the lip and distended with a clear serum. The burning and itching sensations which accompany the lesions are often marked and dis- tressing. In the course of two or three days, thin crusts form whose exfoliation terminates the disorder. The connection betweeu labial herpes and rigors has long been recognized, though particular attention has been directed to this relation by Hutchinson and Symonds. Beside the trophic disturb- ances of this nature, traumatism, exposure to solar heat, unusual fatigue, a simple coryza, exposure to a cool draught of air, and tem- porary gastric disturbances may suffice to induce the disease. There are patients who can produce the lesions at will by tickling the lips with a feather. There is in some individuals an unquestionable susceptibility to the disease. The disorder is always short-lived though often recurrent; and the superficial crusts which terminate the process are never followed by scars. Herpes Progenitalis. — This disorder, also termed Herpes Prse- putialis, is characterized by the appearance of one or a group of transitory vesicles occurring on the inner face of the prepuce, espe- cially upon its upper limb, on the glans, the balano-prseputial sulcus, and the adjacent integument; in women, on the hood of the clitoris, the labia minora, the inuer face of the labia majora, and adjacent surfaces even as far removed as the buttocks. There is usually precedent pruritus or a sensation of heat, followed by the appearance of one or several pin-head sized vesicles seated upon a tumid and hypersemic base. Within the preputial sac the lesions may either rupture at an early moment, or assume the features described as presented upon the mucous membrane of the mouth. The resulting oedema of the prepuce is often displayed in an annular tumefaction encircling the glans, while the labia minora perceptibly project from the general vulvar plane. In these localities the floors of ruptured vesicles are particularly liable to be irritated (coitus, caustic, etc.), and then pus and even blood may be exuded with much angrier excoriation and resulting crusts of darker shade. In the course of a few days even these crusts fall, and the disease is at an end. Recurrence is common. Often a first attack of herpes in the male results in an extraordi- nary sensitiveness of the balano-prseputial membrane, which persists for more than a year. The patients are usually middle-aged men, married, and virgin as to venereal antecedents. The membrane is then tumid, tense, slightly glazed, and dark red to dark purple in hue. Upon any undue sliding of the prepuce over the glans, a very super- ficial fissure occurs, whence a drop of serum oozes. The membrane becomes so sensitive that the passage of the finger over it is resented 14 210 DISEASES OF THE SKIX. as though the conjunctiva had been touched. Unusual friction by the clothing or the use of a stimulating lotion, is followed by intense pain and aggravation of symptoms; and the price of coitus is a week's resl in bed. Naturally the diagnosis of herpes progenitalis is between chancroid and chancre. The latter will be manifested by its induration, its period <>f incubation, and its characteristic double inguinal adeno- pathy. The chancroid, whether in pustular form or inoculated abrasion, is ah oriaine ulcerative in tendency, capable of auto-inocu- lation, and often accompanied by sympathetic, inflammatory, or virulent bubo of one side. Balanitis, with its puriform secretion and superficial patches of reddened epithelium, is readily distinguished by its symptoms, though the two disorders frequently coexist. Tin; practitioner should never forget that the patient who exhibits an herpes of the genital region to-day may have been inoculated at the site of these lesions which may to-morrow or later take on the chancrous modification. The rule to be followed, then, is very simple. No individual with a progenital herpes can be assured of immunity against syphilis, till the longest period of incubation of the syphilitic chancre has elapsed since the date of last suspected exposure. Herpes progenitalis is almost universally the result of naturally or unnaturally induced sexual erethism. Its occurrence in an indi- vidual virgin as to such antecedents may be due to the causes efficient in the production of herpes facialis. Unna, 1 in an interesting paper on the subject, has conclusively shown that, though relatively rare in chaste women, it is of common occurrence in prostitutes. Messrs. Diday and Doyou, 2 who have given special attention to the subject, believe that true herpes of the genital region is always of the recurrent type, and well marked by its special course, career, and consequences. All others of a false type are divided by them into [J] an irritative form, seen in women as the result of vaginal discharges, sexual irritation, etc.; [2] a pseudo-membranous or diph- theroid form, also occurring for the most part in women, vesicular and even bullous in its lesions, whose rupture is the signal for the pseudo-membranous transformation; [3] a neuralgic form, which is merely zoster of the genital region. Treatment. — The milder forms of herpes occurring about the lips and genitalia require the simplest treatment. Sponging with pure water, as hot as can be comfortably tolerated, is best followed by local use of a weak lead lotion, rose ointment, or zinc salve. About the lips it is well to protect the lesions with flexile collodion or isin- glass plaster. Occurring upon the genital region, the lesions are to be protected by the interposition of a pledget of lint or a borated or salicylated dusting powder. As a rule, ointments are unsuited for the moist mucous surface of the genitals, the odorous emanations 1 Jonrn. of Cntan. and Ven. Dis., Aug. 1S83. 2 Les Herpes Genituux, Paris, 18SG. HERPES. 211 from most diseases of such parts being retained disagreeably by all grease-containing compounds. Lotions answer a far better purpose, and these may be made stimulant with alcohol; astringent with tannin, the sulphate of zinc, or the sulphate of copper; painless with opium or cocaine; and antiseptic with carbolic acid or corrosive sub- limate. Prophylaxis by the local use of aromatic wine, or tannin and brandy, with continence, is a matter of importance. Herpes Iris. The behavior of the lesions in herpes iris differs somewhat from that just described; and this has led several authors to consider the affection as a separate and distinct disease. As there is, however, some doubt respecting the question whether herpes iris should not be relegated to the domain of erythema multiforme, it is assigned a provisional position in this connection. The symptoms at the onset are the occurrence of one or several vesicles or vesico-papules, which pursue their usual rapid career in two or three days. Upon the hyperpemic ring which surrounds these a second and even a third and fourth circlet of similar lesions form, each pushing the areola further to the periphery of the patch. The older are in full retrogression while the newer are in process of evolution; and the red blush which surrounds the earlier is under- going color-changes from vivid to paler hues, while the zone of the latest vesicles is assuming its intensest shade. The lesions are pin- head to pea-sized, rather persistent and firm ; and terminate more often by resolution than by rupture and crusting. The concentric and parti-colored rings may make up a single patch an inch or more in diameter, or several such patches may form upon the surface of the integument. In the latter case the central disk of some of the patches will be seen to be made of confluent lesions. The eruption is most commouly situated upon the extremities, especially over the dorsum of the hands and feet, in which situation, especially when symmetri- cally developed, it is always, according to Kaposi, more nearly allied to erythema multiforme. It is, however, also rarely seen upon the face. The subjective sensations produced are usually trifling. Atyp- ical forms occur where the lesions are imperfectly developed from papules, and also where, in consequence of an unusual exudation of serum, bullae appear. The points in which herpes iris most resembles erythema multi- forme are : the variegation of the tints in the peripheral integument (whence the name, iris) ; its localization upon the extremities chiefly ; its occasional symmetry ; its frequency in young adults ; and its tendency to occur in the spring and autumn. Per contra, herpes iris differs from other forms of herpes ; in the absence of a precedent febrile state or neuralgic pain ; in its avoidance of regions near the mucous outlets of the body (prseputial orifice, vagina, mouth) ; and in the behavior of the vesicular lesions after attaining their full development. 212 DISEASES OF THE SKIN. The affection is evidently one upon the border-line between herpes and erythema multiforme ; and might be properly considered under either title. Its existence is another evidence of the impossibility of drawing hard and fast lines between all the clinical symptoms pre- sented by different diseases. It can scarcely be mistaken for other affections, in consequence of the elegance with which its lesions are disposed. Pemphigus simplex and pemphigus foliaceus differ decidedly in their career, however much they may, at the outset of exceptional cases, present certain points of resemblance. The affection tends to spontaneous recovery, and requires no treat- ment. A dusting powder may be applied over the surface, if need be, to protect the lesions from accidental rupture. Herpes Gestationis, or Pemphigus Hystericus, is a name which has been employed to designate erythematous, papular, vesicular, and bullous lesions, accompanied by marked pruritic and burning sensa- tions, occurring usually upon the extremities, but also upon other parts of the body. The subjects are usually pregnant or hysterical women, who are said to exhibit recurrent attacks in successive condi- tions of pregnancy or neurotic disorders. Personal experience has led the author to accept fully the view of Duhring, that this disorder should be included under Dermatitis Herpetiformis. Herpes Zoster. Gr. suoryp, a girdle ; Shingles, Lat. cingulum, a girdle. Herpes Zoster is an acute exudative affection of definite career, characterized by the occurrence of groups of firm and distended vesicles, preceded, accom- panied, or succeeded by neuralgic sensations, usually monolateral in distri- bution, and followed in some cases by persistent cicatrices, the cutaneous symptoms being always limited to an area of the skin supplied by a twig of one or more of the cranial or spinal nerves. Symptoms; — This disorder is also termed Shingles, Zona, and Zoster. The eruption is usually preceded, for a period lasting from a few hours to days and even weeks, by malaise or ueuralgic sensations of moderate or severe intensity. These sensations are usually limited to the area of the integument subsequently or coincidently displaying cutaneous lesions; but there are exceptions to this rule, as the pains are at times experienced elsewhere. Often, though limited to the region about to be attacked, they occur where pain is experienced in other neuralgias, at the points indicated by Romberg as corresponding to the regions where cutaneous brauches are given off by the nerve trunks. According to Fabre, the essential lesion, always present even when vesicles are not seen, is the first macular efflorescence of the disease. This appears in the form of vivid and brilliant-red erythematous macules, groups of which, from six to ten in number, appear in the HERPES ZOSTER. 213 tract supplied by the affected nerve. The vesicles (which are gener- ally regarded as more characteristic of the disease) appear afterward in from a few hours to a day or more, springing from the macules, and are accompanied by a sensation of heat. These typically perfect, isolated vesicles vary in size, from a rape-seed to a coffee-bean. They appear in groups corresponding to the groups of the macules, from eight to a dozen in a single cluster, and appear successively, the indi- vidual members of each attaining maturity simultaneously in about one week, while the succession of others may prolong the period of efflorescence to an entire month. The lesions, when fully developed, exchange their early limpid contents for those of a lactescent or puriform character. They project well from the widely hypersemic base from which they spring; are tense from complete distention ; and have no tendency to spontaneous rupture, so firm is their roof-wall. When abundant, they may coalesce. Involution is accomplished by desiccation, and the forma- tion of yellowish-brown crusts, whose fall is succeeded in certain cases by indelible scars. Several variations from the type thus described require notice. The vesicles may be few and typical ; numerous, abortive, and transi- tory ; or differ in type as they may be transformed into veritable pustules or bullge, or become filled with blood from capillary haemor- rhage. In the latter event there is still further departure from type in their tendency to spontaneous rupture and subsequent ulceration. According to Kaposi, it is in such cases only that cicatrices form ; but this statement, in view of many clinical observations, must be accepted with reserve. Authors have established a number of clinical varieties of the disease merely differing as to symptoms, such as acute febrile, apyretic, subacute, and even chronic and recurring forms. A bluish appear- ance of the eruption in some parts has suggested the name " black herpes ;" blood in the vesicles, a hemorrhagic form ; and the occur- rence of gangrene has added an additional distinguishing term. The anomalies of nervous significance are : extraordinary persistence of neuralgia after the involution of the cutaneous lesions ; neuralgia of an intense and intolerable severity at any period of the disease ; painful anaesthesia of the skin ; paretic and paralytic phenomena with resulting muscular atrophy ; and, in zoster of the head, dehiscence of teeth and hair. The vesicles of herpes zoster are always produced in the areas of integument supplied by sensory nerves proceeding from the cerebro- spinal tract, a circumstance which explains their usual imitation to a single lateral half of the body. This limitation is rarely observed exactly at the median vertical .line of the body, as a few lesions can usually be seen surpassing this boundary. The terms zoster capitis, zoster brachialis, zoster occipito-cervicalis, etc., are used to distinguish the special regions involved in the disease. The fact that the majority of all cases are due to disease of the ganglionic nervous system and not to disease of the spinal cord, 214: DISEASES OF THE SKIN. explains the more frequent occurrence of zoster in the upper portion of the body. Individuals arc commonly subject to but one attack of herpes zoster in a lifetime, though, as usual for all general laws, there are the few exceptions which prove the rule. The same may be said of double attacks, those involving simultaneously the two lateral halves of the body, instances of which are occasionally recorded. These may be complete and symmetrical, or multiple and not symmetrical; or bifid, when there is simultaneous involvement of several branches of one nerve or of several nerves. Barensprung recognized the nine varieties of this disease named below, the difference in each having a purely local significance. Zoster Capillttii depends upon involvement of the second branch of the fifth pair of nerves, and its lesions occupy the anterior and posterior portions of the scalp. Zoster Frontalis occurs in the area supplied by the supra- orbital nerve, which springs from the first branch of the trigeminus. Its lesions extend from the upper eyelid to the vertex, and are spread in a fan-shaped figure over one-half of the brow, forehead, and scalp. Z< »ster Ophthalmicus may be a severe and dangerous manifes- tation of the disease, being often complicated by agonizing neuralgia, formidable involvement of all parts of the eye even resulting in panophthalmia, ulcerative keratitis, pyaemia, meningitis, and death. Typical cases of zoster of this region may not, however, exhibit a single outward symptom of the disease. Zoster Facialis depends upon involvement of the sensory nerve- fibres of the trigeminus distributed to the face, its lesions being displayed over one cheek, the side of the nose, the half of the lip, or of the chin. The facial and seventh nerves may be chiefly affected. Care must be taken in cases of this variety not to con- found the disease upon the nose with acne, or painful tertiary syphil- itic lesions, errors which have occurred. When the lower jaw is involved, there may be severe toothache, dysphagia, and fall of the teeth with great resulting deformity. Zoster Nuch^e seu Collaris occupies the region extending forward from the cervical vertebrae to the clavicle, or upward toward the occipital region and the auricle. Zoster Brachialis occupies the region from the last cervical and first dorsal vertebras over the supra-spinous scapular region and the contiguous portion of the uper arm. Rarely, even the skin of the fingers, and that over the first and second ribs is involved. It is a common and usually mild form of the disease, and characterized by a peculiar isolation of the vesicular groups. It occurs also with lesions of exclusively brachial distribution. HERPES ZOSTER. 215 Zoster Pectoralts is the most frequent form of the disease, from which its common name "shingles" originated. The eruption occurs below the first dorsal, covering the skin of the thorax as far as the lumbar vertebrae, extending from the spinal column behind to the sternal regiou in front. Two, three, or more of the intercostal nerves in this region are commonly involved, and the neuralgia resulting has been frequently mistaken for the pain of a pleurisy. Children are more apt to display this than any other variety of zoster. Zoster Abdominalis. — The area here involved extends from the lumbar vertebrae to the median line of the abdomen. It is usually much less pronounced in its features, and the exanthem less abundant than in the variety of the disease last described. When constipation exists, defecation may be attended with considerable pain. Zoster Femoralis covers the buttocks and sacrum, and extends along the thigh, sweeping from behind forward and from above downward as far as the popliteal space ; in some cases involving the leg and foot. The penis, scrotum, labia, vestibulum vagina, and anus may then exhibit unilaterally arranged vesicles. The scars left by zoster are characteristic. Not only are they limited to the seat of the original disease, but they have a peculiar indented look, as if made by a nail-sett and hammer. They are particularly angular in outline, and do not exhibit the dead-white color of many cicatrices. Etiology. — Herpes zoster occurs in both sexes, and in the young as well as the old, though it is rarely seen among infants. It seems to be somewhat under the influence of the seasons, as cold and damp weather serves to increase its frequency in those susceptible to it. A large list of other depressing agencies are named as effective in its production, such as : certain poisons, carbonic acid gas, belladonna and atropine (Mackintosh), arsenic (Baker, Dyce Duckworth, Hutchin- son); pyaemia, carcinoma, fever (Gerhardt), pulmonary inflamma- tions (including phthisis), septicaemia, haemorrhages, traumatism, and malaria. Inasmuch as no one of these causes can be cited as cer- tainly effective in all cases, it can merely be said that any influence sufficient to induce inflammation of a sensory nerve or its ganglion may be followed by the objective signs of the disease. Pathology. — The researches of Barensprung, Rayer, Wagner, Charcot, Kaposi, and others have demonstrated with sufficient clear- ness that in zoster there is always, at some point in the corresponding nervous tract (cerebral or spinal centres, ganglia, or the nerves them- selves), pathological changes. These are : enlargements, haemorrhagic effusion, separation, softening, or destruction of the nervous bundles, with hyperaemia, infiltration, and multiplication of the elements which surround the latter. Sometimes the ganglia and nerves are both reddened and swollen at the site of the inflammatory affection ; at other times the ganglion 216 DISEASES OF THE SKIN. alone is large and soft, or fatty from metamorphosis of its cells. According to Curshmano and Eisenlohr, the process may begin in the bloodvessels of the nerve-sheath, as well as the peri-neural con- nective tissue, the nerve substance being quite intact. This is termed acute uodose peri-neuritis, as small nodules were recognized by them in one case along the cutaneous branches of the axillary nerve. Lassar, 1 in a post-mortem examination of three cases, found the nerves thin, flattened, and of a transparent reddish-gray color con- tra.-! ing with the normal white. There had been desquamation to the extent of replacing the normal structure with connective-tissue elements. Similar changes wcw recognized in ganglion cells and fibres. Fig. 37. d ^c:g^w a 4,5 t c I F-__f- Longitudinal section of the third spinal ganglion of the right lumbar region from a case of lumbo- inguinal zoster. 0,0, ganglion, the black points correspond with pigmented ganglion cells, the dark lines to engorged vessels; a,b,c,d,e, fatty tissue surrounding the ganglion ; 6,6, nerve filament divided longitudinally at the points of entrance and exit; at c,c, divided perpendicularly. (After Kaposi.) According to Biesiadecki and Haight, the cutaneous lesions origi- nate in the deeper portions of the rete, precisely as in other vesicular diseases. The exudate from the hypersernic corium, especially its papillary layer, presses upward into the rete, the epithelia of which are thus separated and vertically elongated. The serous exudation finally reaches a point where the horny layer is forcibly raised from its bed to form the roof of the vesicle. The mechanical destruction of the papillary layer of the corium by the hemorrhagic or purulent contents of the lesions results in a solution of continuity, which is healed only by granulation and the necessary formation of a cicatrix. Robinson, also, studying the same phenomena in the skin, finds the epithelia lengthening into bands by tension, the lacunas between them distended with serum and a few round cells. Often the vesicles form about the hair-sacs. As the exudation increases, the rete cells i Ctblt. f. d. Med. WisseiiBch., Dec. 1883. HERPES ZOSTER. 217 are progressively separated, and finally discovered free in the exuded fluid, though some, in changed form but still connected, may be found in the upper part of the vesicle. Except at the margin, the mucous and horny layers are separated by the exudation. At first many-chambered, the vesicle represents finally a single chamber filled with serum containing rete-cells and a few pus-cells, the latter in- creasing in number as the vesicle changes its type. Its base at first rests upon the lower portion of the mucous layer; later, upon the corium itself where all signs of papillse are absent. In the vicinity of the vesicle the papillse and corium are infiltrated, and the vessels dilated, this peripheral change not extending deeply into the corium. Beyond this area, however, which is infiltrated in a columnar-shaped region, usually about a hair-follicle deep in the subcutaneous tissue, Robinson has recognized a peri-neuritis characterized by a round- celled infiltration within and around the neurilemma. Diagnosis. — The vesicles of herpes zoster are not rarely confounded with those of eczema. But the distinction between the two is always very readily established. In eczema there is itching but no neur- algia; vesicles which tend to rupture spontaneously, and never per- sist as in zoster; the eczematous lesions are also smaller, more acu- minate, and rarely distinctly limited to the lateral half of the body. Herpes simplex is frequently recurrent, herpes zoster almost never; herpes simplex is exceedingly liable to spread around the mucous outlets of the body, and on either side of the latter, while zoster only reaches such regions after exteusion from other parts, and is then almost invariably monolateral. Its lesions are, moreover, never grouped in the concentric circles of herpes iris. Treatment. — The indications to be met in the local treatment of herpes zoster are the protection of the vesicles from rupture, and the relief of pain. These ends are best accomplished by thickly dusting the entire surface affected, with an opiated powder, such as Anderson's powder, with the sulphate of morphia, two grains (0.133) to the ounce (32.) ; lycopodium with powdered opium, etc. Rupture of the lesions should never be practised. Over the whole should be gently laid a sheet of soft lint or antiseptic cotton, its meshes also filled with the powder, and a bandage, when practicable, smoothly bound over the whole. In the milder cases, nothing more than this is needed from first to last. In others, where the lesions have rup- tured aud their bases undergone erosive or ulcerative changes, the oleated lime-water with zinc oxide, belladonna and opium or morphia, should be applied and covered with the Lister protective. Carbolated and anodyne ointments may also be used, especially toward the latter part of the history of the case. Lotions may be employed of lead-water and laudanum, or the "lead and opium wash." Van Harlingen recommends half an ounce (16.) each of the precipitated zinc carbonate, powdered zinc oxide, pow- dered starch, and glycerine, shaken up in half a pint (256.) of water. Duhring speaks well of collodion with morphia, in the strength of ten grains (0.666) to the ounce (32.). Kaposi warns against the use 218 DISEASES OF THE SKIN. of the diachylon ointment. Generally, it may be said that ointments should be the lasl resorl ; but those containing from ten to twenty grains (0.66— 1.33) of the aqueous extract of opium or belladonna to the ounce (32.) will at times give relief from pain. The oleate of cocaine and menthol have been used locally with great advantage in meeting the same indication. X<> remedy, for internal use, is known to have the power of aborting or shortening an attack. Quinine is certainly indicated and does no harm; but quinine and strychnia alike in full doses have proved quite inefficacious. Other remedies employed are the phos- phide of zinc in one-third of a grain (0.022) doses, repeated every three hours, and, if indicated, in combination with one-sixth (0.011) of a grain of the extract of mix vomica; arsenic (Kaposi) ; and the tonics in general. Anodynes, orally or by hypodermatic injection, are often indispensable. Inasmuch as many patients consider the attack a trivial matter, it is of some consequence that they be warned of the possibilities of the future and be confined to an apartment of equable temperature where they are not exposed to atmospheric changes. This is of special importance in all the zosters of the face. A skilled oculist should be consulted in all eases involving the eye. Prognosis. — Zoster usually runs a benign course, but it should never be forgotten by the practitioner that the prognosis may be in the highest degree grave. Many severe cases have occurred, where the patients, after years of intense suffering, have resumed the occu- pations of life, physical wrecks of their former selves, their faces indented with profound scars, and the vision of one eye impaired or utterly ruined. Rarely the termination is fatal. Dermatitis Herpetiformis. Dermatitis Herpetiformis is a rare but well denned febrile disorder, character- ized by the appearance upon the skin, of multiform lesions, differing in different cases, macular, papular, vesicular, pustular, or bullous in type, attended by subjective sensations of itching and burning, the disease at times being grave in character and fatal in termination. Dermatitis Herpetiformis should be named Dermatitis Multiformis, as the latter term is more descriptive of its phenomena. It is a malady which, in oue form or another and under different titles, has long been recognized and described. The credit, however, of clearly establishing its identity, and of recognizing one process as differently expressed in the several observations of others, is largely due to Dr. L. A. Dnhring, of Philadelphia. 1 It should be noted, at the outset of the study of this malady, that, its identity as a special pathological process having been only i Dermatitis Herpetiformis; its relation to so-called Impetigo Herpetiformis. Amer. Journ. of the Med. Sri., October, lxs-i. Dermatitis Herpetiformis. Case of, caused by nervous shock, etc. Ibid., January, 1885. Case of Dermatitis Herpetiformis, illustrating the pustular variety of the disease. Journ. of Cutan. and Veil. Dis., vol. i., No. 8. Case of Dermatitis Herpetiformis with peculiar gelatinous lesions. The Med. Xews, March 7, 1885^ Notes of a Case of Dermatitis Herpetiformis, etc. N. Y. Med. Journ., November, 1884. A Case of Dermatitis Herpetiformis (Bullosa) N. V. Med. Journ.. July, 1884. DERMATITIS HERPETIFORMIS. 219 lately established, much investigation is yet required before settling definitely many of the interesting questions it presents for considera- tion. Duhring regards its vesicular and bullous forms as identical with "herpes circinatus bullosas" (E.Wilson); "pemphigus pruri- gineux" (Hardy); "herpes gestationis" (Milton, Bulkley, and others); "pemphigus" (Klein); "pemphigus circinatus" (Raver); "herpes phlyctrenodes" (Gibert); "pemphigus aigu pruriginosus" (Chausit); "herpes iris" (Jarish); "fatal pemphigus-like dermatitis" (Mayer); "peculiar skin eruption recurring during pregnancy" (Oswald); "bullous eruption of a peculiar character" (Leigh); "pemphigus compose" (Devergie); and "hydroa" (Jones, Bulkley, and others). Symptoms. — The disease is usually announced by malaise, sensa- tions of chilliness, decided rigors or alternations of cold and hot sensa- tions, with systemic disturbances. The skin usually is then the seat of pruritic or burning sensations followed in the course of from twelve hours to two days by the appearance of the exanthem. This may be macular, papular, tubercular, vesicular, pustular, or bullous, in type; combinations of these lesions recurring in every variation. The lesions may be cutaneous, muco-cutaneous, or mucous in situation. The macular form of eruption appears in small-coin to palm-sized patches, irregularly rounded, coalescing, well or ill-defined as to outline, and slightly raised, suggesting the lesions of erythema multi- forme or urticaria. Imperfectly defined maculo-papules, papules, and papulo-tuberculous lesions, varying in shape, size, and firmness may also spring from or be intermingled with the reddish maculations described above. In typical development the disease, however, presents cutaneous symptoms of herpetic type. Flat, slightly elevated, hard, angular, irregularly outlined vesicles may appear, pin-head to bean-sized, tensely distended with their contents. They may be pale-yellow or darker in color, and with or without areolae. When bullae form, they may be sparse or plentiful, and bean- to egg-sized, with cloudy, lactes- cent, hsemorrhagic or purulent contents. Pustules, when present, are single or clustered, pin-head to bean-sized lesions, flat, and surrounded by a livid areola. When evolution is complete, segments of rings, or distinct rings of new punctate or large pustules surround those first formed, which in less than a week rupture and become covered with a crust, the ' latter being flat, adherent, and yellowish, greenish, brownish, or blackish in color. When there is coalescence, a large coin-sized pustule and crust may result, and even large patches of such coalesced lesions. The lesions may number from a score or fewer to hundreds. The imprint of the cutaneous symptoms is multiformity and recurrence. Vesicles, pustules, and bulla?, without order or regularity of evolution or recurrence, appear at one and the same time, in rapid or slow succession, and without fixed intervals of appearance for months at a time. Generally, however, a prevalence of one special type of lesions may be noted during a single period of out- break or recurrence. This prevalence is in the direction generally 220 DISEASES OF THE SKIN. of lesions of an herpetic type, viz., the vesicular and the bullous, iu variously sized patches with a tendency to coalesce. A.S a result of the conditions described above, a peripheral new formatioD of lesions tends to produce marginate patches where grouping occurs, the groups, however, being interspersed with dif- fusely disseminated lesions of* various types. The irregular, angular, or stellate forms of the lesions containing fluid, are highly suggestive. Pigmentation and infiltration of the skin are commonly noticed. The subjective sensations of burning, increase and diminish as cuta- neous lesions are multiplying or disappearing. The pruritus is in some cases more severe than in eczema, and the traumatisms of scratching add greatly to the multiform features of the disease. The disease lasts for months and years. Duhring reports some cases lasting for five to fifteen years, with periods of relative or entire immunity. In one of Duhring's cases there were thumb-nail sized, raised but flat, golden-yellow colored lesions, of very firm consistency, con- taining a similarly colored, thick, consistent, gelatinous pulp. The author states that he has observed them before in several cases of this same disease. When the oral cavity is invaded, pustules and bulla? appear upon the mucous surface which, being macerated and sodden, rupture, leaving raw erosions and unhealthy looking, even sloughing patches of mucous membrane. Crusts form about the nares aud lips, and the stench of the patient becomes intolerable. In the same way the vulva, anus, and prepuce may be surrounded by vesicular and bullous lesions which form also on the mucous surfaces adjacent and pursue a course similar to that recognized in the mouth. In grave cases, as the skin symptoms exhibit a marked aggrava- tion, the systemic condition changes for the worse. After a low fever alternating with chills and accompanied by progressive cachexia and emaciation, an intermittent diarrhoea or pneumonia may close the scene. The repulsive appearance of the patieut at the last is, in severe cases, as formidable as in the fatal issues of confluent variola or severe pityriasis rubra. The etiology, pathology, and proper mode of treatment of this dis- ease are not yet fully understood. In some cases disorders of the nervous system must be admitted as efficient in its production. Duhring reports a typical case following nervous shock. One of my patients had lost a number of children by accident. The disease occurs in early and middle adult life in both sexes, though in women decidedly oftener than in men; and, among the former, preferably among those in the puerperal and pregnant states. Unquestionably the phenomena of the disease in the later stage of fatal cases are septicemic in origin. Internal treatment in general has been directed to meet the indica- tions presented. Thus, quinine, the mineral acids, ergot, saline laxatives, iodide and bromide of potassium, arsenic, aud chloral, PSORIASIS. 221 have all been administered without appreciable effect upon the dis- ease. Locally, carbolic acid, tar lotions, the unguentum diachyli albi of Hebra, mercurial and zinc salves have all been employed. One of Duhring's patients experienced great relief from the use of a sulphur ointment. Two of my patients were treated with very great comfort to the end in the continuous warm-water bath. The prognosis is always doubtful and generally grave. It is not certain that the disease is ever completely relieved. A male patient, seen by me in consultation and then presenting the typical features of the disease, was reported well after one year. Psoriasis. Gr. tpupd, the itch.. Psoriasis is a cutaneous disease, acute, or, more usually, chronic in course, characterized by masses of whitish, lustrous, and adherent scales, in pin- head sized agglomerations upon the surface of the skin, or in larger disks resting upon circumscribed, usually circular and reddened patches of epidermis, which are readily made to bleed. Symptoms. — In Psoriasis, also termed Lepra, Alphos, and Psora, the primary lesion is a punctiform macule of reddish-brown tint, always, at the earliest moment of observation, covered with a deli- cate, whitish, epidermic scale. When this is removed even by gentle scraping, one or more minute droplets of blood exude from the points beneath which lie the vascular papilla? of the corium. When several or many such small points are visible upon the surface, the disease is called Psoriasis Punctata. Should the disease progress to fuller development, patches of larger size form, always with a definite contour, very slightly elevated above the general level of the integument, and covered with whitish, mother-of-pearl-colored scales in abundance. When these are about the size of drops of water, the disease is termed Psoriasis Guttata. In yet more advanced conditions of the disease other names are employed, all from the external configuration of the patches, none having any pathological significance. Thus Psoriasis Nummularis is characterized by coin-sized patches ; Psoriasis Circinata or Orbi- cularis, by patches where the disease is actively exhibited at the periphery of a circle, in the centre of which the scales have dis- appeared; Psoriasis Gyrata and Figurata, by coalescence and extension of several patches, forming thus fantastic figures covered with grayish-white, imbricated scales ; and Psoriasis Diffusa, by much more extended and uniform involvement of the skin in large areas. The greatest variation is exhibited in the progress of the disease, and to this point special attention should be directed. Thus, in a single individual the eruption may appear upon one or more regions of the body in the form of the punctate lesions described above, and thereafter regularly progress through the degrees suggested by the 222 DISEASES OF THE SKIX. list of names given above, till the entire surface of the body is com- pletely covered (ruin the crown of the head to the sole of the feet. This is fortunately rare. More often the eruption tends to remain stationary when one or another of the less extensively developed phases of the disease lias been displayed. Thus the patches may be at no time larger than a silver quarter of a dollar, and though very numerous, fail for years to extend beyond such a limit. They may even persist for a longer period in even smaller dimensions, or, what is perhaps more common, occur in guttate forms upon the chest, and in patches as large as the palm over the knee or sacrum. The sites of preference of the disease are over the extensor surfaces of the extremities, especially about the elbow and knee, where it is decidedly most common. After these locations should be named in older, the region of the sacrum (where often the largest patch upon the body can be discovered), the upper surface of the chest, the scalp, the face, the belly, and the genitals; more rarely the hands and feet. The disease is essentially chronic in its course, is never contagious, and the efflorescence does not usually awaken any subjective sensation. Its features are so pronounced in typical cases that its recognition is facile, after appreciating the number and distribution cf the patches, their clean-cut outline, the unaltered integument between, the lustrous and shining scales, and the red border of the skin which may crop out from beneath the squamous thatch above, or be completely hidden by the latter. Rarely a single isolated patch betrays the existence of the disorder. When the disease is acutely spreading over the surface it has occasionally a different expression. This is often seen in young adults. The patches are perhaps as largo as the section of a hen's egg ; dark or lurid-red over the whole; covered with a more uniformly con- stituted, thin, squamous film, or sheet of semi-transparent delicate membrane, through which the red glare of the patch beneath is visible. This condition may also be seen in young persons to whom arsenic has been administered for the relief of the disease, with the production of irritative effects. In its indolent moods, the color of the patch varies somewhat with the hue of the patient's complexion. Blonde women with flaxen hair and clear tint of the integument, often exhibit singularly waxy-whitish patches, decidedly differing in color from those occurring upon the muddy and greasy integument of certain dark-skinned men. The scales are usually abundant, and may adhere with considerable firmness to the patch, or, more frequently, be shed freely from the surface, in pronounced cases powdering the clothing of the patient or the sheets of the bed upon which he reposes at night. There is never at any time in the course of the disease, the appear- ance of other lesions or their sequelae, such as vesicles, pustules, crusts, papules, tubercles, ulcers, or any discharge-feature. The eruption is dry from first to last. Exception only may be made in the ease of patches occurring where motion of the skin produces fissure, an acci- dental and by no means characteristic complication. The same may psoriasis. 223 be said of certain acute symptoms, especially developed in young and tender skins, where considerable redness, occasionally with an erythematous halo, appears in and about individual patches, with the production of itching, heat, burning, pain, or other disagreeable sensations. The involution of the disease is evident in a gradual cessation of the scale-formation and the exhibition of a normal epidermis which gradually spreads from the centre, or is at once perceptible over the entire surface of the patches. No cicatrization results. Upon the scalp, plaques of well-defined contour, covered with thick whitish scales, may mat the hairs together, but alopecia almost never results. The dry condition of these scales contrasts with the greasi- ness of the crusts formed in seborrhcea of the scalp. Often a fillet or band of diseased tissue, one or more inches in width, projects be- yond the border-line of the scalp and forehead. When the vertex is bald from physiological loss of hair, the patch of psoriasis usually lingers near the fringe of the hairs left at the sides of the head pro- jecting thence to the regions of baldness. On the face as well as over the genitals, the lesions are usually both indistinct and small- sized, displayed, as regards the former locality, over the cheeks, chin, and nose, avoiding the parts near the mucous orifices. When there is much vascular congestion, especially of the passive kind, the patches assume a violaceous or purplish tint. All forms of lesions are seen upon the trunk, especially the dorsum and near the sacrum ; the patches, in well-marked cases, encircling the body in ill-defined par- allels reaching from the spine forward. The hands, feet, fingers, and toes are not often involved, and the palms and soles only so rarely as to throw doubt upon a diagnosis based upon the existence of the disease solely in these regions. In severe cases, the nails are second- arily involved, being thickened, eroded in points, irregularly lamin- ated, ridged, and becoming brittle and yellowish-white or dirty- whitish* in color. The amount of scaling varies greatly in different persons and in the same individual ; sometimes the scales are abundant and thickly heaped up over even small areas ; sometimes they are sparse over large areas. In acute febrile and other intercurrent diseases, the disorder may fade or disappear. Where the epidermis is thin, the scaling is less ; there- fore, in youth, over flexor surfaces, near the mucous orifices, and on the back of the hands, the scaling is less than in advanced years, over extensor surfaces, in regions remote from the mucous orifices, and on the palms and soles. The disease may be for years limited to two or three continuously existing patches, or, what is far more common, recur at irregular intervals and under varying circumstances. As a rule, it is worse in winter and in cold climates, though patients may demonstrate the reverse of this rule. The scales may display instead of a lustrous white, a deep yellowish shade, and instead of being imbricated, form a thin continuous sheet of exfoliated epidermis. When the disease is disappearing, the scales fall, leaving a pigmented or slightly discolored patch of integument. 224 DISEASES OF THE SKIN. A rare ultimate termination of the disease is the formation of verrucous growths in the psoriatic patches, which later become epitheliomatous. 1 At times the eruption is the source of excessive annoyance, being the scat of intense pruritic and burning sensations of a persistent type. There can be no question that intermediate forms between eczema and psoriasis occur, in which it is difficult to determine whether the two disorders coexist, or the one has assumed the features' of the other. In these cases, there is itching' and infiltration of the skin, with vesicular and other lesions foreign to psoriasis, and a catarrhal discharge. Psoriasis is not known to affect the mucous surfaces. The lesions of so-called "psoriasis linguae," are those of "leucoplakia bnccalis," of "smokers' patches," of syphilitic disease of the mouth, or flat epitheliomata. Etiology. — The causes of psoriasis arc not known. As no external or internal factors can be demonstrated to be effective iu its produc- tion, it is safest to conclude that these unrecognized sources of the affection are limited to the skin itself. The disease is neither con- tagions, hereditary, nor limited to either sex, occupation, or social condition. It bears no relation whatever to syphilis, eczema, gout, rheumatism, struma, or dyspepsia. It appears iu the feeble and delicate as in the most superb specimens of manly vigor and womanly beauty. Though not occurring in infancy, it yet usually first appears iu early life. Kaposi reports a single case in which the eruption appeared in the eighth month, and Eliot, a case of first appearance at the eighteenth month of life. Under these circumstances, the question arises : Is this affection of the integument, when uncomplicated by the disagreeable symptoms named above, a disease or a deformity'.' Certainly iu a very large number of individuals, displaying through life unchanging patches where the characteristic symptoms are the same year after year, the ailment would seem to be more properly' classed with the deformities than with the diseases of the skin. In point of frequency, the eruption ranks next after eczema. Believers in the possibility of the transmission of the disease by inheritance are numerous, and some of them careful observers. Robinson goes so far as to say, that in the "majority" of all cases there is an inherited predisposition to the disease. Others conclude it to be an inherited or transmitted form of syphilis, struma, tuber- culosis, rheumatism, or gout. Weyl thinks that inheritance may possibly be the sole cause. Bazin admits the existence of both an herpetic and an arthritic psoriasis. Bearing in mind the relative frequency of psoriasis ou the one hand, and on the other the strict tests which should be applied in order to prove that a disease is actually transmitted by heredity, we find that the doctrine of heredity in psoriasis fails of establishment. It is putting a low estimate on the actual figures to state positively 1 See Dr. J. C White's paper, American Journal of the Medical Sciences, 1S85. psoriasis. 225 that there are more than one thousand psoriatic patients in this country, no one of whose ancestors, so far as known, ever had psoriasis, syphilis, or rheumatism. They furnish too large a body of evidence to be either ignored or set aside with a word. Thousands of their children are living to-day free for years from any evidences of disease. They, too, call for further proof on this point. It has long been known that in psoriasic subjects lesions may be artificially developed in the lines of mechanical irritation. In this way, figures in the shape of anchors, crosses, hearts, etc., have been produced on the skin of psoriasic patients, one of which has been ingeniously photographed by Dr. Fox, of New York. 1 The disease is rather more common in male than in female patients, and aj>pears to be rare in the negro races. According to Greenough's statistics, it represents about two and a half per cent, of all cases of cutaneous disease. It has followed vaccination, scarlet fever, and other diseases. Dr. Gowers alone reports the artificial production of psoriasis by the internal administration of the biborate of sodium. Allusion has been heretofore made to this circumstance in the chapter on dermatitis medicamentosa (q. v.). Further evidence would be required to estab- lish the fact that these results differed to any appreciable extent from those recognized in any squamous dermatitis produced by an ingested drug. . Pathology. — The observations of Wertheim, Neumann, Auspitz, Kaposi, and Robinson, of New York, are substantially in accord respecting the general character of the changes occurring in the course of the disease, though they differ upon the question whether it depends upon an inflammatory or purely hyperplastic process. So far as this problem is illuminated by clinical facts, it would seem clear that both views are correct, the disease being at times unquestionably the result of a circumscribed inflammation ; at others associated with a simple overgrowth of the elements of the epidermis ; and again at times with an inflammation which the hyperplasia has awakened. There is always abundant development of the epithelia in the rete, and, in recently formed patches, distention of the blood- and lymph- vessels in the papillary layer of the corium beneath. In older plaques the rete either dips downward to an unusual extent between the papillae, or the latter push upward in the manner of wart-like prolongations. It is reasonable to conclude that at times both hypertrophies concur. The corium is thickened later by an increase of its elements which may involve its entire width as far as the connective tissue. In the older plaques also the connective tissue elements are often separated by a slight serous infiltration. Hyper-pigmentation is also noted. The external root-sheath of the hairs in direct connection with the rete participates in the same process, thus explaining the defluvium capil- 1 In his admirable Photographic Illustrations of Cutaneous Diseases. New York. 15 226 DISEASES OF THE SKIN. litii of certain cases, and the resulting transient or permanent bald- ness. The - baceous glands are secondarily involved in the scalp only. Fro. 38. Vertical section of skin from a patch of psoriasis of long standing. 31 P, Malpighian prolongation ; C, corium ; L, leucocytes. (After Jamiesox.) Lang, 1 of Innsbruck, has attracted notice by his alleged dis- covery of certain fungous elements in psoriasis, which he claims to be the cause of the disease. These he finds in the whitish pellicle beneath the superficial squamous layer, to which Bulkley had already called attention. After stripping this pellicle or a part of it from the surface, and subjecting it to the action of a five per cent, solution of caustic potash, the epithelium becomes translucent, and upon and beneath the latter double-contoured and highly refractive spores become visible to him. Lang considers this to be a fungus of the lowest species, different from any previously recognized upon the skin. He terms this " epidermo-phyton." In his treatment of psoriasis the author proceeds upon the principles which govern the management of the other dermato-mycoses. He considers that the value of the remedies hitherto fouud most useful in the disease, such as tar, carbolic acid, chrysarobin, and the mercurials, owe their i Viert. f. Derm. u. Syph., 1878. psoeiasis. 227 efficacy to their destructive action upon the fungus. He has used with advantage a topical application of rufigallic acid in a salve, one part in ten. Weyl, who believes that psoriasis is due to "an inherited weakness of the nervous centres," has seen Lang's "brood-cells," and regards them as " myelin-like exudations ; " but this position is disputed by both Wolff, 1 and Eklund, 2 who confirm Lang's observations, and believe the disease to be of parasitic origin. They explain the arti- ficial production of psoriatic patches in the psoriatic skin, by sup- posing spores to have been deposited beneath the skin, and not previously awakened to activity in the sites of such experiments. Lassar 3 has succeeded in producing a disease of the skin in rabbits, by rubbing into various portions of their bodies, scales, blood, and lymph removed from psoriatic patches in a male patient. The disease thus induced is capable of transmission to other animals. Campana, Tommasoli, and other Italian observers, have repeated these experiments, with the result of reaching the conclusion that psoriasis is produced by a parasite as yet unrecognized. Diagnosis. — The recognition of a pronounced case of psoriasis is made with ease, and often by those unskilled in cutaneous disease. As usual, it is the atypical forms of the eruption which occasion doubt. It is to be distinguished from Eczema. — Eczema and psoriasis differ in a striking manner with respect to their sites of predilection, and their extension from such sites in progressive cases. Eczema, from the head to the toes, elects the anterior surface of the body, the neighborhood of the mucous outlets, the flexor faces of the joints and limbs, the crevices, folds, pockets, depressions, and protected angles of the skin. Psoriasis elects the posterior surfaces of the body, avoids the vicinity of the mucous outlets, spreads abundantly over the extensor aspect of the joints and extremities, and enjoys the regions of pressure and friction, as the skin over the patella and the olecranon process of the ulna. Psoriasis, covering the vertex and scalp, lingers at the brow, where its scaly thatch stretches from side to side close to the line of the hairs, and creeps more indistinctly down the face on either side in front of the ear, reluctant to spread over the cheeks, nose, and lips. Eczema easily escapes from the scalp to the nose, lips, or chin ; or lurks in the folds of the pinna of the ear. Psoriasis will cover the back and reach forward in front by almost symmetrically disposed parallels in the direction of the ribs, while eczema sweeps between and beneath the breasts or around the nipple. Psoriasis will cover the belly and spare the navel and pubes where eczema may originate. As before stated, the largest patch of psoriasis on the body will often be discovered over the sacrum, while eczema creeps upward with a diminishing vigor from the anus between the cleft of the nates. Psoriasis often spares the hands and feet, which eczema punishes. i Viert. f. Derm. u. Syph., 1884. 2 Annal. de Derm, et de Syph., 1885. 3 Deutscb. Med. Zeit., 1885, No. 93. 228 DISEASES OF THE SKIN. In individual patches eczema will be recognized -by its severe itching; the scratching ii excites; the history of moisture, discharge and crusting; its ill-defined outline; its asymmetrical disposition, except upon the similarly irritated hands and feet; and the fewer, more yellowish, smaller, and less lustrous seales which characterize its squamous varieties. Favus of the scalp might be mistaken for psoriasis of the same region, but the occurrence of its sulphur-colored, cup-shaped crusts, the existence of the parasite, the lustreless and brittle condition of the hairs, and a possible history of contagion, will insure its identifi- cation. In psoriasis, too, the hairs are usually firmly attached in their follicles, while they are loosened in favus. LlCHEN Ruber, though a very much rarer disease than psoriasis, must in cases* be carefully recognized as distinct from the latter. In it the lesions are papular, distinct, covered by few scales, and these yellowish in color, never lustrous. There is always a constitutional impairment of health, and, when the whole epidermis begins to break up in scales, a condition of well marked marasmus. When scratched, the patches of the disease do not bleed. Finally, lichen ruber tends to a fatal termination. Lupus Erythematosus. — In any doubtful case where cicatricial tissue is discovered in the site of a patch where the disease has existed, the diagnosis is clear, since psoriasis never leaves a scar. Lupus prefers the nose, the cheeks, and other parts of the face, com- monly spared by psoriasis unless it be very abundant elsewhere. The lupus scales are scanty, firmly adherent, yellowish, and attached to the orifices of the ducts of the sebaceous follicles ; those of psoriasis are abundant, lustrous, and shed freely from the surface. Lupus is never, like psoriasis, a generalized eruption ; and is always much more chronic in course. There is a bluish and violaceous tint to the reddish patch of lupus erythematosus/ especially as it occurs upon the face, while the highly colored patches of psoriasis are rarely facial, being more commonly seen on the trunk and extremities, wdiile the out-cropping disks on the face are the least colored of any on the body. Pityriasis Maculata et Circinata. — In this disease the patches are more oval than circular, and the scales much finer than in psoriasis. It is, moreover, much more rapid in its career and does not recur. When the branny scales are removed, the surface beneath does not bleed. The centre of the patch is usually tawny or salmon- colored. The thoracic surface may also be exclusively involved. Pityriasis Rubra. — If psoriasis be in any case generalized, its distinction from pityriasis rubra would be difficult, if not impossible, on the basis of our present knowledge. Indeed, any such distinction would have but little practical value. A few typical isolated psoriasis. 229 patches of a psoriasic character would point to the origin of the dis- ease in any doubtful case. Seborrhcea. — This disease could only be confounded with psori- asis of the scalp. But the last named affection is, in the vast majority of cases, exhibited also in patches upon other portions of the body where seborrhcea is never seen. Seborrhcea of the scalp also occurs in usually diffuse forms, the surface beneath the crusts being rather anaemic and pallid in appearance, not bleeding readily, as in psori- asis. The crusts, too, iu seborrhcea, are distinctly fatty and greasy when rolled between the fingers, and have a dirty-yellowish hue, never recognized in the whitish scales of psoriasis. Lastly, seborrhoeic crusts may fringe slightly the line of the hairs at the brow, but never form a band an inch or more in width, like a frontlet covering the upper half of the forehead, a not uncommon development in psoriasis. Syphilis. — Psoriasis does in many cases greatly resemble the squamous and papulo-squamous syphilides. The necessity for a clear recognition of either disease occurring in suggestive patches, is often of the highest importance. In syphilis the greatest aid will be attained by a history in both sexes of infection, adenopathy, and mucous patches ; and of abortions, miscarriages, or still-births in women. Psoriasis is a singularly uni- form disease ; syphilis decidedly multiform in its manifestations. The syphilitic patches are less symmetrical, more elevated at the edge, and the scales with which they are covered, fewer, smaller, and dirty- whitish, rather than lustrous in color. In syphilis, the eruption is less generalized, and shares with the other syphilodermata in the brownish and purplish hues of the skin beneath, lacking the vivid redness and pinkish-red of many non-syphilitic lesions. The scales of many of the syphilides, which resemble psoriasis, partake of the character of crusts, being agglutinated by pathological exudations from the patch; they are rarely so exclusively squamous as in psoriasis. In syphilis, the tendency of the patch is to exhibit an affected surface somewhat beyond the line of the scales ; in psoriasis, the scales more frequently reach beyond the border of the affected epidermis beneath. The squamous syphiloderm of the palms and soles often occurs in these localities only. Psoriasis is extremely rare in such situations, and is, almost never, limited to that region exclusively. A psoriasiform circlet limited to the region of the mouth, nose, or chin, will generally prove to be syphilitic. The disease which has for a long time persisted in the production of squamous patches can generally be demonstrated to be psoriasis ; as syphilis changes its type in the course of months. Tinea Circestata. — Here the discovery of the parasite, the his- tory of contagion, and the frequent limitation of the disease to a single patch (a feature exceedingly rare in psoriasis), will usually suffice to establish a diagnosis. In ringworm of the body the scales are bran-like, and more abundantly formed at the margin of the 230 DISEASES OF THE SKIN. patch where the fungus is luxuriant ; while in psoriasis, the scaliness is usually equally pronounced over the entire area of an invaded patch, unless the disease is in process of involution. The occasional occurrence of vesicles and vesico -papules at the peripheral border of the patch in ringworm, is never observed in psoriasis. Ringworm is never generalized symmetrically ; and upon the scalp or beard the discovery of brittle 'and broken-off hairs should always suggest examination for the parasite. Treatment. — As the precise cause of psoriasis is still unknown, all treatment fur the relief of the disease must necessarily be limited to the removal of its objective features. This treatment may be internal, with a view to the indirect action upon the skin, of the drug selected; or topical, with a view merely to the reproduction of a sound epi- dermis in the patches of disease. Arsenic enjoys the highest rank in the internal treatment of psoria- sis. What it is capable of accomplishing in other cases, it can with best effect accomplish here. Whatever failures must be charged to its account in the attempt to relieve other cutaneous eruptions, cannot safely be ignored here. The facts are these: arsenic administered internally is assuredly capable of relieving a certain proportion of cases of psoriasis. Given improperly in any case, it may be either powerless or manifestly in- jurious. In a certain proportion of patients, most carefully selected as fit subjects for its therapeutic action, arsenic will prove utterly valueless in the most skilled hands. It cannot be demonstrated to possess the power to prevent recurrences of the disease, and yet the latter must be recognized as one exceedingly liable to recur. ^ Un- fortunately, the proportion of cases in which it will and in which it will not, exhibit its happiest effects, is not known. The following rules for its administration are to be in general ob- served. It should be given with or immediately after the ingestion of food, so that it may be commingled with edible substances in the stomach. It should be given at first in small doses, which are to be cautiously increased. The possibility of the production of toxic effects should be remembered, and on the appearance of these the remedy is to be given in a smaller dose, and not completely discon- tinued unless such a course be imperative. If its administration is once determined upon, the arsenic should not be hastily withdrawn and another remedy substituted for it, but persistence for months should be enforced if no serious objection exist, lest the time be wasted which has been already expended in the effort to relieve the disease. Arsenic is unsuited for all cases of psoriasis occurring with rather acute symptoms, such as subjective sensations and unusually vivid redness of the patches. It should not be given when the disease is in process of evolution, and, therefore, not in psoriasis punctata and guttata, unless the lesions have been long limited to patches of the sizes to which these names arc given. For the same reasons it is often objectionable in the psoriasis of the young, for, though the drug is usually rather well tolerated in such periods of life, it is, unfortunately, PSORIASIS. 231 in these also where the disease is most often encountered in its pro- gressive stages. The remedial effect of arsenic, when such is obtained, seems to de- pend upon the impression it exerts upon the rete, and that part of it especially which lies in connection with the derma. When the metal is injected subcutaneously, its first effects, according to Jamieson and Nunn, 1 are indicated by the appearance of a faint narrow band along the base of the columnar epithelia immediately next the corium. This is due to a softening of the protoplasm which separates the epidermal from the dermal elements. Subsequently, the remoter epithelia are involved, the protoplasmic threads becoming obscure, the characteristic arrangement of the epithelia less evident, and the natural features of the rete distorted, so that it remains attached to the derma by tags and the prolongations which it sends down to the cutaneous glands. Jamieson suggests that arsenic stimulates the epithelia to exhaustion, that layer which lies next the bloodvessels containing the metal first appreciating its effects. The preparation usually employed is Fowler's solution, the most soluble of all, whose exhibition should be always begun in doses from half a minim (0.033) to three minims (0.20) ; this amount to be contained in a solution of fixed and relatively large dose, such as a teaspoonful of the infusion of peppermint; the wine of iron ; or dilute syrup of gentian or of orange blossoms ; or the compound tincture of cardamom with water. When only remedial effects are obtained, such as diminution of the scaliness, the dose may be steadily continued without change for long periods of time, and usually with advantage for some time after the symptoms of the disease have entirely disappeared. When, without the production of toxic effects, the eruption seems quite unaffected by the treatment, the arsenic may be, very carefully and always under the direction of the physician only, pushed till twenty and even thirty drops of the Fowler's solu- tion [the latter equivalent to one-third of a grain (0.22) of arsenic] are administered at a dose. The constitution of the Asiatic pill has been given in the chapter on general therapeutics. The pill is less likely to be as well tolerated by the stomach as Fowler's solution, but cases are on record in which the psoriasis which proved rebellious under the administration of the liquor arsenicalis, Donovan's solution, and other internal remedies, yielded to the influence of the arsenious acid in pilular form. Hebra has given two thousand Asiatic pills to a single patient before the disease disappeared; and in no instance has he seen any ill effects produced. With regard to the vulgar opinion respecting the arsenic habit which a long familiarity with this dosage has been supposed to beget, the author considers it a curious circumstance that he has never yet encountered such an instance in a psoriasic subject who was consum- ing arsenic. Patients who for several consecutive years have, without 1 See the paper by the former on the Histology of Psoriasis, Edinburgh Medical Journal, January, 1879, p. 627. 232 DISEASES OF THE SKIN. interruption, pursued an arsenical course, thus barely succeeding in keeping their cutaneous ailment out of sight, will in many cases affirm that, apart from any trifling and accidental toxic symptoms, and those evident in the course of the eruption, they would not be sensible of the fact that they had taken the drug. With an enlarging experience, one views with greater distrust each year the benefits to be derived from arsenic in any untried case of psoriasis. The great possibilities of its failure, of the repeated re- currence of the eruption, of the necessity of continuing the medication for one or two years, and even after that period of time, of even then witnessing a generalized development of the disease to an extent quite equal to that exhibited at the outset, all these considerations should certainly have some weight in the mind of an ordinarily prudent man. Is the ultimate result in such cases worth the cost by which it is obtained ? In such cases certainly it would seem not. In the others, where, under a judiciously directed arsenical course, the eruption slowly disappears and fails to recur, the value of the treat- ment is incontestable. As before stated, the proportion in which these two classes of cases are related, is not known. The patients in the last-named category, in all probability, decidedly outnumber the others. The course which, under the circumstances, seems preferable, is this : Instead of resorting first to the arsenical dose and afterward to other measures, the order should be reversed. That psoriasis which fails to respond to other treatment, may be finally subjected to the influence of arsenic. He who, having vainly tried other approved measures, essays at last the virtues of this medicament, ought certainly to ex- hibit no impatience while testing his case with it. He should be willing to try it fully and fairly, and be of all men least ready to exchange it for a less valuable substitute. No reference is here made to the effect of conjoined internal medication with arsenic and external treatment by topical applications However desirable it may be, in the management of any individual case, to arrive at the desired end by the speediest method, it is evidently needful, in order to assign to arsenic its exact therapeutical value, to understand what it can accom- plish unaided by topical measures. As to the other remedies employed internally for the relief of the malady, a very fair estimate of their value can be made by remember- ing that arsenic is superior to them all. If arsenic fails so frequently, what remains to be said of the other articles in the list ? Phosphorus, tar, copaiba, eantharides, colchicum, and pilocarpine, have at times a feeble or transitory influence over the patches of the eruption, but their employment will disappoint far more often than satisfy. Iron, quinine, cod-liver oil, and the salts of the alkalies, will fill important indications in the treatment of certain classes of patients, but these are in the minority, as the eruption is often seen in perfectly vigorous and otherwise healthy subjects. After the use of any one of these remedies, it is rare to recognize any psoriasis. 233 decided effect upon the cutaneous symptoms, even when patients in whose case they were indicated, improve under their use. The same in general may be said of the use of dietary articles in psoriasis. As no ingesta save the substances already named are re- cognized as influencing the eruption to any perceptible degree, the diet suitable for a patient may be in brief described as that which is both wholesome and nutritious. Most authors agree upon the value of a greatly restricted diet. Acids, alcohol, and fatty substances should be excluded. Meat should be sparingly supplied; cooked vegetables and fruits may be freely eaten. Coffee, tea, and tobacco should in general be interdicted. Passavant, of Frankfort, on the other hand, claims to have cured himself and others, by an exclusive diet of meat. The arseniate of sodium in pill form and arseuiate of iron have been recommended by Biell. Lipp has injected arsenious acid subcuta- neously. Robinson advises the liquor potassa?, the citrate or acetate of potassium, or the bicarbonate of sodium in plethoric and rheumatic patients. In the gouty state with excess of urates in the urine, he advises : R . Potass, acetat. . |j ; 32 Spts. asther. nit. f§ss; 16 Vin. colchici f ^ij ; 8 Syr. aurantii f §jss ; 48 M. A dessertspoonful three times daily in water after meals. The influence of climate in inveterate psoriasis should never be ignored. It has been already stated that many patients who suffer from repeated relapses of the disease are worse in winter, and either better or entirely free from the eruption in summer. For the same reason, in a mild climate, where the temperature is uniformly regis- tered at or near a point of maximum comfort for the skin, the disease will be both infrequent and less severe. McCall Anderson believes that sea-air and sea -water are generally prejudicial to psoriasic patients, but the statement is disproved in the cases of hundreds who have removed from an interior climate to the sea-shore, solely with a view to the benefit to be thus received. The external or local treatment of psoriasis requires patience, care, and a certain degree of skill. Properly conducted, its results are reasonably satisfactory in a large majority of cases. The first indication to be met is the complete removal of the epidermic scales from the patches, and this is accomplished in various ways. It is preferable to secure first their maceration in some fatty substance, such as one of the oils, or glycerine, or vaseline, after which they may be washed off by the aid of soap and water, in a general bath if the eruption be extensive. If it be localized, these oily or fatty substances may be spread upon pieces of lint or cotton, and thus retained by a bandage in contact with the skin. The scales may also be speedily removed with the dermal curette, if they occur in few patches, or if the latter are to be found in totality or part 234 DISEASES OF THE SKIN. upon some portion of the body where the disfigurement demands special attention, as upon the forehead and cheeks. The squamous masses arc also removable by water alone, as after maceration of the skin in a bath, or after a profuse diaphoresis, or even moderate exudation of sweat, if evaporation of the latter be prevented by covering the affected part with oiled silk or rubber cloth. Usually there is do difficulty in removing these scales, patients often declaring to their physicians that they can themselves cleanse the surface, if they can be shown how to prevent the recurrence of the desquamation. Baths play an important part in the subsequent treatment of the disease. They may be employed, as by Hebra, so that the patient remains in the water for from four to eight hours in the day; or be medicated by the addition of sulphur, tar, or other substances, so as to combine a medicative with a macerative effect. In private prac- tice, these baths are much less available than in hospitals. When the eruption is generalized and an excessive macerative effect is desired, the rubber clothing answers a better purpose. In such cases an undershirt and drawers may be worn, made of soft rubber cloth, of the size of the undergarments usually worn by the patient, the latter wearing these for several hours of the day. The sweating is often profuse and debilitating to such an extent that the psoriasic skin will rarely tolerate the treatment for an entire day, or for even that part of it in which active labor is performed. By this means alone, it will at times be found possible to secure complete disap- pearance of the patches. In other more obstinate cases, or in those where for any reason such treatment is indicated, as upon the scalp and face, the sapo viridis may be employed with advantage in the soap and water treat- ment. The spiritus saponis kalinus [two ounces (60.) of the soap to one (30.) of alcohol] may be briskly rubbed over the patches by the aid of a piece of flannel or sponge, and then immediately washed off with the oil and scales in a surplus of hot water, or be left for a time in contact with the part. Hebra and Kaposi make use of a species of soap paste, made by rubbing into each patch a small quantity of the green soap to which a little water is added till the proper con- sistency is obtained. These inunctions are repeated twice daily for six days. The epidermis becomes then brownish-colored, and in three or four days afterward exfoliates in lamellae. Then a general bath cleanses the surface. In the French hospitals, a someMhat speedier method is pursued. On the evening of the first day, the patient is anointed with the green soap which he retains upon the skin during the night. In the morning he takes an alkaline bath, and immediately after is thoroughly anointed with lard. This is repeated on the second and third days, after which the patient is usually ready for any topical medication of the diseased parts. For the yet more obstinate cases in which the exfoliation of the epidermis is not readily induced, still more energetic measures have been adopted, such as the local use of salicylic acid in alcohol, one drachm (4.) to four ounces (128.), caustic acids and alkalies, scrub- psoriasis. 235 Hug the patches with nail-brushes, floor-brushes, etc., and the use of clean, white sand. Once ready for topical medication, the patches may first be sub- jected to the local action of tar, a remedy which has enjoyed the highest reputation for the relief of the disease. It will, however, accomplish the result desired, only when applied so that it is well tolerated by the skin. In very young patients, as also in those whose skins are tender and irritable, or who are suffering from any of the acute phases of the disease, it may prove decidedly injurious by aggravating the latter. The rule should be, always to employ it at first tentatively over a relatively small portion of the surface, upon which the medicament should remain for several hours, as tar will not in all cases promptly produce its injurious effects. These are, subjectively, a sense of heat and pain ; and, objectively, heat to the touch, redness, and tumefaction of the part. Often black puncta are visible when the tar is lodged in the orifices of the cutaneous follicles, simulating thus, the "black head" of the comedo, a con- dition termed by Hebra, "tar-acne." Pix liquida, the oil of cade, or preferably the oleum rusci may be •employed, in the form of a salve, a drachm (4.) of either to the ounce (32.) of lard or other fatty basis (lanoline, vaseline, etc.). A thin stratum of such ointment may be, several times in the day or merely at night, painted over, or well rubbed into a patch denuded of scales. In Vienna, a still more energetic effect is secured by using the soft soap freely over the patches while the patient is in the bath, then anointing him with tar, and finally returning him to the bath where he remains for from four to six hours. For localized eruptions, the green soap in combination with tar and alcohol, serves an exceedingly useful purpose, either in the proportion of equal parts of the three ingredients, or by combining them in other proportions, as, for example : R. Saponis viridis Siv; 130 01. rusci | Glycerin, j aa I) ; 30 01. rosmarin. 3jss ; 7 Spts. vin. rectif. Oss;' 500 For external use. M. Other combinations of service are Bulkley's " liquor picis alka- linus," the formula for which is given in the chapter on eczema ; and Wilkinson's salve, as modified by Hebra, the latter combining the remedial effects of sulphur, tar, and soap, as follows : R. Sulphur, sublimat. { -- - ir 01. rusci [crud.vel. rectif.] j aa 3SS ' lb Saponis viridis ) -- z , . „ fl Adipis j aa ^' S0 Cret. praeparat. 9yss; 3 5 M. Sig. Wilkinson's salve modified. . Where the sensitiveness of the skin to the action of the tar has not been tested, or when the skin is particularly tender, a small 286 DISEASES OF THE SKIN. quantity of the Wilkinson salve may be added to any simple oint- ment, or Spender's ointment of tar (see the chapter on General Therapeutics) may be substituted for it; afterward a drachm (4.) of the oil of tar, or oleum nisei, to the ounce (32.) of oil of almonds or of alcohol, may be employed. When toleration is established, the tar may be rubbed over the patches in a pure state with a stiff brush, a procedure preferred in some parts of Germany, after which the patient either remains for some hours in bed, or is powdered with soapstone and bandaged with flannel, so that when the clothing is replaced it may not adhere to the tar. Naphthalan, ichthyol, and carbolic acid operate in psoriasis in the same way as the tars, but are decidedly inferior to it. Absorption of any tarry compound applied externally may result in general toxic symptoms, including fever, vomiting, diarrhoea, strangury, and elimination of the toxic agent in secretions which are blackened by its presence. These symptoms are usually relieved in from twenty-four to forty-eight hours after the discontinuance of the drug. Kaposi 1 was first to employ beta naphthol, the formula of which is C 1() H 8 in psoriasis (as also in eczema). It may be applied in alcoholic solution. Under the employment of a fifteen per cent, ointment, the author reported speedy disappearance of psoriasic patches. It did not stain the skin, hair, or nails. Balmanno Squire, 2 however, reports that the naphthol was, in certain experiments conducted by himself, without appreciable effect when used in the strength of from ten to twelve per cent., and that, when he increased the quantity of the agent till the ointment was applied in the strength of twenty-five and even fifty per cent., there was the production of merely irritative effects. By many practitioners, chrysarobin or chrysophanic acid is placed above all the tars in the local management of psoriasis. It is a crystalline powder of the color of old gold, insoluble in water, but readily dissolved in hot alcohol, acetic acid, benzol, vaseline, and hot fat. It is derived from the "goa-powder" of the East Indies, or the "araroba powder'' of Brazil, whose employment in psoriasis was first recommended by Mr. B. Squire, of London, Eng., in 1878. In 1880 the author collected specimens of this powder from the leading chemists of Boston, New York, Philadelphia, and Chicago; and finding these to vary greatly, both as regards the color of the preparation and the therapeutical effects induced, he has since largely employed the Brazilian araroba em po s with better results. The drug is best applied in the form of an ointment, varying in strength from half a scruple (0.666) to a scruple (1.333) to the ounce (32.) of vaseline or cerate. It is occasionally used in greater strength, but, with pure specimens, it is liable in larger proportions to produce disagreeable effects. These are declared in a hot, itching, swollen,. 1 Wien. Med. Wochensch., May 28, June i and 11, 1S81. = Brit. Med. Journ., Jan. 14, 1882. Ihie article was obtained frum Messrs. Silva, Limaos & Co., of Babia, Brazil. psoriasis. 237 irritable, and erythematous skin, stretching from the surface of appli- cation, with tolerable uniformity, in every direction. It is, even in the strength named above, necessary to begin its use with caution, testing it by application first to a limited area of integument. These excessive effects usually subside in a few days. An ignorant woman to whom a chrysarobin ointment was given in 1879, with directions to test it. carefully at first by application over the elbows of her daughter, stripped the latter before an open fire, and rubbed the oint- ment over the entire surface for the space of half an hour. The result was an intense erythema lasting for six clays with considerable ■distress, and the complete disappearance of the psoriasis which did not fail to reappear in eight months. When the drug produces its most brilliant effects, the psoriasic patch, previously denuded of its scales, assumes a whitish and normal aspect, contrasting thus somewhat remarkably with the chocolate to brownish-black discoloration of the normal skin at the periphery. This coloration, when produced either by the ointment directly or by a frequent transfer of its ingredients to other parts by the medium of the clothing and hands, involves also the nails, hairs, and under- linen of the psoriasic patient. Its employment upon the face and scalp is thus largely interdicted. The staining of the skin and its appendages disappears entirely in time, but always slowly. An improved plan of using chrysarobin externally has been sug- gested by Fox, of New York. 1 A soft paste is made by rubbing the chrysarobin with a sufficient quantity of water, and smeared upon the psoriasic patches, the scales of which have been previously removed by one or more hot baths, with soap friction. As soon as the paste has dried, which it does in one or two minutes, a layer of collodion should be allowed to flow over each patch, and to harden into a protective coating. This will remain in place for several clays, or longer, according to the location of the patches ; and when it falls, or is washed off, the application of the powder and the collodion should be repeated. By this procedure, the chrysarobin in full strength is kept in contact with the affected skin, and prevented from exciting undue inflammation of surrounding parts, or staining the clothing. A mixture of the powder and the collodion may be used, but it is less efficacious. A film of collodion doubtless interferes with the action of the acid upon the skin. A somewhat similar plan consists in the use of gutta-percha tissue to retain a strong chrysarobin ointment in contact with psoriasic patches. The edges of this tissue will adhere tightly to the skin if a small camel's-hair brush, clipped in chloroform, be passed rapidly beneath them. More recently, following Auspitz's plan, this same author has combined these articles in a convenient form, by adding ten parts of chrysarobin and ten of salicylic acid to fifteen of sulphuric ether i The Medical News, March 18, 1882, p. 289. 238 DISEASES OF THE SKIN. and one hundred of flexile collodion. This rapidly dries over the psoriasic patch, whirr its specific effects are produced. Pyrogallic acid, first suggested as a remedy for psoriasis byJarisch, is inferior to chrysarobin. The fact that several deaths have now beeo reported as consequent upon its use deters many from making trial of it in a painless and merely disfiguring disease. It is used in a tin per cent, vaseline ointment; is effective, though less rapid in its effect than chrysarobin; is cheaper; is odorless and painless; and discolors to a less extent the sound skin. Both remedies are capable of being absorbed from the surface, and of producing constitutional symptoms, pyrexia, strangury, ami blackish evacuations. But in the case ->f pyrogallic acid only, so far as is known, have these symptoms resulted fatally. Crocker, of London, similarly uses thymol in ointment, half a scruple to half a drachm (0.666-2.) to the ounce (32.); and Wil- liamson advises turpentine two drachms (8.) to the ounce (32.) of olive oil, with the odor corrected by the oil of lemon. Charteris treated thus a single limb of a psoriasic patient, which was subse- quently wrapped in wool, with the curious result of relieving the psoriasis of the other limb, possibly in consequence of the absorption of the remedy. The danger of strangury in such cases must not be overlooked. The nitrate, as well as the iodides and oxides, of mercury is applied by many practitioners in the form of ointment to patches of psori- asis, usually few in number, and limited in extent. The action of these agents is, however, inferior to those already named, and the range of their availability being quite limited, they should be esteemed lightly in the local treatment of the disease. The local treatment of psoriasis of the scalp and face by many of the articles named above is often forbidden by reason of their dis- agreeable odor or too energetic action, or by the staining which they produce. There is no better substitute for them all in these regions than the ammonio-chloride of mercury in ointment, from ten to thirty grains (0.66-2.) to the ounce (32.). In the same way, the tincture of benzoin may be employed, half a drachm (2.) to the ounce (32.) of salve. PrtKjnoHis. — The permanent relief of psoriasis is not insured by any treatment of a grave case, though hundreds of cases are perma- nently relieved by even the simplest treatment. The disease often recurs, and may do so repeatedly for the greater part of a life. Per- manent relief, therefore, should never be either predicted or promised in any case. Once relieved, it should be the aim of the practitioner to guard against all possible recurrences. After relief of any obsti- nate or recurrent attack, as also in all inveterate cases, the prognosis is greatly improved by removal to a climate suitable for the psoriasic patient. PITYRIASIS MACULA.TA ET CIRCINATA. 239 Pityriasis Maculata et Circinata. Pityriasis Maculata et Circinata is a mild febrile disorder of specific character and determinate course, in which appears a cutaneous exanthem in the form of multiple, circumscribed, superficial, roundish or oval-shaped, yellowish and reddish patches, covered with fine scales, and seated for the most part on the trunk. This disorder, also termed Pityriasis Rosea and Pityriasis Circinata, has been recognized and carefully described by Gibert, Bazin, Horand, and Duhring. It is a rare disorder, the expert seeing not more than from ten to a score of cases annually. It is also non-contagious and benign in its course, lasting from a few weeks to three months. Symptoms. — The subjects are children, or more commonly young adults, but the author has seen it in middle life in both sexes. The outbreak of the disease may be preceded for a variable time by languor, lassitude, inappetence, or a feeling of chilliness. Occasion- ally the first noticeable symptom is in the occurrence of mild fever, the temperature rarely rising above 102° F. The eruption often escapes recognition for a time after its appear- ance on account of its sparseness, or the trifling degree of pruritus it arouses. When fully developed, it is characterized by the conspicuous appearance over large surfaces of the trunk, especially the integu- ment covering the clavicles, ribs, and scapulae, of numerous pin-head to small coin-sized, circumscribed, roundish or oval-shaped, slightly elevated, macular or maculo-papular lesions. These may be discrete,, closely set together, or confluent, and instead of being elevated may be either on a level with the general surface, or even slightly de- pressed, with an annular border. They are dry, covered with fur- furaceous scales, and vary in color from a yellow or tawny shade to a deep red. The infiltration is slight, and the patch is superficially situated. The oval contour is that more often recognized as characteristic of a well developed lesion, its long axis usually at right angles to the vertical axis of the body, and the terminal extremities of the oval slightly frayed by the irregularity with which the fine branny scales are here disposed. The tawny, salmon-shaded hue of such patches is then highly characteristic of the disease, the patch slightly enlarging by peripheral extension, and leaving a relatively clear centre. The scales have often a silvery-grayish hue. The eruption may be toler- ably well generalized, but the face and other exposed parts of the body usually escape, though the scalp may be involved. In the latter event the hairs are unaffected. Etiology and Pathology. — The causes of this disease are obscure. According to Bazin, it occurs in lymphatic and scrofulous patients chiefly. The most of the cases coming under the author's observation were of patients having light hair and delicate skins, who had been 240 DISEASES OF THE SKIN. enfeebled by great physical fatigue or overtaxation in school. Profuse perspiration has been assigned as a cause by Horand. Vidal 1 recog- nized in the upper portions of the epidermis minute spores in heaps, chains, and circles, called the microsporon dispar (s. anomseon.) which have unquestionably been seen in other scaling diseases of the skin. Diagnosis. — The disease is to be differentiated from ringworm of the body by the absence of vesicles, the tendency to symmetry of dis- tribution of the lesions, their multiplicity, the characteristic yellowish centre of the oval rather than circular patch, and the constitutional symptoms. Psoriasis differs greatly in the color, quantity, and char- acter of the scales present, and in the contour of the patch. In the scaling syphilodermata, the region of the body involved, the presence of plantar and palmar lesions, the constitutional symptoms and history, and the color of the patch, which is usually of a deeper and dirtier red than in the disease under consideration, will point to the diagnosis. In the macular syphiloderm ('"syphilitic roseola") the closer prox- imity of the lesions will point at once to the difference, since the patches of pityriasis maculata et circinata are, as a rule, far more widely separated. The greasiness of seborrheic scales and the pallid hue of the integument beneath, when the former are removed, differ from the congested skin beneath the dry scale in the form of pityriasis. The treatment is expectant. Quinine, the sodic salicylate, and, later, the ferruginous tonics are indicated in most cases. Finally, tepid bathing in the alkaline or bran bath is usually found grateful. This is to be followed by the application of a dusting powder. Dermatitis Exfoliativa. Exfoliative Dermatitis is a more or less generalized, cutaneous disorder in which, either in circumscribed patches or over the entire surface of the body, the skin is reddened and covered with scales which are freely exfol- iated from the surface. The disease may be accompanied by febrile and other general signs of systemic disturbance. Some confusion, both as to the names of diseases and as to the dis- eases themselves, has existed in connection with the subject of all generalized exfoliative cutaneous disorders. More investigation is needed before definite limits can be established for several of the disorders to which authors refer under these titles. By some, the term dermatitis exfoliativa is held to be synonymous with pityriasis rubra, the disease next to be considered. In these pages, pityriasis rubra is, for the present at least, distinguished as a distinct disease, and dermatitis exfoliativa is made to include the exfoliative and exu- dative disorders of the skin not properly considered in any other connection. Classing these latter together, as for the most part of acute type, and distinguishing them from the chronic form of dermatitis exfoliativa 1 See a communication by the author in the British Medical Journal, April 2, 1S87, on the distinction between seborrhcea, pityriasis maculata et circinata, and lichen annulatus serpiginosus (Wilson). DERMATITIS EXFOLIATIVA. 241 represented by pityriasis rubra, it may be said of them all that they often present features of wide diversity. At one time the exfolia- tive dermatitis begins and ends in a single patient as a well-defined, distinct, and specific disease of mild symptoms, definite career, and benign type. In another case, it occurs as a sudden or gradual change in a preexisting disorder, such as an eczema or a psoriasis (Gamberini) Again, beginning in one or another of the simpler forms described above, it may become chronic, and, in its symptoms and course, be indistinguishable from a pityriasis rubra. It may be ushered in with mild febrile symptoms, which may have been preceded or not by malaise, languor, or a variable period in which the general health has been impaired. Often, however, all prodromata are absent. The eruptive symptoms are a more or less shining and vivid red- ness of the skin in one or several plaques which become in the course of a week the seat of numerous fine bran-like scales. Any region of the body may be affected, though the articular folds of the skin, genital region, head, and trunk, are often the seat of the disease, which may involve consecutively one part after another till, in a week or a fortnight, the whole surface is invaded. It may be limited to one region, or, yet again, several distinct regions may be simultane- ously involved., as the head and lower limbs, or the thorax and external genitals. The hands and feet are usually the last to be invaded. The eruption may appear in reddish patches of well- defined or very indeterminate outline. The skin affected may be slightly, or apparently not at all, infiltrated and raised. The itching may be slight or severe. The redness displayed in the skin which is the seat of the scaling, may be of the brightest crimson, " erysipe- latous," violaceous, or purplish shade, or with a faint suggestion of yellowness. The scales are usually formed in the greatest abundance and are commonly seen loosely covering the reddish integument upon which they rest, though they are also shed in the greatest profusion when the surface is lightly swept with the hand. They are always whitish, minute, and bran-like, never in the so-called pastrv-crust condition of the scales in pemphigus foliaceus. In well-marked cases, the features may be slightly disfigured by tumefaction of the lips, swelling of the ears, and puffiness of the lids. In all cases, the skin is dry and never moistened by a pathological discharge. The scales shed in such abundance are always white, imbricated, and silvery in hue. They are usually larger and coarser upon the lower limbs than over the neck, face, or chest. In the course of the disorder, the hairs may fall ; and, in some cases, the resulting alopecia is general. When the nails also are lost, there is rarely any special preexisting onychia to be noted. The mucous surfaces of the eyes, nose, mouth, and throat, may participate in the general disorder and become the seat of inflammatory and, in rare cases, even pseudo-membranous and exulcerative processes. The itching may be entirely absent ; when present and in severity, it is relieved even before the complete restoration of the integrity of IB 242 DISEASES OF THE SKIN. the skin. It is apt to recur with each relapse, at which time also the fever is usually relighted. In most cases the disease is terminated in the course of two or three months, after which convalescence from the emaciation and possible complications (furunculosis, abscesses, etc.), may require an equal length of time. Pigmentation is always left for some time after the restoration of the health of the skin. Pathology. — Brocq 1 has made a specially careful study of this dis- order, and his results are more or less confirmed by Vidal and Baxter. These observers recognized an infiltration of the papillary layer of the corium with embryonic cells, dilatation of the papillary and sub-papillary vessels, disappearance of the stratum grauulosum and stratum lucidum of the epidermis, and appearance of nuclei in the cells of the stratum corneum. According to Quinquaud, 2 a dif- fuse myelitis and parenchymatous neuritis of cutaneous nerves may be responsible for all these changes. Etiology. — According to Brocq, the disease affects patients who have not previously suffered from any cutaneous malady. The disease is rare ; and is said to occur more often in adult male subjects. Diagnosis. — The disease is to be distinguished from pityriasis rubra by the variety of its symptoms and course ; from pemphigus foliaceus by the absence of bullae and grave systemic trouble ; and from scarlet fever, by the absence of sore throat and its much more tardy evolution. Though, in general, a disease having a cyclical career and special characteristics, it may at times be lighted into activity by a diffuse psoriasis of acute type, or a squamous eczema becoming generalized. In such cases the diagnosis is qualified by the preexisting disorder. Treatment. — The disease is unquestionably most relieved by any article which induces profuse sweating; and, hence, both jaboraudi and pilocarpine have been employed in it with even brilliant success. Quiniue, the sodic salicylate, and the mineral acids are often indicated. The strength of the sufferer is always to be supported by appropriate measures. Hebra's diachylon ointment, one part to four of vaseline, with from five to ten grains (0.33-0.66) of salicylic acid to the ounce (32.) of the whole, is usually most grateful to the skin. One of the combinations of lime-water, olive oil, and the oxide of zinc, described in the treatment of eczema may, however, be well employed as a sub- stitute for it. Prognosis. — The disorder may prove fatal in exceptional cases. Generally, however, recovery may be expected. Often the conval- escence is tedious, protracted, aud complicated by the occurrence of furuncles and cutaneous abscesses. Dermatitis Exfoliativa Infantum. — Under this title V. Rittershain 3 and others have described an exfoliating non-contagious disease of the skin in infants from six days to five weeks old, the l Arch. Rc-n. do Mi'-d., 1884. 2 Bulletin de la Societe Anatom., 1879. 3 Ctralztg. f. Kinderheilk., 1878, Bd ii. PITYRIASIS KUBRA. 243 disorder running from seven to ten days. It is characterized by dryness of the skin, from which branny scales are exfoliated, leaving a peculiarly dry, reddish, and fissured integument beneath. The angles of the mouth and mucous outlets generally are specially involved. Often buccal lesions are present. The face and limbs are the seat of the chief features of the disease. The malady occurs more often in boys than in girls. In severe cases crusts form where the rhagades exist, and there is considerable pain and constitutional disturbance. Occasionally the skin is attacked by furunculosis after the disease has existed for a week. Pityriasis Rubra. Gr. irirvpa, bran. Pityriasis Rubra is a rare, chronic, and usually grave inflammatory cutaneous disease; as a rule, involving the entire surface of the body, in which the skin is deeply reddened and exfoliates lamellae of scales in large quantities. This disease is characterized throughout its course by a superficial hypersemia and inflammation of the skin, declared by a diffuse red- ness of a vivid or lurid tint, and an abundance of small or large, lamellated, bran-like scales, which are continuously exfoliated from the epidermis throughout the course of the disease. Patients rarely present themselves for observation till a considerable portion of the surface is involved ; but Kaposi states that in two cases observed by him the disease was first noticed in the neighborhood of the articula- tions. There are never at any time other lesions of the skin, betrayed in vesiculation, pustulation, moisture, or crusting. The palmar and plantar surfaces are usually less distinctly reddened than the face and extremities, having at times even a pallid hue ; but they are always covered with a distinctly scaling epidermis. Under pressure with the finger, the redness subsides or assumes a yellowish shade, while, as a rule, when the integument is gathered up between the finger and thumb, no thickening and infiltration can be recognized. Exceptions to this have been, however, noticed by several observers, the author among the number, in an interesting case made the subject of a clinical lecture. 1 The temperature of the skin is slightly increased. The exfoliatiou is, as the disease progresses, one of the most striking of its characteristics, the scales accumulating in large quantities about the coverings of the body of the unfortunate patient, who is engaged, as a French writer has it, in the labor of stripping himself involuntarily of his epidermis. The disease persists for months and years, always more severe in expression as it advances, the papery scales being shed more abun- dantly, and in larger flakes, leaving beneath them a smooth, shining, occasionally purplish or even cyanotic skin. In the cases observed by Jamieson, 2 of Edinburgh, and the author, the skin was so dark-hued 1 Pityriasis Rubra : Chicago Med. Journ. and Exam., Feb. 1881. " Edinburgh Med. Journ., April, 1880, p. 879. L'44 diseases of the skin. ;,, to suggest the color of the mulatto. Gradually the patient is conscious of an increasing sense of chilliness, as it' deprived of suf- ficient bodily covering. The itching may be absent, moderate, or severe. Later, the integument seems to retract, as if insufficient to encompass the body, and becomes subject to fissure from extension and contact, while the lower extremities may even be ^edematous. This retraction may be so marked that ectropion of the lid may ensue, and wide opening of the mouth, become difficult. The hairs and nails lose their lustre, and become friable, often falling, though at times escaping altogether. The influence of this gigantic, epidermal catarrh, involving, as it does finally, every portion of the surface, does not fail, toward the end, to be perceived by the vital forces. Alternating chills and febrile processes, pneumonias of a low grade, colliquative diarrhoea, tuber- culoses, subcutaneous abscesses, bed-sores, and even gangreue of the skin may close the scene. Hebra and Kaposi have together had under observation "about fifteen" patients affected with pityriasis rubra, who, with a single exception, died from its effects. It will be seen thus that the disease is exceedingly rare. A few interesting cases have been reported by English authors. Among Americans, Duhring, George H. Fox, of Xew York, and the author, have published reports of cases. The disease is oue of early or middle life, and preeminently of the male sex. Etiology. — The causes of the disease are absolutely unknown. It will be seen that the small number of cases which have been recognized, furnish but an insignificant field for the study of the malady. It is interesting, however, to note in this connection, that the constitutional symptoms of each case seem to have been induced by the disease of the skin, and not the latter by any internal derange- ment of which the symptoms are made manifest. For not only do these visceral troubles occur chiefly at a late period of the malady, when common observation suffices to show that the cutaneous mis- chief alone is sufficiently extensive to iuduce them, but it is also clear, from the wide range of these disorders (bowels, lungs, etc.), that no special visceral malady has excited the cutaneous disease. Pathology. — The researches of Hans Hebra 1 have demonstrated in two cases that there is, in the earlier period of the disease, an infil- tration of the integument moderate in degree, succeeded at a later period by cutaneous atrophy, in which the rete and papillse of the corium disappear. The connective tissue elements undergo sclerosis; and the glands and the follicles of the skin are destroyed. Pigmenta- tion is abundant. Both he and Fleischinan have discovered coinci- dent pulmonary, intestinal, or cerebral tuberculoses ; and Kaposi, in one post-mortem examination, established an atheromatous condition of the arteries. Baxter, 2 in a case examined bv him, discovered no trace of the i Vierteljahr. f. Derm. u. Syph., Hft. 4, 1876, p. 508. 2 Brit. Med. Journ., 1879. PITYRIASIS RUBRA. 215 stratum granulosum, nor was the stratum mucosum completely sepa- rated from the stratum corneum. There was a gradual transition from the polygonal prickle-cells below, which readily stained, to the horny cells above, which remained colorless. Flattened and faintly stained nuclei lay parallel to the surface, and could be recognized even in the enormously hypertrophied stratum corneum. The papillae were enlarged; the inter-papillary projections of the rete had pushed deeply into the corium. The prickle-cells of the hair-sheaths were multiplied. The remarkable consistency of the thickened corium at the outset of the disease, was regarded by him as chiefly due to a fluid exudate, which was observed before death. Diagnosis. — It is clearly necessary to add to the facts given above, that many cases loosely reported as instances of pityriasis rubra, are not really such. The misinterpreted symptoms are often those of an unusually extensive psoriasis or chronic squamous eczema, which commonly terminates favorably in the course of a proper treatment. Experts are often, summoned to see such eruptions, whose import has been misunderstood. In lichen ruber the essential lesion is a papule, which even in the later extensive scaling of that disease may usually be recognized in some part or another of the infiltrated skin. Psoriasis rarely extends over the entire surface of the body, but it will be at times thus generalized. In these very exceptional forms, a long history of typical psoriasic patches may usually be obtained, while the bleeding surface beneath the scales, and the character of the latter, will point to the true nature of the disease. Psoriasis occurs in healthy, pityriasis rubra in cachectic constitutions. Extensive erythematous or squamous eczema, apart from all other symptoms, can be recognized at once by the excessive distress occasioned by the eruption. The patient lies in bed nursing his or her tender limbs, back, or belly. In pityriasis rubra, the patient rises, dresses himself, and moves about with an expression, not of pain but of listless apathy. His scales are not scanty and adherent, but abundant and exfoliating freely. There is, from first to last in his case, no history of moisture. In every generalized eczema, there will be always, at one point or another, a surface which weeps. In its early periods, pityriasis rubra can be distinguished from pemphigus foliaceus by the absence of bullae, and of the intolerable stench which is then often emitted by the sufferer. When, however, there is present merely a generalized exfoliative dermatitis, the two disorders may be well-nigh indistinguishable. Treatment. — Arsenic administered internally seems powerless in pityriasis rubra. Cases are on record of fatal results after the exhibi- tion of this drug in prodigious quantities for long periods of time. Tar externally promises no better, Kaposi reports a single case relieved by the use of carbolic acid internally. A roborant treatment, including the employment of cod-liver oil, iron, or quinia, is certainly indicated, with the simplest bland unguents externally. Of the latter, vaseline seems best tolerated. It should 216 DISEASES OF THE SKIN. be employed, not merely to soothe, but also to protect the skin. The clothing should he ample and unirritating ; and the diet carefully selected with a view to supporting the strength. The prognosis is necessarily grave. Lichen Planus. Gr. 1 eix?/v, moss. Lichen Planus is a chronic and exudative affection characterized by the appearance upon the skin, of multiple, usually symmetrical, pin-point to split-pea sized, discrete or aggregated, Hat, polygonal, yellowish or pur- plish-red, smooth and glazed papules, having the appearance of umbilica- tion at the apex. Symptoms. — The first symptoms of the disease are the characteristic papules, which are glazed, waxy, umbi Heated, scaling at the apex only after they have existed for some time, pin-point to rape-seed in size, and roundish, angular, or oval in contour. They are usually firm, and particularly well characterized by the minute punctiform depression of the flattened apex, described as an "umbilication." They are at first irregularly disposed, but later tend to arrange them- selves in groups about the flexor aspects of the wrist and knee, the palmar and plantar surfaces, the lips, lids, cheeks, shoulders, penis, and other parts, as of the trunk and limbs. Often, as the lesions persist, they become flatter, assume a characteristic purplish-red or dark-brownish shade, and surround themselves with closely packed, newer lesions in circlets or parallel lines. In this way, distinct, sepia-tinted patches may form, whose progressive involution leaves dark-brown atrophic depressions in the skin, suggesting cicatrices. The itching may be moderate or severe. The eruption is chronic in its course; tends to linger for years within distinctly circumscribed areas, and seems to exert upon the constitutional forces little or no influence. As it is amenable to treatment, it has been less studied in its unmitigated features; but Kaposi thinks that in the majority of cases it would, if unstayed, become generalized. In one case only has he noted the occurrence of emaciation and other symptoms of disturbance of the general economy. Many lesions in the neighborhood of those well developed are the smallest papules recognized in diseases of the skin. They are no larger than the points of small pins, scarcely if at all elevated, and have either the color of the normal skin, or are whitish, lilac-tinted, or yellowish. They all, however, are, as Wilson first described them, "smooth, shining, and flat." The older groups may be either in circles or bands of various lengths having a violet, or bluish-red, or even a coppery hue. The other special characteristics of the papules are their angular outlines and the adherent horny covering of each. As to the former, the characteristic singularity of the sides is most couspicuous as the papule becomes developed ; but even in the exceedingly minute pin- LICHEN PLANUS. 247 point sized lesions with a glass one may often detect the polygonal outline which later on can be distinguished with the naked eye. The surface of each is covered by a thin stratum of horny epidermis, which is not a true mass of scales since it does not exfoliate. In some types of the disease, a patch, whether band-like or circular, of aggregated and well-developed papules may include also an infiltrated interpapular skin, with a grade of inflammation which may result in severe general scaling, and with changes induced by the traumatism of scratching to relieve a consequent mild or severe pruritus. The course of the disease is decidedly chronic, but its lesions are never complicated by vesiculation, pustulation, or by changes in the hairs and nails. Upon the lower extremities, after it has existed for a long time, a single band-like plaque of the disease may lose almost all of the papular features, and come to resemble a deep purplish keloid-like elevation or flat tumor embedded in the skin, with whitish miliary points or streaks at the border. When involution is com- plete, there is usually very deep pigmentation and at times slight atrophy. Weyl describes the whitish points and streaks referred to above as visible at times even in the smaller lesions, the horny scales pro- jecting from others like thorns, and fantastic groups on the body in the form of a cockade or in a whip-shaped curve. Under the title Lichen Ruber Mouileformis, Prof. Kaposi 1 reports a curious form of this disease, in which the lesions were nearly symmetrically arranged upon the extremities, neck, and lower belly, and in which the papules were strung like beads along definite linear cord- like elevations. Lavergne divides all cases of lichen planus into three classes. The first is chronic lichen planus, the disease as it is known in its most common form. The second is acute lichen planus, in which the papules rapidly develop, and form extensive patches, thickened, painful, livid red, and abundantly desquamating. The third form is the lichen planus corneus of Vidal, Fournier, Besnier, and Heguy. It corresponds to the coin or palm-sized, bluish to blackish, scaling and rugous, tumor-like plaques, usually seen on the anterior face of the leg, briefly described above. Pospelow 2 and Thibierge 3 have observed buccal lesions occurring in lichen planus on the mucous surface. Wilson, Hutchinson, Kaposi, and Crocker have described similar lesions, which are to be carefully differentiated from the patches of leucoplakia buccalis (so-called "psoriasis buccalis"), epithelioma, and the mucous patches of syphilis. The plaques are whitish, thickened, and uniform elevations of the mucous surface, grayish-white, or resembling in color the places to which the nitrate of silver has been applied, with irregular contours, often horizontally disposed between the teeth. These may be due to confluence of pin-head size papules of lichen planus. 1 Viertel. f. Derm. n. Svph., 1886, 4 Hft., with chromolithographic illustration. 2 Viert. f. Derm. u. Syph., 1885, p. 533. 3 Annal. de Derm, et de Syph.. 1885, p 66. 248 DISEASES OF THE SKIN. Etiology. — The causes of the disease are obscure. It is seen in both sexes, and at all ages, but is decidedly more common in early and middle adult life. Debility, digestive disturbances, and neuras- thenia have all been named as effective causes; but it is seen in very fleshy middle-aged women and strong men. The evidence that connects this disease more directly with the nervous system is of great value, and annually accumulating. In some cases, distinct coincident neuralgias of the head and lumbar region are reported. In yet others the papules have been noticed distributed in the areas supplied by given nerves, or occurring after injury of such nervous branches. 1 Pathology. — Robinson first clearly showed the pathological distinc- tion between lichen ruber and lichen planus. His observations have been confirmed by those of Bceck, Kaposi, Touton, Weyl, and others. The first changes noticed in the skin are increase in the lumen, and a sinuous condition of the capillaries supplying the one or two papilla? concerned in a single papule. The papilla?, thus largely filled with dilated capillaries, also contain a network of fine connective- tissue fibres, and dense, round cells, which proceed to multiply. Later, more papilla?, are concerned in this process and also the epidermis. In the places where the white points are exhibited, granules of kerato- hyalin become visible. In some portions of a lichen papule of medium development, the stratum corneum exhibits an external, dark, narrow, and firm layer, and beneath it two to four rows of translucent cells forming the stratum lucidnm ; but in other parts, and when fully developed in all parts, the stratum corneum breaks up into definite lamella?, a phenomenon seen in other disorders attended by derange- ment of the kerato-genetic function of the skin. The external layer is dark, when stained, and firm ; next below it is a wider layer of swollen cells with nuclei scarcely visible or relics of liberated nuclei ; and, still deeper, a narrow and solid layer beneath which the stratum lucidum becomes visible. In Robinson's sections, the horny layer was almost entirely absent over the region occupied by the cell-packed papule, below which the corium was normal. The rete was hypertrophied centrally, especially in the region of the sweat-ducts; its cells above the affected papilla? horizontally flattened, and the granular layer thickened. In some places it was difficult, in consequence of these changes, to distinguish between the rete and the corium beneath. The cell-infiltration, com- posed largely of embryonic white blood- corpuscles, extended more deeply into the corium in the neighborhood of the sweat-ducts. Briefly, it appears that the papule of lichen planus is the result of a primary hyperemia of the papilla? of the corium ; a secondary thickening of the lower part of the rete ; a tertiary flattening of the papule by reason of the resulting pressure, producing thus the appear- ance of umbilication ; a proliferation of cells in the granular layer, as a result of which the deposit of kerato-hyalin in whitish points or 1 See Keport of Two Cases, by Dr. Stephen Mackenzie, Journ. of Cutan. and Yen. Dis., 1885. LICHEN PLANUS. 249 sheets occurs sufficient to produce the clinical peculiarities having that appearance (not due, as Neumann supposed, to changes in the sweat- glands) ; and coloration of lesions due to both vascularization and to escape of blood corpuscles. Diagnosis. — The diagnosis rests on the characteristic shape, size, color, grouping, disposition, and umbilication of the papule of lichen planus ; which are not found in any other papular disease. Thus, in its size, apex, color, and course, the papule of papular eczema is quite different from that described above, being brighter, redder, more acuminate at the apex, and much more often followed by or accom- panied by catarrhal symptoms. In psoriasis punctata, the scales are abundant and readily removed ; the individual lesions also increase rapidly by peripheral extension, far beyond the fullest development of the papule of lichen. The papular syphiloderm is not pruritic, not flattened when minute, not polygonal in shape, not covered with a closely adherent horny scale, and always occurs in patients where careful investigation will disclose other symptoms of the disease (mucous patches, adenopathy, etc.). Treatment. — Roborant treatment by quinine, the mineral acids, the ferruginous tonics, and cod-liver oil, is frequently indicated. Though it is claimed that arsenic actually aggravates the disease, the author agrees with Hebra, Wilson, Duhring, and others, in ascribing to it the most brilliant results obtained in the treatment of lichen planus, results far more consistent than are obtained from the same drug in the management of psoriasis. Boeck and Taylor give fifteen grains (1.) of the chlorate of potassium in four ounces (128.) of water, fifteen minutes after eating, followed in a quarter of an hour by twenty drops of the dilute nitric acid, swallowed in a wineglassful of water. Robinson, in generalized and hypersemic cases, praises the alkaline diuretics (acetate of potassium with sweet spirits of nitre), well diluted after meals ; and Fox regards mercury as valuable in the chronic forms of the disease, for which also he administers asafoetida. Finally, Koebner has injected both pilocarpine and arsenic sub- cutaneously with success ; Unna has used one part of corrosive subli- mate, twenty parts of carbolic acid, and five hundred of the benzoated. oxide of zinc salve ; Vidal employs baths of vinegar, one litre to the bath ; and the external application of one part of tartaric acid to twenty of the glycerine of starch ; and Wilson employed a mercurial salve two grains (0.13) to the ounce (32.). Tar, ichthyol, thymol, iodine, and chrysarobin may also be successfully employed topically. Weyl has employed caustic applications ; as also one to two parts of (3 naphthol to ninety of rectified spirits of wine, and ten of glycerine. Prognosis. — The prognosis is always favorable, as the disease, even when chronic, tends to spontaneous disappearance. 250 DISEASES OF THE SKIN. Lichen Ruber. Gr. Taixfyv, moss. Lichen Ruber is an exudative cutaneous disease, characterized by the appear- ance of firm, millet-seed to split-pea sized, reddish, conical, discrete, or confluent papules, whose evolution may be accompanied by a moderate degree of itching, the eruption having a marked tendency to generalization and the induction of a fatal marasmus. Under the terra Lichen Ruber, Hebra was first to describe the dis- ease which is now recognized under this title, and which was, at one time, thought to include lichen planus, the two diseases being merely different expressions of a single pathological process. It has been already shown that lichen planus, which is much the more common of* the two, has no relation with lichen ruber. Very few cases, indeed, of the last-named disease have ever been reported in this country ; and there are authors who deny its existence as an independent affec- tion, claiming that the conditions described under the name should be properly assigned to other categories. Symptoms. — The disease is first characterized by the appearance, without prodromal symptoms, of isolated, pin-head sized, conical, reddish, and scale-capped papules of considerable firmness, bright red or livid in hue, and disseminated over the belly, chest, genitalia, extremities, and other portions of the body. In another form of the disease, these lesions are lighter in color, with a smooth surface, a small central depression at the apex, and a waxy appearance. It is these latter which have suggested that lichen planus is a variety of this disorder. The itching excited may be mild or severe. It bears no relation to the extent of the exanthem. The papules rapidly multiply, forming patches which by aggrega- tion eventually cover entire regions of the body, and, lastly, its entire surface. Throughout all, the individual papules do not enlarge at the periphery, but persist as such till they are lost in a diffuse, dull-red, infiltrated patch, covered with thin, papery, grayish, non-adherent scales, beneath which the orifices of the hair-follicles are seen to be dilated. Occasionally at the borders of a patch thus formed, isolated, shining flattened, or umbilicated papules persist or form circles of densely packed lesions, surrounding groups in which involution of the lesions progresses, leaving pigmented and atrophic areas within. Whether in the form of the lesions last described, or after irregu- larly disposed disseminated patches have been developed, the entire integument becomes eventually the seat of extensive infiltration, reddening, and scaling As a consequence fissures form ; and t the distress of the patieut increases. The skin of the face cracks ; the lids are everted or thickened ; the skin of the palms and soles is converted into leathery tissue; the nails become friable and irregular ; motion at the joints is excessively painful, on account of the inelasticity of the skin covering the articu- LICHEN RUBER. 251 lations ; the hairs are thinned and fall ; the extremities are maintained in a position midway between flexion and extension. The integument is now universally reddened, covered with innumerable delicate or coarser scales, and, especially upon the palmar and plantar surfaces, thickened by dense infiltration. Over the deeper fissures, extending to the corium, blackish and blood-containing crusts form. Emacia- tion progresses pari passu with the invasion of the disease; and death may result from exhaustion, an intercurrent diarrhoea, or a pneu- monia. Etiology. — The causes of the disease are unknown. The sexes seem to suffer in equal proportion, though it is claimed that more men than women are affected. The disease is neither transmitted by heredity nor contagion. In those who display the symptoms of the affection, external irritation is capable of aggravating the eruption. The disease is chiefly encountered in middle life from the tenth to the fortieth year, but has been observed as early as the eighth month. Diagnosis. — In psoriasis the discovery of a typical scaling patch, often with a clearing centre, should suffice for recognition of' that disease. The scaling also in diffuse psoriasis is much more abundant. In papular eczema, the lesions do not persist as such. When these two affections are generalized, it is claimed by French observers that there is always some one area, however small, of unaffected integument. This is not true of generalized lichen ruber. But, in such generalized cases, the distinction between that disease, pityriasis rubra, and dermatitis exfoliativa may be extremely difficult, if at all practicable or possible. At an earlier period, papules are not seen in either of the two last named disorders. The papules of syphilis never scale so generally as those in lichen ruber ; they, moreover, in cases, increase to double their original size ; and are always accom- panied by some other symptom of that disease. In the scaling stage of pemphigus foliaceus, there are bulla? present or a history of such lesions preexisting. Pathology. — According to Robinson, lichen ruber is a paratypical keratosis. It is characterized by hypertrophy of the stratum corneum and incomplete corneous transformation of the individual elements of that layer, which are larger and more polygonal, a feature most noticeable about the sweat-ducts and hair- follicles. The rete is in places enlarged and in places normal. The upper portion has an uneven appearance as the interpapillary portion pushes slightly clown- ward and the increase in size of the other parts is more marked. The papilla? are increased in size ; their bloodvessels dilated and surrounded by emigrated corpuscles. The walls of the sweat-duct are formed of large cells with vesicular nuclei ; corneous cells are heaped also about the orifices of the hair-follicles : the muscle-bundles are much hypertrophied. Treatment. — Arsenic is of greatest value and can be employed with large chances of success in lichen ruber. The drug is to be early given, persistently pushed in the face of new crops of lesions, till the desired result is obtained, and continued for several months after all 252 DISEASES OF THE SKIN. signs of the disease have disappeared. Tonics when indicated, should always be exhibited. The diet should be generous. The external treatment is naturally employed chiefly for the relief of any pruritic sensation. Here the dusting powders and ointments prove serviceable. The local remedies employed in corresponding stages of eczema may, in brief, be here used with advantage, such as the alkaline, starch, or bran bath ; and followed by inunction of the skin with salves containing thymol, salicylic acid, zinc oxide, bismuth, carbolic 1 acid, or benzoin. Prognosis. — The prognosis of the disease, when it refuses to yield to treatment and tends to become generalized, is necessarily grave. Treatment after the occurrence of marasmus, will often prove in- effectual. The disease is said to be occasionally amenable to energetic treatment before it lias advanced to the stage of inducing systemic exhaustion. Eczema. Gr. £k fi'w, to boil forth. Eczema is a non-contagious, acute, or more frequently chronic, inflammatory disease of the skin, beginning as an erythema, or by the appearance of iso- lated or grouped papules, vesicles, or pustules, either singly, simultaneously, or in succession, resulting in redness, catarrhal symptoms, scaling, crusting, and infiltration of the skin, accompanied by more or less intense itchiug and burning sensations, and leaving, after complete resolution, no cicatrices. Symptoms. — Eczema is one of the diseases of the skin of most frequent occurrence. In the statistics gathered by medical men, it would seem to rank first in the order of frequency. But it is only true as regards those diseases for which the physician is commonly consulted. It is easy to become convinced that acne is a more fre- quently encountered affection than eczema, by observation of the faces of individuals on the streets of any large city, eczema being of more frequent occurrence in this situation than upon other parts of the body. Many persons are the subjects of acne who never deem it necessary to submit to treatment for its relief, and the records of such cases do not figure in dermatological statistics. This being noted, eczema may be regarded as the disease of the skin for which most frequently the practitioner of medicine is consulted. By as much as inflammation is the most common accident of other organs of the body, by so much is its enveloping organ subject to the same patho- logical process. The surgical signs of inflammation of any given tissue are usually named as increased heat, redness, pain, and swelling. These are essentially the symptoms of an eczema; and it will be necessary, in order to study the disease intelligently, to inquire how these pheno- mena are modified by the anatomical peculiarities of the organ in this case affected A typical eczema is always betrayed by an eleva- tion of the temperature of the surface, and by a greater or less ECZEMA. 253 degree of swelling. Redness, in various shades, is also true of the eczematous skin. Pain here is represented by a sensation usually of itching, which may vary from slight annoyance to an almost intoler- able distress. The variation in the sensation which accompanies inflammatory disorders of the skin and other organs is merely due to the fact that the former is exposed to the air, and its increase in bulk is not opposed by other contiguous parts, as, for example, the inflamed bone in contact with periosteum, or the pathologically enlarged prostate within its fibrous capsule. Inflammation of the inner skin of the body, as of the lining membrane of the stomach or of the intestines, is generally characterized by the occurrence of in- creased heat, redness, swelling, and severe pain. Inflammation of tissues constituting other organs of the body usually terminates either in resolution, in the free production of pus, or in the occurrence of gangrene. And so an inflammation of the skin may terminate either by resolution, or by the free production of pus on its surface, the living matter rapidly multiplying as the in- tensity of the process may determine. Gangrene is not a classical result of eczema, chiefly because of the freely exposed position of the organ affected. The great variety of expressions assumed by an eczematous dis- ease, and the frequent interchange of these, the one for the other, are to be accounted for in the same way. The atmosphere which sur- rounds the body is but one of many external influences capable of affecting the skin. Thus it is rubbed and scratched, exposed to the friction of the clothing and the incursions of insects, and subjected to innumerable injurious contacts in all the various trades and occu- pations of life. If the inflamed skin could be as perfectly protected from the outer world as is the spleen, we should find the history of this affection much simplified. Clinically, several types of eczema can be recognized. These require separate description. It should not be forgotten, however, that each may prove to be not a variety, hut a stage of the disease, which may speedily give place to yet another. [A.] Eczema Erythematosum. In this form of the disease the conspicuous symptoms are heat, redness, and swelling, with a variable degree of itching, usually less severe than in several of the other phases of the malady. The pro- cess may begin with acute and intense symptoms, to be soon followed by one of the varieties of the disease to be subsequently described, or, what is perhaps more commonly the case, may continue indefin- itely as a subacute or even chronic affection. In color the skin of the part involved varies from a light to a darker shade of red ; and inasmuch as the process is more frequently observed in middle-aged adults, with darker hue of the integument than in early life, the color of the part is frequently noticed to be of a dull shade. In consequence of the swelling, the affected surface is notably elevated 254 DISEASES OF THE SKIN. above the level of the unaffected contiguous skin, and the line of demarcation between the two can be more readily traced than in several of the other varieties of eczema. The surface is usually uniformly and occasionally symmetrically involved. Lesions, other than the erythema, which is the prominent feature of the attack, may not be observed; and, as a consequence, from the beginning to the end of the disease, there may be no history of moisture. But in many cases, minute poppy- to rape-seed sized papules become visible on close inspection, still more rarely with a very minute vesicular apex filled with a droplet of clear serum. The localities chiefly thus involved are the face, the palms, the soles, and the regions about the genitalia, though any portion of the body may be affected. Resolution is accomplished after the occurrence of a very fine superficial desquam- ation of the epidermis, or by very gradual diminution of the red- ness and swelling without the production of scales. In either event the termination of the process is often announced by significant changes in the involved surface, as by the fading of color, the ap- pearance of islets of sound skin between affected patches, and by perceptible relief in the subjective symptoms. Such is the course of a typical erythematous eczema. Variations from this type are, however, numerous and important. Thus the disease may be limited to a patch as small as a finger nail, or may extend over large areas, especially after subjectiou to irritation. At times the coloration is irregularly distributed, producing a mottled appearance, brighter at one point and darker at another, while again, as has been indicated, the variety described may coexist with, or be followed by, the weeping, excoriation, and crusting which are charac- teristic of other manifestations of eczema. Scratching of the part involved produces a change in the symptoms which the skilled eye will promptly recognize. Minute superficial losses of tissue are then visible here and there upon the surface ; the fresher with a reddened floor possibly hidden beneath a thin blood-scale, the older surmounted by a light yellowish-red crust. The scratch-lines, so often recogniz- able elsewhere, are here less frequently evident. Like all the other varieties of eczema, this is extremely liable to recrudescence and relapse. In advanced life, the traces of the dis- ease may be visible for years. [B.] Eczema Papillosum. Under this title are classed all those forms which have long been described as Lichen Eczematodes, Eczema Lichenoides, etc. "Observation of the natural course of an attack of eczema," says Hebra, "furnishes the most unassailable proof of the connection between its various forms. Iu one case an eruption of vesicles begins the series of symptoms ; in another, it is preceded by the appearance of red scaly patches or groupes of papules ; or vesicles and papules are developed together, some of the former rapidly changing to pus- tules, and forming yellow gum-like crusts by the drying up of their ECZEMA. 255 contents." It is of the greatest importance that there should be a distinct aud more general recognition of the fact, that eczema may exist from first to last as a dry infiltration of the integument, for there is perhaps no one of the various manifestations of the disease that is so frequently mistaken, and confounded with other widely different affections. The poppy- to rape-seed sized papules which are developed in its course, are usually seated upon a reddened and thickened base, and are themselves colored in various shades of red to a dark lurid shade. They are usually discrete, though often closely set together; are accompanied by a severe form of itching when irritated by scratching, aud of all eczematous lesions are most apt to be thus irritated. Their summits are toru, and often to such an extent as to bleed, the blood drying in reddish crusts over the area involved, or limited to minute blood-scales on the apices of individual lesions. The extent of sur- face affected varies, as usual in the other varieties, being in cases largely diffused in patches over various portions of the body, or limited to small and single patches no larger than a silver quarter of a dollar. Such patches, covered with a single or several groups of reddish papules, may continue to torment the patient for long periods of time, or, being at one time relieved, recur with each aggravation of the part by the exciting cause. Papular eczema is the dry mani- festation of the disease, and is thus most frequently noticed upon the drier portions of the integument. These are the surfaces of the limbs, the back of the body, and, in particular, the scrotum. In the latter region, the lesions giving a name to this variety of the disease are most fully developed. If the moist forms of eczema are most frequently seen in early life, it is none the less true that the dry forms are most common in adult life or advanced years. It should not, however, be forgotten, that the papules here described may develop into minute or larger pustules, or may exhibit minute vesicular summits when there is free exudation beneath the surface. It should be added, that a patch of papular eczema, where no vesicula- tion nor pustulation has been observed, will, if sufficiently scratched, ooze with moisture, the serum escaping from the abraded surface. There are, in fact, few scratched eczematous surfaces which will not moisten a dry handkerchief applied to the part. This weeping con- dition attracts the attention of patients themselves, who Mall complain of it in describing their symptoms to a physician. A certain species of relief for the pruritus is thus obtained ; and in aggravated cases patients will scratch, or rub, or otherwise irritate their diseased patches, not merely for the purpose of gratifying the intense desire to assuage this symptom, but also to induce the serous exudation for the sake of the relief it affords. The secretion when in contact with linen cloths stains and stiffens them, very much as seminal fluid leaves its traces upon the clothing. Resolution of papular eczema is accomplished after the formation of scales, the tissue beneath the latter assuming more and more the appearance of healthy skin. 256 DISEASES OF THE SKIN. [C] Eczema Vesiculosum. This variety of the disease is, as its name implies, characterized at an early period by the formation of minute vesicles. It is a matter of importance, however, to recognize the fact that the vesicular, like the erythematous, is but one of several manifestations of this singu- larly protean affection. Long after the appearance of the treatises of the early English dermatologists, the term eczema was very generally limited by physicians to the vesicular phases of the disease; aud it is to the Vienna school that we are largely indebted for the recognition of the fact that these simultaneous or successive features, presented often in the same individual, really belong to one and the same malady. To limit the name eczema to-day to its vesicular variety alone would be to relegate the student of diseases of the skin to the misty uncer- tainties of the last half century t)f dermatology. The clinical features of vesicular eczema are chiefly due, first, to the acuity of the inflammatory process present; and second, as the result of the former, to the free exudation of the serum of the blood from the vascular plexus immediately below the pars papillaris of the corium. The involved surface usually feels at the outset hot, itchy, or particularly sensitive, and soon after becomes more or less intensely reddened, the hyperemia producing this effect in the course of a true exudation which may last for one or several hours. Poppy- to rape-seed sized vesicles then become visible on this reddened base. The lesions may be closely packed together, or discrete, or may be so abundant as to coalesce, a frequent behavior of all vesicular lesions. Each is filled with a droplet of clear serum, imprisoned beneath the most superficial layers of the epidermis. The vesicle is readily ruptured, and, if this does not speedily occur as the result of accident, it bursts spontaneously, and its limpid contents are then poured out upon the surface of the integument. The quantity of the fluid thus exuded is in excess of that originally contained in the small vesicular chamber. This is due to the fact that the elevated, macerated, and broken epidermis no longer presents an obstacle to the outflow of the serum from the engorged vessels beneath. Minute and even large drops of a clear fluid of syrupy consistency can be seen forming at the points where the solution of continuity has occurred. If with a slip of bibulous paper the first drop be removed, its place is visibly filled by a second. Crops of new vesicles succeed the first, each followed by the train of symptoms described. The weeping at many points of the surface thus affected, is so promineut a feature of the disease that it has led several authors to describe eczema as invariably a catarrhal disease of the skin. There are, without question, forms of the disease where the history is throughout entirely different from that just described, where no evidence of discharge can be appreciated from first to last, and yet where, by artificial measures, the so-called catarrhal features can be readily pro- duced. The subjective symptoms of the vesicular forms of eczema are more ECZEMA. 257 or less intense itching and often burning. In the very acute forms there is considerable soreness, the patient managing the aifected part with as much care as if it were a fractured limb. In exceptional cases, more frequently observed in children, there is sympathetic febrile disturbance of a mild grade. The discharge from the broken epidermis, whether directly from the vesicles, or from the vascular elements, dries rapidly when exposed to the air, in light yellowish crusts, which are rarely bulky. The extent of surface involved is variable, and the contour of the affected patch or patches is seldom well defined, these portions imperceptibly shading into the sound skin. The color of the area thus diseased varies according to the stage of the process, being at one time of a bright and vivid red, at another yellowish, and when covered with crusts or scales, undergoing a corresponding change of hue. Infiltra- tion of the skin occurs rapidly, so that when a portion of the affected integument is pinched up between the finger and thumb, it is found to be thicker and less elastic than before. As resolution approaches, all the symptoms described above grad- ually decline in severity : the serous discharge diminishes, the redness fades, the limits of the involved area are less distinct, the crusts loosen and fall, and it can be seen that beneath the scales which 'have taken the place of the oozing and broken epidermis, a new and tender epithelial covering has been produced. As a rule, for weeks after the process has completely ceased, the newly formed epidermis has a slightly reddened and tender appearance, though complete resolution is followed by no permanent sequelae. Such then being the typical phases of vesicular eczema, it must not be forgotten that clinically the picture may be quite different from that described. The types here given are convenient for analysis and study, however they may be commingled and obscured in the inflamed integument. Like the erythematous, the vesicular forms of eczema may precede the others, and becoming chronic, torment the suffering patient continuously for long periods of time, or yield, only to reappear at irregular intervals. [D.] Eczema Pustulosum. This variety of the disease may originate in one of the other forms of eczema, which, in consequence of the severity or acuity of the process, changes from an erythematous, papular, or more commonly vesicular type, or the pustular lesions may rapidly form at the onset. Usually a crop of minute vesicles is first seen of the sort just described, which, after enlarging to the size of a coffee-bean, become distended with puriform contents. These either accidentally or spon- taneously burst, and the fluid with which they were distended dries into yellowish-green or darker-colored and friable crusts. In aggra- vated cases the purulent matter seems to form directly upon the sur- face involved. If the process be long continued, infiltration occurs ; and the itching, which in all varieties of the disorder is a charac- 17 258 DISEASES OF THE SKIN. teristic feature Is awakened as an accompanying symptom. It is, however, rarely of the peculiarly aggravated type which accompanies the erythematous and papular phases. Pustular eczema is most fre- quently encountered in the regions of the head, and in constitutions where there is a pyogenic tendency. When existing on the scalp and line there is most commonly an involvement also of the sebaceous glands, whose secretion, altered by the periglandular inflammation, is added to that naturally produced by the exudative process. Singular shades of mixed yellow and green, and even black, are then to be distinguished in the resulting crusts, which later desiccate and fall, leaving a reddened and tender new epidermis beneath. Pustular eczema, as thus observed, has been described under a great variety of titles. Its identity as a form of eczema was first accurately distinguished by Hebra, in his experiments on the artificial produc- tion of the disease upon the surface by the external application of crotou oil. It has been called Impetigo Figurata, Meleitagra, Porrigo Larva lis, and other singular names, which suggest the attempts of the early astronomers to designate the constellations by their resemblance to the figures of animals. These, and many other useless terms, have been finally dropped from the nomenclature of modern dermatology. The four types of eczema considered above are, as has been stated, sometimes encountered in practice as distinct and unmingled forms of cutaneous disease, some of them more commonly than others. To present, however, a picture of eczema as it is seen clinically, it must be understood that these several forms, useful in the analytical study of the disease, often become, in actual observation, well nigh inextricably commingled. It is this untiring interchange of features which distinguishes all the results of manifold causes operating in nature at one and the same time; and it is this which gives the inflammations of the human skin, exposed to almost every external influence, such a manifold physiognomy. Like all other inflammations, eczema may be acute or chronic. Like all others, too, the acute may precede, and the chronic follow ; or the reverse may occur, the disorder, originating in subacute or insidious forms, may become chronic, and then, as the result of fresh or more severe irritation, develop into the acutest symptoms. Thus the name Eczema Rubrum has been given to the red and angry form of the disease, which, because of the free exudation of serum from its surface, has been also termed Eczema Madidans. In this form, the intensely red and wounded integument pours out freely upon the surface a thick gummy or syrupy fluid, which, if artificially removed, leaves behind it the swollen, angry, and still discharging skin, or, being permitted to dry where it has formed, concretes into the thick, dark-colored and often blood-stained crusts already described. Again, the scales which usually form on the eczematous skin toward ECZEMA. 259 the conclusion of the process jnst described, may prove to be the most characteristic feature of the case from the first. Thus on the back of the neck an eczematous patch may often be seen, where the skin is infiltrated and covered with a stratum of thin, whitish scales, the latter having developed rapidly upon an erythematous surface, and continuing for a long period as a scaly disease. It is to this and similar forms that the term Eczema Squamosum has been applied. Again, in the regions about the hand, the move- ments of that organ develop often fissures or cracks in the inflamed and infiltrated integument, and to these fissured forms the term Eczema Eissum, or Eczema Rhagadiforme, has been applied. They are observed wherever an eczematous dis- order has so impaired the elasticity and extensibility of the skin, that its necessary movements, especially about the joints, tear and stretch the torn integument. It is thus seen not only on the hands, but also on the feet and about the ankles, the resulting rhagades being, at times, the most painful of all the complications of the malady. Occurring upon the bodies and the hands of those who are compelled to come into contact with irritating substances, this form of the dis- ease finds its severest expression. Eczema Intertrigo is a name applied by several authors to that form of intertrigo which, surpassing the limits of hyperemia, results in an exudative process. Reference was made to this possibility in describing the symptoms of erythema intertrigo, in a preceding chapter. Here the symptoms are usually those of dhTused redness of surfaces of the skin in close apposition, macerated by previous transudation of sweat, and weeping with the serum which oozes from the several abraded points or patches. Eczema Verrucosum, or the wart-like form of the malady, is occasionally observed, espe- cially upon the lower extremities, in middle life or advanced years, as the result of long-continued disease. The integument becomes thickened and so hypertrophied as to suggest the appearance of warts closely packed together in a circumscribed patch. Eczema Sclerosum is a form of the disease most frequently observed upon the palmar and plantar surfaces, a condition referred to in the paragraphs relating to asteatosis. Here is presented a densely thickened inelastic in- tegument, suggesting the condition of tanned leather, without the occurrence of any of the other lesions of eczema described above. As a consequence, the perfect extension of the digits is impaired. 260 DISEASES OF THE SKIN. Most authors agree in considering eczema as it occurs in its acute and chronic manifestations. These are, as has been seen, inter- ehangeable conditions, the types of which possess, however, a clinical distinct in,—. Acute Eczema. In certain cases an acute attack of the disorder is ushered in by malaise, chilliness, or the recognized symptoms of the febrile state. With or without these prodromata, the affected portion of the surface becomes the seat of a burning sensation which is soon succeeded by redness and swelling. This may occur upon one or several portions of the body at the same moment of time, and the disease throughout be limited to this single area or those several spaces; or it may extend from one or all to other regions. This extension may proceed by continuous development of the disease along the surface, or an eczema of the thigh be suddenly followed by an eczema of the face, and this by an eczema of the scrotum. According to Kaposi, extension of eczema by the last-described method is due to the extraordinary sen- sitiveness of the skin when involved in an acute attack, in con- sequence of which the slightest friction, and even reflex irritation of the bloodvessels, produces a new focus of the disease at a distant point. This is a consideration of special importance. Patients will fre- quently point to an acute eczema upon several portions of the body widely separated, the one from the other, and urge this as an irrefutable argument in favor of the fact that they suffer from some " poison in the blood." The tumid and erythematous surface already described soon assumes the features of either papular or vesicular eczema, which need not be again detailed. In this manner the evolution of the disease occurs, and may continue for weeks, the patient, if unrelieved, tor- mented by the itching; and, if the disease be extensive, prevented from attending to his usual avocations. Acute eczema of severe grade will frequently prostrate a strong adult, confining him to his bed- chamber and often to his bed. When there is a simultaneous febrile process, the emaciation and adynamia are proportioned to its severity. Weeks and even months may elapse before recovery can be pro- nounced complete, subacute patches of the disease lingering here and there upon the surface, crust-hidden, scale-covered, occasionally oozing from recrudescence of symptoms. Recovery, even when complete, leaves the patient, it should never be forgotten, with a skin sensitive to irritation and more prone to a fresh attack of the disease than one long virgin of an inflammatory process. Such is the course of an attack of acute eczema of severe grade. Needless to say that a circumscribed patch of the skin may exhibit all the features of vesicular eczema in an acute form ; and, under the influence of an appropriate treatment, be satisfactorily relieved in the course of a few days. Lastly, acute eczema may be followed by chronic forms of the disease, the one passing into the stages of the other by scarcely definable gradations. ECZEMA. 261 Chronic Eczema. The symptoms and pathology of chronic eczema are largely those of the acute form of the disease. The chief differences to be noted relate to diminished intensity of the inflammatory action, or marked tendency to recurrence and persistence of the process, and a pre- ponderance of scaling and infiltration as contrasted with the active secretion and crusting of the acute phases. It is, however, important to remember that chronic eczema is not only the frequent sequel of such acute phases, but is particularly prone to recurrent exacerbations of acute grade, during which the serous discharges, consequent crusts, and angry aspect of the affected surface, do not fail to reappear. The itching so characteristic of the malady in all its manifestations is here also a tolerably constant symptom. Chronic eczema may involve a limited surface of the skin, or invade the entire surface of the body from the head to the feet. Rarely thus generally developed, it is more frequently observed upon circumscribed patches of the integument, as, for example, the scrotum or flexor surface of a joint, in which situation it may linger for years, or even for a lifetime, now better and now worse, or disappearing for brief periods only to return with each recurrence of its cause. Etiology. — Eczema is a disease of both sexes and of all ages ; and is, moreover, neither contagious nor inherited. The study of its etiology is thus to a degree simplified. In many cases no cause of eczema can be discovered, beyond those which operate exclusively within the skin-organ, and are proper to itself. These are necessarily obscure, and will remain so until we are in possession of far more knowledge as to the complex and inscrutably delicate processes by which innervation, nutrition, and new formation of the living matter of the skin, are both conserved and impaired. The autonomy of the integument must be conceded to the extent recognized in other organs of the body. There are diseases of the liver which are neither referred to the blood, the nerves, nor the action of poisons. There are diseases of the heart which can be induced by neither rheumatism nor syphilis. When the etiology of the disorders of all the viscera is perfected, that of the skin displaying the lesions of eczema will be assuredly more distinct. These remarks are justified by clinical facts. Eczematous affec- tions occur in the persons of individuals who are in every respect superb examples of good health, where the most thorough and careful examination fails to reveal for the disorder either an external or in- ternal cause. Eczema occurs also in persons who are affected with every form of bodily ailment ; those suffering from acute and chronic disorders of every viscus and system of the body ; and even those affected with other disorders of the skin. This is only what a study of established facts would suggest, having in view the probable pro- portion of eczematous attacks in every thousand individuals. Such coincidences would, however, scarcely furnish a satisfactory etiological basis for the disease, unless a certain degree of constancy between 262 DISEASES OF THE SKIN. eczema and these disorders could be established. Thus eczema is often seen in patients affected with rheumatism, gout, dyspepsia, malaria, obstinate constipation, anaemia, scrofula, and pulmonary dis- orders, a list of affections exhibiting surely very wide pathological differences. Yet he would prove to be a physician of exceedingly limited experience who could not select from patients under his own observation, twenty individuals affected with any one of the diseases oamed, no .-ingle person of the entire number having ever exhibited symptoms of eczema. If figures alone were to decide the question, these, and a larger list of maladies which have been named in similar connection, would be excluded in the study of the etiology of the disease. As predisposing causes, those operating by inducing systemic debility, many if not all the diseases named above, may be effective. In this way, chlorosis, albuminuria, tuberculosis, struma, gout, rheu- matism, uterine disease, dyspepsia, hepatic disease, constipation, and other gastro-iutestinal disorders may lay the foundation for a per- sistent eczematous attack. In a similar way it is possible that a pre- disposition to this disease may be inherited, but, as distinguished from all the diseases known to be transmitted by heredity, it may be asserted that no child was ever born into the world with an eczema. Eczema seems, in exceptional cases, to bear some relation to spas- modic asthma, sometimes coexisting with that disease in one person, or its attacks alternating quite regularly with the asthmatic parox- ysms. This may be due to the exquisite sensitiveness of the skin, mucous membranes, and nervous system exhibited in some patients. The so-called internal causes of eczema must be, for reasons given above, considered for the most part as either coincidences or condi- tions which favor the development of diseases in general, eczema not excepted. By interference either with innervation, nutrition, develop- ment, excretion, or the performance of the important functions of the body, as well as by reflex irritation of the surface, they operate by inviting, aggravating, or prolonging an eczematous attack. Among these may be named : not merely the diseases enumerated above, but also as physiological states, pregnancy, lactation, and dentition ; as associated with the habits of life, occupations necessitating inordinate fatigue of body or mind, especially with the exclusion of sunlight ; and lastly, as originating in the irritative action upon the mucous surfaces, of substances foreign to the body, dietary and medicinal articles capable of exciting cutaneous rashes, intestinal parasites, and instruments inserted and fluid injected into the mucous canals, as, for example, the male urethra. This much premised, it should be added that every phase of eczema can be artificially produced upon the surface of the skin by the action of external irritants. Several authors, notably those of French nationality, take exception to this view, claiming that the induced disease in such instances is an artificial dermatitis, but they fail to point out the distinctive objective differences between such dermatitis and eczema. They content themselves with observing the ECZEMA. 263 subsequent evolution of the malady, and pronounce that to be an eczema which fails to respond promptly to treatment; and that, a dermatitis which is capable of speedy relief. The climax of such absurdity is reached when they are shown obstinate cases of eczema of artificial origin, and the response is, that the induced dermatitis gave rise to an eczema in a predisposed subject. One step further and we are in position to estimate the approxi- mate value of the etiological factors in eczema. The large majority of all generally recognized and externally operating causes of the complaint, fail to have such an effect in the mass of individuals. Whether any one of them be necessarily followed by the disease is open to some question. Even the poison ivy, a fertile source of the disorder in susceptible individuals, will fail to influence others. The late and eminent Professor Boeck, of Christiania, when he last visited America rubbed the tender leaves of this plant over his hands and face in repeated efforts to produce the disease in his own person, and utterly failed of the desired end. Respecting the numerous agencies operating thus externally and capable of producing the disease under consideration, it is to be re- marked that they can all be referred to either : solar light and heat ; contact with foreign bodies in various vaporous, fluid, or solid states ; toxic agencies of a widely differing nature ; traumatisms in varying degrees ; and the action of parasites. Many of these cooperate ; some include others ; and some become effective by aggravating a disease which others have engendered. The reader is referred to the chapter on general etiology for fuller consideration of this subject. It will be sufficient to note here that acids, alkalies, antimonial and mercu- rial compounds, mustard, sulphur, castor oil, capsicum, arnica, tur- pentine, chloroform, ether, alcohol, and a long list of other medica- ments are capable of producing eczema when applied to the skin externally. The same is true of articles manipulated in many of the trades — those, for example, handled by the grocer, the baker, the confectioner, the seamstress, the ink-manufacturer, the mason, the cook, the gardener, the laundress, the painter, the dyer, the printer, the tobacconist, and the chemist. Then, too, the eczema of the person exposed to intense cold, or intense solar light and heat, aided by re- flection from the water, or even by excessive artificial heat, as the fire of a furnace, illustrates the action of other causes named. Pres- sure and friction -effects are exhibited in the eczema produced by the contacts with gaiters, cuffs, trusses, saddles, crutches, and corsets. Scratching is a fruitful cause of eczema when the skin is affected with pruritus as a distinct disease, or as a symptom of other cutaneous disorders. Thus it is efficient in urticaria, scabies, and the prurigo of Hebra; in the skin bitten by lice, insects, bed-bugs, and fleas (which even without such interference are capable in many cases of inducing the disorder) ; and in the lower extremities, where the skin is distended by varicose veins. Water is capable of exercising an injurious effect upon the skin to the extent of producing an eczema, whether it proceeds from the 264 DISEASES OF THE SKIN. sudoriparous glands in au excessive exudation of sweat which is not duly removed by ablution, or be applied externally as a fluid in ex- cessively cold or hot temperatures, or in the vapors of the popular Turkish and Russian baths, or yet again be rendered irritating by its saline or other constituents. The exterual sources of eczematous trouble named above should be regarded simply as suggestive illustrations. It should be borne in mind that every contact with the external world, sufficiently severe or prolonged to awaken the resentment of the healthy skin, may be followed by the protest of the latter in the shape of an eczema ; and the same may be true when even the most trivial external accidents occur to the sensitive skin of certain individuals particularly prone to the disease. Pathology. — The pathological changes in eczema are those of in- flammation of the skin, varying somewhat with the acuteuess or chronicity of the process, and the character and career of the exudate furnished in each expression of the disease. In all cases there is, first, a circumscribed or diffused hyperemia of the affected part. This results from a series of more or less rhythmical and alternate dilatations and contractions of the vascular capillaries, the apogee of which is persistent vascular distention, blood-stasis, and the condition generally recognized as engorgement of the affected parts. This engorgement becomes visible to the eye in various shades of increased redness. Then occurs an exudation, by which a material in various degrees of fluid or solid consistency is added to the tissues. This process is also coarsely appreciable, either by the free ooze of serum from the surface, or by the imprisonment of such exuded fluid in the chambers of the vesicles which it produces, or by an increased thickening of the various constituents of the skin, perceptible when these are pinched up between the finger and thumb, or, lastly, by the appearance of various solid or semi-solid projections concerning the skin proper, 02', secondarily, its glandular appendages, which visibly spring from the involved area. Thus are explained the various erythematous, vesicular, pustular, and papular manifestations of eczema. A history of the many doctrines which have been held regarding the part played in these phenomena by the bloodvessels, the nerves, and the tissues would simply exhibit the several steps which have been taken in arriving at the facts now demonstrable. The researches of Heitzmaun serve to throw light upon this inflammatory process in the skin in a highly satisfactory way. As to the part played by the epithelium, Heitzmann 1 shows that the initial step of the inflammation is declared by an increase of the living matter, both within and between the protoplasmic bodies ; the former produces a coarse granulation of the epithelia due to increase of living matter. This increase is evidently due to augmented afflux of nutritive material in the stage of hyperemia. It is declared at 1 Transactions Amer. Derm. Association, Fourth Annual Meeting ECZEMA. 265 the points of intersection of the protoplasmic network (the formerly so-called granules) by their enlargement, and by the shining and solid condition of that part of the network called the nucleus. The increase of living matter between the protoplasmic bodies is declared in a thickening of the threads traversing the cement-substance. Every particle of the living matter, either within or between the epithelia, is capable of producing a new formation of epithelial ele- ments. Thus is explained the part played by the epithelium in the thickening of the skin, the production of scales in squamous eczema, etc. Chronic eczema — vertical section of the skin of the forearm, a, epidermis ; 6, thickened rete ; c, hyper-pigmented layer of rete ; cl, enlarged papillae ; e, atrophied sebaceous gland ; /, atrophied hair- follicle ; g, infiltrated corium. (After Kaposi.) In connective tissue, the first manifestation of the inflammatory process is the dissolution of the basis-substance, and reappearance of the protoplasmic condition ; by this process, and the new formation of medullary elements which may start from any particle of living matter, the inflammatory infiltration is established. The sum total of the inflammatory elements which remain united with each other by means of delicate offshoots represents an embryonal or medullary tissue. In the case of erythematous eczema, the new formation of medullary elements is scanty, and resolution is accomplished by refor- mation of the basis-substance. In papular eczema the papillae of the skin are enlarged in all 266 DISEASES OF THE SKIN. diameters, partly owing to a dilatation and enlargement of their capil- lary bloodvessels, and partly to the peculiar connective-tissue changes already described. Plastic formative inflammation may be accom- panied by the accumulation of a larger amount of serous or albu- minous exudation in the epithelial layer as in vesicular eczema. Suppuration in the epithelial layer of the rete mucosum is pro- duced by the accumulation of an albuminous or fibrinous exudate, in consequence of which a number of epithelia are destroyed, and by a new formation of pus corpuscles from the living matter of the epithelial elements themselves. Epithelial suppuration of this sort is not followed by a cicatrix. This is the pathology of eczema pus- tulosum aud eczema madidaus. The elevation of the temperature in the inflamed skin is somewhat proportioned to the rapidity of the process. In acute eczema, such elevation may exceed 105.5° F. (41° C), while in chronic eczema it can scarcely be appreciated. The fluid exuded iu eczema, whether taking part in tumefaction of any portion of the skin, as in vesiculation, or in a free discharge from the surface, is always identical. It is a yellowish-white, sticky and syrupy liquid, feebly alkaline in its reaction, depositing albumen in abundance when treated by heat and nitric acid, and .exhibiting the characteristic features of the serum of the blood under the micro- scope. Exposed to the air, it desiccates in light yellowish to brownish, friable crusts, which resemble honey or gum. Increase in the pigment particles distributed to the epithelia of the rete is characteristic of the chronic forms of eczema, and more espe- cially of those where the circulation is somewhat impeded by the influence of gravity, as, for example, in the lower extremities. This is true, however, of all diseases accompanied by an augmented afflux of blood to any part of the body, as, for example, over the surfaces of joints to which for many years stimulating embrocations have been applied. Diagnosis. — Eczema is such a protean disease in its manifestations, and is, moreover, of such frequent occurrence, that it is necessary to establish a differential diagnosis between it and a large number of other cutaneous disorders. The more important of these are named below in alphabetical order for convenience of reference, the distinc- tive differences of each being briefly appended. It must be remem- bered, however, that the identity and characteristics of eczema are made clear only after a close study of all its features ; and that is the surest basis for an accurate diagnosis in every case. Acne. — Acne occurs chiefly on the face, neck, and back of the trunk, and its pustular forms might be mistaken for eczema of the same localities. But pustular acne is usually accompanied by a deeper-seated infiltration than the similar lesions of eczema; and this infiltration is also generally limited to the sebaceous glands or peri- glandular tissues. In eczema the itching is often severe, while in acne the subjective sensations are those of heat or burning; come- ECZEMA. 267 dones intermingled with the pustules of acne will aid in distinguishing the two. Erythematous eczema of the face is to be distinguished from Acne Rosacea by its more generalized infiltration, its production of itching, and its greater diffusion over the face; while acne rosacea is more often limited to the cheeks, nose, brow, and the regions adjacent to these parts. The patch of erythematous eczema is " hot ;" that of acne rosacea "cold" to the touch. The former is seen in infancy; the latter is rare in that period of life. Acne rosacea is also in many cases readily distinguished by the development of visible bloodvessels in the skin of the cheeks or nasal region. Lastly, in erythematous eczema, the lids are apt to suffer, while in acne rosacea this is the exception. In severe forms of acne the sub-epidermic pus formation and the resulting scar will prove significant. Dermatitis. — Dermatitis, of artificial origin, is to be distinguished from idiopathic eczema rather by its history than by special differ- ences in the appearance or evolution of lesions. In many cases the two affections are indistinguishable. A history of traumatism or of the external application of irritant or toxic articles will often serve to distinguish the two. Dermatitis of artificial production is usually sudden in its onset, the date of which will nearly correspond with the time of the operation of the exciting cause. The subsidence of the symptoms after the withdrawal of the cause will also point to the nature of the affection. Eczema is also much more capricious in its distribution and career. Erysipelas. — Erysipelas is generally accompanied by febrile symptoms, and in many cases by bullpe. The affected surface is red- dened, much more swollen than in eczema, and exhibits besides a characteristic shining appearance, which is always absent in erythema- tous eczema. The line of demarcation between the affected and un- affected portions of the skin is usually distinctly defined in erysipelas, ill defined in eczema. Erysipelas spreads from one point to another with a rapidity which is never noticed in eczema, the latter disease, moreover, exhibiting under a glass its minute papules or vesicles. In eczema also, when occurring upon the face in the erythematous form, the scalp is usually spared, while erysipelas tends to invade the scalp and the regions covered by the beard. Erythema. — Eczema is to be distinguished from the forms of erythema which are due to hyperemia only, by the presence of an inflammatory process. The erythema simplex which advances to exudation, at once transgresses the artificial line of distinction between the purely congestive and purely exudative disorders. It must there- fore be remembered that many eczemas begin as erythemata, and that, clinically, the latter may represent but a stage in the disease process. The discharge in erythema intertrigo results from imprisoned or chemically altered sweat, and will not stiffen linen, as does the serous 268 DISEASES OF THE SKIN. exudation of vesicular eczema, for example. Erythema multiforme, an affection really on the border-line between the two pathological classes here sought to be distinguished, will be recognized by the absence of severe itching, and the recurrence of the disorder at certain special seasons of the year; while E. papulosum, E. tuberosum, and E. nodosum, display solid elevations of the surface much exceeding in size the minute lesions of papular eczema. HERPES. — Eczema is, in the minds of many, so associated with the occurrence of a vesicle, that other vesicular disorders are apt to be confounded with it. But in herpes febrilis the vesicles are usually grouped about the mucous outlets of the body, and when actually under observation exceed in size the minute and transitory lesions of vesicular eczema. In herpes zoster with the limitation of the eruption to one side of the body, there is also a history of precedent neuralgic pain. The subjective sensation is a decided burning rather than itching, and there is a possibility of the subsequent production of scars. Impetigo and Impetigo Contagiosa. — In these forms of disease the pustular lesions are usually isolated, do not spring from an in- filtrated surface where other lesions may be visible, and are unaccom- panied by the intense pruritus which is characteristic of eczema. The pustules, moreover, are larger, and the resulting crusts, as a rule, bulkier and darker colored than in eczema. Again, in pustular eczema the cutaneous affection usually occurs in one or more patches, while in impetigo a dozen or more isolated pustules may be irregularly scattered upon the entire surface of the body. In the contagious form of impetigo, there may be a history of the extension of the disease from one member of a family to another. Lichen Planus. — In this disorder the papules never become vesicular as in eczema ; while those of the last-named disease never assume in any stage the peculiar sepia-tinted hue of the similar lesions of lichen planus. The latter, moreover, are often umbilicated, are chronic in development, frequently symmetrical in disposition, and are scaly at the flattened summit. Lichen Ruber. — Here the dull red, non-excoriated papules, covered with minute scales, unattended by severe itching, could scarcely be mistaken for the vivid, angry, and scratched papules of eczema, which, moreover, are often accompanied by secretion from the surface. AVhen the scales covering patches of coalesced papules in lichen ruber are removed, the orifices of dilated hair- follicles become visible. This is never true of papular eczema. But the important symptoms of a grave disease in lichen ruber, such as marasmus and the indications of a fatal termination, will not fail to attract attention. ECZEMA. 269 Lupus Erythematosus. — Lupus erythematosus greatly resembles certain forms of squamous eczema. The greater chromcity of lupus; the firm attachment of the scales; the symmetrical distribution of certain patches upon the face; the association of the disease with the sebaceous glands; the definite border of each involved area; and, above all, the discovery of the cicatrix where it has existed, will sufficiently distinguish the disorder. In eczema there is usually itching, often vesiculation, more rapid extension of the borders of a single patch, and scales much more loosely attached, than in erythematous lupus, which are never provided as in the latter disease with stalacti- tiform plugs on the inferior surface. Lupus Vulgaris. — Lupus vulgaris is readily distinguished from eczema by its more chronic career, its larger papules and tubercles of dark reddish-brown hue, and by every one of its destructive pro- cesses, none of which is ever recognized in eczema. Pediculosis. — As eczema is often induced by lice upon the head, pubes, or clothing, it is always necessary to exclude the operation of such causes both for diagnostic and therapeutic purposes. Eczema, limited to the pubic region or existing there, and elsewhere only about the axillae, should suggest careful examination of the skin and hairs for the discovery of the crab louse. As for the pediculus corporis, it should be the rule of the physician, invariable and never to be forgotten (whatever the social position or refinement of his patient), to search for evidence of the parasite upon the under surface of the clothing worn next to the skin, at the instant of its removal and while the patient supposes him to be busied with the inspection of the cutaneous lesions. The excoriations produced by scratching wounds inflicted by body lice are usually out of all proportion to the amount of skin disease present ; and this is the most significant of all symptoms next to the discovery of the corpus delicti. Head lice may precede or follow eczema of the scalp, but either they or their ova (nits), clinging in numbers to the hairs, will be visible to him who looks carefully for them. Pemphigus and Pityriasis Rubra. — The large isolated bullae of pemphigus vulgaris are never seen in eczema. In pemphigus foliaceus the lesions are succeeded by the formation of pastry-like crusts, scaly exudation, superficial soreness, and the eventual produc- tion of an extensive and usually fatal exfoliative dermatitis. The marasmus becomes then rapidly conspicuous, while, as a rule, itching and infiltration are not present. The disease known as pityriasis rubra is equally rare and fatal ; and, though unattended with the production of bulla?, is characterized by an equally abundant epidermic exfoliation, itching and infiltration being either entirely wanting or of insignificance in comparison with the other symptoms present. The scales too are papery, large, and thin ; there is no vesiculation and moisture, and little, if any, infiltration of the skin. The latter is, 270 DISEASES OF THE SKIX. moreover, of a uniformly reddish hue. Both pemphigus foliaceus and pityriasis rubra are particularly liable to be complicated with chills or uncontrollable diarrhoea. Without question, many of the reported cases of so-called pityriasis rubra are instances of squamous eczema. Here the localization of the disease to one or more patches upon the body, the severe itching, and the distinct infiltration of the patch, will point to the eczematous character of the disease. Observa- tion of such patients will finally convince the observer, in many cases, that there is occasional weeping from the surface. Prurigo and Pruritus. — In the prurigo of Hebra, a disease exceedingly rare in this country, there are infiltration, intense itching, and numerous minute papules. But the disease usually occurs within a year or two after birth, and lasts for a lifetime, extending generally over the greater part of the body, sparing only the palms and soles (which eczema does not), and is accompanied by inguinal adenopathy. In pruritus, often confounded with prurigo, there is itching without disease of the skin save that induced by the nails to relieve the sensa- tion. Hence, pruritus without scratching will not reveal a cutaneous disease; while the same disorder with scratching will exhibit either excoriations, or an eczema induced by the attacks made upon the skin. The last is, however, rarely noted. The distinction will be clear when it is remembered, first, that pruritus is usually of a paroxysmal character, worse regularly at certain hours or seasons; secoud, that pruritus not originating in a cutaneous lesion, but in- directly producing the latter by the medium of the nails, never ex- hibits as much cutaneous excoriation as the skin bitten by lice or attacked with eczema. The impressive symptoms here are always the disproportion between the complaint of the patient and the visible symptoms, and the vast preponderance of all lesions, when the skin has been scratched, in those regions of the body most accessible to the hands, such as the anterior faces of the limbs, the genital region, lower belly, etc. Psoriasis. — Psoriasis and eczema in typical forms are distinct. Variations from type in the direction from one to the other furnish many obscure cures. The following are the chief diagnostic points in psoriasis : Sharp definition of contour of patch; abundance and lustrous hue of scales; absence of moisture ; vascularity of tissue beneath the scales ; sites of election on posterior aspect of trunk and extensor surfaces of limbs; chrouicity in course; uniformity of lesions; and usually absence of itching. In eczema : there is an ill-defined contour ; usually scanty scales not having a nacreous hue; a preference for the flexor surfaces of the extremities, though the disease may occur in any portion of the body ; generally, at some period in its course, a history of moisture ; polymorphism, as regards lesions ; and a marked intensity of subjective sensations. Upon the scalp, psoriasis is partic- ularly apt to extend beyond the hairy border in a fillet stretching ECZEMA. 271 across the upper portion of the forehead and thence irregularly down in front of the ears ; while eczema of the face, when the scalp is also invaded, departs boldly from the hairy parts to the lower limits of the forehead, the lips, nose, cheeks, or chin, regions which are rela- tively spared by psoriasis. Finally, the two diseases, in doubtful cases, will generally be distinguished by carefully searching the entire surface of the body, upon some part of which, in psoriasis, there will usually be discovered a tell-tale patch of typical appear- Scabies. — Scabies is really an artificial eczema induced by the incursions of the acarus scabiei, and its lesions are thus those of eczema. In scabies, however, the pruritus is intense and the several papules, vesicles (these much less closely set than in eczema), and pustules are more likely to be coincident than successive, exhibiting thus the multiformity characteristic of the disorder when produced by the parasite. The discovery of the presence of the latter, especi- ally if there be a history of contagion and the localization of the disease in its sites of preference, will at once determine the diagnosis. Scabies never attacks the scalp. Its sites of preference are, in both sexes, the fingers, hands, wrists, and axillae ; in women, the breast and the nipple ; in men, the penis ; and, in children, the buttocks. The presence of the acarian furrow, if the disease has existed for some time, and the appearance of minute blackish dots or points upon or about the lesions, usually suffice to establish the real nature of the disease. Scarlatina. — This disease could only be confounded with certain of the varieties of eczema exhibiting an erythematous type. Tn scarlet fever, however, the elevation of temperature, the appear- ance of the tongue and fauces, and frequently the history of contagion, serve to distinguish the disease. The peculiar " boiled lobster " appearance of the skin, and its symmetrical distribution over the surface of the body, with gradual extension from the head and trunk to the lower extremities, are never seen in eczema. The finger-nail drawn across the skin of the patient affected with scarlet fever is usually followed by the occurrence of a whitish line corre- sponding with the impression made with the nail, which is highly characteristic of the eruption. Lastly, a generalized eruption of eczema will never disappear with the rapidity of the scarlatina rash. Seborrhcea. — Seborrhoea and eczema may coexist, either disease preceding the other. Typical forms of each are readily distin- guished. In eczema there is infiltration and much consequent itching ; in seborrhoea, neither. The scales of seborrhcea are more voluminous, greasy, freely shed from the surface, and seated usually upon an integument of scarcely altered hue. In eczema the scales are dry, scanty, and more firmly attached to a usually hyperaemic base. Seborrhoea of the hairy parts is generally symmetrically 272 DISEASES OF THE SKIN. diffused ; eczema, though occurring with ill-defined contour, is rarely as symmetrical, usually more acute, and seldom followed by alopecia. Upon the non-hairy portions of the body the same distinctions can be to a great extent observed. The crusts of eczema removed from the face generally disclose beneath them an oozing surface, while the under surface of these crusts never exhibits the stalactite-like pro- longations which pass from the under surface of the seborrheic crusts into the patulous orifices of the excretory ducts of the sebaceous glands. SYCOSIS — Both the parasitic and the non-parasitic forms of sycosis are limited to the region of the beard, while eczema of the hairy portions of the face will usually be found to aifect other regions. In eczema the itching is severe, the exudation spreads beyond the limits of the beard, and the discharge is characteristic, while in both forms of sycosis there is no oozing, and the subjective symptoms are trivial. The discovery of the parasite in the root or shaft of the hair will at once distinguish the parasitic forms of the disease. In sycosis, each pustule is perforated by a hair. Eczema limited to the region of the beard is even rarer than the two varieties of sycosis. The circumscribed indurations and tuberculations of the affection produced by the trichophyton, as well as the loosening of the hairs in their follicles, constitute further distinctive differences. Syphilis. — There can be no question that several syphilitic eruptions resemble certain forms of eczema. In the eruptions due to syphilis, however, there is usually a history of infection ; of involve- ment of the glands and mucous surfaces ; of ulceration and cicatrices in advanced periods ; and, especially in the case of infants with an eczema-like eruption, a history of snuffles. It should always be remembered that the intense itching of eczema is characteristic of no one of the syphilides ; and that the latter are remarkable for their tendency to occur with a circular or partially circular outline, and to be covered with bulky crusts of an offensive odor. A point partic- ularly worthy of note is suggested in the diagnosis of chronic eczematous affections. A syphilitic eruption limited for an equal period of time to one locality will often ulcerate or exhibit evidences of repair by scar tissue, no such lesions occurring in eczema. Syphilis of the palms and soles exhibits very distinctly limited outlines in the usually circular, circumscribed and deeply infiltrated patches present, which are often symmetrical in development, or at least situated on both sides of the body, even if more fully developed upon one limb. Syphilitic pustules upon the scalp usually rise above well-defined ulcers. Syphilitic eruptions encircling the mouth in children are less angry-looking and formidable than severe eczema of the same region, being often made up of flattened papules, moist or scaling, grouped in circles about the lips, with mucous patches at the angles. ECZEMA. 273 Tinea Circinata. — In ringworm there should be a history of contagion, microscopical discovery of the vegetable parasite, distinct contour of all separate patches, absence of marked subjective sensa- tions and of discharge. These are not symptoms of eczema. In ringworm of the scalp the hairs are usually either brittle or actually broken at a short distance from the scalp; the scales are fine, dirty- white, and not torn from the surface by the finger-nails. In eczema the hairs are unaffected, and their extraction from the follicles is accompanied by pain. In ringworm of the body the patches are distinctly circular ; more scaly or papular at periphery than centre ; and, moreover, yield with exceeding promptness to the action of a parasiticide. Occurring about the thighs and ano-genital region, the disease may be compli- cated by eczema, but the characteristic "festooning" of the advancing border of the patch downward along the thigh, or upward over the pubes, will suggest a microscopical examination of the scales scraped from the surface. Tinea Favosa. — The cup-shaped, friable, yellowish crusts of favus in the scalp might be mistaken for the crusts of eczema of the same part ; but here the exudation is slight ; there are no pustules of eczema, and hence no history of discharge. The odor, moreover, is characteristic. In case of uncertainty the microscope would indicate the parasitic nature of the disorder. Tinea Versicolor. — In this disease, also, the microscope will reveal, beneath the epidermal plates, the spores and filaments of the vegetation which produces the ailment. From eczema it is easily distinguished by the absence of infiltration and of any history of inflammation, by the very slight subjective sensation it produces ; by its peculiar fawn to chocolate-colored, slightly yellowish patches, with superficial furfuraceous desquamation, limited often to the anterior surface of the trunk, and readily removed by the action of a para- siticide. Treatment. — It is proposed to describe here the treatment of eczema in general, reserving the consideration of the treatment of the forms occurring in particular localities of the body to the pages which follow, and which are allotted especially to such local mani- festations of the disease. In acute eczema, as well as iu many of the chronic forms of the disease, the first and most important requisite is that which is the simplest, and, perhaps, for that reason most commonly overlooked. This requisite is the exclusion of all sources of irritation. This completely secured, a large number of cases of the disease will proceed to a prompt recovery without any other treatment what- ever. Failing this, acute become chronic phases of the disease ; or there is a history of exacerbation, recurrence, or development of the disorder in new and perhaps distant portions of the body, from 18 274 DISEASES OF THE SKIN. reflex irritation or augmentation of the sensitiveness of the skin to other sources of mischief. The exclusion of all sources of irritation necessitates, first, the withholding of all harmful internal medicaments. The number of patients presenting themselves for treatment of this disease, both in dispensaries, hospitals, and in private practice, who have aggravated their eczema by the medicaments they have swallowed, is incredibly large. Men and women, infants and adults, those who have been under the charge of physicians, and those who have purchased their drugs of the apothecary at the suggestion of the latter or of their friends, exhibit patches of acute or chronic eczema, intensely aggra- vated by the injudicious use of arsenic, iodide of potassium, bromide of potassium, Donovan's solution, and other harmful preparations contained in the various "blood-purifying" remedies sold in the shops. The practitioner whose patient comes to him after making trial of any such remedies, is strongly urged to set aside carefully the operation of such mischievous agents, and to watch the eruption care- fully, while their effect is vanishing. The result is often marvellous. The exclusion of all sources of irritation necessitates, in the second place, the avoidance of all injurious external contacts. Only gross ignorance or carelessness will overlook the fact that the inflamed skin, like the inflamed bone or the inflamed bladder, calls imperatively for rest. The prevalent idea is, however, that the patient with an inflamed joint retires to his couch or bed, while the patient with an eczema, uuless his disease is so formidable as to necessitate temporary withdrawal from the pursuits of business or pleasure, belongs always to the peripatetic class. He consults a physician, s\vallow T s some medicine, anoints his eczematous skin with a salve, and returns to the vocation where his complaint was begotten, just as the man with a gonorrhoea will occasionally solace himself by embracing the source of his affliction. The baker goes to his baking ; the seamstress still pushes her weary needle through the dyed fabrics which first injured her hands ; the man with an eczema of the thigh walks the street with his trowser leg rubbing the affected surface; the nursing mother, with an eczema of the infra-mammary region, still suffers the milk, chemically altered in the heat of the summer, to flow over the tender surface of the breast; or, in the case of her infant affected with eczema, stuff's the folds of a coarse diaper, half laundered or yet covered with the dejections from the bowels, between its thighs and over the anal region. Next is involved the exclusion of all topical irritants in the hands of either physician or patient, designed to relieve the disorder but having a precisely opposite effect. The number and variety of these articles are far from being commonly appreciated. Some are useful in advanced stages of the disorder, and harmful in its earlier periods. These are generally ordered by persons with a limited experience in diseases of the skin, and include a long list of stimulating and astringent ointments. Some are employed in sheer ignorance of their effects, as, for example, crude petroleum, strong acids and alkalies,. ECZEMA. 275 nitrate of silver, turpentine, and concentrated solutions of corrosive sublimate, intended to " burn out " the disease. Lastly, the exclusion of all sources of irritation necessitates saving the involved surface from the excoriations and other traumatisms produced by scratching, rubbing, and excessive washing of the eczem- atous skin. In the case of adults some restraint is here needed ; in the care of infants, this restraint may need to be enforced. This is the only proper treatment of eczema. That which is con- ducted without regard to this, is unworthy of the name. The methods of treatment about to be described in detail, are to be regarded as entirely auxiliary to the measures and precautions suggested above. If the latter could be perfectly secured in every case, no other treat- ment would be required. If the patient protest that he must continue his vocation ; the hands of the sugar-baker returning to their accus- tomed manipulations ; the feet of the busy pedestrian to the frictions incident to his daily locomotion, then let both physician and patient distinctly understand the facts of the case. The former advises the speediest method of relief; and the latter elects a slower and more uncertain course. In doing this he should be made to understand that the responsibility is, to that extent, to be borne by himself. What competent surgeon consents to be responsible for that fracture in which the extremities of the bone are daily subjected to movement on the part of the patient ? The great importance of rest and freedom from irritation of all sorts in eczema is well illustrated by two classes of cases. There is, first, the newly born infant, whose sensitive skin responds early to its first harsh acquaintance with the outer world, by an explosion of eczema. But it is a fact of singular importance that no child is born into the world eczematous. If the nervous system were responsible for eczema, such a result might occur, for that system is not only capable in intra-uterine life of producing club-foot and other deformi- ties, but also of influencing skin disorders. The author has reported a case of pigmentary moles at birth, and other observers have described similar facts where the lesions were distributed exactly in the situation of herpes zoster of the trunk, along the lines of the intercostal nerves. If the blood were responsible for eczema, the foetus surely might display its lesions, as it does those of syphilis. Animal poisons, as those of variola and scarlatina, do not spare the unborn child. Nor is it exempt from certain diseases of the integu- ment which are generally regarded as due solely to tissue changes, since newborn infants are occasionally seen affected with ichthyosis or sclerema neonatorum. Why is the tender skin of the foetus saved from every form of eczema, and the tender skin of the infant accessible to all by such various approaches ? Will it be responded that the child has begun to respire and digest for itself; that it has become suddenly strumous, dartrous, rheumic, arthritic, gouty, or herpetic ; that its standard of health is impaired ; that it is suffering from assimilative, nutritive or nervous debility, or from any one of the other numberless perturba- 276 DISEASES OF THE SKIN. tions to which eczema has been ascribed? For him who can divest himself of all prejudice, there can be but a single answer to the question. The difference between the child unborn and the child born is, as regards eczema, a difference solely of skin protection and skin exposure. The former enjoys what Dr. White has aptly termed a "prolonged, placid, subaqueous life." Anointed with unguent and immersed in its water-bath of grateful temperature, its skiu cannot be fretted to produce an eczema. The latter, abruptly and often rudely brought into contact with the outer world, may speedily exhibit the most formidable symptoms of the disease. The second class of cases to which reference is made, exhibit the reverse of this picture, and are best observed in hospital practice. Attacked with such severe symptoms of the disease as to justify admis- sion to these charities, eczematous patients, usually impoverished in their resources and often injured by exposure during severe bodily toil, rarely fail to improve greatly during the course of a few r days, when no treatment of an active sort has been adopted. In the larger number of cases, while waiting to study the evolution of the disease, one is limited to the observation of its involution. The mere rest in bed in a recumbent position, with a proper regulation of the diet and exclusion of all sources of irritation, has here been sufficient to secure relief. If any apology be needed for the space devoted to this part of an exceedingly interesting subject, it must be based upon the great fre- quency of the disease ; the wide diffusion of erroneous doctrines respecting its nature and the method of its management ; and the mischief resulting from the too common aggravation of the disease in its earliest manifestations. The dietary allowed the eczematous patient should be limited to the most digestible articles of food, and should exclude those known to be capable of exciting cutaneous irritation, a list of which is given in the chapter on urticaria. A moderate use of fresh meats, cooked vegetables, and fruits may be permitted, but starchy articles in excess, hot breads and cakes, pastry, confectionery, cheese, pickles and pickled meats, cucumbers, cabbage both raw and cooked, pars- nips, turnips, beans, oatmeal, cracked wheat, peas, celery, shell-fish, salted fish and meats, pork and veal should be avoided. Milk, when not the source of constipation, may be drunk. Coffee, tea, and cocoa, are in the doubtful list; as these are positively injurious to some patients, and apparently without effect in others. Tobacco should always be cut off from male patients suffering from anything like a serious eczematous attack. Alcohol in every form is contra- indicated save in such conditions as debility or previous habitual use in moderation by persons of advanced years. Internal treatment. — In the management of acute eczema, cooling draughts are useful ; and in all cases occurring in patients who are plethoric, who are constipated, or who suffer from other symptoms of imperfect excretion, aperients and cathartics are needed. Often a brisk mercurial purgative may be ordered at the outset in the form of blue ECZEMA. 277 mass or the compound cathartic pill. The rhubarb and soda mixture answers well in some cases. Podophyllin, irisin, and eupatorium may- be substituted for these. The saline cathartics, whether employed in medicinal formulas, or in natural mineral waters, such as the Hathorn, Hunyadi' Janos, or Friedrichshall, are exceedingly useful in the man- agement of most cases. The following is a valuable combination often advised for cases where both iron and the sulphate of magne- sium are indicated : R. Magnes. sulphat. 3ij; 64 Acid, sulphur, dil. f#j ; 8 Ferri sulph. 9ss; 66 Sodii chlorid. Sy, 4 Cardamom, tinct. comp. f3j; 4 Aq. dest. ad Oss ; 256 M. Filtra. Sig. A tablespoonful before breakfast in a tumblerful of cool or hot water. In some cases of renal derangement, the alkaline diuretics are indicated, such as the potassium acetate, carbonate, or citrate, adminis- tered with nitre, squills, caffein, or the benzoate of lithium in three to five grain (0.26-0.33) doses before meals (Piffard) ; and, in gouty cases, colchicum, Vichy water, etc. In patients suffering from acid dyspepsia, the liquor potassse, sodium bicarbonate, or ammonium car- bonate may be required. Aloes and iron, or aloes and ergot are often indicated in special cases. The late Dr. Tilbury Fox employed in cases where diuretics and alkalies were both indicated, a formula of this kind : . Magnes. sulphat. 3ss; 16 Magnes. carbonat. 3y, 4 Colchici. tinct. fSss; 2 Menth. pip. ol. "lij ; Aq. dest. . flvj ; 192 M. Two tablespoonfuls in a wineglassful of water every three or torn.- hours. Cod-liver oil is indicated in all cases of struma and tuberculosis ; phosphate of lime in bronchitis ; steel in anaemia and chlorosis. In fleshy children affected with eczema capitis, calomel internally is a valuable remedy, one to two grains (0.06-0.133) of calomel, with two to three (0.13-0.26) of rhubarb rubbed up with five of calcined magnesia (0.33) may be given once in the day to an infant; or one-twentieth of a grain (0.003) of calomel rubbed up with sugar of milk, may be given three times daily, for ten or twelve days. Van Harlingen advises small doses of the unspiced syrup of rhubarb, with or without magnesia, for the constipation of infants, or from one to three drachms (4.-12.), each of powdered rhubarb and the bicarbonate of sodium in four ounces (128.) of peppermint Avater, of which a tea- spoonful may be administered two or three times daily. Quinine, strychnia, the syrup of the iodide of iron, and the wine of iron may also be used with advantage when indicated in these little patients. Beside the articles enumerated above may be named the following, 278 DISEASES OF THE SKIN. which, after internal administration, have been reported as efficient in the hands of various authorities : Calx sulphurata and viola tri- coloi (Piffard) ; hyposulphite of sodium, ichthyol, chrysarobin, tar (for adults, two drops of purified pix liquida mixed with one-eighth part of rectified spirit, gradually increased — Anderson); carbolic acid, sulphur, and hydrocotyle Asiatics. If the remarks which have preceded are justified by the clinical and pathological history of eczema, it follows that there is no con- stitutional treatment of the disease, save that which excludes all sources of irritation, a point to which attention has been already called. Once fully persuaded of this important truth, the physician should be capable of managing the complaint without mental bias in the direction of futile experimentation with drugs. The treatment of the patient, however, may be in one sense re- garded as the treatment of his disease, though a very large number of eczematous patients are, except as regards the skin, in conditions of health. Constitutional treatment, to meet any general conditions of ill health, should be, in short, such as is made familiar to the physician in his experience as a general practitioner of medicine. Mention has been made of but few of the disorders in the long list which may coexist with eczema. Some male patients with a gleet have an eczema of the thigh, kept up by the discharged secre- tion, which calls for treatment calculated in a very indirect manner to relieve also the cutaneous disorder. The same may be said of an otitis externa ivith a purulent discharge, and of other local and con- stitutional ailments which the skilled physician should be competent to recognize and treat. Be it clearly understood the while, that all such treatment will not relieve an eczema. It simply places the patient in the most favorable condition for getting rid of local trouble. If one has had the opportunity of observing a large number of eczematous patients of every social class treated by internal medica- tion of the character approved by those who still cling to a belief in the constitutional nature of the disease, he will see that the statements here made are based upon a conscientious study of this experience, and of the results of personal experiment in the same direction. He who desires to build solidly will not lay his corner-stone upon the shifting sands, where so many have been disappointed before him. Bearing in mind the fact that an eczema will occasionally vanish under even the worst mismanagement, the value of arsenic adminis- tered internally for its relief should be duly estimated. It is an un- certain remedy in all cutaneous diseases ; it is as uncertain in eczema, and has unquestionably aggravated as many cases as it has relieved. Its value in chronic and persistent forms of the disease is attested by men of distinguished reputation ; and upon such authority it may be conceded a position among the internal remedies for the malady of possible value. It is indeed not as remarkable that a few patients annually recover under its administration, as that more do not attain the same fortunate end ; for it is the favorite dernier ressort in chronic scaling diseases of the skin with physicians of every grade of pro- ECZEMA. . 279 fessional proficiency; and, having in view the large percentage of ^czeraatous cases with which they are confronted, it is a curiously suggestive fact that the position of arsenic in eczema is yet open to discussion. If arsenic, which certainly does possess an influence over the skin, cannot to-day be demonstrated to have therapeutic value in the large proportion of all cases of eczema, what can be said for the host of other drugs, too commonly employed for a similar purpose, which are inferior to arsenic in their cutaneous effects ? Sunlight, fresh air, suitable clothing, and due regime as to pleasure and busi- ness — these must be, for many patients, controlled by the physician. They do not cure eczema. They may do much to aid in its manage- ment; they may do more, if neglected, to furnish sources of its aggravation. External treatment. — The most soothing applications which can be made to the skin affected with acute eczema are, in various propor- tions and combinations, water, oil, dusting powders, and occasionally ointments. These will be separately considered, but two important circumstances must be remembered in their employment — first, that an article which will be grateful to the skin of one patient may prove irritating to another, the two being to all appearance similarly affected ; second, that where the surface is broken, from rupture of vesicles, excoriations, abrasions, or fissures, an applied fluid should be of greater specific gravity than the serum which is exuded, since other- wise endosmosis and exosmosis will occur, and. the surface in conse- quence become more tumid and painful. Olive or other bland oils may be poured over the surface, applied upon folded pieces of lint, or used by inunction. Even these sub- stances are at times, however, the sources of irritation. They are made more soothing by combination with an equal part of liquor calcis, as in the Carron oil, constituted of equal parts of linseed oil and lime-water. For the linseed oil it is frequently advantageous to substitute cod-liver oil, palm oil, oil of sweet almonds, neat's foot oil, olive oil, or lard oil, flavored very slightly with bergamot or lavender to correct the disagreeable odor. In combination with equal parts of lime-water, one of these may be gently smeared over the surface, while a piece of lint, saturated with the same preparation, is also applied. In many cases the value of this dressing is greatly enhanced by sur- rounding the whole with oiled silk or other impermeable tissue. The dusting powders, described in the chapters on General Thera- peutics and the Erythemata are available in many cases where the surface of the skin is, or is not, broken. These may be composed of lycopodium, magnesium, boric acid, bismuth, talc, the oxide of zinc, and camphor when an anti-pruritic effect is desired, in combination with finely powdered starch. The Anderson powder, the formula for which has been already given, is a useful combination of camphor, starch, and zinc. In their preparation it is of prime importance that they be made perfectly impalpable by sifting them carefully through silk bolting-cloth, as they are sources of irritation when they contain grain-like particles of untriturated material. The finely bolted 280 DISEASES OF THE SKIN. "Oswego gloss starch," "corn starch farina," and rice flour, sold by the grocers, cither singly or in combination with the other articles named, are generally accessible, and prepared at hand. It will often be of advantage, where exercise in the day is not to be prohibited, to employ one of the oily preparations during the night, which can be removed in the morning by a weak alkaline bath containing borax or the sodic bicarbonate, while the patient employs a dusting-powder in the daytime. This can be freely dusted over the surface, as also over the soft lint in contact with the eczematous skin, the stocking, gloves, or suspensory bag being also well protected by the powder on its inner face. Water is of value in many cases when properly applied. Excessive washing of the eczematous surface is not only disagreeable to the patient, but irritating to the inflamed skin. Hot water, applied either as a lotion, bath, fomentation, or by sponging, is frequently grateful and alleviates the itching. If employed at all, its use should be immediately followed, as soon as the part is carefully dried, by the other medicament selected for topical application, such as an oily or fatty substance, or a dusting-powder. Cold water is of service only when it can be continuously applied, as its intermittent employment is followed by a vivid reaction in the skiu capillaries, whereby the itching is greatly increased. Thus are explained many of the nocturnal exacerbations of the disease, notably those occurring soon after the patient retires to his or her bed. A cold bathing of the part before retiring has been followed by a tem- porary calmative effect, the blood being driven from the capillaries by the contraction of the tissues. The return of the circulating fluid in excess has then been aided by the warmth retained by the bed and the bed-clothing. The continuous application of cool or cold water requires a constant supply of the fluid from a reservoir of fixed temperature, and the exposure to the air of the part to which the dressing is applied. Thus evaporation is not checked ; and what is intended to be a continuous cold dressing is not transformed into a hot fomentation. Such fomentations are, however, frequently grateful to the patient's skin, and at times fulfil a good purpose. They are applied by dipping pieces of soft cloth in hot water, applying them neatly over the affected surface, and covering them with oiled silk, rubber cloth, or the " protective material" employed in antiseptic surgical dressings. Poultices of flaxseed, elm bark, or other bland materials operate in a similar manner, but are chiefly useful in softening crusts or other morbid concretions upon the surface. When too continuously or too frequently employed, they are productive of harm in their macerating and relaxing effect upon the skin, whereby its natural tonicity and instinct of self-repair (if such a term be permitted) are to a degree obtuuded. They are hence but little used in eczema. The combined employment of water and fatty substances is an exceedingly valuable method of soothing the eczematous skin, but, with the means accessible in the private practice of many physicians, can rarely be secured. It ECZEMA. 281 certainly approximates most closely the sebaceous envelope and warm- water bath of foetal life. The eczematous skin is first anointed gently with a bland unguent, such as mutton tallow, suet, cold cream, or vaseline, and is then immersed in a bath of water kept continuously at the temperature of the blood. In the case of the lower extremities this is accomplished without great difficulty. Less perfect than this is the anointing of the surface and the subsequent application of a warm fomentation, by strips of soft lint dipped in the water, super- imposed with neatness, and subsequently covered with the protective gauze. Imbibition of fluids by the skin is prevented by its careful anointing ; and, when immersed in the water, the pressure is both uniform and gentle. 1 Medicated water in baths and lotions plays an important part in the treatment of acute eczema. The liquor calcis with calomel, half a drachm to one drachm (2.-4.), and pure glycerine or mucilage half an ounce (16.) to the pint (51 2.) ; the lead and opium wash ; glycerine one drachm (4.) to liquor plumbi subacetatis four ounces (128.) ; car- bolic acid one drachm (4.), and glycerine two drachms (8.) to one pint (51 2.) of camphor or lime water ; a decoction of opium, made by boiling five to ten grains (0.33-0.66) of powdered opium in a pint (512.) of water, which is strained and rendered demulcent with mucilage; sulphate of zinc ten to thirty grains (0.66-2.) to the pint; dilute hydrocyanic acid two drachms (8.) to the pint of water ; these and similar lotions, the ingredients of which are changed to suit the indications of each case, often serve to alleviate the itching, and in that proportion to diminish the intensity of the disease. Dr. White, of Boston, after bathing the parts for several minutes with the lotio nigra, dilute or in full strength, gently smears the surface with a small quantity of the oxide of zinc ointment, or, in winter, four scruples (5.) of powdered zinc oxide to half an ounce (16.) each of cold cream and vaseline. Dr. Taylor, of New York, has suggested the following : . Liq. plumbi subacetat. 3ij; 8 Opii tinct. 3\j; 64 Camphorse tinct. SJ; 32 Glycerinse IS; 64 M. Sig. To be mixed with a quart of water and applied on lint. To this solution, a greater astringent effect can be given by the addition of the subnitrate of bismuth, or oxide of zinc, half an ounce (16.) of either to the pint (512.) of the lotion. Dr. Duhring, of Philadelphia, has greatly popularized the use of the fluid extract of grindelia robusta in the proportion of one part to four of water, as a lotion in eczema. Many patients will in this way secure relief which they cannot otherwise obtain. 1 A convenient method of making the applications described above, is by the aid of spongiopiline The eczematous surface is first anointed with a bland, neutral unguent, and then covered with a piece of spongiopiline, cut to the required size, sewn to a somewhat larger sheet of oiled silk or Lister pro- tective, so that the edges may project on every side. The whole is retained in place by a flannel or muslin bandage, to which the edges of the impermeable material are attached by stitches. The spongio- piline is moistened with pure or medicated water, as desired, of a temperature nearly that of the- stomach, and may be re-moistened from time to time. 282 DISEASES OF THE SKIN. Other useful lotions contain finely levigated calamine, one to two ounces (3'2.-G4.) to the pint of rose-water, with a small quantity of glycerine, and, if the itching he severe, in addition half a drachm (2.) to one drachm (4.) of dilute hydrocyanic acid. Boric acid, one to two drachms (4.-8.) to the pint of an opiated wash ; thymol, one part to one thousand ; and borax or the bicarbonate of sodium in the same proportion, containing besides an equal proportion of alcohol, spirits of camphor, or chloric ether, is also available. With any of these it is proper to moisten frequently the soft lint upon which they are applied, and this after ablution with hot, pure or slightly medi- cated, water, for the purpose of relieving the itching. Van Harlingen uses also poultices made of crumbs of bread mixed with ice-cold lead water, where the skin is oedematous. From what has preceded, it will be clear that the chief end in the treatment of an acute eczema, is the relief of the subjective sensation of itching, and the exclusion of all irritants, the two being practically one. That which is not grateful to the skin of a patient thus com- plaining, had better be, for the time at least, abandoned. So great is the difference between different patients as to the toleration by the skin of various topical remedies, that it is well, as a rule, at the time of the first consultation, to order an alternative treatment, the one to be immediately substituted for the other, if such necessity arise. Especially is this true in cases where the epidermis is wounded, and where the patient can sometimes with comfort to himself exchange a dusting powder for a lead wash, or a weak carbolized oil and lime- water lotion, while his eczema is tormenting him in different degrees at different hours of the day. The necessity for this relief is so imperious that at times it over- shadows all other symptoms of the disease. He who has never studied the case of a man or woman possessed with a furious impulse to relieve an intense eczematous pruritus, has not yet completed an education in medicine. The fury, for such it really is, has been likened to the sexual orgasm, with which it is undoubtedly allied, as the two are not rarely coincident when there is severe anal or genital itching. The features of the patient are drawn ; he is but half conscious of his ejaculations and surroundings ; with his nails or other object which he employs he attacks the too vulnerable skin with an incalculable savagery. In these exaggerated paroxysms, nothing but blood will suffice for his relief. Not till the torn and wounded surface oozes with red drops at every point does he emit the sighs which indicate that his desire is satisfied. Men and women forcibly withheld from doing themselves this severe damage, will at times, exhibit muscular spasm, facial expression, and movements of the body, scarcely distinguishable from the symptoms of an epileptic seizure. This brief outline of a picture familiar to those who have had experience of exaggerated cases, will serve to enforce the need of the utmost care in selecting a topical remedy in acute eczema, the greatest gentleness in its application, and the nicest provision for the special needs of each individual patient. ECZEMA. 283 111 proportion as the disease progresses to a subacute or chronic stage, the various topical medicaments employed may be changed in character so as to produce an astringent or stimulating effect upon the part. The utmost skill and prudence, however, are needed at this juncture ; and when uncertain as to the proper course, it is well to continue the dusting powder, oleated lotion of lime-water, or whatever other article may be externally employed. For it is at this time that the disorder is readily awakened to renewed activity, a turn of affairs which is especially annoying to the patient, and particu- larly so to the practitioner if there be a suspicion (truth to say, often too well founded) that the aggravation has been due to the treatment. It goes without saying, that the routine practice in eczema has long been to order an application of the benzoated oxide of zinc ointment, irrespective of particular features of the malady in any individual case. Now no greater error in this sjjecial direction could be com- mitted. The acutely inflamed skin will rarely tolerate the most perfectly medicated ointment; and as this acuteness subsides, such tolerance is first to be carefully tested, as, for example, by applying a weak ointment to a part only of the affected surface. The term rarely is, however, here used advisedly. With that singular capri- ciousness which distinguishes the eczematous skin of different indi- viduals, the zinc ointment occasionally affords very great relief in the severest forms of acute vesicular disease. In the application of such ointments it should be remembered first, that they must be sweet and freshly and carefully prepared ; second, that they can be advantageously applied by gently rubbing them into the part by the tip of the finger, after which soft lint in strips, spread with the same material, may be neatly superimposed ; third, that an ointment, if selected, need not necessarily be applied to every part of the inflamed skin, since a little pad or circlet of lint may be applied only to an oozing or pustular patch ; lastly, that the debris of one dressing should be carefully removed before another application is made. Strata of any ointment, the older next to the skin possibly rancid and having imprisoned beneath them pus or other products of the disease, are positive sources of harm. The most soothing ointments for use at this stage are the benzoated oxide of zinc salve which may be reduced with cold cream one-half or more for extremely sensitive conditions of the skin ; Hebra's diachylon ointment, described later, of which one part may be combined with three or four parts of vaseline or cold cream and from five to ten grains (0.33-0.66) of salicylic acid added to each ounce (32.) of the whole; or the oleate of bismuth, prepared according to the formula of McCall Anderson given below. Appended are a few formulae for ointments useful in this stage of the disease : R. Zinci oxid. 3ss; 2 Hydrarg. amnion, chlorid. gr. v-Qss ; Camphor, pulv. 3ss-3j ; 2-4 Ungt. aq. ros. §j ; 32 33-. 66 M. 284 DISEASES OF THE SKIN. For the oxide of zinc may be substituted the subnitrate or the subcarbonate of bismuth, or from two to four grains (0.133-0.266) of the red oxide of mercury, or from four to ten grains (0.266-0.666) of the mild chloride, or from ten grains to half a drachm (0.66-2.) of the ammonium chloride. The cold cream makes an agreeable basis for these ointments, though lard, simple cerate, lanoline, vaseline, or equal parts of vaseline and the other preparations answer a good pur- pose. The cerates are made sufficiently soft for gentle manipulation by adding a drachm (4.) or two of glycerine to each ounce (32.) of ointment, and may be flavored with lavender, rosemary, or bergamot to suit the taste. The oleate of bismuth or zinc is prepared by rubbing up one drachm (4.) of the oxide of either metal with eight (32.) drachms of oleic acid, which is then allowed to stand for two hours. It is after- ward heated in a water bath, when ten drachms (40.) of vaseline and three (12.) of Max are dissolved in it, the whole to be stirred until cold. It is especially useful in the papular forms of eczema. The well-known diachylon ointment of Hebra occupies a foremost place in all lists of articles useful at this period of the disease, and even later. It is prepared as follows : Fourteen ounces of the best olive oil are added to two pounds of water, and heated to boiling in the water bath. Three ounces and six drachms of an equally good article of litharge are dusted over the fluid in ebullition, which is constantly stirred throughout, in order to prevent the formation of fatty acids. During the cooking, water is occasionally added as required. The stirring is to be con- tinued till the ointment is quite cold. Duhring has lately modified this ointment as follows: One part of freshly precipitated (from acetate of lead) pure white hydro-oxide of lead is rubbed down with two parts of water, and well mixed with six parts of the best Lucca olive oil. Stir the mix- ture for about two hours over a hot-water bath near the boiling point, and then cool with constant stirring until the proper consistence is obtained, and while the mass is cooling add one drachm of the oil of lavender to each half pound of ointment. The preparation, according to Eisner, a Philadelphia chemist, is said to contain the oleo-stearate of lead. When properly prepared this ointment is perfectly homogeneous, of a light yellowish color, and of the consistency of butter. It has been modified by Piffard, and after him by Kaposi, in combining equal parts of lead plaster and vaseline. It is commonly flavored with the oil of lavender. It is technically known as the uuguentum diachyli albi of Hebra. It may be imitated fairly well by melting together two or three parts of olive oil, and four of diachylon plaster, stirring till cool. This valuable ointment, though useful often in full strength and even to the exclusion of all others, is yet with such others often com- bined with manifest advantage. Thus a drachm or two (4.-8.) of it may be added to the ounce (32.) of lard, cold cream, or cerate, with ECZEMA. 285 or without the addition of another drachm or two (4.-8.) of the oxide of zinc ointment, or even one of the tarry preparations to be mentioned later. For the management of acute eczema many rely to-day upon the salve niuslins, glycerolates, pastes, etc., which are fully described in the chapter on General Therapeutics. Unna's paste is prepared by mixing one ounce (32.) of zinc oxide with two ounces (64.) each of glycerine and mucilage. To it one per cent, of carbolic acid or sali- cylic acid may be added, and the mixture then applied with a brush. Veiel recommends as a mull for the face and genitals R. Emplast. plumb, simpl. Sebi benzoinati 3ijss ; 10 Adip. benzoinat. 3ss • 2| M. [To make benzoinated sebum : R. Seb. taurin. Sijss; 101 Benzoes. subtil, pulv. grs. xv; l| M. Digere in balneo vapor, per horas duas et cola. To make benzoinated lard : R. Adipis 3ijss; 101 Benzoes subtil, pulv. grs. xv; l| M. Digere in balneo vapor, et cola.] With these may be named the glycerole of starch, cucumber oint- ment, the emulsion of sweet almonds, the decoction of Irish moss, and the salicylated paste made by combining half an ounce (16.) of vase- line or lanoliue with two drachms (8.) each of zinc oxide and starch, and ten grains (0.66) of salicylic acid. In chronic eczema it is necessary at first to remove from the sur- face all dried products of the inflammatory process which usually remain upon the surface, such as crusts, scales, and masses of effete epidermis. For this purpose oil is to be freely used, and care should be taken that it is rubbed gently into every part of the affected patch. A species of oil poultice may also be applied by saturating pieces of flannel or layers of antiseptic cotton with either cod-liver or olive oil, and covering these with protective silk gauze and a light bandage. As soon as the inflammatory products are softened they are removed by washing with soap and water, using for this purpose either the ordinary toilet soap, or, where the skin will permit, the spirit of green soap, described in the chapter on General Therapeutics. The Sarg glycerine soap is an admirable substitute for these articles when the skin is tender, and where an elegant toilet preparation can be ordered. The crusts and scales once removed, subsequent topical application may be made as required in each case. The acuteness of the disease having fairly subsided, not only as regards the question of time, but more especially as concerns the question of what the skin will tolerate, the tarry and allied prepara- tions become for the first time worthy of consideration. Valuable indeed when such toleration has become experimentally established, 286 DISEASES OF THE SKIN. they arc source- of positive injury when the acuteness of the inflam- matory process lias not completely subsided. The articles of this class most commonly employed are pix liquids (pine tar), oleum rusci (the oil of white birch), oleum cadi num, and terebinthina Canadensis (the balsam of fir). The oil of cade, as found in most of the shops, is inferior to the oleum rusci, which is certainly the better of the two articles. They arc best applied in the form of ointments, but are occasionally painted over the surface with a camcl's-hair brush in a liquid state. From one-half to two drachms (2.-8.) of the tar, in combination with a suitable quantity of the sub- carbonate of potash, arc sufficient to add to a single ounce (32.) of ointment, the proportions suggested being varied to suit the require- ments of each ease. In attempting to meet such requirements, it may occasionally be found useful to combine with these ointments the oxide of zinc, the mercurial compounds, or the diachylon ointment of Hebra, already described. The following formulae are illustrations merely of the manner of compounding these articles : R. 01. rusci (vel. cadini) Jss-3jss ; 1-6 Potass, subcarbonat. 9j-3ss; .G6-2 Unguent, aq. ros. sj; 32 Ft. ungt. M. For the potassic subcarbonate one-half to one drachm (2.-4.) of the zinc oxide may be substituted, or from two to four grains (0.133-0.266) of the red oxide of mercury, or yet half a scruple (0.666) of the mild chloride. The vehicle also of such ointments may be vaseline, lanoline, simple cerate, or half an ounce (16.) of either in combination with an equal quantity of diachylon ointment. Of the fluid preparations may be mentioned alcoholic solutions of tar, half an ounce (16.) of the latter to the pint (512.) of alcohol; and in cases where the detersive action of soap is also needed, the sapo viridis may be added as follows : R. Picis liquidse f 3j-ij ; H2-64 Sapon. virid. f^jss-iij ; 48-96 Glycerin. flj; 32 Spts. vin. recti f. i.5v"i ; 256 01. rosraarin. f3ss ; 2 M. Sig. To be rubbed gently into the skin with a flannel rag. Dr. Bulkley, of New York, has devised an alkaline solution of tar and caustic potassa, which is especially serviceable, as it is mis- cible with water in all proportions. It is constituted as follows : R. Picis liquid* f,$ij ; 64 Potassae causticae 3j ; 32 Aq. destillat gv; 160 M. Dissolve the potash in the water, and add slowly to the tar in a mortar with friction. Sig. '' Liquor picis alkalinus." To be used diluted as a lotion. A drachm (4.) or more of this solution may be added to a pint (512.) of water; and, as an ointment, the same quantity to the ounce R. Picis liquid, (vel. ol. rusci) giv; 128 Adipis £; 32 01. olivse 3 ss ; 16 Misce et adde Terebinth. Canadens. 1 . Sulphur, flor aa S3 5 32 Si2 . To be applied three times daily with i soft brush ECZEMA. 287 (32.) of cold cream, lanoline, or vaseline. It should be remembered, however, that the caustic alkali renders it exceedingly irritating to a sensitive skin, and it should be employed with caution upon any un- tested surface. The formula recommended by Spender and described in the chapter on General Therapeutics, is a useful means of testing the efficacy of tar upon an eczematous surface. When fluid or semi-fluid com- pounds of tar are needed upon the scalp, a drachm (4.) of the article selected may be rubbed up with an equal quantity of glycerine, and added to six ounces of Cologne water (192.). Hebra disclaimed any special value for sulphur in eczemas uncom- plicated by the acarus scabiei, but in Wilkinson's and other oint- ments, it has certainly served a good purpose. The following formula supplies an ointment rather less severe, which has practical efficacy in chronic eczema : M. To this may be added the green soap, if a stronger effect is de- sired. Olive or cod-liver oil may be rubbed into the eczematous skin, after combination with equal parts of one of the tarry preparations \ and carbolic acid in lotion and ointment, with the balsam of Peru, though less effective, answers well in many cases. Ichthyol, in ointments of the strength of ten per cent, and less, is useful in localized patches of the disease, especially of the papular and scaling varieties. The ammonium sulpho-ichthyol is preferable to the natrium compound. Its influence upon the skin seems to resemble both that of the tars and of chrysarobin, and cannot be regarded as greatly, if at all, superior to these agents. Whichever article be selected, it should be thoroughly rubbed into the affected surface several times in the day, after a small portion of the skin has been attacked to test its susceptibility. Should the redness, itching, secretion, and infiltration be aggravated by such application, it will be needful, for a time at least, to exchange the local treatment for one less stimulating. Should, however, the tarry or other similar application be well borne, it should be reapplied till it is no longer washed away by the ooze fronl the skin. Sometimes it is well to permit the former to accumulate till it is naturally shed from the surface by exfoliation, a course which will be indicated by the absence of all local distress. The new epidermis which forms beneath such a coating, should be for a time protected by a dusting powder. Occasioning no further subjective sensation, it speedily loses its redness and assumes a normal appearance. In other cases, indicated by local distress and exaggerated secretion, 288 DISEASES OF THE SKIN. it will be found useful to remove the tarry application completely. After saturating it for a few hours with oil, the surface may be cleansed with a weak alkaline lotion, and the tar compound then reapplied to the oozing skin with flannel or a eamel's-hair brush, according as recourse is had to an ointment or solution. Hebra used to employ in chronic eczema of obstinate kinds a remedy which he claimed to be his ultimum refugium, and which "cures every case without exception," the concentrated liquor potassre. The objections to its use are, however, grave. It produces severe pain, and in inexperienced hands it is dangerous. As a consequence, this distinguished dermatologist adopted two methods which he re- garded as partial substitutes for it. The first was the inunction of the body thoroughly and firmly with green soap, which was not re- moved by washing, but left in contact with the skin for several days, while the patient was wrapped in blankets. The second was his well- known method of treating more circumscribed patches of chronic eczema with soap washing and ointment, the process being described below in nearly his own language: A piece of green soap, as big as a walnut, is spread upon a flannel rag, and rubbed into the eczematous part for several minutes, pressing firmly the while, and from time to time dipping it into water in order to produce a better lather. The part is then washed free from suds with water, carefully dried, and the oil or ointment selected for topical use immediately applied on strips of muslin. These ate neatly ban- daged to the part. The soap must be rubbed in at least twice every day, so long as any excoriated points appear after its application. Soap rubbed into the healthy skin will not be followed by such effects, the part feeling clean, smooth, and comfortable after it has been washed off with water. The contrast this offers to the eczematous parts is very striking, the latter presenting numerous intensely red, raw, and moist spots. These are all caused by the action of the soap in softening and destroying the layer of cuticle which was before undermined by the eczematous fluid so as to form coverings for vehi- cles. Each, therefore, represents the floor of a vesicle, the roof being removed. The appearance of these red, shining, moist points after the first inunction suggests to the inexperienced eye that the malady has been aggravated; but they become fewer in number after each application, and finally entirely disappear, the eczematous surface being then no more affected by the soft soap than is the surrounding healthy skin. For the production of marked effect upon different patches of the eczematous skin — thos"e, for example, upon the palms and soles characterized by callosities, thickening, or even verrucous growths — a ten per cent, salicylic acid salve can be used after the shampooing, or Unna's salicylated gutta-percha plaster mull. Energetic effects are also obtained by the use of naphthol, chrysa- robin, and pyrogallol, in the strength of from one part to ten, to one part to thirty of salve. It is well to begin with a strength not exceeding one to two per cent., and gradually increase. ECZEMA. 28*9 Frazer 1 speaks highly of the application of iodoform to eczematous patches. It is employed in the form of an ointment, containing from ten to thirty grains (0.66-2.) of powdered iodoform to the ounce (32.) of cerate. Other stimulating articles have been found useful in the treatment of eczema. Among these may be named cautharides, employed as a blister, the nitrate of silver in crayon or solution, and iodine in com- bination with carbolic acid. The following formula should furnish a^clear vinous-red fluid, which may be applied pure or in dilution : R. Iodin. tinct. 3ss; 21 Acid, carbolic, (cryst.) 3j ; 4 Glycerin. Alcoholis aa 3ij ; 8j Aq. destillat. ad f|j ; 32j M. Sig. Iodized solution of carbolic acid. In cases where there is considerable pruritus, especially in obstinate patches of papular eczema, the iodized phenol of Bellamy may be substituted for this. The formula is : R. Iodinii cryst. } . A Acid, carbol. j aa 6 ] ' 4 | Combine with gentle heat and add an equal part of glycerine. Sig. Iodized phenol ; to be applied twice daily with a glass rod. Balmanno Squire, of London, has suggested a substitute for the diachylon ointment, in the glycerole of the subacetate of lead. It is certainly a valuable preparation in many cases, but not superior to the other ointment named. The " stock" is prepared as follows : Take five parts of the acetate of lead, three and one-half of litharge, and twenty of glycerine; heat for half an hour in a boiling glycerine bath, constantly stirring, aud filter in a gas-oven or other kind of heated apartment. From one-half a drachm to two drachms (2.-8.) of this stock, added to the ounce (32.) of pure glycerine, are suffi- ciently strong for application to the oozing surfaces of eczema rubrum. Lassar 2 recommends that the part affected should be at first well soaked with antiseptic oil, of which a considerable quantity is ab- sorbed by the skin. A muslin bandage, soaked in oil, is then ap- plied, and covered with oil-silk. The oil may be rendered antiseptic by the addition of one to two per cent, of carbolic or salicylic acid, or one and one-half per cent, of thymol. Sometimes the carbolic acid can only be borne for a short time, as it will of itself produce eczema. Rape-seed oil may be used in place of the more expensive olive oil ; but drying oils, such as linseed oil, are to be avoided, as they may cause inflammation. In chronic eczema, especially in in- fants aud in eczema of the face, he recommends an ointment. The i British Medical Journal, July 10, 1881, p. 80. 2 Annal. de Derm, et de Syph., Sept. 1881. 19 290 DISEASES OF THE SKIN. formula for an ointment which cannot be rubbed off during sleep, in eczema of the face, is : R. Acid, salicylic. 3ss; 2 /inc. oxid. 3vj; 24 Amyli Svj; 24 Vaselin. oil ; 64 M. Wyndham Cottle 1 has employed chaulmoogra oil, or gyuocardic acid, in a large number of cases of eczema occurring in persons with delicate skins, and over such exposed surfaces as the face, hands, and anus. In both acute and chronic forms he has employed these sub- stances in the form of ointment, in the strength of from fifteen to twenty-five grains (1.-1.5) to the ouuce (32.) of vaseline. The oint- ment is applied several times in the day, and, if possible, kept in contact with the part on rags over which it has been spread. Other mercurial preparations than those named above have long been in favor for application to localized patches of the disease. Among these may be named corrosive sublimate, the ammonio- chloride, the iodide and biniodide, the two oxides, and the nitrate. Calomel, which is exceedingly useful in the strength of a scruple to a drachm (1.-4.) to the ounce (32.) of zinc, lead, or simple ointment, can be often advantageously employed also as a powder in full strength, or diluted with bismuth or starch. In localized patches of papular eczema, where such a dressing can be tolerated, marked re- sults follow this dry dusting of calomel over the part, followed by alternate superposition of neatly adjusted strips of Maw's surgeon's plaster — the whole kept in situ by means of a neat bandage. If the itching is alleviated by such a dressing, it can be reapplied for a week as soon as it is loosened, when the redness and infiltration will be found greatly reduced. Other surgical appliances used in the local treatment of eczema are Martin's solid rubber bandage, Fox's tubular bandage of rubber, and other dressings composed of starch, gutta-percha, and plaster of Paris, intended to support the extremities when the integument is weakened. None of these are equal to rest in the recumbent posture. The most useful purpose subserved by rubber in the treatment of cutaneous affections is as an impermeable outer dressing for watery and oily applications. Here the mackintosh and silk protective of the Lister dressing answer all the indications. Prognosis. — The greatest uncertainty attends the prognosis of eczema, so far as regards the duration of the disease and the proba- bility of the recurrence of a relapse. With respect to the cpuestious most frequently asked, those relating to contagion, heredity, and per- sistent lesion-relics, naturally a favorable response can be made. But the fact remains that some forms of the disease are insignificant, some persistent, and some peculiarly liable to relapse from very slight provocation. Only after careful weighing of all the conditions ex- hibited by the skin and by the other organs of the patient can a 1 British Medical Journal, June 25, 1881. LOCAL VARIETIES OF ECZEMA. 291 reasonable probability as to the future be estimated. All this is un- satisfactory, and must be so. Eczema is truly a curable disease, but unfortunately one not only exceedingly common, but one open to aggravation by causes well nigh innumerable. Were the physician always in position absolutely to insure his patient the exclusion of all sources of irritation, the prognosis would be much more satisfactory. In hospital patients, where such control is more perfectly attained, the results of treatment may be predicted with some confidence. In general, it may be said that acute eczema is more readily re- lieved by proper treatment than the chronic forms of the disease ; that eczema with a discoverable cause is more manageable than one whose etiology is obscure ; that eczema of the very young and of the very old is at times particularly rebellious ; that the non-discharging phases of the disease are rather more persistent than those accom- panied by secretion ; that eczema lingering at the mucous outlets of the body (auditory canal, nostrils, mouth, nipple, anus, vagina) is more obstinate than when it affects the skin of other parts (shoulder, neck, lumbar region) ; that eczema with constant aggravation or complications (fissure of the hands, varicose veins of the leg, appa- ratus for anchylosis of knee) is more stubborn in proportion as those complications or aggravations cannot, from the circumstances of each case, be set aside ; and, finally, that an eczema which has long existed, or repeatedly recurred, as, for example, with every season of extremely cold or hot weather, is, after relief, extremely liable to return. THE LOCAL VARIETIES OF ECZEMA. Eczema of the Scalp. [E. Capitis. E. Capillitii.] When the scalp is affected with eczema, the symptoms differ some- what, according to the age of the patient. In adults, the erythema- tous and squamous varieties of the disease are more common ; in infants and children, the pustular. In the former the eruption is usually circumscribed and in patches ; in the latter it is more diffused. In the same proportion also the former is generally asymmetrically and the latter symmetrically developed. In infants and children, the pustules rupture early; and their contents dry into dirty- whitish, yellowish, or greenish crusts, matting together the hairs, serving as foci for dust accumulation and nests for lice, superimposed upon a reddish, oozing, pus-covered, or occasionally indolent skin, often foul-smelling, and usually complicated by a seborrhoea. The so-called " milk-crust " is usually a compound of dried pus and altered sebum. The itching is not so intense as in some other forms of the disease. Post-cervical, pre-auricular, and occipital adenopathy are common, and in strumous children suppura- tion of the affected glands may occur, though this is rare. The causes of this form of the disease are evidently associated with local conditions. The rapidly growing hairs of the scalp are in intimate association with the numerous and large sebaceous glands of the same 292 DISEASES OF THE SKIN. part, which unquestionably respond at times to the physiological stimulus they feel, by an exudative process. The acne of the young man whose beard is growing, illustrates the same fact. Local irri- tants arc not often wanting to push the disturbed equilibrium into the scale of disease. Dr. White calls attention to the common neglect in removing the " pre-natal cap of cheesy material," as well as to the rude and unskilful attempts to accomplish the same end. Extremes of temperature, friction, excess, neglect, and absence of endeavor to wash the scalp, all these contribute to originate or aggravate the dis- order. The affection when complicated or induced by lice, is more common in children than in infancy, doubtless in consequence of the greater independence of the former and their gregarious habits. In girls with relatively long hair, the ova, or nits, of the parasite are readily distinguished, adhering closely to the hairs and accumulated espe- cially about the occipital region. The itching is usually more annoying than in pustular eczema not thus complicated. The erythematous and squamous forms of the disease, rather more common in adults, originate frequently in seborrhcea, when scratch- ing or irritant applications have been made. The eruption here usually occurs in asymmetrical patches, or may be limited to a single patch tolerably well-defined in outline, and this often upon one side of the scalp, not as in infancy preferring the vertex. Reference is made in the chapter on seborrhcea to a form of eczema of the scalp occurring in adults where finger-nail sized, circular, oozing or slightly crusted patches are generally disseminated over the surface. They result, as a rule, from the scratching of an obstinate seborrhcea in " nervous" women; and suggest traumatism, in their reddish friable crusts, the color being due to exuded blood. The diagnosis of these forms of disease has been already considered. In the treatment of the eczema of the scalp in infants and children, the first indication to be met is the removal of the accumulated crusts. When this is harshly accomplished, it becomes a fruitful source of further mischief; it is, therefore, necessary to proceed with great gentleness, and thus the thorough softening of the crusts is all important. For this purpose it is necessary to soak them in oil and to retain this substance in intimate contact with the scalp. Olive or cod-liver oil may be selected, and, if needful to correct the odor or for other purpose, one drachm (4.) of carbolic acid may be added to each pint (512.) with two drachms (8.) of the balsam of Peru. A neatly fitting skullcap should be then smoothly applied, constructed of the Lister protective or flannel, and fastened in place by a light bandage, never by elastic rubber bands. After several hours of soaking, the crusts should be removed by warm water and spirit of soap washing, and the entire process be repeated till the crusts are completely detached. In selecting an article for subsequent medication of the scalp, it should always be remembered that even infantile eczema will proceed to a natural involution if uuirritated. Hence the oleated lime-water, or oil of sweet almonds alone, will often answer better LOCAL VARIETIES OF ECZEMA. 293 than an ointment, and, even where there is considerable acuity of the inflammatory process, lime-water alone, with possibly a small quantity of glycerine added. In other cases the lime-water can be better medicated with calomel or the oxide of zinc. At times, also, it is well, even when these applications are kept in constant contact with the scalp, to order that a small pea-sized mass of one of the ointments described above [such as the benzoated oxide of zinc ointment with cold cream, or one medicated with a mercurial compound, e. g., calomel, twenty grains (1.33); or white precipitate, ten to twenty grains (0.66-1.33) ; or the subnitrate of bismuth half a drachm (2.) to the ounce (32.)], be applied at the time of the dressing. This is to be gently rubbed in the surface with the tip of the finger, and the skin afterward protected as before. It is rarely needful to cut the hair unless nits be found, though in public charities it certainly is a more expeditious method of arriving at the end, when a uurse has to dress the heads of several children in a single ward. In adults, especially in women, the hair should be spared, while the patient is warned that the loss of the growth upon the scalp may be considerable. As a sequel of obstiuate seborrhoea such an eczema may be succeeded by alopecia ; in the absence of the former, the hairs are usually reproduced. It is rarely necessary to employ the skullcap in adults, since one can succeed in insuring the necessary applications by directing the attention of the patient to the necessity of care and thoroughness. Lice when present may be destroyed by the application of petro- leum. Nits are removed from hairs which it is not desirable to cut, after the petroleum dressing, with alcohol or cologne water. As the disease in both classes of patients advances to a subacute or chronic stage, the treatment may be changed so as to include the various stimulating applications already described, such as ointments and spirit lotions containing tar, oil of cade, balsam of fir, pyrogallol, alcohol, and sulphur. In the case of infants, however, such stimu- lating topical remedies are very rarely to be employed. An eczema of the scalp which has once entered upon resolution, in an infant or child, should be generally soothed and protected. Many little patients thus affected are in excellent general health, and require no internal medication. Others, however, demand the interposition of the wisdom of the physician to protect them from the ignorance or folly of those to whose charge they are intrusted. Here is not space for a discussion of the pressing questions relating to the nutrition of the infant deprived of the breast and starving on the " proprietary" diet purchased of a chemist, or an equally vicious aliment compounded by lime-water, and imbibed through a tube by which it is flavored with India-rubber and the chemically altered casein of milk several days old. A word to the wise is sufficient. Fresh pure milk, animal broths, cod-liver oil, must not be neglected. This concerns the health of the child, and has indirect connection with the eczema. A record of one hundred infants dead of artificial foods 294 DISEASES OF THE SKIN. and marasmus in a public Charity of Chicago, includes in the list not a single case of eczema. Lastly, patients of both classes are to be saved from mercury, arsenic, and the iodide of potassium. Eczema of the Face. [E. Faciei.] Erythematous eczema of the face in adults is projected prominently among the varieties of the disease by its uniformity of type. It occurs in early and middle life and advanced years; and is a particularly intractable ailment. In well-marked cases, the forehead, checks, eyelids, and nose of the patient are involved, exhibiting an infiltrated, usually dusky-red, often symmetrical patch of disease, the affected surface being slightly elevated above the level of the sound skin. This surface is uniformly smooth and reddened; occasionally, near the root of the nose and about the lower line of the forehead, minute, closely set papules are visible. Very slight oozing, especially after irritation, may be noticed. At the height of the disease or in its involution, exceedingly fine scales form, which are scarcely per- ceptibly shed from the surface. The lids, especially the lower lids, in advanced years become puffy. The line of demarcation is unusually distinct, and rarely invades the scalp-border or the region of the beard. Itching is at times intense, the patient complaining of this bitterly, and usually preferring to rub the face with the hands or pieces of cloth. Sometimes, however, the face is well scratched with the nails, and excoriations and blood-crusts disfigure the countenance. Patients of intelligence usually describe the itching as paroxysmal, and starting at the root of the nose, whence it travels upward over the forehead, and laterally to the brows, often in the line of the supraorbital nerves. Certainly at the root of the nose, the exudative process is of the most marked character. The eruption also is seen in asymmetrically disposed patches of various sizes, with islets of sound skin between. In resolution of the symmetrical form, this is commonly observed. Patients thus affected are often those whose faces have been espe- cially exposed to irritation, such as locomotive engineers, wheelsmen of sea-vessels, mechanics in trades where the hands are soiled with irritants and afterward applied to the face, and women spending hours of each day over the laundry-tub or the kitchen-stove. In each class the operation of the cause is made manifest by the exacerb- ation of the disease after exposure. The affection is most commonly mistaken for erysipelas, a disorder from which it is readily differentiated by the chronicity of its course. The latter feature is particularly characteristic of this form of eczema. It is rarely completely relieved after the age of sixty within a twelve- mouth ; and, when it has existed for a long period of time, is partic- ularly obstinate under the best treatment, recurring with exasperating frequency upon exposure of the face to atmospheric changes. The great vascularity, abundant supply of sensory nerves, and necessary LOCAL VAKIETIES OF ECZEMA. 295 exposure of the face, probably explain this peculiarity. In its treat- ment the dusting powders fulfil an important part. Soothing appli- cations should always be first employed. The more stimulating applications may be tried later. In patients of younger years the face is apt to display vesicular and pustular phases of the disease, forms more often of acute eczema, and correspondingly more manageable. The itching, and especially burning sensations, are apt to be severe ; crusts form rapidly ; and in infants the picture presented is often that seen in the scalp, except that the hairs are not matted into the crusts ; and there is often a reddish blush at the edge of the crust ; or, when the latter has been removed, a redness of the oozing surface somewhat more marked than the similar patches on the less vascular scalp. The scratching in these little patients is severe ; crusts are torn off in part or wholly ; blood-crusted excoriations are common. The area of surface involved is in this way clearly extended ; sleep is greatly disturbed ; and the irritability and fretfulness of the child, thus produced, bear heavily upon its general nutrition. In severe cases of long standing the mental tone of the little sufferers becomes singularly perverted, and the character unquestionably changed. They will occasionally, when permitted, pick off and devour the crusts with voracity, and undergo nervous crises which are but a step removed from convulsions, and doubtless allied to the petit mal of the epileptic. 1 This chain of formidable symptoms, well linked together, will often bid defiance to the most skilled efforts to impart ease to the tormented skin. In such cases the harness employed by Dr. White, of Boston, fills an important office. The skullcap, described above, and made of firm old cotton or linen cloth, is closely fitted to the calvarium, and a mask of the same material is shaped to the face with exactly placed apertures for the eyes, nose, mouth, and ears. It is gathered in beneath the chin, and laps over two inches at the back of the head. This may be used only during sleep, or in aggravated cases, also during the hours of wakefulness. A species of strait-jacket is made by passing the head of the child through a hole in the closed end of a small pillow-case, which is then drawn down over the body and arms, and the latter confined at the sides by stitching the case together between the trunk and the upper extremities, or accomplishing the same end with safety-pins. The jacket is finally secured by similar means between the thighs. When it is necessary to imprison the lower extremities, these are similarly secured by pins within the case; and the outer edge of such trousers can be fastened to the bed or cushion on which the child reclines. Of course this treatment does not preclude the employment of the washes, ointments, etc., which are to be neatly applied next to the skin beneath the " trousers " or "jacket." The result is that rest is given to the tormented skin, 1 Among the criticisms elicited by the appearance of the first edition of this treatise, it was charged that the picture given iti this paragraph is exaggerated. The experience of the critic, however had been too narrow. The accuracy of the description given above has been more than once confirmed in the observation of the author since these lines were first written, and they are left standing to-day as a hint of the truth. 296 DISEASES OF THE SKIN. which is not suffered to be exposed to a single .scratching even during the dressing of the parts; and its natural tendency to repair soon brightens up the case. In the treatment of these cases, the black wash and zinc salve treatment will be found valuable, as also the diachylon salve, lead lotions, and the glycerole of starch. Van Harlingen gives the following : R. Pulv. zinc. oxid. 3j; 4 I Sevi purificat. 3ij; 8 Adipis 3iv; 16 Pulv. ulmi flaw 4. s.; M. To protect the face from the cold air he also employs half an ounce (16.) each of glycerine and gum tragacanth, half a drachm (2.) of borax, and water sufficient to make a paste. In obstinate cases tar should be employed. It is well to remember in the management of any case, that while a tarry application may be well tolerated over one part, as, for example, on the cheeks and near the nose, in another, as, for example, over the lids, a zinc salve may be better employed in the same individual. Eczema of the Lips. [E. Labiorum.] Reference has been already made to the obstinacy of eczema occurring near the mucous outlets of the body, a result due, probably, to the secretion furnished by the adjacent mucous tracts. The lips furnish an illustration alike of this pertinacity and aggravation. Their frequent motions in mastication and articulation aggravate an eczema, which is, moreover, apt to be teased by a no less frequent thrusting of the tongue out of the mouth, where there is no beard, to wet the parts with mucus and saliva. One or both lips may be involved, vesicular, pustular, squamous, and erythematous lesions occurring at one point, or along the entire line of either, with frequently resulting crusts and fissures. The vermilion border of the lips commonly participates in the process. The lips become hot, sometimes much thickened by the swelling and infiltration, their mucous faces being rarely implicated. Scarlet, dull red, and other peculiarly purplish hues of the vermilion border become visible. The parts are more picked than scratched, though the itching is at times severe. The pustular and vesicular forms are more common in children. The erythematous form, its reddened outline roughened by scales, evenly projected beyond the vermilion border, is rather an affection of maturer years. In young children the disease is frequently aggra- vated by nasal discharges which flow over the lip, giving the latter an elephautiasic aspect or even the appearance of an animal's snout, a condition noted also in later life. Occurring upon lips covered with the hairs of the moustache, the disease exhibits the usual symptoms of eczema barbse. In these male patients, the pipe, the cigarette, the cigar, and the tobacco chewed and expectorated may aggravate the malady. In all cases it is obstinate, and calls for LOCAL VARIETIES OF ECZEMA. 297 either emollient, stimulating, or protective applications. In cases displaying acute and painful symptoms, frequent fomentations of the part with soft rags dipped in hot mucilaginous and alkaline waters, will aid in controlling the swelling and alleviating the pain. In chronic cases, where stimulation is demanded, this can be effected at the time of dressing, the parts being subsequently protected by collo- dion or other material. Carbolic acid and the nitrate of silver are often needed for such dressing. In eczema of the hairy lip it is often of great service to remove the moustache by shaving. Fox suggests the use of thymol, five grains (0.33) to the ounce (32.) of cold cream. Van Harliugen applies equal parts of dilute phosphoric acid, glycerine, and syrup ; and to the outer edge of the lip, two scruples each (2.66) of zinc oxide and honey, six drachms (24.) of the oil of sweet almonds, and two drachms (8.) of wax. Veiel paints the lips twice daily with soft soap. Taylor's application of the tincture of benzoin, each ounce (32.) containing one to two grains (0.06-0.13) of corrosive sublimate, is a valuable solution for painting over the cracks and fissures near the angles of the lips. The diagnosis is between sycosis parasitaria, herpes labialis, and epithelioma, the points of difference having been already suggested. The first is accompanied by loosening of the hairs, and caused by a parasite ; the second is vesicular in lesion, brief in duration, and trivial in severity ; the third is a disease of advanced years, rather than of early and middle life, and is never accompanied by itching, but usually by more or less ulceration. Syphilis is fond of the angles of the lips; in most cases when thus limited, typical mucous patches of the mouth Can be discovered. The lesions of syphilis at the angles of the mouth are seldom linear fissures, but more often irregularly outlined erosions, secreting a puriform mucus. Eczema of the Nostrils [E. Narium] is naturally often associated with a chronic coryza. Inasmuch as one of the common symptoms of hereditary syphilis is the "snuffles" of the child, the physician should carefully exclude the possibility of such disorder in every instance when an infant with coryza exhibits an "eczema" of the nares or lips. The age of the little patient ; an inspection of its anal region (which should never be omitf-ed in infan- tile eczema); and the history of the case will throw considerable light upon this important question. Whether occurring in the adolescent or child, the disease may linger only upon the alge in pustular or squamous forms, or block up the nares with crusts. In infants this enforces respiration with an open mouth, and the grasp of the nipple by the lips is thus inter- rupted either by respiratory acts or cries of agitation. The Schnei- derian membrane participates in the inflammatory process, and pours out its secretion upon the eczematous skin. The membrane when inspected is seen to be either raw and succulent, or in a condition 298 DISEASES OF THE SKIN. analogous to that seen in the pharyngitis sicca of" authors, dry, glazed, aud free from discharge. The nostrils are often thickened in con- sequence of infiltration or fissured, especially at the lines of the nares laterally and interiorly. In severe cases, and when the lips partici- pate in this process, the pouting, swollen, and distorted organs suggest the snoul of the lower animals. Adults as a result frequently suffer from non-parasitic sycosis and furunculosis. Care should be taken to exclude syphilis in making a diagnosis, bearing in mind the fact, that the pustular syphiloderm (which see) frequently selects the furrow on either side of the nares for its evolu- tion. In treating these cases all crusts should be removed, and the parts carefully protected. Picking the nose in children should be pre- vented if needful, by the "strait-jacket." Pencillings with the com- pound tincture of benzoin, iodized phenol, nitrate of silver, and collodion will often prove serviceable. In softening crusts, oil may be freely used. For this purpose the warm carbolized spray of the atomizer answers well, medicated with resorcin which may also be efficiently employed for the relief of the nasal catarrh, often responsible for the disease in adult cases. Unna recommends drainage tubes in such patients, wrapped with lead ointment mull, and, after the softening of the crusts, painting every second day with yellow precipitate ointment. In the same way a weak citrine ointment or white precipitate salve may be used. When the disease extends well up the nares, Neumann employs bougies made by combining two grains (0.138) of zinc oxide with sixteen (1.06) of cocoa butter. Eczema of the Ears. [E. Aurium.J The ears are affected with eczema both in infancy and maturer years, rather more often in women and children, the disease being limited to the whole or part of the organ, or extending backward over the post-auricular region, or downward over the ramus of the superior maxilla. It may be acute, or chronic, and originate in chronic or catarrhal discharges from the external auditory meatus; in exposure to temperature changes, especially when aided by high winds; in frost-bite; in the irritation set up by pediculi and by the auricular limb of the frame of spectacles ; in the toxic effect induced by the hook of cheap ear-rings and dyed bonnet ribbons; in the traumatism of ear-piercing; and in the habit of unnecessarily picking the ear to relieve it of wax or trifling sensations of irritation. The pustular and moist forms are common at the superior, inferior, and posterior boundaries of the pinna, where a linear fissure is apt to form in the line of the angle made by the auricle with the plane of the adjacent integument. The motions impressed upon the ear by handling it, placing the hat on the head and tying hat strings over it, always tend to aggravate the disorder. Long hairs worn over the ears may have a similar effect by the production of friction aud the retention of heat. The lobules are apt to display the erythematous LOCAL VARIETIES OF ECZEMA. 299 and scaly phases of eczema, becoming infiltrated, having a deformed appearance, a lurid red color, and indolent course. The lobules alone of both ears in young women may be similarly affected, and exhibit these phenomena for consecutive years. Often the chronic inflam- mation may lay the foundation for a keloidal growth, an accident of several inflammatory processes in other parts. At other times the entire auricles present a similar appearance, uniformly dark red, infiltrated, alternately weeping and scaling, and projecting to a noticeable extent from the side of the head in consequence of their increase in bulk. The itching is usually more annoying than severe, being accompanied by a characteristic sensation of tenseness and ful- ness of the part. Like the eczema which occurs at the other mucous outlets of the body, the affection in these parts is particularly obstinate when it assumes a chronic form. Symmetry to the extent of involving both ears, though commonly to a different degree in each, is rather the rule than the exception; and is doubtless due to the simultaneous operation of effective causes. The diagnosis is between erysipelas, seborrhcea (which occasionally occurs in the concha of the auricle), erythema simplex and multi- forme, and dermatitis calorica. The mouth should always be care- fully examined in these cases for sources of trouble. The treatment should be at first soothing and protective by the zinc salve or diachylon ointment ; afterward stimulating. A firm bandaging of the ears to the head may be required to support the parts, to prevent irregular pressure (head upon the pillow), and to secure contact with external medicaments. In chronic cases, stimu- lant applications are often well tolerated, and the tarry ointments here play an important part. Treatment appropriate to the otitis externa may be required. Bulkley recommends a tannin ointment, one drachm (4.) to the ounce (32.), deeply and thoroughly passed into the meatus on a camel's-hair brush. French authors generally recommend small tampons smeared with an ointment and left in the canal. Burnett employs two drachms (8.) of the oil of tar to one ounce (32.) of alcohol. Great benefit is derived from pencilling the indolent surfaces with solutions of the silver nitrate. The intractable forms almost invariably affect adults, and in them there is usually a history of improvement under treatment, then, in men, exposure, as, for example, to the wind, or, in women, excessive dancing, etc., and subsequent aggravation. Eczema of the Lids. [E. Palpebrarum.] Here the free edge of the lid, or the skin over the orbital margin of the tarsal cartilage, may be chiefly affected ; and either, both in children and adults. When the free edge of the lid is involved, there is a species of sycosis non-parasitica present, the hair- follicles becoming inflamed and furnishing a purulent discharge which may agglutinate the lids. The latter are thickened and swollen, become the seat of a moderate itching, are picked rather than scratched, and 300 DISEASES OF THE SKIN. exhibit minute crusts between, or glued to, the hairs. The disorder is often accompanied by a seborrhoea of the Meibomian follicles, and is described by oculists under the designation of "blepharitis" and "tinea tarsi." Inasmuch as the facial expression is quite charac- teristic when the lids are thus involved, the patients exhibiting this form of eczema are usually set down as "scrofulous," though it occurs in mauy individuals with no other sign of struma, and eczema surely is not such a sign. Fissures occasionally form at the commissure of the lids. The disorder may complicate eczema of the other parts of the face. In the erythematous eczema faciei of adults, there is usually swelling 1 with puffiness, especially of the lower lid. The conjunctiva may, or may not, be implicated. A chronic granular condition of the lids is not noted as frequently as might be suggested by a priori reasoning. The edges of the lid should be carefully cleansed with a weak alkaliue solution and soft camel's-hair brush whenever the lid itself is involved, then as carefully dried and auointed with cold cream. In acute cases the closed lids may be frequently bathed with warm alkaline solutions; and strips of soft lint, soaked in the same material, or a very dilute glycerine or carbolic acid solution, may be laid over the closed lids for as long periods during the day as they are com- fortably tolerated. In chronic cases the red oxide of mercury oint- ment, one grain to ten (0.06G-0.66) to the ounce (32.), has always been held in high esteem. Oculists, in the treatment of this affec- tion, are fond of using an ointment of the yellow sulphuret of mercury. In place of these, the unguentum hydrargyri nitratis, one part to six of cold cream, may be applied. Epilation of the eye- lashes may rarely be necessary. Pencillings with solutions of the nitrate of silver in various strengths are also useful in chronic cases, but these must be carefully confined to the lids, and not suffered to come into contact with the conjunctiva. Excessive use of the eyes must be prohibited. In the diagnosis, care must be taken to exclude syphilis, lupus, and pediculi. The author has seen but one instance of piedra of the eye-lashes. Instead of the ordinary nits of the lash, there were in this case jet-black, small pin- head sized masses of ivory-like hard- ness attached to the hairs. Eczema of the Beard. [E. Barbae.] Eczema may involve the region of the beard only, or may spread to such parts from those in the vicinage, or may, finally, extend from the beard to other parts of the face. The first is common, and fur- nishes, perhaps, the best type of the disease; the second is also common, but usually subordinate in importance to other trouble of the facial region. The last is decidedly the rarest. It is indeed a matter of surprise that an eczema should, as it often does, endure for years, limited exclusively to the region of the beard and never for once transgress these limits. LOCAL VARIETIES OF ECZEMA. 301 This fact furnishes a convincing argument in favor of the local origin and of the frequency of local sources of aggravation of eczema. Rarely will one see a picture more suggestive to the uneducated eye of " scrofula " or " humors of the blood " than the face of a middle- aged man, with long-standing eczema of the entire region covered by the beard. The hairs are thinned, and fail to hide completely the reddened surface beneath, covered here and there with pustules or floors of broken pustules, dried inflammatory products, yellowish and greenish scales and crusts. Beneath the crust the surface is smooth, not lumpy, as in parasitic sycosis. The hair-follicles are not solely involved, as in the non-parasitic form of sycosis, but evidently they and also the integument between them. In recent eczema the hairs are not loosened in their follicles, but in chronic cases such loosening does unquestionably occur, and there is a true defluvium capillitii. The disorder is evidently one primarily involving the skin of the region of the beard, and secondarily the hairs, extending smoothly over that surface, as smoothly as an eczema on the cheek of a woman. There is commonly a certain degree of symmetry, to the extent at least of involving the beard in different degrees on both cheeks at once, or the chin on both sides; often the symmetry is perfect. This is rare in the parasitic affection of the same part. The disease is accompanied by itching, rarely as severe as upon the smooth parts of the face, is particularly obstinate, and extremely dis- figuring. When extending into the region of the beard from other parts, it is usually associated with eczema of the ears. When limited to the region of the moustache, it may be connected with an eczema of the nares and a chronic nasal catarrh. The explanation of the obstinacy of eczema of the region of the beard is to be found in the hairs which cover it. Whether the latter be long or short, feeble or strong, each during the twenty-four hours acts to a certain extent as a lever in motion upon the portion of the integument in which it is implanted. In conditions of health, the skin tolerates well this motion ; in disease it becomes a positive source of trouble. Multiply by thousands the impression produced upon the healthy skin when a single hair or group of hairs is moved by a strong current of air, by the fingers, by a brush, or by any other externally operating cause, and some idea may be had of the extent to which this force may become effective. But the best evidence of the fact is to be found in the results which follow the removal of the beard. Clipping short the hairs of the face will not answer, though generally preferred by the patient as exposing to a less degree the unsightly surface beneath. Nothing short of shaving, and continual shaving every second day, will effect the desired result in chronic cases. As soon as the disease is reduced practically to an eczema of the non-hairy parts, it improves, in proportion to its distance from the mucous outlets of the body. When limited to the bearded cheeks, the most obstinate cases may be in the course of a single month robbed of one-half of their unsightliness. It may be needful to employ the usual methods — oil, hot water, and soap — to remove the 302 DISEASES OF THE SKIN. crusts before the first shaving, and any imprisoned pus should be evacuated. The patient should he encouraged by reminding him that usually it is but the first step which costs; each succeeding re- moval of the beard is accomplished with greater comfort to himself physically and mentally. After each shaving, the skin should be bathed in water as hot as tolerable, and, if at night, a lotion may be used, or an ointment, or the latter after the former. The salves most useful for this purpose are sulphur, one drachm to the ounce (4. to 32.); the diachylon ointment with salicylic acid, five to ten grains to the ounce (0.33-0.66 to 32.), and the zinc ointment. Best of all, however, is the dusting powder; and, as soon as practicable, the patient should limit himself to this application. The shaving should be continued for months after the disease is at an end. It is indeed surprising to note in such cases how quickly the "scrofulous" look disappears, and the evidences of a " humor of the blood" are no longer evident in the face. The longer the limitation of the disease to the region of the beard, the more brilliant, as a rule, is the result. It is not often necessary to resort to the tarry applications in this form of the affec- tion. When complicated by eczema of the post- or infra-auricular region, stalactite-shaped crusts depending from the infiltrated lobule in consequence of the unintermittent drip of serum from above, eczema of the region of the adjacent whisker is less readily managed. Flat epitheliomata of the bearded cheek are not to be confounded with eczema barbae. The points of difference have been previously noted. It should be remembered also that the age of the patient, the career of the disease, the possible eversion of the neighboring lid, or agglutination of the adjacent lobe of the ear, distinctly high eleva- tion, or ulceration of tissue, absence of itching, and distinct localiza- tion of the disease are all characteristic of this form of carcinoma. Eczema of the Genital Organs. [E. Genitalium.] Here the disease is remarkable for the severity of the subjective sensations it occasions ; for its tendency to persistence, recrudescence, and nocturnal exacerbation, and for the liability to the production of the sexual orgasm by the act of scratching. In men the surface most often involved is the anterior, posterior, or lateral faces of the scrotum where they meet the thigh, though the surface of the penis, as also that of the pubes and perineum, may be involved. In women, the labia majora, more rarely the labia minora and vestibule of the vagina are affected, with occasional extension of the disease to the same contiguous parts as in men. Eczema thus located is, as a French writer has well said, "a dry disease in a moist locality." Vesicular and pustular forms are much rarer than the erythematous, the papular, the papulo-squamous, and the erythemato-squamous. In women, the moister forms are more frequent, doubtless because of the wider mucous outlet, and the more extensive mucous tract in the vicinage. The labia are then heightened in color, oedematous, agglutinated by crusts, and often torn viciously LOCAL VAEIETIES OF ECZEMA. 303 by the finger-nails. Blood-crusted excoriations are seen in most severe cases. An eczema intertrigo at the labio-femoral angle is common. Over the whole may be poured the secretions from uterus or vagina, normal or pathologically altered. The disease is, however, sufficiently common after the menopause, when there is physiological atrophy of the uterus. The typical disease in men is recognized in the thickened, reddened, perhaps slightly scaling integument of the scrotum, which may also be fissured, excoriated by the nails, or covered by blood- crusts. Torn papules, often closely packed together, may be seen with a peculiarly lurid, even purplish hue. In exaggerated cases the infiltration is so great as to deform the parts, increasing the thickness of the scrotal integument to many times its normal dimensions, pro- ducing thus an elephantiasic appearance. In eczema of the penis the prominent symptoms are also oedema, itching, and redness, with slight scaliness. In both sexes, as before stated, the attempts to relieve the itching are often as severe and prolonged as they are ingenious. Commonly no relief is obtained till a serous sweating or weeping of the thickened tissues is induced by the friction. Inasmuch as the latter is in severe cases frequently repeated, the physical dangers are obvious. Apart from this, however, the disorder has a marked tendency to disturb the mental tone and the general health. Shame deters many from seeking speedy relief, so that cases of long standing are those more commonly registered by the physician. Though entirely unconnected with venereal disease of every kind, there is, for the many, a special dread of an eczema of these parts, precisely because of its location. With sleep disturbed, the mind agitated, and the nervous system teased by an intolerable pruritus, one can scarcely wonder at the eloquence with which many patients describe their sufferings. It is a disease of middle life and advanced years. It is rare to see a well-marked, obstinate case in a child. The causes, exciting and aggravating, of eczema of the genital region are to be sought in heat, moisture, and friction. These primary factors are favored — first, by the effect of gravity, the organs in question being situated, when the body is in the erect position, at the inferior apex of the double cone forming the trunk, and being thus subject to the force of gravity ; second, by the arrangement of the clothing in both sexes, by which heat and friction effects are heightened ; third, by uncleanliness, the secretions and discharges from the adjacent mucous tracts being suffered to accumulate upon the person ; fourth, by a long list of sexual errors which operate by obstructing what may well be termed the sexual ebb — that is, the natural reflux by which each periodical physiological congestion of these organs is by a natural process relieved. That the skin of these organs participates in such periodical congestion is a fact demon- strable to the eye. The abundant supply of bloodvessels, lymph- 30-1 DISEASES OF THE SKIN. atics, and nerves to tlie parts, furnishes all necessary elements for the explanation of the formidable series of symptoms often displayed in eczema genitalium. , In many eczemas of the surface, especially of the genital organ-, the urine will be found to contain albumen or sugar, and these conditions have been supposed to lie at the root of the eczema. One author has even prescribed a diet for the eczematous patient with saccharine urine The explanation of the phenomenon is, however, sufficiently simple. It is the eczema which causes the elimination of the sugar or albumen, and not the reverse. Sugar and albumen are known to be producible in urine by external irritants, and, among the latter, by cutaneous diseases. Merely varnishing a portion of the skin has been followed by these effects. If patients with saccharine urine and severe genital eczema can be kept in bed, in the recumbent position, for a few days, while any soothing application productive of comfort is continuously applied to the tender and excoriated surface, the sugar will often rapidly disappear from the fluid excreted from the kidneys. These renal symptoms are in part reflex, resulting from the extraordinary irritation of the nerves distributed to the involved surfaces. The so-called diabetidcs genitaks of French authors may include some genital eczemas occurring in diabetic patients. But it is certain that many cases of very extensive and severe eczemas of the genital region in both sexes occur in patients in wdiom the most careful and repeated examination of the urine fails to reveal traces of sugar. The practitioner is urged never to omit such examination in his treatment of a typical case. The treatment is to be conducted on the general principles hereto- fore enuuciated. Sponging of the genital region with alkaline water as hot as can be well tolerated, followed by the blander oils and ointments at night, and the use of anti-pruritic dusting powders in the daytime, must not be omitted. In eczema of the scrotum, the suspender lined with lint which is wet with a lotion, smeared with an ointment, or thoroughly covered with a powder, can be usually employed to good advantage. The habit of scratching must be broken up at all hazards. In chronic cases, the treatment by soft soap and diachylon ointment will be found useful. Caustics, solu- tions of the mercuric bichloride and other mercurials, carbolic acid, and especially the tarry compounds, are often necessary. Finny, of Dublin, uses the following formulae, which are useful in allaying the irritation : R. Liniment, calcis f<§iv; 128 Liniment, calcis f£iv Belladonn. extr. gr. xij Zinci oxid. oij Glycerini f3ij Aq. calcis f3iv 128 M. Lotion to be applied at night after bathing the parts in hot water." LOCAL VARIETIES OF ECZEMA. 305 . Lin. calcis. fgiv; 128 Acid, hydrocyanic, (dil.) m ; 4 Liq. plumbi subacetat. fsij ; 8 Glycerin. m ; 8 Aq. ros. ad. f^vnj ; 256 M. Sig. " Cream, for application on strips of old linen. Exceedingly obstinate eczema of the pubic region is benefited by shaving and subsequent appropriate treatment. When complicated by intertrigo, the latter condition requires special relief by the inter- position of soft lint spread with an ointment. The diagnosis is between ringworm of the genitals, acne, pruritus, pediculosis, the venereal disorders, aud herpes progenitalis. The first named may occur alone, or induce, or be grafted upon the eczema. It will be recognized by the discovery of the trichophyton, and is clinically distinguished by the crescentic edge of the spreading patch, with its convex border looking away from the genital centre. The "follicular vulvitis" of gynecoolgical authors is a genital acne, and manifestly limited to the glands and peri-glandular tissues. The same is true of bromine and iodine acne, which may be developed in the same situation in both sexes. Genital pruritus may beget an eczema by scratching, but is accompauied by no proper skin lesion. The pubic louse is visible to the eye, as are also its reddish excreta and nits. The ulcers and sclerosis of the chancroid and primary syphilis are not accompanied by pruritus, and though occasionally multiple, never exhibit diffuse patches of disease. The syphilo- dermata are recognizable by their characteristic features, and by the history of an infectious disease. In herpes progenitalis there are pre- cedent burning, smarting, or neuralgic sensations, the occurrence of vesicles or groups of vesicles (lesions rare in eczema of the genitals), and frequent limitation of the disorder to the mucous surfaces or the rnu co-cutaneous lip by which such surfaces are bounded. In eczema such boundaries are usually respected, and the disease is much more strictly cutaneous. Eczema of the Anus and Anal Region [E. Ani] in its etiology and characteristics is closely allied to the same disease in the genital region. The presence of ascarides and haemorrhoids occasionally induces or aggravates the disorder ; though this is rarer than is commonly supposed, since multitudes of men and women who suffer from piles never complain of eczema. The eczema may occur in erythematous, squamous, or papular form, in the order named ; thus exhibiting here, as in the genitals, " a dry disease in a moist locality." The redness, infiltration, and itching, may be limited to the verge of the anus, radiate from the latter in stellate lines, creep upward between the nates in the cleft, sweep forward over the perineum to the genital region, or extend laterally with intermediate intertrigo over the inner face of each thigh. Rarely the buttocks are covered with the same lesions. 20 30*3 DISEASES OF THE SKIN. The disease is common in infancy, where want of care in the removal of the napkin is a fertile source of mischief; and also in middle life and advanced years, when it becomes particularly intract- able. The itching is intense in the latter class, with frequent noc- turnal exacerbation. Unfortunately the scratching is often reflex, and practised during the unconsciousness of sleep, from which the patient is often roused by his or her manipulations. Pollutions fully recognized, or occurring during profound sleep, or, more usually, in states of semi-consciousness, complicate certain cases; defecation becomes painful. The harassed nervous system of the sufferer is often in a deplorably wretched condition. In cases of long standing the usual congested, thickened, infiltrated, aud almost elephantiasic appearance is presented, with exaggeration of the natural furrows and occasional fissures. The part may simulate in aspect the formid- able conditions discovered in passive pederasty. Excoriations are common around the anal verge. The diagnosis is that of eczema of the genital regiou. In the treatment of these cases the use of very hot water by sponging, and the subsequent application of ointments, has yielded the best results. In the case of infants the dusting powders and blander ointments are alone to be employed ; in adults, especially in chronic cases, the tarry applications are especially valuable. Here the tincture of tar may be freely painted over the surface, or one of the tarry ointments, such as the Wilkinson salve, of sufficient firm- ness to retain its form as an unguent when subjected to the heat of the part. Caustics are useful when there are fissures. Corrosive sublimate, one-half to one-quarter of a grain (0.033-0.016) to four ounces (128.) of the milk of almonds; Squire's glycerole of the plumbic subacetate, half a drachm (2.) in two ounces (64.) of glycerine and water, or, as a substitute for the latter, the soft soap and dia- chylon plaster, are here of special service. Van Harlingen recom- mends almond oil containing twenty per cent, of carbolic acid. When defecation is painful the stools should be semi-liquid in order to insure non-aggravation of the local disorder ; not, it need scarcely be remarked, with a view to eliminating any materies morbi by purga- tion. Small tampons of cotton may be smeared with an emollient ointment, and gently inserted for a short distance within the anus. Kaposi recommends butter of cocoa suppositories, containing zinc oxide with belladonna or opium. When complicated by true fissure of the anus the sphincter ani must be stretched, divided, or dilated with medicated bougies. Besnier recommends the use of a clyster after each bowel movement, the fluid being retained for but a short time. At night, a cataplasm is applied. The parts are frequently washed with tepid water, and the anal tampons are smeared with cocaine. During the day, the oxide of zinc salve, thirty grains (2.-32.) to the ounce of vaseline, is applied, and the parts are also thoroughly sprinkled with equal parts of the zinc oxide and subnitrate of bismuth in fine powder. Vau Harlingeu suggests after the use of the hot bath, with the LOCAL VARIETIES OF ECZEMA. 307 addition of starch and glycerine, an ointment composed of one part of cod-liver oil to two parts of suet. Veiel prefers the cautious use of chrysarobin to tar, employing the latter either in the form of spirits or as a tar diachylon, one part to twenty, gradually increased in strength. Carbolic acid and glycerine, a few drachms of each to the pint of elder-flower water or almond emulsion, are specially indi- cated in fleshy women when the disorder, as is often the case, is com- plicated with intertrigo. Eczema of the Nipple and Breast of Women [E. Mammae] is common in nursing women from either the irritation produced by the mouth of the infant, or, more commonly, in consequence of a galactorrhoea. Eczema intertrigo is common below and between the breasts. The eczema here is vesicular, erythematous, or squamous in form, with fissures of the apex, side, or base of the nipple. The serous ooze from the infiltrated areas dries as usual into light-colored crusts. There are the characteristic burning and itching. The disease may occur on one or both breasts, and, especially with a galactorrhoea in summer, may spread extensively, covering both breasts, the surface of the belly, and the intermammary region. The circumscribed forms occur also in pregnant or unmarried women, and are to be distinguished from scabies, which in women is apt to occur upon the breast. u Paget' s Disease of the Nipple," or "malignant papillary derma- titis," the so-called eczema of the nipple and cancer of the breast, is designated by Thin 1 as a destructive or malignant papillary der- matitis. The mammary tumors here formed are found to originate in the epithelial lining of the lactiferous ducts, the elements of which undergo, at an early period of the disease, a cancerous transforma- tion. Clinically, there is usually observed in such cases a sunken nipple, its site occupied by a bright red or livid infiltrated patch of distinct outline, differing thus from the irregular definition of the contour of the eczematous area. In all cases of subcutaneous tumor or coincident axillary adenopathy, the physician should be especially careful in the matter of prognosis. The treatment is in general that described above. In severe cases with galactorrhoea, nothing short of weaning the child and a cessa- tion of all demands upon the breast will insure relief. Every effort should be made in milder cases to avoid this dernier ressort. At first, scrupulous care; pencillings of fissures with a crayon of silver nitrate or the tincture of myrrh; gentle anointings with emollient zinc, thymol, or carbolic acid ointments, which should be carefully washed off before the child is put to the breast; and, finally, dusting powders, with soft lint retained between and beneath the breasts, are measures to be tried. Later, the sublimate solutions, diachylon oint- ment or naphthol, two per cent, in alcohol, may be employed. Veiel 1 London Lancet, Amer. ed., p. 533, June, 1881. 308 DISEASES OF THE SKIN. recommends the application to all fissured nipples of Lister's borax salve : R. Acid, boracic. subtil, pulv. I -_- Cerse alb. j ° Paraffin. ) -- _. 01. amygdal. j ME. Fournier recommends a breast-plate of caoutchouc. When limited to the nipple and areola in nursing women, the glass aud rubber apparatus sold in the shops may be tried in the hope of saving the nipple from the mouth contacts in nursing. Sometimes they answer admirably; often they fail utterly. Paget's disease of the nipple should be treated as a carcinoma, and may eventually require removal of the breast. Eczema of the Umbilicus. [E. Umbilici.] This local variety of the disease is briefly described in the chapter devoted to seborrhea. In most cases it is either induced or aggra- vated by a local seborrhcea fluida, which gives origin to the peculiarly nauseating odor characterizing the disease. Generally a reddish and infiltrated, more or less annular patch surrounds the umbilical depression, which may be filled with crusts. Syphilodermata, pedi- culosis, and scabies in womeu are to be carefully excluded in -the diagnosis. The liquor sodre chlorinatse, carbolic acid solutions, and, in chronic cases, iodized phenol will be required in its management. Care should be taken that the dressing of the navel in the newly born infant, the improperly adjusted apparatus for retention of an umbilical hernia, and the corsets or "uterine supporters" of women, do not occasion or aggravate the disease. Anderson reports that in typical cases, especially of those affected with scabies, the navel is swollen and projects in the form of a small tumor. Eczema of the Superior and Inferior Extremities. [E. Membrorum. E. Crurale.] The flexor surfaces of the extremities, especially in the vicinity of the joints, are particularly prone to exhibit symptoms of the disease. With these should be properly included the axillary and inguinal spaces. In all such localities the alternate tension and relaxation of the integument serve when the limbs are in motion, to increase the pruritus, aud, correspondingly, to aggravate the disease. Often a certain degree of symmetry can be perceived, the two popliteal spaces, for example, being simultaneously affected, though each to a different degree. The parts most favorable for the complications of intertrigo are those nearer the trunk where the moisture and heat are greater, as the groins and axilla?, while the elbow and popliteal spaces are more frequently dry, exhibiting papulo-squamous ridges in lines at LOCAL VARIETIES OP ECZEMA. 309 right angles to the axes of the limbs, with hypersemic patches on either side. Upon the legs, where the force of gravity is more potent than in other parts of the body, exaggerated forms of eczema are found complicated with varicose veins and oedema, with dense infiltrations and indurations. In ancient cases the frequent elephantiasic aspect is significant, one limb being by several inches larger in circumfer- ence than its fellow, covered from knee to ankle with enormous patches of eczema rubra m of an intensely angry appearance, moist and crust covered ; or dry, glazed, and of a lurid reddish hue ; or dry, horny, and ridged with irregular projections surmounted by scales resembling the rough bark of a tree ; or, again, with or without oedema, tense, inelastic, seamed with scars of old varicose ulcers, and deeply and irregularly pigmented, a condition with great difficulty distinguished from syphilitic ulceration of the same region. At its onset, eczema of these parts may assume any one of its known forms. In infants with long clothing, where the lower extremities are sub- jected to a higher temperature than in adults, the vesicular and pustular forms are common. The exceedingly obstinate forms of eczema of the legs, especially those complicated with varicose veins, are, of course, those encountered in middle life and advanced years. The diagnosis is, in general, to be established by considering the points heretofore discussed. The chief difficulty lies in distinguish- ing the eczema associated with ancient varicose cicatrices of the leg, from syphilitic scars of the same locality which have resulted from degenerating tubercular syphilodermata or gumtnata. In some cases when no distinct history can be obtained, there will be a necessary doubt, as the force of gravity upon the vessels, even without vari- cosities, produces certain common features notably deep pigmenta- tion in both classes of cases. In women, the sexual history is all- important, including the order of abortions, miscarriages, and viable infants. In both sexes, the discovery of other lesions, and especially of characteristic cicatrices elsewhere, must be attempted. It will be remembered that the syphilitic ulcer tends to the shape of a circle or segment of a circle, and though occasionally existing as the sole lesion upon one leg, it is frequently multiple, or may involve both extremities, the pigmentation in old cases occurring chiefly at the periphery of the scar. Very extensive pigmentation about ancient cicatrices, especially disposed between irregularly defined scars, is truer of eczematous forms, as the pigmentation due to syphilis, though long-lived, is yet the more ephemeral. With periosteal nodes the diagnosis is clearer. The treatment of eczema of the extremities does not differ from that described above, except as regards the indications to be met relative to support of the parts, thus counteracting the effect of gravity. Excellent results are here obtained by the use of the pure rubber bandage, applied immediately next the skin, especially in cases com- plicated by oedema, ulceration, and venous varicosity. The method of applying the well-known Martin bandage has been made generally 810 DISEASES OF THE SKIN. familiar to the profession ; and for details respecting its availability in eczema of the leg, the reader is referred to the essay on Eczema and its Management, by Dr. Bulkier, of New York, 1 who is enthusi- astic in its praises. Such treatment, however, deserves only subordinate rank in com- parison with the essential rest of the affected limb in the horizontal position. With a grave eczema of the lower extremity, such rest should be enforced ; and patients whose limbs have proved rebellious under the rubber (for such there are) may thus be relieved. The local applications to be made meanwhile are those adapted to the particular features in each case present. To a less degree, the same may be said of the arms. In these localities, it is rarely necessary to resort to elastic pressure. In all cases, however, a neatly applied bandage over the dressings will add the effect of pressure and support, and generally contribute to the comfort of the patient. A favorite dressing, in dry, papular, erythem- atous, and squamous patches of the disease, is applied as follows : The parts are first bathed with hot alkaline water for several minutes till the itching is relieved, and then carefully and thoroughly dried. The patch is then completely covered with a dusting powder, which, according to the indications of the case, is either emollient, astringent, or stimulating. Finely powdered tannin with French chalk ; or even pure calomel ; or bismuth, zinc, and starch, may be thus used. Over the whole, strips of Maw's surgical plaster are alternately and neatly superimposed in the manner some years ago recommended by Baynton. A snugly fitting rubber bandage encompasses the whole. The dress- ing is left in situ as long as it is comfortable, often for two or three days, when it can be removed. In properly selected cases, the itching is relieved, the infiltration reduced, and the patch soon loses its hyperaemic aspect. Occasionally no other treatment will be required. Nor should it be forgotten that with care and patience, the starch bandage of the leg, the plaster-of- Paris dressing over folds of Canton flannel arranged so that it may be removed at pleasure in the manner in which it is used by some surgeons in the treatment of diseases of the joints, these and other immovable dressings may accomplish even more in obstinate cases than elastic apparatus. For the exudative phases of eczema of the leg, the forms so often seen here of eczema rubrum, the gelatine medicated plaster meets the indications well. Morrow makes this by adding two hundred and fifty parts of glycerine to one thousand of gelatine, and two thousand of water medicated with ten per cent, of the oxide of zinc and one per cent, of carbolic acid. It may be left in situ several days and furnishes a smooth, elastic, and uniform coating. Eczema of the Hands and Feet. [E. Manuum. E. Pedum.] No more striking illustration of the significance of the etiology of eczema can be adduced than that to be discovered in the hands. By i G. P. Putnam's Sons, N. Y., 1881. LOCAL VARIETIES OF ECZEMA. 311 these organs man toils to earn his bread, and the eczema they display- is their protest against the rude contacts which are thus necessitated. Unfortunately, in too many of such patients the imperative necessity of bread-winning forbids consent to the best method of relief, viz., temporary disuse of these organs. The feet may or may not be similarly attacked, and for similar reasons. All forms of eczema are here seen, erythematous, vesicular, papular, pustular, and squamous, involving the entire surface, or limited to the wrists, ankles, inter- digital spaces, palmar or plantar surfaces, or one or more digits on either face. The motions of the part are so free, that fissures are -common and often exceedingly painful. The itching may be severe, and the parts of one hand or foot extensively rubbed, torn, or abraded by the other. Vesicles are more frequently encountered upon the more delicate portions of the skin, as over the dorsum and interdigital spaces, while in the denser palm and sole they are represented by sub-epidermic points from which by puncture a clear serous or cloudy fluid may be evacuated. Usually, however, in the regions last named, there is a dry, dead-whitish or hypersemic, uniformly indu- rated and thickened integument, which may be fissured or produce such a tense inelasticity of the surface that the fingers are semi-flexed into the palm, or, much more rarely, the toes rendered considerably less extensible. Circumscribed patches of eczema, with fairly defined outline, red- dish in color beneath crust or scale, subacute in course, and accom- panied by paroxysmal itching, are of common occurrence on the dorsum, and also in the palm or sole. In the latter situation, they may be traversed by one or more painful fissures, the same being true of the dorsum of the fingers and toes. Upon the back of the hand, these circumscribed patches are apt to assume an indolent course, improving temporarily under appropriate treatment, and becoming aggravated by every exposure to the causes by which they were first induced. The long list of etiological factors which may here be efficient can scarcely be enumerated. Several have already been considered in discussing the causes of eczema in general. The influence of all articles handled in the trades, occupations, and professions of life, as well as of the action of toxicants and dyes, must be remembered. Thus printers, bakers, aud masons suffer in the hands ; and the wearer of dyed stockings, and coarse, ill-fitting shoes and boots in the feet. Because needle-women are often overworked, nervous, pale, and thin, their digital eczema, really due to the implements and stuifs they handle, has been erroneously attributed to their general condi- tion. The poor seamstress starving for sunlight, nutritious food, and open air exercise, may return to her weary routine with her eczema quite relieved. In the matter of diagnosis, it should be remembered that an eczema of the hands may be induced by the Rhus toxicodendron, the disease being then liable to a transfer by contact from the hands to the face and genital or mammary region. Scabies of the same region is in 312 DISEASES OF THE SKIN. this country much rarer than eczema manuum. In scabies the vesi- cles are firmer, more often unruptured, fewer, more isolated, more intermingled with crusts, pustules, and even bullae, which latter are rare in eczema. The discovery of the parasite and a history of con- tagion will aid in removing doubt. Abundance of pustular lesions in young subjects is, however, according to Hebra, most commonly produced by the acarus. The characteristic burrow made by the parasite, an irregularly curved, thread-like, beaded, or dotted line, about one-quarter of an inch in length, either running at a tangent from the unruptured vesicle or across its summit, is proof of scabies only second in value to the discovery of the parasites themselves. The occurrence of the erup- tion elsewhere on the body is also to be expected in the last named, disease, with respect to which it should be remembered that the burrow may not be visible, and may be wanting when the parasites are present. Psoriasis of the palms and soles is always accom- panied by the presence of patches in other parts of the body, whose typical characters should throw light on the local disorder. They are dry, non-discharging lesions, very rarely fissured as is the eczema of the hands, have a distinct contour, and are covered with more abundant and more lustrous scales. The scaling syphilodermata of the palms and soles occur early and late in the disease, and usually after a distinct history of infection. The lesions in syphilis are usually isolated, firm, deep infiltrations, circular in outline, with" very sharp definition, and may be covered by dry, adherent, dirty- white scales, beneath which the brown and red hue of the persistent lesion can be discovered. Superficial or deep circular excavations of tissue are visible, single or multiple, with punched or ragged edges. The eruption is rarely, like eczema, accompanied by itching or dis- charge, but painful fissures may form. It occasionally affects the dorsum of the hand or foot, favorite sites of eczema manuum, but almost invariably has in such cases swept thither from the palm or from the sole. In both syphilis and eczema of the hand, the right organ in right- handed laborers is invariably most involved, even when there is apparent symmetry of distribution of lesions. The treatment demands, first, rest for the organs, and a simulta- neous discontinuance of the exciting cause. In the trades, the result of the latter can be usually demonstrated by the patient, who notices the difference between the condition of the skin on Monday morning after a Sunday's rest, and that which was distressing on the precediug Saturday night. When practicable, protection during labor must be secured by the use of gloves, finger-cots, rubber-stalls, or bandages, neatly applied and retaining dressings to the part of the hand or foot which is the seat of the disease. For circumscribed, non-discharging patches on the dorsum of the hand or foot, the dressing described in connection with eczema of the extremities may be applied. When the nature of the labor performed is such as to render it impossible to secure protection of the hands or fingers in this way, something may be LOCAL VARIETIES OF ECZEMA. 318 accomplished in a few cases by directing that the hand be frequently dipped into a protective solution, or powdered during the hours of labor. Thus printers may dust their fingers with lycopodium, and those compelled to retain their hands in irritating solutions, can anoint these organs occasionally with an oily or fatty substance. Generally it may be said that an eczema of the hands is too fre- quently washed, and the ill effects of such practice are made evident not only in laundresses, but in mothers who personally attend to the dressing of young infants. The local applications made to each case may be those described above as suitable to each stage of the disease. When extensively involved, the hand should be carefully dressed, each finger being separately wrapped in soft linen rags smeared with camphorated or carbolized, pure or diluted, linimentum calcis in acute cases ; or, later, with a bismuth, zinc, or mercurial ointment. The tarry compounds are here very useful ; and the caustics more than ever needful when there are fissures. Protective flexile collo- dion plays an admirable part about the nails where irritable seams- and fissures form with overhanging fringes of a torn and ragged epidermis, bordered with red. In all painful eczemas of this region the immersion, particularly at night, of the entire hand or foot in hot water should be practised, followed by careful drying and anointing with a salve or an oleaginous semi-liquid. This should be spread thickly upon pieces of muslin, wrapped neatly about each finger separately, and other affected parts, and the whole covered with waxed paper. The Lister protective gauze, or a pair of rather large undyed gloves which can be readily drawn over the whole, may be substituted for the former. When the epidermis of the palm is greatly thickened, it should be shampooed at night with green soap, pure or in spirit, by the aid of hot water, followed by a salve containing either the white precipitate,. ten to twenty grains to the ounce (0.66-1.33 to 32.), or the Wilkinson tar salve. For intractable cases, caustic potash, in the strength of twenty to thirty per cent, solutions, can be mopped well into the thickened palm, and followed by a salve-application. Van Harlingen suggests : R . Hydrarg. ammoniat. J}j ; 1 2 10 24 Hydrarg. ammoniat. 9j; Adipis 3ss; Sevi benzoinat. 9vij ; 01. amygd. dulc. ttlx; Vaselin. ad 5vi ; M. For the fingers and hands, Unna's mull plasters fill very perfectly every requirement. These may be cut into strips, and applied with neatness to every digit. The zinc oxide, tar, and ichthyol mulls are all available for this purpose. Eczema as it Affects the Nails [E. Unguium.] There is nothing characteristic of eczema in its effects upon the nails. These horny plates participate in the diseases which affect 814 DISEASES OF THE SKIN. their matrices, and thus exhibit nutritional changes. There is, there- fore, no eczema of the nail proper, but only an eczema of the digit by which the nail is affected. In well-marked cases, one, several, or all of the nails of either hands or feet may lose their polish, or become rough, punctate, furrowed laterally, and clubbed, or present an appearance suggestive of worm-eaten surfaces. They lose their uniformly smooth attachment beneath, and become tilted on their beds, with marked friability of their tissue. In such cases, an eczem- atous condition of the skin at the margin may be detected, where the usual redness, infiltration, and scaling, with a sensation of itching, point to the nature of the trouble. Rarely the nails are shed. The most misshapen will be succeeded by smooth and natural growths of nail-substance, if the disease of the matrix be completely relieved. The treatment, therefore, is the treatment of the cutaneous disease. Care must be taken to exclude ringworm of the nails, which end can be reached by microscopically examining the scales scraped from the uail-surface. The zinc oxide and tar salves will be found most effective for the larger number of cases. Often the organs may be with advantage protected during the daytime by the combination of gelatine and glycerine described in the management of eczema of the extremities. Eczema of the Tropics (Prickly Heat). [E. Solare. Lichen Tropicus, etc.] Under these titles have been described a number of disorders, some of which are more closely related to the forms of sudamen described in connection with the functional derangements of the sweat appa- ratus, some of which are instances of papular eczema, associated or not with profuse sweating under the influence of high temperatures (solar heat, tropical climates, hard labor in the heated air of engine- rooms, etc.). The disease is aggravated by all external and iuternal sources of irritation, including alcoholic beverages, opiates, flannel garments worn next the skin, undue exertion in a heated medium, fatigue, and obesity. Etiology. — The disease is more common in those subjected to rapid and intense fluctuations in the temperature of the atmosphere than in those long accustomed to a relatively hot climate. It is thus ex- ceedingly common in the northern parts of our own country, where the absence of a regulating Gulf stream ushers the inhabitants sud- denly from the rigors of a severe winter to the prostrating heats of summer. It attacks alike individuals of both sexes and all ages, being often particularly severe in the obese and in infants, whose delicate skins, no less than their bowels, resent sudden and severe thermal changes. It moreover affects equally those who are vigorous and the debilitated. The disease is characterized by the occurrence of pin-point to pin- head sized vesicles, bright-red papules, vesico-papules, or the two as coincident and commingled lesions. They are exceedingly numerous, LOCAL VARIETIES OF ECZEMA. 315 and may in severe cases cover almost the entire so-called non-hairy surface of the body, though they may be much more limited in their diffusion. They are usually acuminate and discrete, though often very thickly set together. They are rapid of occurrence, but may, in consequence of persistence of the cause, be slow to disappear or recur repeatedly. Whether vesicles be or be not present, the affected region is usually bathed in sweat. The eruption is accompanied by characteristic sensations of tingling, pricking, and burning; its lesions, even though generalized, may be most vivid or most dis- tressing about the trunk, axillae, head, neck, or extremities. It may last for but a few days, or be severe for a week or more. It is un- questionably seen in the severest grade among fleshy Europeans, or Americans emigrating to tropical climates who are habitually ingesting alcoholic beverages in excess. The local treatment of prickly heat is, in brief, that of the cor- responding stage of eczema. Unguents are generally to be avoided, as the skin rarely tolerates them, and the same may be said of plas- ters and very cold baths. Baths or lotions, tepid, warm, or moder- ately cool, as the feelings of the patient may decide, to be most grateful, medicated with alkalies, bran, gelatine, or starch, will be found useful. After each, the skin is to be dried, not by rubbing, but by gently pressing dry cloths over the surface, and is then to be thoroughly protected by a free use of one of the dusting powders. When large tracts of the skin are involved, and general baths have been ordered, a package of " corn-starch farina " will often be found sufficiently well suited for such topical employment. Lotions may also be employed, composed of lead, or lead and opium, or the black wash, or alcoholic and ethereal solutions con- taining camphor and glycerine in the proportions given when con- sidering the subject of acute eczema. Modifications of the oleated lime-water are serviceable in severe cases, as, for example : R. Sig, 01. lini fSij; 64 Paraffin. } Sapon. Castil. j aa gij ; 64 01. bergamii ad Oj ;' q. s. Aq. calcis 500 For external use. M. This makes a demulcent creamy solution which often proves exceedingly grateful to the skin ; and to it may be added the zinc oxide or dilute hydrocyanic acid, as may be required. The general treatment of the patient is a matter of importance. The cause must be removed if possible. Withdrawal from the light, heat, and labor of the day ; unstimulating food and drink, unirri- tating apparel, and rest, are of the greatest importance. The saline and acidulated beverages are usually acceptable to the palate, and useful if not drunk too cold. The chief value of Apollinaris water, lemonade, Vichy, and Kissengen, lies not in their action as medica- ments, but as supplying the water demanded by the cutaneous loss through evaporation. 316 DISEASES OF THE SKIN. Prognosis. — The disorder may be trivial and severe, and last but for a few hours, or for as many months. It is usually relieved without difficulty, and often by domestic measures alone. It is most annoying and severe when complicated by the exudative process in other parts of the skin than the sweat-ducts and their immediate vicinage. Prurigo. Lat. prurire, to itch. Prurigo is a chronic, exudative, cutaneous affection, commonly beginning in infancy or early childhood, and continuing through life, characterized by the occurrence on the extensor surfaces of the extremities and also on the trunk, of minute, pale or reddish, millet to hemp-seed sized papules, with extensive infiltration and intolerable pruritus. Symptoms. — In this affection, pin-head to rape-seed sized, firm, whitish or reddish-white papules form, chiefly and primarily upon the extensor faces of the extremities, but from these localities extending gradually over the entire surface of the body. The itching they occasion is of the severest type. The earliest symptoms are usually displayed in the latter portion of the first year of life, in the form of an urticarial rash, which persists and is finally succeeded by typical papules. The latter are minute, often sub-epidermic, and become rapidly covered with blood- stained crusts in consequence of the induced scratching. Then ensues a long train of symptoms, including pustulation, fissures, excoriations, dense infiltrations, crusts formed of exuded serum and dried blood, oedema, diffuse dark-brown pigmentation of the surface in large areas, and consequent adenopathy. Fully developed, the disease presents in general the same physiognomy in different patients of different ages. The lower extremities always exhibit the severest manifestations of the disease, especially the thigh and leg as distin- guished from the foot ; though the trunk, forehead, cheeks, neck, arms, and head may be also involved. The protected surfaces, as of the axilla? and groins, except as regards adenopathy, are free from the disease. The general health of the patient manifestly suffers from the insomnia and nervous agitation induced by the state of the integument. Emaciation, malnutrition, and cachexia are common sequela?. The mental and moral tone of the patient thus harassed from early childhood throughout an entire life is necessarily pro- foundly impaired. Insanity and suicide are reckoned among its remote consequences. Mild and severe forms of the disease are distinguished under the terms Prurigo Mitis and Prurigo Ferox, or Agria. Incessant care, judicious treatment, climatic influences, and the comforts of life commanded by wealth, seem to determine the difference between the two. Etiology. — The disease occurs chiefly in Austria, few cases being recorded elsewhere. A patient was, however, exhibited at the Inter- national Medical Congress in London, whom both Kaposi and H. PRURIGO. 317 Hebra recognized as affected with prurigo. Wigglesworth, Camp- bell, and others, have reported cases in this country. It is needful to remember that the term prurigo is here employed to designate the disease recognized by some authors as the " true prurigo of Hebra." It should never be confounded with pruritus, which, under various usages, may be the title of a mere symptom of a disease. Prurigo is more often encountered in the male sex ; is never contagious ; and never induced by lice ; but, according to Hebra and Kaposi, may be grafted upon an hereditary predisposition. " Scrofula," tuberculosis, malnutrition, "misery," poverty, ansemia, and filth, are held to be severally favorable to its development. Unquestionably the superior resources of the poorest classes in America will long protect them from the incursion of this inveterate malady. While the typical prurigo ferox, as described by the Vienna school of authors, is of such rarity that probably less than a dozen cases have been observed in this country, the opinion is gaining ground that the same disease with milder manifestations (prurigo mitis) is much more common here than has at times been believed. Two patients with severe prurigo treated by Hebra himself, found their way to the author's clinic with unmistakable symptoms of improve- ment after a residence in this country; and almost every expert in America has observed cases of the milder type. Pathology. — Kaposi practically admits that, striking as is the clinical portrait of this disease, its anatomical features are indistin- guishable from severe forms of obstinate papular eczema. The microscope reveals merely an hypertrophy of the various elements of the epidermis and derma, deposits of pigment in the corium, thick- ening of the root-sheaths of the hairs, enlargement of the cutaneous muscular elements (erectores pilorum), and a consequent atrophy of the integument which has long been the seat of the disease. The hairs are thinner, the root-sheaths loosened, and young cells are collected in abundance about the follicles. Schwimmer calls atten- tion in this connection to the fact that many prurigo nodules are pierced with a hair. An spitz believes that the disease is in fact a sensori-motor neurosis without essential lesion. Riehl 1 regards it as a chronic form of urticaria. Morison 2 regards the prurigo papule as formed by an infiltration beginning around the upper plexus of vessels in the corium, which thence spreads to the papillary vessels, enlarging the papilla?, elevating the epidermis, which at an early stage becomes thickened above them. Finally the latter is penetrated, and within its strata a vesicle forms, containing serum, blood, and lymph-cells. The regions of infiltration about the hair-sheaths and sweat-ducts are regarded by him as secondary, and not as an essential part of the process. The color of the papule does not at first differ from that of the skin in the neighborhood, on account of the depth of the slight infiltration by which it is characterized, and for the same reason it can be distinguished by the touch before it becomes visible. i Archiv. f. Derm. u. Syph., 1884. 2 Amer. Joum. of the Med. Sci., 1883. 318 DISEASES OF THE SKIN. Diagnosis. — Remembering the extreme rarity of prurigo in America, it is to be distinguished chiefly from the various forms of papular eczema by the location of its lesions, the course of the disease, the age of the patient when it is first developed, the great extent of the eruption, and the uniform type of its lesions. In prurigo, also, the fingers and toes, flexor aspects of the extremities, and face are more or less -pared. Under treatment eczema commonly yields at least in some portions of the skin while prurigo doe- not. From pruritus, prurigo is readily diagnosticated by its general physiognomy and history; its peculiar pigmentations and infiltrations; and by the special region chiefly affected. But, both diseases may complicate prurigo, especially eczema, which is then ordinarily of artificial origin. In pediculosis corporis, the parasites will usually be found upon the underclothing, while the lesions induced by the nails never form closely packed papules. There is something highly characteristic in the widely separated excoriations, puncta from wounds of the insects, and inflamed papules seen upon louse-bitten patients. In scabies, the characteristic burrows of the parasites will usually be recognized, as also vesicular and pustular lesions. Urticaria can be mistaken for prurigo only in the earliest stage of the last named disease. Treatment. — In Vienna, sulphur, tar, green soap, baths, and fre- quent anointings with oily and fatty substances have occasionally served to ameliorate the severe symptoms of the disease. Mercury, carbolic acid, boric acid, the diachylon, and zinc ointments may also be employed upon different portions of the skin when indicated. The Wilkinson salve, representing a combination of tar, sulphur, and green soap, has proved of special value in many cases. Vle- miuckx's solution (q. v.), followed by hot bathing and corrosive sub- limate baths one drachm (4.) to thirty gallons, has also been recom- mended Internally, arsenic has proved valueless, while carbolic acid has occasionally seemed beneficial. Cod-liver oil and the ferru- ginous tonics with the bitters, will naturally be indicated in many patients suffering from malnutrition. A generous diet and tonic regimen are essential to the management of most cases, the patients afflicted with prurigo being usually found in the most wretched hygienic conditions. Prognosis. — The disease usually persists through life. The most favorable conditions are those where the patient is quite young and surrounded by circumstances which permit of untiring provision for all his needs. Many authors to-day pronounce the disease entirely curable in the early years of life. ACNE. 319 Acne. Gr. axpy, a point. Acne is an inflammatory disease of the sebaceous glands, in which appear usually multiple, and painful, firm, reddish, pin-head to small nut-sized nodules, which may result in suppuration and the formation of cicatrices. Symptoms. — Acne is probably the cutaneous disease of most com- mon occurrence, not excepting eczema. The latter affection occurs upon the face as often as upon other parts of the body, and is yet seen upon the street with far less frequency. Eczema, however, is more distressing in its symptoms, and for that reason physicians are more often consulted for its relief, the disease thus acquiring a statis- tical preponderance. Acne is more tolerable, and therefore more tolerated and less treated, especially among the poor. The disease is characterized in general by the occurrence of several and usually numerous, light red, dull crimson, or violaceous, pin- head to small nut-sized, circumscribed, ill-defined papules, nodules, tubercles, or non-projecting indurations of the skin, often commingled with the lesions of comedo and seborrhoea sicca. They are usually both slightly painful and tender, though upon this point there is a wide range of difference in different individuals, some patients toler- ating with a surprising equanimity the most extensive invasions of the disease. The inflammatory process, which manifestly involves the sebaceous glands and periglandular tissues, may result in suppura- tion of one or several adjacent follicles, as a consequence of which coalescence occurs and pea- to large nut-sized, cutaneous and subcuta- neous abscesses may form. In the larger number of cases, however, the suppuration is limited to the area of the individual nodule, every feature of the entire process being displayed at the same moment in an affected individual. Under circumstances of special aggravation, the disease may occur in acute forms, but it is commonly chronic; and such acute phases are usually accidents of the general process. The disease occurs chiefly upon the face, but is seen also upon the neck, the back and front of the chest, the genitals, and the extremities, the palms and soles alone excepted. It is emphatically a disease of the early puberal epoch in both sexes, though occasionally seen in middle and later life. It usually lasts, when unrelieved, for years,, being during this period subject to occasional exacerbations and remissions ; but commonly spontaneously disappears as the full maturity of the body is attained. In severe cases, it leaves indelible traces of its ravages, in the scars where suppuration has been ex- tensive. It occurs also in very mild and severe forms. The various terms used in the description of the forms of the disease refer chiefly to its external features. Acne Artificialis. Various substances, either applied topically to the skin or ingested,, are capable of producing acneifortn lesions. Among them may be- 320 DISEASES OF THE SKIN. named tar, which may prove such an irritant, whether employed externally or internally, and, far more frequently, the salts of iodine and bromine after ingestion. Tar acne occurs both among workers in that substance, aud in those subjected to its action for the relief of other cutaneous disease. Pin-head to pea-sized reddish-brown papules then form, at the apex of which is perceptible a minute blackish punctum, produced by the lodgement of a minute particle of the medicament in the orifice of a sebaceous follicle. Pustular and fur- uncular lesions are, however, also produced ; and the same is true of bromic and iodic acne. In the latter, Adamkiewicz and others have demonstrated the presence of the drug in the contents of the pustular lesions. Chrysarobin and a number of other medicinal substances are capable of exerting a like effect. Acne Atrophica and Acne Hypertrophica are terms employed to designate merely the lesion-relics of the dis- ease. In the former, there is complete atrophy of the gland-tissue, indicated by a minute sunken pit in the site of the former orifice; in the latter there is, in consequence of the periglandular exudation, a thickening of the tissues about the acini, and a projection from the surface of persistent, pea-sized, and indurated masses. Acne Cachecticorum includes the symptoms encountered in the subjects of struma, scor- butus, marasmus, chloro-ansemia, and tuberculosis. The lesions more often develop on the trunk and extremities than over the face, and are papulo-pustules, pin-head to bean-sized, particularly indolent, and remarkable for their livid, purplish, lurid-red, or violaceous tint. The lesions are rarely indurated; more often they are seen as softish, pus- and blood-containing nodules, sluggish of career, and leaving minute cicatrices. Their features are due entirely to the general cachectic condition of the subjects in whom they occur. Acne Indurata. This is a form of the disease less frequently observed than several others, but one which possesses certain distinct clinical features. In- duration of the base of the acne papule may be noted in many cases of the simple form of the malady ; but in others the glands seem generally to be distinguished as minute, very firm nodules, with no tendency whatever to suppuration. The surface of the skin is often without marked change in color or heat, the individual lesions indeed exhibiting at times an unnaturally whitish aspect. They are felt when the finger is passed over the surface as dense, often conical projections, occasionally painful, and giving to the touch a sensation suggestive of the nutmeg-grater. Comedones may be often dis- tinguished intermingled with the papules. The disease, when well marked, is apt to be extensive, occurring with characteristic expres- ACNE. 321 sion among brunette, hairy male patients well advanced to the twenty- fifth year. It is often generalized over the forehead, cheeks, chin, and the back of the neck. Acne Papulosa. Here the lesions are of a papular type, ranging in size from a millet-seed to a coffee-bean, whitish or reddish in color, and varying in the amount of firm induration at the base. They are evidently due to hyperplasia of the periglandular tissue, and are often com- mingled with pustules, papulo-pustules, and comedones. At the apex is often distinguished the blackish point characteristic of acne punctata, or a minute, greasy, yellowish-white spot, which represents the non-pigmented extremity of an inspissated sebaceous plug. Acne Punctata. In this variety, the acne papule is formed about a comedo. When examined, its apex is discovered exhibiting the characteristic blackish punctum of that hsion. Acne Pustulosa. This is probably the most frequently observed of all the forms of the disease. The lesions, as usual, are apt to be commingled with papules, comedones, and intermediate phases between the functional and exudative disorders of the glands. The pustules may be large or small, containing merely a droplet of pure pus, or, when a true furunculosis ensues, a teaspoonful or more of the same fluid mingled with blood and serum. This may be speedily evacuated artificially or accidentally, be absorbed, or remain for a long period of time in a species of cyst-like loculus, whence it can be finally ex- pressed. In aggravated cases, two or more of these pustulo-furun- cular depots may coalesce, forming nut-sized abscesses, or, not rarely, become united by fistulous tracts, through which there is free com- munication of the fluid contents of two or more chambers. Acne Varioliformis is the term employed, by the French especially, to designate the lesions elsewhere described as molluscum epitheliale, the name being selected in consequence of the resemblance of the latter to the um- bilicated pustules of variola. Acne Vulgaris is a term applied by several authors to the composite eruption which is common to many clinical cases. Here the various lesions described above are associated, usually on the face and over the shoulders, each in several degrees of development, often in conjunc- tion with the scars left by a prior eruption. 21 322 DISEASES OF THE SKIN. Etiology. — The causes of acne are in many cases exceedingly obscure and are probably numerous. It is common to describe the puberal changes in both sexes as a frequent cause of the disease, but one should be slow to regard a physiological crisis as a disease-factor. It can merely be asserted with safety that, with the growth of the hairs in both sexes at the period of puberty, there is an unusual activity of the sebum-producing function, and that this physiological is then the more readily perverted to a pathological activity. Need- less to say that tens of thousands escape acne who survive puberty. The disease, however, is apt to appear first at this time of life, aud, if not improperly treated, to disappear spontaneously when the full maturity of the body is attained. Inasmuch also as there is a close physiological connection between the genital function and organs, and the appendages of the skin, not only in man, but in the lower animals (antlers of the stag, plumage of birds, etc.), it seems reasonable to conclude, a priori, that the dis- turbances of the former may be reflected to the latter. Many facts support such reasoning. The effect of castration upon the male of many animals is displayed in the appendages of the skin. In the same way, perverted sexual instincts and habits, or a poorly regulated sexual hygiene, aud uterine disease (which is indeed often traceable to the causes just named) are often associated with an acne. To the same category belong the disturbances of the gastro-iutestinal tract, including constipation, dyspepsia, malnutrition from various causes, and the struma, tuberculosis, etc., which are responsible for acne cachecticorum. The medicinal agents capable of producing artificial acne, either by ingestion or after external application, have been already named. It should not, however, be concluded that any one of these condi- tions can be recognized as efficient in the majority of patients. Many cases of acne occur in perfectly healthy young people of both sexes. A careful record of cases of the disease, preserved upon blank forms in which is space for noting irregular performance of function in the other organs, will exhibit no ailment common to the larger number. In these, therefore, it is proper to believe that the causes of the dis- ease are entirely local, such as suffice merely to induce primarily alteration in the consistency, quantity, or chemical character of the sebaceous secretion, and, either as a cause or result of this, an adenitis or periadenitis. Apart from the local causes to which reference has been made, one should not forget that the use of cosmetics ; neglect of soap, or the use of the cheaper and irritating- varieties; excessive shaving on the part of the young man; friction from hat-bands; "frizzes," "bangs," and dyed veils ; too frequent fingering of the face ( Wigglesworth) ; improper compression of the neck by tight collars ; aud a long list of other agencies may prove the immediate or remote cause of the disease. It is believed that blondes of both sexes are the more frequent sufferers. But this observation may have been suggested by the circumstance that in the light complexions the symptoms of ACNE. 323 the disease are more conspicuous and disfiguring. It certainly seems that young brunettes, with thick skins and abundant growth of dark lanugo hairs, furnish the most obstinate cases. The distinct cause of acne is the mechanical irritation set up by the inspissation of the secreted contents of the gland. The next efficient cause is perversion of the glandular function, in consequence of which the secretion is changed in character. Pathology. — The microscopical appearances are briefly those of an inflammatory process with exudation involving the peri-glandular tissue of the sebaceous glands and hair-follicles, and that about the common excretory duct. There is the usual vascular engorgement, the multiplication of protoplasm within and without the focus of the phlegmon, its metamorphosis into pus often mingled with blood, the destruction by suppuration of the sebaceous gland, and often the preservation of the hair-follicle though the latter may also be involved in the destructive process. According to Kaposi, there is no question that the first stage of the disease is always an anomalous performance of secretion or excretion in the sebaceous gland. Visible cicatrices rarely result, unless the destruction of the elements of the derma surpasses the original limits of the gland itself. Where suppuration does not occur, there is generally relief of tension by extrusion of the inspissated gland-contents and resorption of the plastic or fluid exudate in the periphery. Diagnosis, — The typical facies of acne vulgaris is readily recog- nized by the characteristic features already described. The reddish papules, pustules, comedones, and "lumps" in the skin of the face of a young subject ; the evident involvement of the sebaceous glands ; the history of a chronic affection destitute of itching and quite unscratched ; the occasional blood-crusts where lesions have been squeezed or incised, are all significant facts. The pustular syphilide of the face is not only to be differentiated by its share in the history of au infectious disease, but by the occurrence of characteristic crusts, its selection by preference, of the regions about the nose and mouth, its evolution in groups, and its sequelse in the form of superficial or deep ulcerations. Nevertheless, and this is a matter of prime importance as regards diagnosis, simple acne is exceedingly common in syphilitic subjects. The iodide of potassium is so largely adminis- tered for the relief of syphilis, and in so large a majority of cases induces its artificial acne, that the latter eruption often precedes the evolution of the macular syphilide, and also with surprising frequency masks the latter by a commingling of lesions. Simple acne is common also among those who are veterans of syphilis. Acne does certainly at times resemble variola, and cases of the former have actually been mistaken for the latter. In most instances, the absence of fever and a brief delay will soon put an end to any doubt. Treatment. — Acne is an entirely remediable disease in every case properly managed from the first. Scars of ancient ravages of the affection are, it is true, indelible ; but even these are smoothed down 324 DISEASES OF THE SKIN. in the progress of time, so that they become yearly less conspicuous and disfiguring. An important consideration, at the outset of treatment of a patient affected with acne, relates to any local or internal medication which has been previously employed. A very large proportion of all patients first claim the attention of the physician after ingesting drugs or making topical applications which have decidedly aggravated the original trouble. With or without the advice of others, such persons have often been engaged for months iu swallowing the iodide of potassium, "red clover," and various nostrums calculated to "drive out" the disease; or in rubbing over the skin equally noxious pro- prietary substances. In every such instance the skilled physician should delay active treatment of the affection until the artificial acne has subsided, and the real condition of affairs cau be clearly recog- nized. The patient should be directed to discontinue his or her former practice, to bathe the affected part in hot water at night, and after it is dried to apply any bland unguent. By these simple measures alone, many cases can be very greatly improved, and some completely relieved. Their simplicity should commend them to every reader of these pages. It is a good thing to know what not to do. The constitutional treatment of acne rests for its success upon the discovery of the cause of the disease. Many cases certainly require uo such management, being entirely relieved by local treatment only. A thorough investigation of the habits of living, food, diet, bathing, occupation, and bodily functions of the patient, such as is described iu the chapter devoted to General Diagnosis, is essential at the outset. Since dyspepsia and constipation are frequent causes of the disease, it is necessary to correct these when present ; also any conditions of acidity of the stomach, distention of the transverse colon (Jewell), or marked anaemia. Some modification of Startin's acid mixture, such as the following, will be found suitable for many cases : R. Magnes. sulphat. 3ij ; 64' Acid, sulphur, dil. . f'3ij ; 8 Sodii chlorid. 3j ; 4 Ferri sulph. gr. v; 33 Cardamom, tinct. co. f3j I 4 Aq. dest. ad f J viij ; 256 M. Filtra. Sig. A tablespoonful iu a tumblerful of water before breakfast. Other cathartics, saline and alterative, will often prove serviceable. It is rarely found necessary to resort to arsenic, although this metal is highly recommended in acne papulosa, by both Duhring and Taylor. The internal employment of ergot in full doses for the relief of acne, as suggested by Denslow, has, without question, been frequently followed by excellent results. Cod-liver oil, iron, the mineral acids, and the bitters will prove valuable in chlorosis and ACNE. 325 cachexia. The sulphide of calcium, iu quarter of a graiu (0.016) doses, is of decided benefit in obstinate cases. Glycerine in teaspoonful to tablespoonful doses three times daily has also proved valuable (Gubler). The mineral waters, Hathorn, Hunyadi Janos, oftener Racoczy or Kissiugen, a tumblerful before breakfast, are exceedingly valuable in cases of habitual intestinal torpor. When there is an acid form of dyspepsia, the rhubarb and soda mixture, or the acetate of potassium in half drachm doses (2.), will be serviceable. Temperate gratification of the sexual instinct in a happy marriage is couducive to good results ; and such a condition should generally be recommended as favorable for the future of young adults. Uterine disease should receive proper treatment when such compli- cation exists ; and this, far less by topical applications, than by attention to the general health, as the patients of this class are more often chlorotic young women with menstrual derangements, leading sedentary lives, or overworked at the school-desk, the sewing- machine, or the shop-counter. The diet should be carefully regu- lated, and the rules of hygiene enforced. As to the former, hot breads and cakes, sweets, pastry, oat-meal, uncooked vegetables, and all alcoholic beverages should be scrupu- lously avoided ; while fresh cooked meats, fish, and vegetables, fresh fruits, and tea and coffee in moderation should be permitted. In all cases, whether previously treated or not, which have been purged of suspicion of an artificial element, the local treatment is of prime importance, and in the perfection with which its details are observed, lies the key to success. It is not the selection of one of the several remedies of the many advocated for the relief of the disease, nor yet the successive substitution of one for another to meet any transitory indications in each case, which conduces to the happiest result. It is rather the use of a single method of recognized value, and its skilful adaptation to the changing conditions of the disease. It is first necessary to evacuate the contents of all pustules, to express from the summits of papules where are the orifices of seba- ceous ducts, all densely inspissated plugs of sebum, and to remove any comedones which are present, by the aid of the comedo- extractor. For the purpose of opening the superficial and smaller purulent collections, the long needles used by gynecologists are decidedly preferable ; and for the larger and deeper furuncular lesions, a bistoury with a delicate and very narrow blade. A slight degree of skill will here repay the operator. Piffard's acne-lance is useful in this same connection as is also Volkmann's spoon as modified by Auspitz, which may be employed in removing pathological debris. By counter-depression with the fingers the whitish-yellow or blackish orifice of the duct may be detected, and at that point precisely the needle or bistoury should be thrust sufficiently deep to insure the removal of pent-up pathological accretions. Should blood flow in droplets from any of these slight wounds, it is rather to be en- couraged than repressed, as relieving the hyperemia and engorge- 326 DISEASES OF THE SKIN. ment of the small peri-glandular phlegmon. In one or several sittings, all lesions requiring such interference should be carefully attacked, and immediately after each, preferably while the pus and blood are still oozing, the part is to be bathed for several minutes in water as hot as can be borne with comfort. For many reasons, the hour before retiring is preferable, though not always practicable, iu treating such cases, as then a bland ointment can be thoroughly applied and permitted to remain till the following morning. When one or several of such operations have completely relieved the skiu of its engorgement and retained inflammatory products, a systematic use at night, of the spiritus saponis viridis with hot water, should be for a time practised. Let it be noted here, however, that man}- eases which do not require the minor surgical operation described above, should be from the first treated in this manner. As the face is the most common seat of the disease, it may be, for the purpose of description, considered as the affected part. The patient is seated before a basin of water, as hot as can be tolerated with comfort, and with a pad of white flannel or soft sponge, bathes the face till the skin is thoroughly moistened and softened by the heated water and steam. From ten minutes to half an hour may be well employed in this way, and it is a fertile source of the improvement which follows. Then, while the face is still wet, all pustules which have formed are emptied, and a sufficient quantity of the spirit of green soap is poured over the flannel or sponge, and the face thoroughly scrubbed with it. Finally the surface is cleansed with a surplus of the water, carefully dried, and anointed with a sulphur ointment. Some range may be observed in the employment of the two articles named. Thus the spirit may be diluted with cologne or rose-water, one half or more ; or the soaps employed, in less imperative cases, may be the best toilet, Sarg's glycerine, or sulphur soap. The oint- ment, too, may be compounded by adding half a drachm to two drachms (2.-8.) of the flowers of sulphur to the ounce (32.) of cold cream or vaseline. In the morning, the face is to be washed with cold water. This operation of steaming, soaping, and anointing, is to be con- tinued, according to the severity of the case and the tolerance of the patient, nightly, twice in the day, or on alternate nights, till the face is free from papules and other inflammatory lesions. At this time it is usually unsightly, reddened, slightly tumid, and often mod- erately furfuraceous, but free from acneiform lesions. To the patient, it feels tense, slightly painful, and as if made of leather. This accom- plished, the spirit, or other preparation of soap may be for the time discontinued. The improvement which follows is marked and speedy; and usually quite satisfactory to the patient. When this is reached, a wider latitude of treatment is permitted. Gradually the hot ablutions may be withdrawn, and the use of lotions and ointments other than those containing sulphur, may be advised. The last-named substance, having the highest reputation ACNE. 327 in the disorders of the sebaceous glands, the lotions thus employed. Taylor 1 advises the following : a constituent of many of Sig. Sulphuris loti 3iij ; 12 Camphorge spts. f^iij ; 12 Sodse biborat. 3ij ; 8 Glycerin. f£vj ; 24 Aq. fontan. ad f|iv ; 128 M. Shake well and apply freely, leaving a thin film of powder over the face. Various combinations of sulphur with alcohol will be found useful. Thus Kaposi recommends a paste composed of : R. Sulphur, praecip. Spts. vin. rect. Lavand. spts. Glycerin. Sijss ; fSjiss ; rt^xx: M. Sig. To be spread over the face and retained during the night. Or, R. Sulphur, flor. Spts. sapon. virid. Lavand. tr. Peruv. bals. Camphor, spts. Bergamot. ol. 3ijss : f3v; m; Tt\,xx; ttlxv ; Sig. To be applied over the face at night. Duhring recommends the following : R . Sulphur, prsecipit. 3ij ; Glycerin. f^ij ; Alcoholis f^j ; Aq. calcis fgj ; Aq. ros. fgij ; Sig. Shake the vial before using. 33 M. R . Hum. crisp, rad. Adipis Cerae flav. Occasionally the rumex ointment may be used with advantage as the basis of sulphur and other salves in acne. It is prepared according to the following formula : gix ; 288 §vj ; 192 IU 32 Aq. pur. q. s. ; Wash and bruise the roots ; boil for two hours ; strain ; evaporate to four ounces (128.) ; gradually add the wax and lard in a melted state ; and stir till cool. The English hypochloride of sulphur, in ointments of the strength of those given above, and the sulphuret of potassium, half to one scruple (0.66-1.33) to the ounce (32.) of lotion or ointment are effective, but objectionable on account of their odor. Various cosmetic ointments will be found useful in superseding those described above, as the case progresses. Among these may be named, the oxide of zinc, the subnitrate of bismuth, and freshly 1 Amer. Clin. Lectures, vol. iii. No. 10, New York, 1878. 328 DISEASES OF THE SKIN. levigated calamine in the strength of from one-half to one drachm (2.-4.) of one or more of these substances to the ounce (32.) of cold cream, to which, as required, the tincture of benzoin, glycerine, oil of roses or bergamot, may be added in suitable proportion. For mild cases an excellent lotion is obtained by adding a drachm each (4.) of the simple tincture of benzoin and glycerine to four ounces (128.) of distilled water, to which, where a more stimulating effect is desired an ounce (32.) of cologne water or rectified spirit of wine may be added, or a scruple (1.33) of the sulphuret of potas- sium. The following is the formula of the "Oriental Lotion," according to Hebra : R. Hydrarg. chlor. corros. 3j; 4 Aq. destill. •3iy; 16 Ovorum iij albumen Succi citri 3iij ; 12 Sacchari 5J; 32 M. The bichloride of mercury is very generally employed in the strength of from one-eighth to one-half a grain (0.008-0.033) to the ounce (32.) of emulsion of bitter almonds as a lotion; and the prot- iodide, biniodide, and ammonio-chloride of the metal are similarly applied in both lotions and unguents ; the first two, in the strength of from five to ten grains (0.33-0.66) to the ounce (32.); the last-named, in the strength of from half a scruple to a scruple (0.66-1.33). One should be careful not to make use of the mercurials at the same time with a compound of sulphur, lest a chemical combination occur by reason of which the sulphuret of mercury is precipitated upon the skin and produces the appearance of comedo. Heitzmann highly recommends the solution of Vleminckx. 1 Kaposi recommends also mercurial plaster applied on strips of linen iu obstinate cases, for which may be substituted iodated glycerine, five parts each of pure iodine and the iodide of potassium to ten of glycerine, applied with a brush twice daily till from six to twelve applications have been made. Van Harlingeu's favorite prescription is one drachm each (4.) of the sulphuret of potassium and sulphate of zinc to four ounces (128.) of rose water. Fox applies half a drachm (2.) of chrysarobin to the ounce (32.) of collodion. Taylor advises five to twenty-five grains (0.33-1.6) of the iodide of zinc to the ounce (32.) of vase- line. Veiel employs the uncertain unguentum Rochardi : R . Hydrarg. chlor. mit. 9j ; 1 Iodi. puri. gr. vij ; Leni igne fusis adde Ungt. rosae aq. 31J ; 64 M. The use of caustics in acne, though recommended by several authors, should be discountenanced as quite needless. In extreme 1 The formula is : Jjfc. Calcis, Sss; Sulphur sublini. Sj ; Aq. dest. Sx ; Ooque ad Svj [192.] deinde filtra. Si;;. " Vk'iniiiukx'.s Solution." ACNE ROSACEA. 329 induration of the lesions, they may be rubbed with fine pumice-stone till the desired effect is produced. The powders employed in the milder forms of the affection, are finely powdered sulphur, which may be freely dusted over the face; and those compounded, in various proportions, of starch, rice-flour, zinc oxide, and the subcarbonate of bismuth. Finally Sherwell, Denslow, and others in this country report relief of acne in young male patients after the passage of the urethral sound and, in both sexes, by hot and cold water injections of vagina and urethra. Acne Rosacea. Acne Rosacea is a chronic disease of the skin, chiefly of the face, often devel- oped from, or associated with, the lesions of acne vulgaris, characterized by hyperaemic rnaculse, patches of diffuse, dull red erythema, telangiectases, inflammatory papules, or vegetating masses, which may attain the size of a hen's egg. It is usual to describe three grades of this disorder, also named Gutta Rosea, or simply Rosacea, which is most often displayed upon the nose, though it may also affect the cheeks, lips, chin, and, rarely, the lateral regions of the neck. Symptoms. — In the first grade, there is a more or less diffuse and uniform, pinkish or dusky, but transitory reduess, involving the ex- tremity of the nose and its contiguous parts, which may extend from this part in a somewhat symmetrical figure over the cheeks and chin. The parts give rise to little or no subjective sensation. Under the finger, the color disappears under pressure, the surface seems cool rather than hot, and the sebaceous glands are seen to be affected, as there is usually present either a seborrhoea oleosa or an accumulation of yellowish-white, moderately inspissated sebum in the patulous orifices of the gland ducts. When the redness has existed for some time, minute bloodvessels can be seen ramifying over the erythem- atous surface. This disorder varies greatly with the general condition of the patient. At times, it may be scarcely perceptible ; again after the stimulation produced by ingested food or alcohol, after mental excite- ment, a paroxysm of coughing or laughing, or exposure to external irritation, the lesions may be even conspicuously deforming. This may endure for months or years, and then disappear or be succeeded by the second stage of the malady. In this second grade of the disease, the reduess becomes permanent, the capillaries dilate passively and appear as conspicuous, tortuous, straight or anastomosing lines of reddish color about the nose, cheeks, chin, or forehead. Firm, purplish-red, painless, pin-head to pea-sized nodules or papules often rise from the erythematous surface, and either display minute superficial and tortuous bloodvessels in the integument by which they are covered, or project from a base about which such a 330 DISEASES OF THE SKIN. telangiectasis has been very irregularly developed. The lesions are apt to be intermingled with those of eeborrhcea oleosa or acne vulgaris. When fully developed, this stage of the disease, though generally not productive of marked subjective sensation, produces an exceedingly conspicuous deformity. In the third stage, which is the most pronounced of the three, roundish, sessile, or pedunculated, lobulated or pendulous, firm, elastic, pinkish-red, bluish, livid, or violaceous vegetations, traversed by liner or larger networks of bloodvessels, slowly develop about the affected part of the face, chiefly the nose. These may be single or multiple, and, in the latter case, isolated, or so closely united as to be scarcely distinguishable from each other. The acneiform lesions seen in the second grade of the disease, may here also be apparent. In other cases, there is a uniform, symmetrical, and elongated hyper- trophy of all the soft parts of the nose, which may thus attain colossal proportions. It is these consequences of acne rosacea to which the term Rhixophyma 1 has been applied. The course of the disease is very slow, and in by far the largest number does not produce the exaggerated types of the second and third grades. The lesions may persist indefinitely as indolent symp- toms of the malady in any one of its stages, or, in the cases where there has been no new growth of vessels or tubercles, proceed to spontaneous involution. Etiology. — The first and second grades of acne rosacea are common in women either at puberty or near the period of the menopause, in those who are pregnant, or who suffer from utero-ovarian disease, frequent miscarriages, sterility, irregular performance of the menstrual function, and chlorosis. It is, however, seen in men of early and late adult life. In both sexes, it may occur in anaemic and asthenic states. In both, also, its association with dyspepsia and the immode- rate use of alcoholic drinks, beer, wines, and spirits, is a matter of common observation. According to Kaposi, the rosaceous nose of the wine-drinker is bright red; of the beer-drinker, cyanotic or violet ; of the spirit-drinker, smooth, supple, fatty, and dark blue. The new growth of vessels and tubercles, with the rhinophyma of the advanced grade of the disease, is much more common in men than in women. In those whose faces are bronzed by exposure to the weather, the telangiectasia condition of the cheeks rather than of the nose, is of frequent occurrence. Veteran sailors and soldiers are thus commonly affected. Persons who have frozen the nose or the cheeks on one or more occasions, are similarly liable to the telangiec- tasia development. Any externally or internally operating cause which tends to retard the capillary circulation in the superficial por- tion of the skin, is capable of inducing the result. It is at times conspicuously displayed in the mulatto. Pathology. — In the first stage of acne rosacea there is merely passive 1 For a full discussion of this subject, consult a valuable paper by Hans Hebra. in the Viertelj. f. Derm. u. Syph , 1881, 4 Hft., p. 603, illustrated by cuts giving the gross and microscopical appearances of the disease. ACNE EOSACEA. 331 hypersemia. The circulation of the blood in the superficial capillary plexus of minute vessels is retarded. Persistence of this condition for long periods of time results in paresis of the capillaries, with their consequent dilatation and hypertrophy, phenomena which char- acterize the second stage, the sebaceous gland disorder being a com- plication of the process. In the third stage, the nodules are found to be composed of new-formed gelatinous elements, which become formed by organization. According to Biesiadecki, there are also dilatation and hypertrophy of the sebaceous glands, with dilatation, hypertrophy, and new growth of the superficial vessels, and enlarge- ment also of those trunks which ascend from the corium. Diagnosis. — Acne vulgaris is distinguished from acne rosacea by the absence of telangiectasis, and of the hypertrophic growths which characterize the developed lesions of the last-named disease. The tubercular syphiloderm is recognizable by its tendency to ulceration and crusting, and by the entire absence of telangiectasis. When the tubercles of syphilis are limited to the extremity of the nose, and are unusually small in consequence of the influence of treatment, they often degenerate into characteristic, split-pea sized, irregularly cir- cular ulcerations, superficial in seat, and frequently isolated. They leave similarly shaped and sized, depressed cicatrices at the tip and neighboring parts of the nose. As the process is much more rapid than in acne rosacea, these lesions, considered in connection with the absence of telangiectasis, furnish the most significant diagnostic symptoms of the disorder, for they often occur late in the history of syphilis, in individuals of middle life, and in varying shades of a dull reddish color, circumstances particularly favorable for confusion re- garding the identity of the two diseases. A case of zoster from involvement of the superior maxillary branch of the trigeminus, with diffused redness of one side of the nose and efflorescence of vesicles over its tip and ala, certainly strongly resembles acne rosacea with pustular lesions. Here the painful character of the disorder, its limitation to one side, its transi- tory career, and its vesicular lesions are sufficiently characteristic. Lupus vulgaris, like syphilis, when occurring upon the nose, is to be recognized by the tendency of its papulo-tubercular lesions to ulceration and crusting, the absence of vascularity, and the frequent presence of characteristic cicatrices. Unlike syphilis and acne rosacea, however, the history of lupus vulgaris usually extends to early child- hood. Lupus erythematosus is yet more readily differentiated, as it is not only unaccompanied by vascularization and ulceration, but is characterized by scaling and symmetrical diffusion over much larger areas, commonly extending from the bridge of the nose well on to the cheeks. Treatment. — As far as there can be said to be any internal treat- ment of acne rosacea, it is that of acne vulgaris, but in neither dis- order can such be confidently described as effective in the dispersion of the local lesions. The treatment is that of the patient rather than of his disease. When alcohol has been in any degree productive of 332 DISEASES OF THE SKIN. the local effects, the use of spirits, wines, and beer is to be inter- dicted; but as regards confirmed rosacea, this will prove to be of but little avail. The disease, when resulting from spirit-drinking, may persist after live years of total abstinence. The diet should be of the simple character described above as proper for the patient with acne. All imbibition of hot liquids, even tea and coffee in excess, should be restricted as tending to congest the bloodvessels of the face. Everything having the same result in the habits, occupation, or clothing of the patient should be, as far as possible, deprived of influence, as, for example, the wearing of tight collars and corsets, the working over hot fires, etc. All gastro-intestinal sources of mischief should be also, when practicable, set aside. In acne rosacea, even more than in acne sim- plex, dyspepsia and constipation are conspicuously effective factors. Here it is well nigh imperative that there be a daily evacuation of the bowels. The local treatment of the first grade of acne rosacea is substan- tially that of acne vulgaris. Stimulating lotions of green soap, alcohol, bichloride of mercury, or sulphur in connection with ablu- tions by hot water, are of the highest value. In addition, the various ointments containing sulphur, the mercuric oxide and iodides, and the continuous application of mercurial plaster should be employed if necessary. Van Harlingen reports rapid results from the application, several times in the day, of a lotion composed as follows : R. Sulpkuris prsecipit. 3j; Pulv. camphorse gr. v ; Pulv. tragacanth. gr. x ; Aq. calcis | Aq. rosre J aafgj; 32 M. Fox, of New York, applies chrysarobin in traumaticine, half a drachm (2.) to the ounce (32.), but this should certainly be re- served for intractable cases, as it may have severe results. Even, however, after the production of these severe effects, the benefit secured may be appreciable for months after. When the diseased condition is that of the second grade, the indi- cation is the destruction of the superficial capillaries, as well as the removal of the other indications present. Hardaway, of St. Louis, was early in destroying the vessels by single or multiple puncture of each with a fine cambric-needle attached to the negative pole of a galvanic battery, with six to ten elements in the circuit. This is better than the knife, which has repeatedly failed. The operation may be regarded to-day as the established and effective method of removing all blemishes produced by dilated bloodvessels in this stage of rosacea. It is simple, readily executed, requires no anaesthetic, and is in many ways superior to all other methods, which now should be relegated to a second grade in the list as only to be proposed when, for any reason, electrolysis cannot be employed. The author has ACNE ROSACEA. 333 operated in many cases, with the result of destroying the vessels completely without the production of a cutaneous cicatrix which, in the course of a few months, could be recognized by the unaided eye. For details of this simple and elegant operation the reader is re- ferred to the chapter on Hirsuties, where it is more fully described. For the cambric-ueedle may often be substituted with advantage a fine jeweller's brooch, annealed in the flame of a spirit-lamp. The vessels may be entered in one or several places, and the opera- tion repeated till the last thread-like evidence of their existence has disappeared. The number of cells brought into the circuit must be somewhat graduated to the requirements of each case and the locality of the skin operated upon. Fewer can be tolerated for the lip and alse of the nose than for the root of it, the cheeks, or the forehead. Next in value after this operation may be named : Brushing the part cautiously with solutions of caustic potash, ten to thirty grains (0.66-2.) to the ounce (32.) of water; and the local use of pure carbolic, chromic, pyrogallic, and glacial acetic acids, acetum cantharidis (Taylor), iodide of sulphur, and the pernitrate of mercury. Before any of these, however, is employed, an effort should be made to produce exfoliation, by spreading over the part a plaster made of green soap. Unna's mercurial plaster-mull is simi- larly applied. Kaposi highly recommends the solution of iodated glycerine employed by him in acne vulgaris (q. v.), which is painted over the part eight to twelve times daily for three or four successive days, and immediately covered with gutta-percha paper. Multiple scarification of all new growths after the manner of attacking lupous nodules ; erasion with the dermal curette, or Braun's spoon ; and surgical ablation or decortication of tumors by ligature and. knife, are also available. After any destructive attack upon the diseased portions of the skin, the soothing lotions, fomenta- tions, or ointments should be regularly applied. Prognosis. — A favorable prognosis can be established only in cases where the disease is presented in its mildest forms. In those com- plicated by marked telangiectasis and hypertrophy, the results of treatment are not in the highest degree encouraging. In spite of the most energetic procedures, the vis a tergo of passive hyperemia, involving often the deeper and unassailed bloodvessels, works its slow progress. For women, the future is in general more promising than in the case of men. With the most unfavorable prognosis, however, it is to be remembered that, after all, the disease is one of deformity rather than of physical discomfort. 334 DISEASES OF THE SKIN. Sycosis. Gr. ovkov, a fig. Sycosis is an acute or chronic non-contagious inflammatory affection of the surfaces provided with relatively long hairs, in which the follicles and perifollicular tissues are involved in an exudative process, producing papules, pustules, tuhercles, infiltrated patches, and crusts perforated by hairs. Symptoms. — This affection, also termed Mentagra, occurs upon the face, involving one or both cheeks successively or simultaneously, the chin, upper lip, eyebrows, scalp, axillae, and pubes. It is, how- ever, almost always a disease limited to the region of the beard in men. In this respect it differs from acne and other disorders of the sebaceous glands of the face with which authors have sought to identify it, since not only is it as a rule strictly limited to the region of the beard, but the more hairy portions of the face of the patient are free from comedones, acne lesions, and other symptoms of a cutaneous disorder. When seated upon the upper lip the first symptoms may be a nasal catarrh ; elsewhere an eczematous attack may precede the onset of the disease. It may be ushered in with such acute symptoms as are found in the early stage of some of the forms of eczema, tumefaction accompanied by a sensation of heat and burning ; but often a few isolated and indolent lesions whose presence scarcely awakens atten- tion, are the first traces of the disorder. Soon may be recognized a larger or smaller number of discrete, flattened or conical, reddish and painful papules, tubercles, or pustules, whose anatomical seat is dis- tinguished as the hair- follicle by the penetration of each by a filament of hair. These lesions may persist, and when typically discrete and visible at the part where the hair makes its exit from the duct of the follicle, have suggested the appearance of the surface of the fig, whence the disease has its name. They are apt to occasion a burning and at times a decidedly pruritic sensation when, being picked or torn open by the fingers, the pus concretes into a crust at the base of the hair. In severer cases these lesions while not coalescing, are so closely set together as to form a patch of continuous infiltration. These patches may be weeping or crusted; in the latter case the crusts are apt to be small and numerous, each being limited to the shaft of a single hair, and leaving when removed a minute crateri- form excavation at the mouth of the follicle. Involution of several lesions may be followed by fresh crops, and, sooner or later, distinct patches of disease are thus formed. AVhen fully developed, the surface of the skin is reddened, swollen, infil- trated, and thickened; covered irregularly here and there with papules, pustules, crusts, scales, and often with excoriated surfaces. The dis- ease is apt to lapse into chronic conditions, usually as the result of improper treatment ; and in ancient cases the deformity is character- istic and totally unlike that produced by the vegetable parasites. sycosis. 335 The hairs are usually fixed firmly in their follicles, but from those where active suppuration is in progress they may be plucked without occasioning much pain. In the cases which have been treated for years, the hairs are thin and decidedly lacking in vigor. There is no parasite to be discovered. In typical neglected cases of long standing, where the region of the beard is involved, an important clinical feature is the symmetrical, general, and uniform involvement of the entire surface. The picture of one cheek is very nearly that of the other. The thin hairs scarcely serve to disguise the reddened, tumid, painful surface beneath, displaying the several lesions of the malady. Furuncles, abscesses, cicatrices, vegetations, and eczema of the ears may compli- cate the process. It is occasionally acute in its course, but more often chronic and rebellious. A typically chronic and untreated case of the malady rarely terminates by spontaneous involution. The thinning of the hairs described above as a consequence of long persistence of the disease is far more characteristic of it than any distinct resulting alopecia. The latter, however, very rarely ocgurs but is then remediless. The same may be said of resulting cicatriza- tion, which is one of the very rarest of consequences. The absence of certain symptoms in this disorder is as significant as the presence of others. Adenopathy of the cervical glands is very rare, and when present should awaken suspicion of another malady. The disease when of longest persistence as to time, produces great unsightliness, but no deep-seated, subcutaneous, small- or large-nut sized nodules or tubercles, forming the " lumps" so characteristic of trichophytosis of the beard. It is a disease of chronic course, which may last for years and be characterized by relapses and aggravations, but it is entirely curable and it is only in neglected and badly treated cases that such persistence may be expected. Etiology. — The exciting causes of the disease are obscure. It is encountered chiefly among men after puberty, and these in all social conditions and grades of health. It is non-parasitic, non- contagious, and not transmissible by heredity. Shaving is not known to produce it. At times, the immediate cause of the disease can be recognized, as when the upper lip is constantly irritated by the dis- charge from a profuse nasal catarrh. One such patient was seen by the author two years after Hebra first assumed charge of his case. In others again, all the causes of eczema may be invoked in explanation of the result. A careful study of many cases, however, suggests that the hairs themselves are the aggravating causes of the disease and the sources of its peculiar obstinacy. In health the motions of the free shaft of the hair do not irritate the follicle in which it is set. In conditions of disease it is quite different. Each free hair operates like a lever upon the inflamed ring of tissue which encircles it on its escape from the follicle beneath, and this whenever by the touch of the hand, by the action of brushing, by currents of air, or by any agency what- ever, a movement is imparted to it. Every such movement must 336 DISEASES OF THE SKIN. tease to a variable degree the surface beneath, already irritated; and when estimate is made of the hundreds of such movements to which cadi hair is subjected during a period of twenty- four hours, the relative importance of this apparently insignificant factor may be appreciated. Pathology. — The disease is due to an inflammatory process, which, whether originally follicular or peri-follicular in its seat, may extend unquestionably either toward or from the follicle. Sometimes the extraction of the hair is followed by a drop of pure pus, which exudes from the follicle; and the root-sheaths of the hair are seen to be altered in consequence of the circumscribed follicular abscess. At other times, the follicle itself is free from disease, and the exuda- tive process has evidently expended itself upon the peri-follicular or even the inter-follicular tissues, in which case the papillary layer of the derma exhibits the usual phenomena of hyperemia, infiltration, and multiplication of protoplasm, with abundant vascular dilatation. According to Robinson, the disease always begins as a peri-follic- ulaj- inflammation, under the influence of which transuded serum penetrates the follicle. Maceration and eventual destruction of the root-sheath of the hair result with the ultimate production of pus within and without the follicle. The pus, when the hair remains in the follicle, finds its way to the surface by breaking through the epi- dermis near the hair; occasionally exit is obtained between the shaft and the follicle-sheath. Diagnosis. — The most important consideration here is the distinc- tion between the parasitic and the non-parasitic forms of disease of the region of the beard, upon which naturally the microscope finally decides. Still the clinical features of the disease are quite distinct. The non-parasitic form is recognized (a) by the greater redness of the involved surface; (b) by the extension of the disease in advanced cases to larger areas of symmetrical involvement ; (c) by the more superficial character of the lesions, and (d) by the firm implantation of the hairs in their follicles in the earlier periods of the disease, and their relative freedom in all cases from fracture and relics in the form of stumps. The parasitic disease of the hairs is peculiar, in consequence of (a) decidedly less redness of the surface attacked ; (b) its frequent limitation to a circumscribed area, or to several such, irregularly dispersed over a large region ; (c) the peculiar " lumpy, tubercular, nodular, and uneven " characters of the patch, upon which Duhring has laid significant emphasis; and (d) the earlier loosening of the hairs in their follicles, as also of the occurrence of fractured hairs and stumps, exhibiting usually at the bulb unmistak- able evidence of the nature of the disease. The malady is often mistaken for syphilis, chiefly on account of its deformity, but the pustular syphiloderm is very much less chronic in its course, is never limited for years to the face exclusively, and, when long persistent in one locality, is characterized by ulceration and the production of very characteristic crusts. Eczema may complicate non-parasitic sycosis ; but typical instances sycosis. 337 of the two disorders may be recognized by the occurrence, in the former case, of a discharging disease not usually limited to the region of the beard, characterized by a more intense itching, and with marked absence of the papulo-tubercular lesions described above. The lesions, moreover, in eczema are not invariably perforated by hairs. Erythematous eczema of the shaven face is reddish in color, and desquamates, after full evolution of the disorder, without pustu- lation. Treatment. — In all cases of sycosis, the essential and important step is the continual removal of the hairs which, as indicated above, are the chief sources of aggravation of the disease. This is best accomplished by shaving, an act which, though often painful at the onset, is soon well tolerated by the sufferer. The majority of patients, however, object to the removal of the beard, far more on account of the consequent greater exposure to view of the deformity induced by the disease (then no longer partly masked by the hairs) than on account of the distress occasioned by the operation. To these objec- tions there is but one response. The shaving is essential ; the defor- mity is rapidly reduced after its successful initiation ; the discomfort diminishes with each repetition of the process. For the disease in patients positively refusing to have the beard removed whose cases are so severe as to require it, the practitioner will do well to decline to be responsible. There is no limit to the tedious and obstinate course of the malady in the one case ; and in the other, the results are speedily satisfactory, often in the course of a few weeks. When there is much tenderness, pain, swelling, pustulation, or crusting, the hairs may first be clipped short, and a bland poultice of oil, elm-bark, or bread and milk applied. The practice in Vienna is to substitute for the latter strips of soft muslin or linen spread with diachylon ointment, and firmly bandaged over the cheeks, chin, or lips for from twelve to twenty-four hours, after which the razor is passed over the entire surface. The integument which thus becomes visible, is usually a reddened infiltrated area, with pustules, papules, pustulo-papules, and some crusts dispersed here and there over it. This is best treated by very hot water lotions, pure or alkalinized, after exit is given to all puru- lent collections; and then a bland ointment is to be applied at night, and a dusting powder in the morning. The subsequent treatment is largely that of eczema of equal grade of severity. In the more acute periods, the oleated lime-water, medicated with calomel or zinc oxide, half to one drachm (2.-4.) of either to the pint (512.) may often be employed with benefit; or for this may be substituted two ounces (64.) each of linseed oil, castile soap, and paraffine, to the pint (512.) of aqua calcis. Later, ointments may be used, particu- larly cold cream, to which either sulphur, the zinc oxide, or, less preferably, one of the mercurials may be added. Lotions of the mercuric bichloride, sulphur, alcohol, cologne water, or iodated glycerine, may be useful in stimulating any indolent patches of infil- tration. The treatment of these is indeed that of chronic eczema. 22 338 DISEASES OF THE SKIN. In Vienna, epilation is successfully practised for relief of the disease; and, by many, severer methods are employed, including the use of green soap, tar, cauterization with acetic and even nitric acids. Erasure with the curette is to be named in the same category. It is possible that these measures have been employed in much more aggravated cases than those commonly observed here; but as the disease is certainly curable in a majority of cases without having recourse to these heroic methods, they are to be regarded in the light of a dernier ressorU It is not necessary in the immense majority of non-parasitic forms of sycosis, either to epilate or employ caustics. By repeated and frequent use of very hot water, and the milder stimulants, with constant shaving, the desired result is always within reach. Shaving should be continued for nearly one year after all traces of the disease have disappeared ; and it is a point of some im- portance to substitute a continuously applied dusting powder for a fatty application, so soon as the skin will tolerate the persistent use of the former. Van Harlingen advises for acute cases a wash composed of half a pint (256.) of rose water, to which one drachm each (4.) of precipi- tated carbonate of zinc and oxide of zinc in powder have been added, with two drachms each (8.) of glycerine and dilute liquor plumbi sub- acetatis. Veiel recommends a solution of pyrogallol, one part to fifty, for painting over the part affected, followed in the day by emollient cataplasms, and in the night by diachylon or weak tannin ointments. Sycosis of other portions of the body is to be treated as described for the region of the beard. Internally, treatment is of minimum value, and when indicated, should be of the kind demanded by the wholly accidental constitu- tional condition of the patient. It is a matter worthy of special attention, however, to purge every previously treated case of all suspicion of an artificial element, by withdrawing for a proper time all internal medication. The disease is so disfiguring that many patients swallow the iodide of potassium, arsenic, and other deleterious drugs for months before consulting one who is wiser than they in these matters. Exposure of the face to dust, smoke, wind, and other sources of irritation should be for a time avoided. Prognosis. — The disease is entirely curable, and will, in the large majority of all cases, either disappear entirely or be very greatly improved by judicious treatment. The latter requires the personal supervision of the physician and close attention to details. Dermatitis Papillaris Capillitii. Under this title Kaposi describes a disorder characterized by pin- head sized, isolated, or confluent elevations of the surface, with inter- spersed pustules, which finally form cicatriform plaques over which the hairs are either clustered in tufts or totally absent. The pilary filaments are atrophied yet firmly fixed in their follicles, and suffer elongation or fracture before withdrawal. The disease is encountered sycosis. 339 chiefly upon the nucha, occiput, and vertex. Papillomatous vegeta- tions, crust-covered, hemorrhagic, and with a foul-smelling secretion, sometimes form, and eventually retract into a sclerotic tissue. The author has seen and described two typical cases of this dis- order, 1 and each concluded with the production of a keloid-like, cicatriform, irregularly shaped, but circumscribed elevation of the surface. This feature is that by which it specially differs from all other sycosiform disorders. The disease seems to be due fully as much to inflammatory processes in the subcutaneous tissues between the unyielding pericranium aDd the thick scalp as to the derma proper, and is not, therefore, strictly speaking, a dermatitis. Punc- ture, for example, of one of the pin-head sized pustules, commonly gives exit to the usual quantity of pus; but pressure upon the scalp in the periphery will at once be followed by the appearance of a still larger quantity of similar pus, which evidently is expressed from a circumscribed subcutaneous abscess. When by such pressure the abscess cavity is emptied, it slowly fills with venous blood, and pro- duces a firm, semi-solid elevation of the surface, which subsequently undergoes sclerosis, and the starved hairs above behave in the manner well described by Kaposi. The papules and plaques are formed in a similar way, by the abundant supply of venous blood. The case of one of the author's patients (presented at the clinic) had been erro- neously diagnosticated by a surgeon as aueurismal in character. Punc- ture of all such semi-solid, cicatriform lesions is invariably followed by oozing of venous blood in abundance. The disease is chronic in character, particularly liable to relapse in crops of pilary or peripilary pustules and papules, and extends from nucha to vertex, curiously avoiding the frontal and temporal regions. Over the bald or par- tially bald keloid-like elevations there is seen, in some cases, a species of seborrhoea in the form of more or less adherent, fatty crusts, with occasional characteristic tufts of hairs. None of these hairs was invaded by a parasite, though repeatedly examined with the micro- scope with a view to such discovery. The disease seems to owe its special character to the anatomical peculiarities of its location. It occurs preferably at the points where the venous supply of the scalp is not only greatest, but in most direct connection with the large vessels beneath, and where an inflammatory process in the derma or subcutaneous tissues invites with readiness a pathological afflux of blood. Such a focus, limited beneath by the dense calvarium, and with the relatively thick scalp above, readily undergoes organization and sclerosis, the subsequent behavior of the hairs and hair-follicles being an accident of the process. Sangster (in a paper read before the International Medical Con- gress in London, 1881) described a pigeon's egg-sized tumor of the scalp, which Kaposi, who was present, recognized as a case of derma- titis papillaris capillitii. The method of treatment to be employed in this rare disease can 1 See a paper on this subject by the author, published in the Journ. of Cutaneous and Venereal , vol. i., No. 2, p. 33. 340 DISEASES OF THE SKIN. scarcely be described as established. The affected surfaces are first freed from all subcutaneous abscesses by puncture and expression of the contents. Then the patch is washed with hot carbolized water, dusted with boric acid or iodoform, and a compress, moistened with an antiseptic solution, such as corrosive sublimate wash, rather firmly bandaged over the part. When the pathological fluids no longer form under the scalp, the patch is best epilated, and anointed with a salve containing one drachm (4.) of precipitated sulphur to the ounce (32.) of scented vaseline, which may also be kept constantly over the part. When crusts form, they may be removed by sham- pooing with green soap. Generally, internal treatment is suggested by the constitutional condition of the patient, and this should often include cod-liver oil, the ferruginous tonics, and a roborant regimen. Impetigo. Lat. impetere, to rush upon. Impetigo is an acute inflammatory affection of the skin, in which discrete, roundish, and acuminate or globoid vesicles, of the average size of a coffee- bean, form and rapidly fill with pus, which, being set free after rupture of the lesions, desiccates in characteristic crusts. Hebra has distinctly stated that the pustular, cutaneous affection described by authors under the name Impetigo has no existence as "an independent disease. Unquestionably a long list of disorders hitherto described under this term have been, in fact, forms of pustular eczema; and there are good grounds for believing that the symptoms detailed below are not those of a disease having a special identity. The reasons for retaining the name given above and for assigning to it certain peculiar eruptive features, are based upon the simple fact that the latter, probably in consequence of the operation in a similar way of similar causes, reproduce themselves again and again, so as to exhibit the same clinical picture in different patients. With a larger experience, it must be admitted that the convenience of the name, impetigo, as descriptive of a group of cutaneous symptoms, is more and more apparent. Symptoms. — The disease is sufficiently common iu practice, being observed chiefly in children and young adults of both sexes. In such patients, one to twenty or more isolated and often widely separated minute vesicles or vesico-pustules usually acuminate, ap- pear upon the surface either simultaneously or in rapid succession occasionally after a slight access of fever. They are speedily trans- formed into split-pea sized or larger pustules, so rapidly, in fact, that often the early vesicular phase is not manifest, the lesions showing as minute pustules from the first. When fully developed, they are globular, yellowish-white in color, discrete, well distended with their puriform, rarely bloody contents, and projected clearly from the sur- face on which they rest. They may be surrounded by an erythema- IMPETIGO. 341 tous areola, or be simply superimposed upon an integument of un- altered color. They may persist as such or burst, and their contents dry into a yellowish crust resembling honey, or into brownish-tinted concretions which adhere with firmness to the superficial and circum- scribed base, where a slight weeping can be determined. They are much more commonly observed upon the face, but are recognized elsewhere, always sparsely upon the trunk and extremities. The eruption is never in any sense generalized, its characteristic feature being the fewness of the lesions, which rarely exceed twenty in number, which are scarcely ever grouped, and which occur in capriciously selected locations. The subjective sensations are slight, and the eruption is more picked than scratched. It is common in dispensary and hospital patients ; and since these are often the vic- tims of neglect and the subjects of vices of nutrition, it has been considered the appanage of scrofula. But the disease is also encoun- tered in well-nourished and rosy-cheeked children. In the latter, when well cared for, the eruption proceeds regularly to its natural resolution, while, in the former, it is prolonged and often aggravated, thus attracting to a greater degree the attention of a physician. The pustules are never umbilicated, never seated upon ulcers, never fol- lowed by cicatrices, and are incapable of transmitting the disease to another individual. Etiology. — The causes of the disease are not clearly recognized, but there is some reason to believe that it originates exclusively in local irritation. It occurs rather at the age of childhood than in infancy and adult life, a period when the hands are first brought into habitual contact with the face ; and these are, quite suggestively, the two sites of election. The lesions are very rarely scratched, more often torn with the nails in picking, so that the crusts may be a little blood-colored. There is reason to believe that the habit of picking the nose and other parts of the face and body with unwashed hands, is the sole source of the mischief. In later life the habit of refraining from carrying the hands to the face when the former are soiled, becomes instinctive. Before this instinct is well established, that is in child- hood, the hands will convey to the head any particle of filth or dust with which they may have been brought into contact. Pathology. — The lesions have been examined microscopically by Duhring and others, who have thus been able to establish clearly the purulent character of the contained fluid. Plainly, each is but a distinctly circumscribed and superficial pea- to bean-sized abscess, the sources of the pus being the horny layer of the epidermis. Diagnosis. — In order to establish the identity of this affection, it is necessary to define its exact diiferences from eczema pustulosum. These are, first, the absence of infiltration of the tissues affected; second, the absence of itching; third, the failure of the lesions to form patches ; fourth, the isolation and wide separation, each from the other, of lesions distinctly pustular; fifth, the large development and rather persistent character of individual pustules; and sixth, after involution of the latter, the evident termination of the disease, 342 DISEASES OF THE SKIS'. which dors not, as dues eczema in many cases, progress to form a freely discharging and crusting surface, the pustular being but the initial stage of a distinct disease process. Manifestly, however, an impetigo of the sort described is not incompatible with an eczema which is often originated by less irritating causes. In ecthyma, the pustules are much more formidable in appearance, in consequence of their size, depth, inflammatory base, areola, flat, dark, bulky crust, and erosive action upon the skin. From impetigo contagiosa, the disease is distinguished chiefly by the absence of the evidences of contagion. The lesions of the latter are also, at first, strictly vesicular, not vesiculo-pustular or pustular, there is often umbilication, and the pus is auto-inoculable. The lesions may also coalesce. Treatment. — The individual pustules are to be opened with a comedo-needle; the purulent contents gently removed by washing with tepid water and soap, and the floor smeared with any mild oint- ment, such as five grains to half a scruple (0.33-0.66) of ammoniated mercury to the ounce (32.) of cold cream, or the subnitrate of bismuth half a drachm (2.) to the ounce (32.), or the benzoated zinc salve Van Harlingen recommends, after the application of salve on bits of muslin, the covering of the whole with waxed paper. A dusting powder containing calomel may be substituted for the salve or cm- ployed afterward. The disease tends to spontaneous recovery, if the lesions are not irritated. When they are situated within reach of a child's tongue, which is constantly thrust out of the mouth to moisten them, they may linger obstinately, and require protection by flexile collodion. Impetigo Contagiosa. Impetigo Contagiosa is an acute, inflammatory, contagious disease, character- ized by the formation of multiple, usually isolated, flattened or slightly umbilicated, roundish or ovalish, split-pea-sized and larger, vesicles, vesico- pustules, or blebs, which terminate by the production of yellowish, slightly adherent crusts. The disease is also termed by Pontoppidan, Pemphigus Acutus Contagiosus Adultorum . In 1862, Dr. Tilbury Fox observed and described the disease now under consideration, to which he gave the name by which it is most generally recognized to-day. Symptoms. — The eruption, occurring in infancy, childhood, and early adult life, is often preceded by a febrile process, and appears in the form of rarely numerous, isolated vesicles, vesico-pustules, pus- tules, or bulla?, usually about the face, but also on the neck, buttocks, hands, or feet. In severe cases these are surrounded by an areola. The lesions are roundish, flat, have the average size of a split-pea, and become covered iu the course of a few days with dry, granular, straw-colored crusts, which adhere closely to the slightly reddened base on which they rest. Very superficial erosions are to be dis- IMPETIGO CONTAGIOSA. 843 covered beneath, which become rapidly covered with epidermis. They occasionally coalesce, and their complete involution requires from a week to a fortnight. When of the dimensions of bullae, a pseudo-umbilication may be observed at the apex, produced solely by naccidity of the roof-wall, which is never tied down as in variola. The contents of the lesions are inoculable and auto-inoculable, the disease thus spreading from one member of a family to another, and also from one part of the body of an individual to another. The mucous surfaces are said to be occasionally invaded. The subjective sensations are mild, the itching being rarely severe. The disease runs a tolerably definite course, being usually at end in a fortnight. It may recur. Kaposi states that it is at all times accompanied by submaxillary adenopathy. Etiology and Pathology. — Kaposi, Piffard, and Geber have all described a microscopic fungus which they discovered in the crusts of the disease, but neither they, nor Tilbury Fox, nor observers who have succeeded them, have ever been able to demonstrate the existence of a parasite in the contents of the lesions. Plainly, a parasitic vegetation on the exterior crust can have no etiological significance in this connection. The eruption often occurs during convalescence from a more or less actively contagious disease. The antecedence of some fever in many cases is admitted by all observers. Duhring and Fox himself have seen it follow vaccinia ; and the former admits that some connection between the two seems probable. The author has seen it occur typically in four children, each of whom was convales- cent from varicella ; and in one interesting case, that of a young woman convalescent from confluent variola, the lesions sprang from an integument where the pigmentation of the scars of the last-named disease had not begun to disappear. Stelwagon, in 1883, 1 making a new study of the subject, reports only six cases out of eighty-eight observed by him following vacci- nation, and concludes that the disease is non-parasitic, but an acute specific contagious exanthem, with cutaneous lesions pursuing a definite career. Pontoppidan, in 1885, found, as had many before that date, only epithelial cells, blood-corpuscles, and detritus in the crusts, never any indications of a parasite capable of explaining the' etiology of the disease. Dewevre 2 reports a number of successful inoculations and auto- inoculations practised with the contents of the vesico-pustule, with finely powdered impetiginous crusts and with the products of scraping the subjacent erosion. He reports finding reticulated mycelial tubes of the thickness of three thousandths of a millimetre in the rete mucosum beneath the lesion. In 1884, the author succeeded in producing an almost typical vesico-pustule upon his left forearm by inoculation, all due precau- tions observed, with the moistened debris of crusts. This was done i Med. Recorl, Deo. 22, 1883. 2 Arch, de Med. et de Pharm. Mil., Sept. 16, 1885. 344 DISEASES OF THE SKIN in the Dermatological Clinic, the crusts being taken from typical lesions upon the face of a young girl inoculated while under obser- vation fiom the lrd for the inoculation of two students then present at the Clinic, in one of whom there was no result, and in the other an abortive lesion. The disease is contagious, and its lesious inoculable and auto- inoculable; but whether it be a specific exanthem, or due to a purely local parasite, or other cause, must be regarded as an unde- termined question. Diagnosis. — Impetigo contagiosa is distinguished from impetigo by its frequent pyrexic symptoms; its flat, yellowish, superficial, friable crusts; its vesiculo-bullous rather than distinctly pustular lesions, and its contagiousness. In pustular eczema, there are itching, infiltration, profuseness of discharge, iudefiniteness of duration, coalescence of lesions, and extensive bulkier crusts. In varicella, the lesions are small, much more widely distributed over the body, and are vesicular only, never bullous. In pemphigus and herpes iris, the seat, character, and period of evolution of the lesions will suffice to establish the diagnosis. Treatment. — The crusts are removed and a salve applied consisting of cold cream or vaseline with from five to ten grains to the ounce (0.33-0.66 to 32.) of ammoniated mercury. Impetigo Herpetiformis. Impetigo Herpetiformis is a cutaneous disease of women, frequently compli- cating the puerperal state, characterized by the occurrence upon the skin and mucous membranes of concentrically grouped pustules, and by a febrile condition which usually terminates fatally. Symptoms. — Our knowledge of this rare disease is limited to the reports of thirteen cases observed in the Vienna clinic by Hebra and Kaposi ; one in New York, by Heitzmann; one by Pataky; and a few scattered cases recorded by others. Of the Vienna patients, twelve were women, and these usually in the puerperal state. Pin-head sized pustules, usually closely packed together in groups, filled with an opaque or yellowish-green fluid, are discovered upon the surface of the groins, navel, axillae, breasts, and other portions of the body. A dirty brownish colored crust is formed by the rupture or desiccation of these lesions, and about this, single, double, or triple concentric circlets of new and similar lesions appear in succession, > each series undergoing a similar process of involution. The erup- tion thus extends till the circlets from different foci of origin unite ; and extensive areas of the skin are involved. Beneath the crusts the skin is reddened, infiltrated, smooth, and covered with a new epi- dermis, moist as in eczema, or exhibiting a denuded corium. It is never in a state of ulceration. In the course of three or four months, the eruption is well nigh universal, the skin being swollen, shining, ECTHYMA. 345 and crust-covered, or seamed with excoriations here and there sur- rounded by circlets of pustules. The lingual mucous membrane exhibits grayish, centrally depressed patches, well-defined in contour. Alternate rigors and febrile accesses mark the periods of recrudescence when new pustules form. Delivery seems to have no favorable eifect upon the course of the disease occurring in pregnant women. An endometritis with peritonitis was discovered, post-mortem, in a single case. Two women only, of the thirteen Vienna patients, survived ; and one suffered from a relapse after several weeks of improvement. The etiology and pathology of the disease are necessarily obscure, having in view the relatively small number of reported cases. Duhring describes a much milder malady of similar type, occurring in women not pregnant, and has latterly included impetigo herpetiformis in the list of diseases covered by the title, dermatitis herpetiformis ; but Kaposi, in the last edition of his treatise, refuses to admit any such reduction of impetigo herpetiformis to a class of other maladies. Robinson also has described a case supposed to represent one of the mild manifestations of the disorder. Kaposi is inclined to associate the disease with a pathological coudition of the uterus. Heitzmann thinks it related to pemphigus. Besnier and Doyon conclude the disease to have a septicemic origin. The diagnosis of the disease is between herpes, dermatitis herpeti- formis, and pemphigus. In herpes, the purely vesicular character of the lesions and the cyclical career of the disease indicate its nature. In dermatitis herpetiformis there is commonly a distinct multiformity of lesions ; and the subjects of the disorder are not, in such great preponderance, pregnant women. In pemphigus, the size of the bullae, and their distribution in other than concentric groups, will indicate the character of the disease. The treatment is conducted on general principles, including anti- pyretics, and the local employment of alkaline, or carbolated baths ; starch and other dusting powders ; anodyne, carbolated or simple salves; and a mixture of plaster and coal-tar. The uterus should be relieved of its contents. The prognosis is necessarily grave. Ecthyma. Gr. endvfia, a pustule ; kudvu, I burn out. Ecthyma is an inflammatory disease of the skin characterized by the forma- tion of few or many, large, discrete pustules, implanted upon a dense, deeply situated base, the pus of which dries into dark colored, firm, bulky, and attached crusts, beneath which there may be superficial ulceration and resulting scarring. Symptoms. — Attention has already been directed to the position of Hebra in denying the existence of iurpetigo au d ecythma as distinct diseases. Ecthyma is, however, entitled to separate consideration, for 346 DISEASES OF THE SKIN. the clinical reasons whose Importance appears after a careful study of a few typical cases. The disease is characterized by the occurrence of one or several, roundish, bean- to rilbert-sized, yellowish or reddish pustules, which are the result of a distinctly circumscribed, inflammatory process, limited to the base of each lesion, or extending from it at the periphery in a diminishing hyperemia. This process is distinguished by the formation of an indurated phlegmon at the base of the pustule, which is converted into a loss of tissue involving the corium. The purulent or sanguinolent contents of the lesions dry in dark colored, thick, rough, adherent crusts, the color being somewhat dependent upon the quantity of the blood with which they are commingled. On the removal of this concretion, a minute, shallow, and circular pit is discovered, invading the true skin to various depths, and lined with a tenacious, puriform, and often blood-stained product. When carefully wiped clean, this solution of continuity, which really con- stitutes a minute ulcer, is seen to have a floor reddish or grayish in color, and indolently granulating. The pustules may be acutely or indolently developed, and be, when multiple, coincident or successive. They occasion rather a sensation of heat, burning, and pain, than of itching, the latter being usually more distinct when the lesions are healing under their crusts. Their formation may be preceded by mild general pyrexia. They occur at all ages and in both sexes, usually upon the extremities, but also upon every portion of the body. Etiology. — The causes of the disease are practically those of eczema and dermatitis (traumatism, heat, scratching, parasites, etc.), but these usually operate in excess, or in subjects affected with other diseases, such as anaemia, asthenia, struma, variola-convalescence, and men- strual disorders. Filth and neglect are most common aggravations ; in other words, that circumscribed cutaneous ulcer will be the angrier and the deeper, which occurs in the victim of any depressing disease, whose skin is scratched with nails begrimed with dirt, and is covered with the effete products of the excretory processes. The pus thus jDroduced may be in various degrees inoculable and auto-inoculable, as is the product of many inflammatory processes of similar grade. Pathology. — The pustule of ecthyma differs iu no respect patho- logically from the pustule of eczema or the pustule of impetigo, save in the severity of the exudative process by which it is produced, and in its limitation to the exact site of external irritation. By the ex- tension of that process to the corium, there is an actual loss of some of the elements constituting the papillary layer ; and the result is a cicatrix, which contracts as it grows older, and is, in milder cases, finally barely visible as a minute cicatriform punctum. One who frequently examines the skin of the entire body with care can usually detect the ancient sites of these lesions by their indelible though insignificant relic-. Diagnosis. — Ecthyma is liable to be confounded with the other pustule-producing exudative affections, but as the distinction between ECTHYMA. 347 them is largely artificial, and based upon the severity of the inflam- matory process, there is small danger in the consequence. Kaposi well expresses the truth in his suggestion that there can be but little objection to the employment of the term ecthyma when it is desired to characterize precisely the pustular grade of any cutaneous inflam- mation at a given time. The pustules of variola are "ecthyma-form," and many of those seen in syphilis possess similar characters. But in each the history of the general affection should throw light upon the identity of the cutaneous disease. In the latter, moreover, the ulceration at the base of the lesion exhibits the pronounced features of the syphilitic ulcer in its secretion, floor, edges, base, crust, and career. The crust, in particular, of the flat pustular syphiloderm has the rupioid conical appearance which suggests the shell of the oyster, and its underlying ulcer is larger and deeper than in ecthyma. In the furuncle there is usually a central core ; in impetigo, the pustules are not deep-seated, and there is no ulceration at the base. In im- petigo contagiosa the crust is superficial, yellowish, firmly adherent, and the lesions are more numerous. Treatment. — The general treatment of patients affected with ec- thyma is a matter of some importance. A proper regulation of the food and hygienic surroundings is not to be neglected. Tonics are fre- quently indispensable, including iron, quinine, and strychnia. The destruction of any pediculi, and the cleansing of the skin by soap and water will often be sufficient to effect a great change. This is well illustrated in hospital practice, where the little patients rapidly im- prove after a bath, followed by inunction with vaseline, and a few substantial meals of a nutritious character. When the lesions are abundant, the treatment is in general that of pustular eczema. Crusts are to be removed after soakings with oil or fat ; and the floors of the former pustules, after washing with carbolated water, should be dressed with an ointment containing ten to fifteen grains (0.666-1.) of the ammonio-chloride of mercury to the ounce (32.) of lard. If the minute basal ulcers are sluggish, they may be, after careful cleansing, touched with a small swab dipped in a solution of the bichloride of mercury in the tincture of benzoin, one grain (0.066) to the ounce (32.) Car- bolic and boric acids or iodoform may be employed for the same purpose. ' For the salve mentioned above may be substituted one containing ten grains (0.66) of calomel, or half a drachm (2.) of the subnitrate of bismuth to the ounce of salve basis. In every case of the disease it is desirable to inquire whether any medicines have been ingested prior to the appearance of the eruption, since these may be responsible for the lesions. The prognosis is always favorable. 348 DISEASES OF THE SKIN. Pemphigus. dr. -infrt, a bladder. Pemphigus is an acute or chronic disease of the skin, often characterized by febrile and other symptoms of constitutional disturbance, accompanied by the production of a series of pea- to egg-sized bulla?, irregularly distributed over the surface, and distended with serum or blood. Symptoms, — The cutaneous lesions in this disease are usually preceded by febrile symptoms; and the disturbance of the economy is declared in cardiac, respiratory, and gastro-intestinal derangements of function. The fever may be continuous, remittent, or inter- mittent, and is usually exaggerated just before the appearance of a fresh crop of blebs. The eruption first appears in reddish maculae of rather vivid hue, in the centre of each of which appears later a whitish elevation of the epidermis suggesting a wheal. Either upon these or unaffected points of the skin, tense, well-rounded bullae subsequently form, varying in size from a pea to a hen's egg and even larger, and in number from three to six only, to a hundred and more. They are usually irregularly distributed (Pemphigus Disseminatus), but may be clustered in groups, or very rarely be found the younger encircling the older lesions, so as to form a circinate appearance (Pemphigus Circtnatus) ; their contents are serous, bloody (Pemphigus ELemor- rhagicus), or later purulent, with color corresponding to these fluids. Whether ruptured or not, the involution of the lesion is accomplished by desiccation and crusting, the crusts being usually found to contain blood, pus, epithelial debris, and the exudate from the base of the bleb. Beneath such a crust a new epidermis forms, which is usually violet, purplish, or bluish-red in color, and, later, displays a brownish pigmentation which may for several weeks survive the disease. Occasionally the affection occurs with very mild and even insig- nificant phenomena (Pemphigus Benignus). There may be no fever, and a very few blebs appear ; in some cases but a single lesion can be seen (Pemphigus Solitarius). In other instances, the fever is intense ; the eruption abundant ; the skin (edematous, painful, pruritic, excoriated, and the underlying lymphatic glands enlarged. This general condition with exacerbations and remissions may persist for months, and the eruption then disappear never to return or to recur, as it often does, in the future. The term Pemphigus Vulgaris is applied to the more common clinical forms of the malady, but it is also employed generically by many authors to include all varieties of the disease. Pemphigus Diutixus designates that pemphigoid eruption in which the charac- teristic lesions follow each other with rapidity, fresh bullae appearing each day. Fortunately, all forms of the disease are relatively rare. The lines technically drawn between many conditions of disease are PEMPHIGUS. 349 quite artificial, however useful aud uecessary for systematic study and classification. Clinically, many of these distinctions disappear. This is especially true of the varieties of pemphigus. Between the benign processes just considered and the grave form of pemphigus foliaceus described in another chapter, several intermediate gradations can be observed, and even the most benign may at times unexpectedly assume the most malignant phases. Pemphtgus Malignus is a name given generally to those intermediate varieties of the disease, most of which are distinguished by persistent and prostrating fevers; cachexia, especially in infants; the occurrence of diphtheritic patches upon or about the lesions, with infiltration of the derma and slough of its superficial layers ; or extensive crusting, and even subsequent ulcera- tion. A form is described by Hebra and Kaposi, in which vegeta- tions and fungosities rise from the base of the blebs. Pemphigus Pruriginosus is another grave form of the disease, in which the lesions give rise to an intense pruritus, under the scratching induced by which they are torn, excoriated, and commingled with the crusts and exudations of an artificially engendered eczema. Several of these malignant and intermediate forms may terminate fatally. In all varieties of the disease, the lesions may be, exhibited upon the mucous membrane of the accessible outlets of the body. An important distinction, which has been established only within late years, should be made between acute and chronic pemphigus. Acute pemphigus occurs in adults, children, and infants, more fre- quently among the very young. It may be epidemic in hospitals and other public institutions. With or without an antecedent febrile movement, the blebs may appear before birth or within a fortnight after, in infants which are either well nourished or cachectic, more often the latter. In favorable cases, the evolution of the disease is completed in three or four weeks. Any part of the body may be affected, but, what is important from a diagnostic point of view, the face, hands, and feet are often exempt. The conjunctiva and mucous lining of the mouth may, however, become implicated. In some cases the pemphigus may be of hgemorrhagic type. Underneath the lesions, the rete is exposed, and has a reddish, glistening look. The termination may be fatal. Acute pemphigus of adults is still rarer. As in the case of infants, there may be marked febrile antecedents and systemic disturbance. The eruption of pea- to large nut-sized bullae may be sparse or abundant, covering in cases the entire body, and attacking the mucous surfaces. The vesicles or bullae may be tense, flaccid, and filled with clear, serous, or puriform contents. Beneath may be seen a smooth, raw, mucous layer or a diphtheritic exudation. According to Weyl, Bulkley's Herpes Gestationis is an example of acute pemphigus adultorum. Chronic pemphigus exhibits the greatest variation both as to its symptoms and the period of their efflorescence. There may be a week or month of immunity, followed by benign relapses, or by malignant and rapid recurrences. The bulla? may form upon an unaltered or deeply hypersemic skin, in all sizes from a pea to an 350 DISEASES OF THE SKIN. orange, invading the skin and mucous surfaces including the vagina, the lesions at the base exhibiting the several features described above. The eruption is rarely generalized, and throughout not more than half a dozen Lesions may be at any one moment visible upon the surface of the skim The contents may be removed by evaporation, absorption, or rupture, leaving a crust whose color is largely deter- mined by the contents of the bleb. Etiology. — The causes of pemphigus vulgaris are so obscure that they may be said to be unknown. The disease is more frequently encountered in infancy and childhood, because, it would seem natural to conclude, the powers of resistance at a tender age are inferior to those of a maturer epoch. The disease is in general observed in debilitated patients, who are variously described as suffering from "nervous prostration," "mental worry and exhaustion," u neuras- thenia," " general debility," visceral disorders, and impairment of nutrition. Occurring in a vigorous, rosy-cheeked, strong-limbed adult, the disease would certainly be regarded as a curiosity. It is, therefore, safe to conclude that those states in which there is marked impairment of bodily vigor are particularly favorable to the develop- ment of the disease. Kaposi relates one case in which the disease seemed to be inherited, as the patient's mother, sister, mother's brother, and some of the children of the latter had been affected with the malady. While, however, this author admits such association of nervous disorder with the disease as occurs in hysteria and pregnancy, he concludes that there is little if any etiological significance in the fact. I have, however, observed one case in an adult where pemphigus of typical appearance occurred after mental depression, which was so greatly increased by the appearance of the exanthem as to lead to suicide. There is good reason to believe that, at least in some of its forms, the disease is contagious. The bullous lesions, however, seen in syphilis, lepra, and other similar disorders, should not be here included. Pathology. — Kaposi and Weiss found anatomical changes in the spinal cord of but one out of nine fatal cases of pemphigus. In this there was diffuse sclerosis, but the case was complicated with cancer. Jarisch discovered swelling of the processes of the ganglion-cells and interstitial fibrous deposits in a similar case. Dejerine and Leloir found changes in the peripheral nerves due to degeneration in a case of pemphigus. The contents of the bulla? of acute pemphigus were found to con- tain bacteria by Gibier in 1882. The microbe recognized by him was, when mature, arranged in chaplets, each containing a series of joints. His observations were confimed by Vidal and Roaser. Riehl in 1883, discovered both conidia and spores in the layer of epidermis beneath the lesions of an infantile pemphigus. Demme, 1 in 1886, found cocci both in the contents of the bulla?, and in the blood. 1 Viertel f. Derm. u. Syph., 1886, p. 636. PEMPHIGUS. 351 On the other hand Thin, of London/ after full trial of all methods of staining and cultivation now employed, had entirely negative results in his attempts to discover microorganisms in the contents of the bullae of pemphigus. Diagnosis. — From what has preceded it will be inferred that pem- phigus is a name given to a disease, and not merely to bullous lesions upon the surface of the skin. It is of some importance to remember this fact, as several authors have used the term in a purely descrip- tive sense, the fact being that bullae are manifestations of several disorders, including syphilis, lepra, pemphigus foliaeeus, herpes iris, and erythema multiforme. At the outset, consequently, the blebs of pemphigus can scarcely be differentiated from those of other diseases. It is necessary for its recognition that proper consideration be had of all the cutaneous and other phenomena present in the disease. In syphilis, such lesions are rare in the adult, and relatively more frequent in infants heredit- arily diseased. With the latter, the blebs are usually seen at birth, often upon the palms and soles, and are frequently superimposed upon an exulcerated base. The coexistence of mucous patches of the mouth, vulva, and anus with the evident polymorphism of the lesions and signs of grave cachexia, will usually indicate the nature of the disease. The cutaneous symptoms of such infants are improperly designated as pemphigus. Such an eruption is a bullous syphiloderm. In the bullae of lepra, there is usually coexisting cutaneous anaes- thesia, and the involution of the bleb is followed by a strikingly characteristic atrophic patch, usually pigmented and insensitive. In pemphigus foliaeeus, the extraordinary and usually generalized des- quamation which ensues, is sufficiently distinctive, though it must be borne in mind, as heretofore stated, that the several varieties of pemphigus may be transformed, the one into the other, by well-nigh insensible gradations. Among its graver forms susceptible of such transformation may be named, impetigo herpetiformis, pemphigus cachecticus, pemphigus diphtheriticus, and pemphigus pruriginosus. In herpes iris, the lesions are more vesicular ; much more tran- sitory; subject to a concentric arrangement and variation with respect to color; and are situated more frequently upon the extremities, especially the backs of the hands. The bullous lesions occasionally seen in urticaria and erythema multiforme, are to be recognized by the other characteristic symptoms of those diseases ; in the former, more particularly, by their intermingling with typical wheals ; and in the latter, by the location of the eruption, and its climatic or seasonal significance. Some of the reported contagious forms of pemphigus, epidemics of which have been described by Besnier, Hervieux, and other French authors, were possibly, as Duhring sug- gests, instances of impetigo contagiosa. This inference is sustained by the frequent allusion of the writers named to the "varicella-form" appearance of the lesions. i Lancet, May 30, 1886, p. 981. 352 DISEASES OF THE SKIN. Some of the ingested medicaments are capable of producing bullous lesions, for example, the iodide of potassium ; and such a possibility should always be borne in mind when establishing a differential diagnosis. Scabies in infants and children is occasionally character- ized by the formation of blebs, in which case the other lesions present, as also a history of contagion and the discovery of the parasite, will point to the real nature of the disease. Lastly, the external application of cantharides, mezereon, the stronger acids, alkalies, and other chemicals may be followed by blebs produced either by accident or intention with a view to feigning disease. The intentional production of such symptoms is usually effected upon the anterior faces of the lower extremities, regions within easy reach of the right hand. Erysipelas and dermatitis calorica are also diseases in which blebs appear, always, however, of minor significance as compared with the other symptoms of disease present. The same may be said of the bullae which form upon a gangrenous integument. Treatment. — The internal treatment of pemphigus is a matter of importance, as will be suggested by even a brief consideration of the constitutional states in which it occurs. Mr. Jonathan Hutchinson, of London, Eng., in his valuable Lectures on Clinical Surgery, 1 dis- tinctly asserts his belief that "arsenic is a specific for the state of health upon which relapsing pemphigus depends." In many years' trial of this remedy, he .declares that, in his own practice, he has never recorded a single failure, though he makes exception, properly, of many infantile cases supposed to be syphilitic. The remedy is certainly a valuable one, but should be employed with the same caution and in accordance with the rules already prescribed in the chapter on psoriasis. Kaposi, however, declares that he has been unable to obtain favorable results from its employment. Iron, quinine, ergot, strychnia, and the mineral acids are certainly indicated in many cases, in conjunction with a particularly nutritious diet. Cod-liver oil and the malt preparations now in the market should not be neglected. Not infrequently the treatment should be directed to the relief of the anomalous performance of the sexual function in women, as the disease has been found to occur in the hysterical and chlorotic states sufficiently common as a result of such disorder. The local treatment of the lesions should consist, first, in a punc- turing of each bleb with a fine needle, in order to give exit to its contents, which should be carefully removed from the skin by the aid of cotton-wool. Then the parts are to be thoroughly enveloped in an inert dusting powder. When there is considerable pyrexia with heat and distress in the skin, the surface may be treated as in acute eczema, with oleated lime-water, containing also opium or dilute hydrocyanic acid in some such proportions as those already detailed. 1 London, J. & A. Churcliill, 1878, p. 49. CUTANEOUS HEMORRHAGES. 353 The ordinary lead and opium wash, with or without the addition of the oxide of zinc, will also answer a good purpose. In Vienna, the continuous hot-water bath still enjoys the highest favor. Kaposi has kept one patient day and night for eight months with his body thus immersed, to the great advautage of the latter. Such a course is often impracticable outside of a large hospital ; but the author has, in two cases of grave pemphigus, employed the con- tinuous hot-water bath in private houses, with the happiest results. Prognosis. — The prognosis in mild cases of pemphigus, though much less grave than in the malignant forms of the disease, should always be formulated with caution. Unlike several of the diseases heretofore considered, the aifection is one not frequently encountered in persons of fair general health. The constitutional condition of the patient must be carefully considered; nor should it be forgotten that the disease is not only one liable to relapses, but also one in which the graver may succeed the more benign manifestations. A flaccid summit of the bleb, sanguinolent or ichorous contents, an abundant efflorescence, and a rapid succession of new after the involution of more ancient lesions, are in general unfavorable symptoms. The same may be said of degeneration of the floor of the bleb, after rupture and discharge of its contents. CLASS III. HJEMOEBHAGES. Cutaneous Haemorrhages. Cutaneous Haemorrhage is characterized by the issue of a part or all of the constituents of the blood from the cutaneous or subcutaneous vessels, with and without rupture of the vascular walls. Haemorrhage into the skin may be active or passive, idiopathic or symptomatic, and may vary greatly in extent. It may be limited to but a small area of the integument, or may be symmetrical and universal, or coexist with similar blood extravasations in the mucous membranes, and the investments and parenchyma of the viscera. It may result from undue intra- vascular pressure, as in violent effort with extraordinary demand upon the circulatory system. It may occur with a normal intra-vascular pressure when there is lessened extra-vascular atmospheric pressure, as after ordinary exer- tion in high altitudes. It may result from disease of the vascular walls, as in malnutrition. It may occur after traumatism of the latter, or by diapedesis through the walls of uninjured capillaries. It may result also from lack of Support of the vessels due to various disorders of peri-vascular tissues, as in the case where the epidermis 23 354 DISEASES OF THE SKIN. is artificially removed, or where au abscess cavity is evacuated of pus, and the sac immediately fills with blood. Idiopathic haemorrhage into the skin and neighboring tissue is usually the result of traumatism, and accomplished through rent of the vascular wall. The discolored patches which result from con- tusions of the surface of the body are illustrations of this condition. Examples of symptomatic cutaneous haemorrhages are to be found in the course of such general diseases as septicaemia and variola, and of such cutaneous disorders as herpes, pemphigus, and erythema multiforme. Bullae ELemorrhagicle are globoid, bean- to egg-sized eleva- tions of the epidermis, filled with a sanguineous or sero-sanguineous fluid, giving such lesions a reddish, brownish, or purplish shade. Ecchymomata are nut- to egg-sized, and even larger, firm or fluctuating, flattened or elevated tumors, filled with blood, and having a cutaneous envelope. Ecchymoses are small coin- to palm-sized, and even larger, light red to dark purplish, irregularly shaped, macular colorations of the skin, not fading under pressure, and due to circumscribed cutaneous haemorrhage. Petechia are pin-point to small coin-sized, light red to dark purplish macular colorations of the skin, not fading under pressure, and due to circumscribed cutaneous haemorrhage. Vibices are linear maculations of various lengths, due to the diffusion in the skin of extravasated blood in the form of streaks or bands. They are often commingled with petechias and ecchymoses. Purpura. Gr. -rropQvpcog-, purple. Purpura is a disease characterized by the appearance in the skin, of reddish- purple or livid maculae, varying in size, usually not clustered, and not wholly disappearing under pressure, which may be associated with systemic symptoms. Some confusion has existed in connection with the term, Purpura, in consequence of the fact that it has been employed indiscriminately by authors in the designation of both symptoms and diseases. The following disorders are commonly included under this title : [A.] Purpura Simplex. In this form of cutaneous haemorrhage, pin-head to pea-sized light red to dark purple petechia? and small ecchymoses, usually PDEPURA. 355 multiple and symmetrical, of slow or sudden occurrence, appear upon various portions of the surface, chiefly over the lower extremities, and here doubtless by preference, because of the greater effect of gravity upon the column of blood. They usually awaken no sub- jective sensation, and may occur in persons of apparently unaltered health, though rigid examination will often disclose some facts having a bearing upon the etiology of the disease. The subjects of the dis- order are frequently asthenic, and complain of unwonted lassitude and malaise. The disease may last for a fortnight, and in exceptional cases be accompanied by a febrile rise of temperature. Lesions of this sort may be due solely to an ingested medicament, such as arsenic, salicylic acid (Freudenberg), or quinine. The author has seen the lower extremities completely covered with petechia?, induced by the ingestion of the iodide of potassium, a fact reported by other observers. Purpura Urticans is that form in wdiich there is an irritability of the skin sufficient to produce w r heals, urticarial lesions accompanied by itching in various degrees, which have the purpuric hue in consequence of circumscribed cutaneous haemorrhage. Purpura Rheumatica. (Peliosis Rheumatica.) This is a variety of purpura which has a striking analogy to ery- thema multiforme, and is probably an exaggerated form of some of the conditions recognized under that title. It is preceded by the usual febrile or other premonitory symptoms associated with arthritic pains, especially of the knees and ankles, which may become swollen, or be affected with an hydrarthrosis. In a few days, petechial to ecchymotic, light red to dark purplish maculations appear upon the extremities, trunk, or the entire surface of the body, fadeless under pressure, and usually with coincident relief of the arthritic paiu. The subjective sensations are ordinarily trivial. In a fortnight, the eruption may subside, its color undergoing the usual variations from greenish to orange and light yellow ; but relapses are common in the course of weeks, with recrudescence of the fever, return of the rheu- matoid symptoms, and progressive asthenia. Kaposi describes cases in which there was coincidence of purpura rheumatica with renal haemorrhage, albuminuria, and gangrene of the soft palate in conse- quence of its over-distention with blood. Cases are also on record where there were cardiac involvement and grave disorder of other viscera. According to Mackenzie, 1 the disease occurs in both sexes, more frequently in women however, and between the ages of twenty and thirty, though also at earlier periods of life. The purpuric spots observed by him usually made their appearance regularly in the afternoon or evening, sometimes daily, and often with several i Brit. Med. Journ., March 18, 1882, p. 383. 356 DISEASES OF THE SKIN. days' interval, accompanied by pain, stiffness, and .swelling of the joints. The maculae were at first of a bright reddish hue, but became purplish by the ensuing day. The site of predilection was the extremities, but the eruption in his cases was sometimes more generalized. The lesions displayed this amount of symmetry : if they occurred on one extremity, upper or lower, they would generally be found on the other. As a rule, there were not profuse sweats, unless the attack occurred with rheumatic fever; the joint affections and pyrexia, though distinct, were not severe. Sometimes there was a certain amount of erythema accompanying the haemorrhages; often the eruption was purely haemorrhagic. The attacks were frequently very protracted, lasting even some months, and were liable to recur. The disease occurs in both sexes, though more often in young women, and is to a certain extent influenced by the changes of climate and season. Its diagnosis, in consequence of its marked characteris- tics, coincidence of petechias and ecchymoses with rheumatoid pains, is readily effected. Duhring calls attention to the danger of con- founding it with the macular syphiloderm, the lesions of which, however, fade under pressure. The prognosis is in general favor- able, though the disease may persist for long periods of time, and may, in rare cases, terminate fatally. [B.] Purpura Haemorrhagica. (Morbus Maculosus Werlhoffii.) This disorder, called also land-scurvy, is usually ushered iu with phenomena of a febrile character, accompanied by symptoms of general depression. Subsequently, ecchymoses appear upon the ex- tremities aud trunk, both spontaneously and at points where the integument has been specially subjected to pressure and friction. Usually petechias appear simultaneously upon the nasal, laryngeal, buccal, and other mucous surfaces, which may also be the seat of exhausting haemorrhages, resulting rarely in fatal collapse. A symp- tomatic fever is usually awakened. The disease occurs equally in the robust and feeble of all ages, and, though usually as a sporadic affection, it may assume an epidemic form. The disease is slow in its course, but commonly terminates favorably after the lapse of several months. The lesions commonly appear first on the upper extremities ; then over the trunk, and finally over the lower extremities. They are usually dark red or purplish in hue, varying in size from a pin-head to a bean, but may be of the size of the palm. It is distinguished from purpura scorbutica, or "scurvy," by the absence of distinctive premonitory symptoms of the latter disease, and its invariable occurrence among those suffering from improper alimentation, vitiated air, and lack of exercise. PURPURA. 357 Purpura Scorbutica. (Scurvy.) This disorder is peculiar to those who are compelled to subsist for lengthened periods of time on improper food, more particularly that from which fruit and fresh vegetables are excluded; to respire a vitiated air ; and to endure such confinement as precludes the pos- sibility of duly exercising the body. The disorder is hence more common among sailors, prisoners, Arctic voyagers, and men similarly situated. The cutaneous lesions are, as in so many other forms of purpura, preceded by an almost characteristic sense of languor and depression. One or several joints may then enlarge. There may be, however, a distinct febrile action. The haemorrhages which result are quite like those of purpura haemorrhagica; and the cutaneous lesions are petechia?., ecchymoses, and painful ecchymomata, usually first appearing on the lower ex- tremities, which may fluctuate, open, and result in offensive ulcera- tions reaching to the bone. Simultaneously with the cutaneous eruption, the gums become involved, and show as tumid, haemor- rhagic, or ulcerative ■ fungosities, smeared with a dirty yellowish secretion, and having a fetid exhalation. The subcutaneous connec- tive tissue, muscles, fasciae, and viscera become also involved. The disease is accompanied by febrile and other general phenomena of asthenia, and, when the causes are persistent, results fatally. It is, however, remediable by proper treatment, though convalescence is usually tediously prolonged. Purpura Pulicosa is the result of the traumatisms produced by fleas, lice, and bugs. The lesions are punctiform, and due to the welling up of blood into the minute punctured wound, surrounded usually by an hypersemic halo which is the result of the irritation. When the latter fades, the centra] hemorrhagic point usually for a brief time persists. The disease is characteristically manifested upon the filthy skins of indi- viduals long bitten by bugs, and covered with excoriations and dark colored crusts, the result of scratching. Such cases are often pro- nounced scorbutic. The symptoms of cutaneous haemorrhage are also observed in other conditions besides those named above. Petechias and ecchy- moses are also in cases noted upon the lower extremities of the sub- jects of tuberculosis, cancer, and the plague. In Haemophilia, a disease occasionally of hereditary origin, and characterized by the facility with which trivial traumatisms of the surface are followed by incoercible haemorrhages, purpura may be the first signal of the predisposition. A young man with purpuric lesions of both lower extremities, and otherwise in apparently good health, lately presented himself at the Dermatological Clinic for the relief of the difficulty. 358 DISEASES OF THE SKIN. There was at the time no suspicion of haemophilia, but two weeks later, as the result of a vaccination, he bled continuously for eight days. Pathology. — Many cutaneous haemorrhages, not resulting from traumatism, however manifestly and immediately due to morbid conditions of the vessels, are by many authors believed to have a neurotic origin. Purpura hemorrhagica, for example, in conse- quence of the frequent absence of lesions of the vascular walls suffi- cient to explain its phenomena, is by Wagner, Henoch, and others explained by supposing either abnormal excitation of the sympa- thetic system, or paresis of the vaso-motor centres. Cavalier 1 reports a case of purpura alternating with paralytic symptoms. The fre- quently symmetrical disposition of the lesions has received a similar interpretation. Tyrrell 2 reports cases induced by marsh-miasm, and' Satterthwaite, 3 of New York, a similar case, in which the eruption followed a chill lasting three-quarters of an hour. In all these eases, the haemorrhages occur chiefly in the derma, though often in the subcutaneous connective tissue, a fact well illus- trated by the drawings made by Variot 4 of sections of the purpuric skin of a patient dead of haemoptysis. In this case there was nu- merical diminution of the red corpuscles in life, as demonstrated by the hematimetre, without any change in their form, volume, or color. Inflammatory complications in these conditions are rare. The color of the several lesions induced is, without question, derived from the hsematine, which not only stains the environing fluids, but also the tissues themselves where the extravasation occurs, and appears, when absorption of the fluid portions of the clot has been accomplished, in the form of variously sized granules. In this way, the color-changes between red, orange, yellow, purple, and violet in the resolution of petechia? and ecchymoses are to be explained. The persistence of the pigmentations varies with the quantity of the effused blood and its seat. In mild cases, especially of lesions involving the upper half of the body, all traces of the haemorrhage may be removed in the course of a few weeks. Dark pigmentations resulting from purpura scorbutica, affecting prisoners at Audersonville during the late civil war in this country, are still, in some persons, perceptible upon the lower extremities. The explanation of the diapedesis of blood through the vascular walls by supposing changes to have occurred in the fluid itself, has been made by dial vet, Andral and Gavarret, and others. The pale and watery appearance of the fluid, the increase in the proportion of fibrine in the clot, the diminution in the number of the red blood- corpuscles, and the lowered specific gravity of the blood have all suggested this view. Kietschy has called attention to irregularity in the shape and metamorphosis of figure in the red blood-corpuscles. i Bull. Gen. de ThSrap., 1879. = Pacific Med. and Surg. Journ., June, 1876. 3 Med. Gazette, Jan. 14, 1882, p. 14, cited by DnhrinK. 4 Journ. do l'Anatoni. et de la Phys , Nov.," Dec, 1881, p. 520. PURPURA. 359 Wilson, Fox, and others, again, have recognized lardaceous or inflammatory changes in the vascular walls, with embolism or thrombus in others. Watson Cheyne 1 discovered in a case recorded by Russell, some of the capillaries in the neighborhood of the haemor- rhages plugged with bacilli, and colonies of the same in the blood effused after rupture. Treatment. — The treatment of these various forms of cutaneous haemorrhage will clearly depend upon the nature of the cause in each case. In general it may be said that internally the use of ergot, of the chloride or other salt of iron, and of quinine is advisable. The oil of turpentine, the tincture of the muriate of iron, the acetate of lead, and dilute sulphuric acid, have all been employed at times with marked success ; at others, without ; in the treatment of these cases. Hypodermatic injections of Bonjean's ergotine, one part to two of distilled water, repeated every second day, have been speedily followed by favorable results. A generous diet, the use of wines, malt liquors, and even spirits, and strict observance of the demands of hygiene, are often essential methods of relief. In the way of local treatment, the gums often require an applica- tion of rhatany, one part of the extract to fifty or sixty of lotion ; or equal parts of the tincture of cinchona and tincture of myrrh, diluted as required. Rest in the recumbent position is advisable, and, if haemorrhage be actually in progress, the free use of haemostatics will be required with local application of ice. For those who are convalescent from systemic disorders accompanied by purpuric lesions of the lower extremities, resorption of the extravasated blood may be hastened by the local application of stimulating spirit lotions with friction ; and the pres- sure of the blood column may be partly relieved by elastic bandaging of the extremities. The prognosis has been given, as far as might be, in connection with each disorder named. i Brit. Med. Journ., Sept. 1, 1883, p. 416. 360 DISEASES OF THE SKIN CLASS IV. HYPERTROPHIES. 1. Of Pigment. Lentigo. Lat. lens, a freckle. Lentigo is that condition in which occur pin-head to bean sized, yellowish to brownish, circumscribed, and usually multiple maculations of the cutaneous surface, due to an excessive deposit of pigment, most often seen on the face and dorsal surfaces of the hands. Symptoms. — This condition, termed also Ephells, is due to exces- sive and irregular deposit of pigment in the skin, producing the pin-head to bean-sized spots of circinate or irregular outline, frequently grouped and even confluent, which are commonly desig- nated as " freckles." They are most frequently seen symmetrically distributed on the parts of the body ordinarily exposed to the light and heat of the sun and atmospheric influences, such as the face, the neck, and the backs of the hands in persons of both sexes. In those whose bodies are to a greater extent similarly exposed, they occur upon the chest, the back, and over the extremities. In other indi- viduals, they may be seen upon parts not thus exposed, such as the penis, the scrotum, and the inner faces of the thighs, a fact which indicates that they are not always the result of the operation of the agencies noted above. They vary in color from light yellow, salmon, and red to the deepest brown ; and are most noticeable in persons having red hair and a delicate skin. They occur rarely in infancy, partly, perhaps, on account of the infrequency of out-door exposure in tender years ; and are usually seen first about the age of six to eight years. They are commonly observed in mulattoes, individuals of a race particularly disposed to the anomalies of pigment distribu- tion. Once developed, the lesions may persist through life without marked alteration ; or fade with each recurrence of the season of winter ; or, in milder cases, entirely disappear. They usually share in the atrophic changes of old age, and, when persisting to that period, may then spontaneously disappear. They are not the source of subjective sensation. Etiology. — Freckles are, without question, produced and aggravated at times by the action of the light and heat of the sun, as a common experience declares ; but it is evident that these forces must act upon a susceptible skin. Of a hundred sailors exposed in precisely similar situations on a long cruise, some of the number will be uniformly " tanned," and others deeply " freckled." Attention has been called to the occasional occurrence of lentigo in the protected parts of the skin. Dr. White, of Boston, in an interesting paper on melano- CHLOASMA. 361 derma, 1 calls attention to the fact that exposure to sea-air and fog, with obscuration of the suu, is sufficient to produce the result. Pathology. — Freckles are due to an increase of deposit of pigment in definite areas of the epidermis, never in the corium. Lesser urges, with strong probability in his favor, that there is always a congenital predisposition to these pigment formations which requires certain external conditions for development. Treatment. — The treatment of lentigines is that of chloasma and other pigmentations of the surface. Prof. Wertheim, of Vienna, advises : R. Hydrarg. ammon. muriat. gr. lvj ; 3 75 Bismuth, magister. gr. lij ; 3 50 Ungt. glycerini §j ; 32 M. Sig. To be applied only every other night. Bulkley employs : R . Hydrarg. chlor. corros. gr. yj ; 4 Acid, acetic, dilut. f £ij ; 8 Boracis £)ij ; 2 66 Aq. ros. fgiv; 128' M. Sig. To be applied night and morning, at first with gentle brush- ing ; afterward by rubbing. Hardaway touches each freckle with a rather stiff needle connected with the negative pole of a galvanic battery, and finds the results satisfactory. Most of the secret methods employed by charlatans for the removal of freckles depend for their success upon thorough blistering of the surface. Inasmuch as by this process the epidermis is removed, it is evident that the pigment of its cells is also removed with it; and the new epidermis is for a time quite free from blemish. But in all such cases the ultimate result is a deeper and more persistent pigmentation than that which was previously visible. Chloasma. Gr. x^oa^a), to possess a greenish color. Chloasma is that condition in which occur yellowish to blackish, finger-nail to palm-sized, circumscribed, diffuse, and ill-defined maculations of the cutaneous surface, due to an excessive deposit of pigment. Symptoms. — In this affection the skin is either diffusely discolored in various shades, or the maculations occur in patches larger than those of lentigo, fairly well-defined, and irregular in contour, the so- called " liver-spots." In color they vary from a scarcely perceptible staining of the skin, which requires a strong light for its detection, to a deep yellow, a yellowish-green, a chocolate-brown, or a blackish shade (Melanoderma). They may be either idiopathic or symp- tomatic in character. 1 Boston Med and Surg. Journ., May 16, 1878, p. 624. 362 DISEASES OF THE SKIN. The idiopathic varieties of chloasma are produced by all externally operating agencies, in eonsequence of which an undue afflux of blood is persistently determined to any portion of the skin. It is largely from the blood that the pigment is derived, and hence the stains produced by the latter are, to a certain extent at least, proportioned to the hyperemia, stasis, or extravasation of the vascular fluid. Among these externally operating agencies may be named, pressure and friction (as over the part covered by the pad of a truss) ; trauma- tism (as after the severe scratching of the skin affected with lice, eczema, or scabies); heat (as in diffuse "tanning" of the face, or "sunburn" following exposure to the solar rays) ; and the toxic or irritating effect of externally applied substances, such as mustard, capsicum, cantharides, and other articles capable of producing either vesication or pustulation of the surface. The physician should always remember the possibility of producing long, persistent, or even permanent pigmentations of the skin upon the face, shoulders, and bosom of young women especially, by the repeated application of such topical medicaments. The symptomatic varieties of chloasma are the results of disorders either systemic or involving the internal organs. They occur as either circumscribed or diffuse, localized or generalized, spots, mottlings, stainings, or " masks " of the skin ; and vary in color from the lightest to the darkest shades. One of the most common, and at the same time the most marked of these, is Chloasma Uterinum, so called because of its frequent association with certain physiological or pathological conditions of the uterus, both among married and single women. Thus in pregnancy, sterility, hysteria, chlorosis, ovarian disorders, and tumors, and functional derangements of the uterus, there can be observed at times a facial discoloration extending equably over the forehead and reaching nearly to the line of the hairs at the scalp, in the form of a faint or decidedly yellowish, reddish- yellow, or deep brownish tinge. At other times, the discoloration is macular and asymmetrical, involving the lids, the cheeks, the lips, or the chin. When the chloasma assumes the mask-like form, it is usually most pronounced over the forehead, but may involve the whole facial region, being less distinctly defined below than above. Similarly, the well-known changes occur in the areola of the nipple, along the linea alba, and about the external genitalia. Melanoderma, or Chloasma, Cachecticorum is another of the symptomatic pigment -disorders, characterized by the changes in the color of the integument of the subjects of tubercu- losis, . syphilis, cancer, chronic alcoholism, malaria {e.g., " Chagres fever"), and other disorders. The peculiar bronzing of the skin in Addison's Disease, formerly thought to be due exclusively to lesion of the supra-renal capsules, is of the same nature. Overbeck and Greenhow have shown that the capsules may be completely destroyed without changes in the CHLOASMA. 863 skin-color resulting. The pigmentation may be general or partial ; and in the latter case is without definite lines of demarcation. It is commonly most pronounced over the face, neck, scrotum, groius, axillae, and nipple and areola The hairs become coarse and dark ; and dark patches are at times visible over the mucous surface of the lips, gums, and other parts of the mouth. The bronze or mulatto- like color of the skin is intensified by stimulation or erosiou of the cutaneous surface. In these cases there is generally marked asthenia, with a feeble pulse, with anorexia and other signs of gastro-intestinal disorder. When the result is fatal, there may or may not be recog- nized pathological alterations of the supra-renal capsules. Among the cutaneous disorders capable of producing skin pigmen- tation may be named scleroderma, lepra, angioma pigmentosum et atrophicum, eczema, especially e. venis varicosis; and general exfolia- tive dermatitis. From all of the discolorations named above, which are due solely to deposition in excess of coloring matters normally existing in the skin, it is necessary to distinguish the various dyschromia? which are owing to the introduction into the integument of coloring substances, either supplied by other portions of the body or entirely foreign to it. Thus, in icterus, the bile may color the skin from a light yellow to a dark chrome color, the duration and severity of the cutaneous symp- toms depending upon the nature and gravity of the hepatic disease. It is frequently accompanied by pruritus in various grades of severity, the exact causes of which are obscure. In Argyria, the bluish, bluish-gray, slate-colored, or bronzed coloration of the skin results from the introduction from without of the nitrate of silver. It is most commonly the result of the adminis- tration of the drug in the treatment of epilepsy, but is said also to have resulted from the topical application of the silver crayons to the throat, to the conjunctiva?, and even to the skin. Under what form the silver produces this effect, whether as an albuminate or other salt, is not known. The deposition, however, occurs in the form of minute particles of the metal in the connective tissue of the derma. The discolorations are most evident upon the parts of the skin ex- posed to the light, as the face and hands ; but the author has seen the chest and lower extremities similarly stained. The connective tissue of the viscera is also at times involved, showing thus that the action of light is not essential to the production of the dyschromia. Two cases are reported as relieved by the administration of the iodide of potassium. The administration of arsenic in full doses for relief of nervous disorders in children has been followed by a characteristic dull brownish or dirty-colored discoloration of the skin of the neck and chest. Several cases of this sort have been presented to the author's observation in his clinic by Dr. H. JST. Moyer. By the process of tattooing, lastly, several mineral and vegetable substances are directly introduced into the corium by means of 364 DISEASES OF THE SKIN. needles, for the production in the skin of various devices in colors. Individuals whose entire integument has been thus artificially covered with figures of different patterns by tattooing with indigo, vermilion, and cinnabar have been from time to time exhibited in this country. The results are indelible. Post-mortem, these pigments have been discovered not only in the derma, but in the lymphatic ganglia nearest the site of their introduction. Pathology. — The lentigines, ephelides, and chloasmata are all due to excessive deposit of the natural pigment of the body in the rete mucosum of the epidermis. Restoration of the normal color of the skiu is usually proportioned to the extent and depth of the deposit, but the process is always very gradual. It can lie well studied in the slow bleaching of the pigmentation of syphilitic cicatrices upon the lower extremities. In the dyschromias due to the introduction of coloring- matters foreign to the body or foreign to the skin, the corium and subcutaneous connective tissue are commonly stained. Diagnosis. — The diagnosis of the cutaneous pigment hypertrophies is readily effected by observing the persistence of the discoloration under pressure ; the absence of all symptoms of hyperemia, inflam- mation, and secondary changes in the skin, as also by the charac- teristic shades of color presented to the eye. In tinea versicolor there is usually slight furfuraceous desquamation, and the existence of a vegetable parasite is readily demonstrated by the mieroscope. The rare pigmentary syphilide is usually seen upon the neck and shoulders of infected women in the form of yellowish to brownish maculations, often arranged in an irregular network. It is, indeed, one of the symptomatic chloasmata. Treatment. — In all the symptomatic pigment anomalies, the indi- cations for treatment are presented by the disease which begets the cutaneous disorder. The local treatment of both the idiopathic and symptomatic varieties of the disease demands the use of external applications which will hasten the physiological reproduction of the epidermis, substituting thus new and unpigmented for old and pigmented epi- thelia. This must also be accomplished without the artificial pro- duction of such an hyperemia as will tend to add to the very coloration which it is attempted to relieve. The substances used for the slow accomplishment of this end are muriatic and acetic acids, borax, sulphur, tincture of iodine, potash, and soda (including the soaps of these alkalies), and the mercurials. None of these is more generally employed than corrosive sublimate, which constitutes the basis of most of the cosmetic lotions sold in the shops. The following are formulae given by Dr. White 1 for use in the evening. The preparation in each case should be left upon the sur- face during the night, and removed by a soap and water washing in the morning. They are to be used for weeks in succession, but only after a cautious preliminary testing of the sensitiveness of the skin CHLOASMA, 365 to their action. In order to avoid the possibility of error, the prac- titioner would do well to order a poison-label upon all vials con- taining the sublimate : R. Hydrarg. am. chlor. Bismuth, magister. Amyli ) Glycerin, j Ammon. muriat. Aq. colognien. Aq. Hydrarg. bichlorid. Acid. mur. dil. Glycerin. Alcoholis I Aq. ros. J Aq. aa 5ij ; aa .|ss ; 3ss; fsj; Oss'; gr. vj ; aa f 3ij ; 16 2 32 256 4 128 1 M. M. The following are formulae for ointments given by Kaposi : 16 R. Hydrarg. ammon. Sodse biborat. 01. rosmarin. Unguent, simpl. R . Acid, boracis } . Cera? alb. } Paraffin. 01. amygd. dulc. Van Harlingen recommends : R. Hydrarg. chlor. corros. Zinci sulphatis j Plumbi subacetat. j Aq. dest. aa ^ss ; gtts. x ; 5j; aa 3} ; 3ij; 5J; gr. vss; aa, 3ss ; fgiv 128 M. Sig. Lotion, for external use, morning and evening. The rapid removal of pigmented patches is accomplished, in Vienna, by covering the part with strips of linen dipped in an aqueous or alcoholic solution of corrosive sublimate of the strength of four grains (0.26) to the ounce (32.), with which also the dressing is occasionally moistened. Vesiculation is usually accomplished in about four hours, when the serum is evacuated by puncture, and the detached epidermis covered with any inert dusting powder. The resulting crust falls in about eight days. The procedure is attended with the danger of producing, in the end, the precise deformity which it seeks to remedy, a danger explained above. The internal administration of the iodide of potassium, recom- mended for the removal of argyria, has in my hands failed of any good results. Yandell's two patients, one completely and the other partially relieved, were both syphilitic. One of my patients was a veteran syphilitic, fifty years of age. 366 DISEASES OF THE SKIN. 2. Of Epidermal and Papillary Layers. Keratosis. • ■!'. fiipag, a horn. The term Keratosis was first applied by Lebert to hypertrophic lesions of the epidermis. It has since been made to include changes in both the epidermis and curium ; and is employed by some authors in a generic sense to embrace a number of both localized and general hypertrophic-, including callosities and corns. In the classification of the American Dermatological Association, however, it includes merely the two disorders described below, the others embraced by authors in the same category being in these pages separately con- sidered. [A.] Keratosis Pilaris. Keratosis Pilaris is a disorder, chiefly of the extremities, characterized by multiple, millet-seed sized, whitish, grayish, or slightly reddish aggregations of epithelium, about the orifices of the hair-follicles. Symptoms. — This condition, termed also Lichen Pilaris, and Pityriasis Pilaris, may be a mere temporary and functional dis- turbance of the skin, awakening no subjective sensation, inappreciable by the patient, and apparent only to the careful observer, or it may really constitute a disease. Its symptoms are the occurrence of pin- head sized, pointed elevations of the surface, which may be described as papules, though, strictly speaking, they are not such, constituted by an accumulation of horny epithelia and a small quantity of inspissated sebum about the lanugo hairs of the extensor surfaces of the extremi- ties and trunk. These aggregations of material are usually of a dirty whitish or grayish hue, and pierced by a lanugo hair implauted in the follicle about which the abnormal condition exists. Occasionally, however, the hairs are of the finer and shorter kind, and are often coiled in or otherwise covered by the little heaps of epithelial debris. The skin of the individual thus affected is generally harsh, squamous, and dry to the touch ; being also, in the majority of cases, long unwashed. The color of the quasi-papules also differs with the complexion of the individual ; at times they have a distinctly reddish tinge. They are often surmounted by a scale. The condition is sufficiently common in skins long uncleaused by ablution, and can thus be artificially produced. In some individuals it persists for long periods of time, and awakens no concern. In others, and especially in children, it speedily becomes the source of a pruritus, and each lichenoid papule may be then transformed into an urticarial wheal, with distinct and sometimes very annoying, pricking and tingling sensations, the entire trouble being at once relieved by a bath in warm water with soap. In other cases, especially in adults, an exaggerated form of the disease can be recognized, the skin pre- senting a roughness to the touch suggestive of the nutmeg-grater, KERATOSIS. 367 and exhibiting numerous fine, conical, grayish, horn-tipped filaments, which several dermatologists are disposed to regard as a form of ichthyosis. Here, there is doubtless a true hypertrophy of the epidermis. In the former case, there is scarcely more than a mechanical accumulation of effete organic material. There can be little doubt that the malady, simple though it be in character at the onset, may become the first stage of a series of chronic cutaneous disorders. Tilbury Fox has reported four cases in which the disease was well marked, under the title Cacotrophia Follictjlorum, the name being employed to designate its peculiarities as to wide distri- bution over the body, implication of the deeper portion of the follicles, and its congenital history. In these cases, the reddish tint of the lesions is distinctly shown. Pathology. — The disease is produced by the accumulation of the cells of the horny layer of the epidermis and sebaceous material about the orifices of the hair-follicles. In some cases the result is an irritation which produces a more or less persistent hypersemia of the periglandular tissue. Etiology. — Puberty and uncleanliness have been assigned as a cause of the disorder ; and both conditions may be in some patients effective. A careful study of a group of exaggerated cases, however, occurring in adult men and women, suggests more essential reasons for the disease. In such exaggerated cases, the outer faces of the limbs and even the entire face of the belly may be Covered with faintly pinkish or bright reddish firm papules, many of them scale- capped, all seated at the orifice of a hair-follicle. In these patients there may be a history of regular ablution and persistence of the malady long after puberty. But in general they will be seen to have peculiarly thick, coarse, usually dark colored skins, and also to be persons of marked muscular vigor and unusual development of most of the other bodily tissues. In brief, the disorder seems to be due often to marked inherited predisposition in persons of vigorous constitution. The varieties of keratosis pilaris seen in cachectic hospital patients, and in persons who have aggravated the disease by inducing a medicamentous rash upon the person, belong to a different category. Patients in the two last-named classes may be so perfectly relieved that there is no predisposition to return of the disorder, a relief not always to be secured by the others. Diagnosis. — The disease should be readily recognized by the peculiarities of its seat, its course, and the nature of its symptoms. From ichthyosis, it can be distinguished by its limitation to the orifice of the hair-follicle ; from the transitory condition known as "goose flesh," by its persistence after the surface of the skin is thoroughly warmed ; from papular eczema and the other lichenoid eruptions, by the relatively insignificant character of the lesions and their evident association with follicular inertia. It is a matter of very considerable importance to distinguish this disease from the papular syphilodermata, since many male patients have for years swallowed medicaments for relief of a supposed 368 DISEASES OF THE SKIN. syphilis whose sole symptom is a keratosis pilaris. But the papular syphilodermata arc not persistent year after year, not persistently symmetrical, and not limited largely to the outer faces of the limbs, especially of the thighs. They are preceded by a history of infection and invariably accompanied by some other manifestations of the dis- ease. They are not limited to the orifices of the hair-follicles, and are not capped by the peculiar horny scaling tip of the papule of keratosis pilaris. Treatment. — For patients affected with this disorder in its typical forms it is not sufficient merely to order a bath. The bathing should be conducted systematically for years at a time. As soon as it can be well tolerated, the patient should be urged to bathe the entire surface of the body every morning, by the use of the sponge and cold water, following this with brisk friction by the aid of a coarse towel or flesh-brush. The daily and habitual use of this cold bath continued for years, iu persons who can tolerate it (and patients affected with keratosis pilaris are usually of this class), accomplishes results of the most satisfactory character, exerting as it docs, a profound influence on the nutrition and healthfulness of the skin. For immediate treatment, however, of the most of these cases the hot bath with the soap is desirable. This may be repeated as often as required to remove the lesions, and followed, in the more urgent cases, by inunction with the fats or oils. In the congenital and severer cases, such as those described by Fox, cod-liver oil, internally, should be ordered. [B.] Keratosis Senilis. The senile changes in the skin are commonly of the character studied by Neumann, in which granular opacities appear in rows in the corium, giving it a dull greenish-yellow or saffron-colored hue. Later, the fibrillse of the corium are almost entirely replaced by finely granular masses, the remaining fibres becoming swollen and gelatiuiform, reverting thus to an embryonic type. Side by side with these degenerative changes, but also without the latter, the skin of the aged may become harsh, dry, and unusually cornified either diffusely or in certain definite regions, such as the hands, feet, or extremities. This may be regarded as the simplest form of keratosis senilis. The skin of the entire body, or of the region affected, is then dark in color, dry to the touch, occasionally covered with fine, rather adherent scales representing merely attached and cornified cells of the horny layer of the epidermis, and notably unprovided with the natural unguent of the skin. In a more advanced grade of this affection, the skin undergoes changes which are closely allied to epithelioma, and which indeed often both furnish the first symptoms of that affection and also coexist with its gravest destructive effects. The skin, in these cases, more commonly of the face, hands, or forearms, less often of the feet, legs, and genital regions of the aged, is covered with thin, horny, MOLLUSCUM EPITHELIALE. 369 often greasy looking, pin-head to nail-sized and larger, dark yellowish plates or scales, between which the integument which has undergone the atrophic changes in the senile skin, is visible. Pigmented puncta and macula? may also appear, scattered irregularly over the surface, with rough, dirty yellowish to dark brownish, granular accumula- tions upon the skin of certain regions, such as the clefts beside the alse of the nose, the temples, etc. The appearance is quite suggestive, in some cases, of a seborrhoea sicca of the face. In many of the patients exhibiting these features a fully developed papillomatous, superficial, or deep epithelioma may be present. In other cases one or more varieties of the senile wart may be visible, as described in the chapter on verruca. Viewing the subject of senile keratosis in the light of the knowledge had upon the subject to-day, it must be admitted that the boundary lines between it and epithelioma are not well established. Unques- tionably the exaggerated lesions of the former disease are frequently the first stages of the latter, and the treatment of the skin of the aged, conducted on the general principles already set forth, should never lose sight of the possibly serious consequences in one or more regions of the skin affected. Molluscum Epitheliale. Lat. molluscus, soft. Epithelial Mollusca are smooth, globoid or acuminate bodies, situated either within or upon the skin, and in the latter case either sessile or peduncu- lated, varying in color from a yellowish- white to a dark pink, and in size from that of a piri-head to that of a bean. Symptoms. — Molluscum Epitheliale, a disease first, recognized by •Bateman, in 1817, under the title Molluscum Contagiosum, is to be distinguished from auother, known for a long time as molluscum fibrosum. The two disorders are quite distinct, and no longer to be confounded by a similarity in their names. Typical mollusca are firm, roundish bodies, averaging in size the dimensions of a pea, and in color varying from a waxy whitish hue, nearly that of the integument, to the dark red tint of all injected masses. They are either imbedded in the skin, or project from it in semi-globular tubercles, sessile or pedunculated. Usually a dark- colored aperture can be detected at the apex or side of the lesion from which, on pressure, milky and curd-like, semi-fluid contents can be made to exude. Occasionally inspissated, or even horn-like masses project from these orifices, as though forced out by a vis a tergo. The disease is rare, and the lesions usually single and isolated, though hundreds may appear upon the person of one individual. They consist of semi-fluid collections derived from that portion of the rete which either lines the sebaceous glands or penetrates between the papilla? of the derma ; or are actual transformations of the glands into cornified amorphous deposits, surrounded by thickened parietes. They may be artificially removed ; or be shed spontaneously ; or inflame, 870 DISEASES OF THE SKIX suppurate, and result in circumscribed abscesses; or terminate by ulceration. Most often they are insidious and slow of development; and may persist for years without producing annoyance or subjective sensation. They occur on the face, the side of the neck, and the nucha; on the penis and scrotum of meu, and the breast and labia of women; on the trunk ; on the flexor surfaces of the extremities, and the dorsal surfaces of the hands and feet. They are most com- mon in children. In consequence of the depression of the centre of the little tumors (which Hutchinson has aptly likened to small pearl buttons), they may suggest the lesions of variola, and are hence described by French writers under the term, Varioliform Acxe. Fig. 40. Molluscum Epitlieliale. (After Allex.) Hebra, Virchow, and Nicolaysen have reported colossal mollusca, as large as an orauge or a small cocoauut. Microscopical examina- tion of these gigantic lesions demonstrated their identity with the smaller tumors. Similar smaller bodies have been found interspersed among epitheliomata. Etiology. — In England, where the disease was first recognized and where, according to Hutchinson, it is far more frequent than on the continent of Europe, the belief in its contagiousness is quite generally accepted. Excellent authorities are, however, divided upon this question. At present, therefore, it can only be definitely stated that MOLLUSCUM EPITHELIALE. 371 the contagiousness of molluscum is not yet established. If contagious, the lesions certainly possess this power of transmission in a feeble and imperfect degree, one much inferior certainly to other lesions recog- nized as contagious. Retzius, Vidal, Peterson, and Wigglesworth succeeded in producing the disease by inoculation of the contents of molluscous tumors. Allen, in an interesting communication upon the subject, 1 reports an abortive result from an inoculation practised in two places upon himself by Dr. Bulkley. He reports fifty cases observed among children in an infant asylum of New York City, and expresses himself strongly in favor of the contagious character of the disease. Experiments with inoculation have been, however, often unsuccessful. The proofs of contagion rest chiefly upon the circumstance of lesions observed simultaneously or successively on the breast of a mother and the mouth of her nursling, as observed by both Bateman and Allen, or upon the successive development of mollusca in several members of one family. These are possibly explicable as coincidences. Fox, of New York, has called attention to an interesting relation which would seem to subsis tbetween mol- lusca and verruca, or ordinary warts. If simple warts are ever shown to be in a feeble degree contagious, it can scarcely be doubted that a demonstration of the contagiousness of mollusca will soon follow. According to Kaposi, eczema, sweating, pruritus, and macera- tion of the skin, predispose to their occurrence. There are not sufficient grounds for assuming that, in adults, they ' are always associated with venereal disease. They are not rarely seen in large numbers upon the scrotum of youths who have never exercised the sexual function. Pathology. — Upon section, a typical molluscous tumor is found to contain either a thick caseous fluid, or a mass of smooth, whitish, and roundish bodies, which are often clustered about a short stalk. Micro- scopically, these are seen to be composed of epidermal masses, fat globules, and FlG - 41. peculiar bodies of oval shape, partly or wholly contained in an epithelial pod, the so-called "molluscous corpuscles." The origin and significance of these corpuscles have been the subject of a great deal of careful investigation with no little divergence of opinion as to the result. The disease has been consequently regarded by many authors as one con- o , J J Molluscous corpuscles. cernmg the sebaceous glands, and the (After Kaposi.) fluid or more or less solid contents of the tumors as the result of the various metamorphoses which the pent-up secretion of those glands underwent. By such authors, the disease is termed " molluscum sebaceum," " contagiosum," etc., and is classified with the sebaceous gland disorders. 1 Journ. of Cutan. and Yen. Bis., August, 1S86. 372 DISEASES OF THE SKIN. But the later studies of Retzius, 1 Lukomsky, 2 Renaut, 3 Yidal, 4 and Thin 5 make it clear thai the disease is one which concerns chiefly the rete mucosura of the epidermis. The name molluscum epi- theliale, first suggested in this connection by Virchow, in the title epithelioma molluscum, is hence seen to be appropriate in the desig- nation of the disease. Molluscous tumors may evidently take origin either in the portion of the mucous layer whose involution forms the lining membrane of the sebaceous gland, or in the prolongations of the rete downward between the papillne of the corium where there is no follicle. In either situation, the molluscous elements are earliest recognized as simply enlarged epithelia which assume, as a consequence of this enlargement, a globular form. In the midst of these, there are certain individual elements which acquire a granular appearance, the granular masses finally giving place by union to a globoid or oval- shaped body, large, shining, and stratified or homogeneous. This is the molluscous corpuscle which represents a colloid metamorphosis of the original epithelia. According to Ranvier, the stratum granu- losum of the epidermis is composed of elements which contain minute particles of a substance called eleidiue, the keratogenic material by whose transformation the stratum corneum is actually produced. This substance Renaut declares to be abundantly de- posited in the enlarging corneous globes characteristic of molluscum; and the process is by him shown to be identical with that occurring in the transformation of the elements of the mucous into those of the horny layer of the skin. The pathological resemblance of cer- tain molluscous bodies to epithelioma is thus very clearly suggested. According to Thin, 6 the internal root-sheath of the lanugo follicle is the original source of the disease, whence molluscous elements pass to inoculate, at various points about the follicular orifice, the adjacent epidermis. The coalescence of these points forms the tumor, in the course of the development of which the lanugo hair is shed, and the sebaceous' gland disappears. Auspitz denies that the transformation of the prickle-cells of the epidermis into molluscous bodies has anything in common with col- loid or amyloid degeneration. Robinson classes the disease with the new growths. At present, we must be content with recognizing the molluscous corpuscle as the result of a transformation undergone by the prickle-cell. Diagnosis. — Mollusca resemble the lesions of variola more than any other cutaneous phenomena. They are, however, readily dis- tinguished from the latter by their chronicity, their semi-fluid con- tents, the absence of febrile symptoms, and the career of the vario- lous pustules. From warts they are also differentiated by their contents, hemispherical shape, and the dark punctum almost invari- ably present ou one part or another of the lesion. i Viertel f. Derm, and Svph., iv. Hit. 3, 1877. - Virchow'a Archiv, Bd. lxv. 3 Lyon Med., July 25, 1880 4 Sue. de I5iol..j,'k\ 1877-1878. l> Jouni. of Aiiiit. und Puys., vol. xvi., 1881; and Brit. Sled. Journ., Jau. 15, 1881. 6 Loc. Cit MOLLUSCUM EPITHELIALE, 373 Molluscum epitheliale in no way suggests molluscum fibrosum, with which it has only been confounded in consequence of the simi- larity in the two names. The tumors of molluscum fibrosum are Fig. The author's rare form of molluscum verrucosum. (From a painting in oil.) solid new growths, usually occurring in great numbers upon the trunk of individuals in adult years. They may attain enormous dimensions of several pounds weight, and though in cases they de- 374 DISEASES OF THE SKIN. generate by ulceration, they never have the curdy contents of mol- luscum sebaceum. Papillary warts are to be distinguished from mollusca, though without question lesions are to be occasionally seen of a type inter- mediate between the two forms. Warts are to be recognized by their general papilliform character, and their evident relation to the papil- lary layer of the corium overlaid by a thickened stratum corneum. Physicians are occasionally consulted by patients who have dis- covered mollusca upon the genitals, and who suppose these lesions to be of venereal origin. An error in this respect can scarcely be committed by the expert. Neither the solid papule of the initial lesion of syphilis when observed on the skin of the penis, nor the pustule and resulting ulcer of the chancroid are ever characterized by the particularly waxy look of genital mollusca with their de- pressed puncta. In such cases, the inguinal glands should always be carefully examined, remembering, however, that a forcibly squeezed and cauterized molluscum may be accompanied by a sympa- thetic adenopathy. Treatment. — Molluscous tumors may be removed by ligature, scissors, knife, curette, or the needle in contact with the negative pole of a galvanic battery, their contents having been previously expressed. When desired, the surface may be first chilled or frozen with the ether spray, to diminish the pain of the trifling operation. Bleeding is easily arrested by a pledget of lint. Occasionally the point of a crayon of nitrate of silver may be introduced, after their removal, either to check hemorrhage or to insure destruction of the cyst. According to Hebra, the return of the complaint, when it occurs at all, may be expected at points where no tumors have been removed. When the lesions are small and numerous, they may be made to exfoliate by the local application of green soap. Removal of the larger lesions may be followed by minute cieatrices. Prognosis. — The disease can always be terminated by removal of the tumors — the process to be repeated in case of recurrence. Cica- trices, when these result, are of trifling moment. Callositas. Lat. callus, hard flesh. A callosity is a whitish-gray, yellowish-gray, or brownish, semi-transparent, localized and circumscribed thickening of the epidermis of the skin, due to hypertrophy of its horny layer, most commonly occurring upon the hands and feet. This condition is also termed Tylosis, and the callosity itself, Tyloma. Callosities are superficial, circumscribed, dirty white, yel- lowish-white or darker, flattened, thickened, and horny patches of epi- dermis, dense in structure and usually insensitive. A section of the plaque shows it to be largest at the centre and least at the periphery. They vary in size from a finger-nail to a section of a hen's egg, being at CALLOSITAS. 375 times larger ; and occur chiefly upon parts of the integument subjected to long-continued intermittent pressure, as the hands and feet ; also upon parts stretched over osseous prominences, as those over the ischia. They may be complicated by hyperemia, fissure, acute inflammation, or erysipelas ; and readily serve as foci of cutaneous disease (eczema, psoriasis, etc.). They are commonly encountered among mechanics, carpenters, shoemakers, etc. ; among persons wear- ing ill-fitting shoes (heel, ball, or big toes), stockings, or surgical apparatus ; among workers in metals, acids, or heated substances ; and among musicians (harpers, banjo-players, etc.). They are pro- duced by such external causes as pressure, friction, chemical agents, and heat. By careful consideration, they can be readily distinguished from eczematous, psoriasic, and ichthyotic patches, being always limited to the sites of external contact. They are said to be so characteristic of the several professions and trades, that by their locality alone they point in many cases to the occupation of the individual who exhibits them. Often they are, in these cases, essential to the prosecution of such work ; and their removal would only expose a tender epidermis to the operation of an injurious pressure or friction. They are, pathologically, pure hypertrophies of the stratum corneum of the epidermis, the deeper layers of the latter as also the coriuni and subcutaneous tissue being quite unaffected. Callosities require treatment only when they are sources of pain or discomfort. They may be removed ; surgically, by the knife ; chemically, by the destructive action of acids or alkalies ; rationally, by disuse of the part to an extent sufficient to interfere with the operation of the cause. When painful, they may be poulticed. A nightly soaking of the part with warni oil, kept in contact with the thickened epidermis during the hours of sleep, by a compress of flannel saturated with the same substance, will in the end always soften the induration. Callositas of the Hands, with Unusual Complication [reported by Dr. Morrison, 1 of Baltimore], is illustrated by the case of a negro who was engaged in stoking the fires of a steamer. In this instance the combined effects of heat and friction resulted in ulcerations beneath the callosities which eventually produced necrosis and fall of some of the phalanges. This patient recovered as soon as the hands were properly protected, a fact which seems to justify the assignment of this and similar cases to a class apart from those which follow. Perforating Ulcer of the Foot [Malum Perforans Pedi; Mai Perforant du Pied]. This disorder, first named by Vesigne, has been studied by Messrs. Savory and Butlin, 2 Mr. Treves, 3 I) u play, 4 Michaud, 5 and others. i Journ. of Cutan. and Vener. Dis., Jan. 1886. 2 Med. Chir. Trans., vol. lx., 1879. 3 Lancet, Nov. 29, 1884. * Arch. gen. de Med., 1876. 5 Lyon Med., 1876. 376 DISEASES OF THE SKIN. The name is an unfortunate one, since many cases to be classed only in this category, have neither ulcerative nor perforating symp- toms. The first symptom is a proliferative thickening of the epidermis, like a corn, usually single, occasionally multiple, appearing over a point of pressure (first or fifth metatarso-phalangeal joint, etc.). Inflammation aud suppuration proceed beneath this thickening, spreading first to the soft parts of the sole and then to the bone itself. Gradually a sinus forms, reaching from the side of the corn to the deeper parts involved. Meantime the skin in the neighbor- hood becomes greatly thickened, heaping itself especially about the sinus. The ulcer which eventually forms is roundish, deep, aud at times very destructive in its effects. Thus far, the lesion might be supposed to be the result merely of a greatly irritated corn, but other phenomena exhibited in these cases are quite inexplicable in this way. The nails are altered ; superfluous hair grows on the dorsal surface of the foot and the skin of the involved extremity ; pigmentation, erythema, or eczema may occur ; and the parts become affected with either anidrosis or hyperi- drosis. These disorders have, again, been noted as the result of spinal injury, congelation, posterior spinal sclerosis, ana?sthetic leprosy, and, in animals, after section of the sciatic nerve. Among the most common symptoms in typical cases are anaesthesia, neuralgic and rheumatic pains, hyperidrosis, and coldness of the feet. The author has had the opportunity of studying this disorder in a group of cases which illustrate both extremes of its symptoms. The perforating ulcer occurred in the following case : In the centre of a dense callosity which had formed over the right first metatarso-phalangeal articulation of a young man, there was exposed the orifice of a sinus which could not be made to close. The course of the disease was exceedingly iudolent, the parts being the seat of little pain. The weeping from the sinus was scanty, and it was not surrounded by granulations. It was more an annoyance at first, than a serious disease. Finally, by the aid of a fine probe, it was discovered that the sinus beneath led to exposed bone. A deep incision was made at this point, and the osseous surface thoroughly scraped, after which antiseptic dressings were applied. The sinus, however, reformed in time ; and it became finally neces- sary to amputate the toe and remove by the gouge a large portion of the head of the corresponding metatarsal bone. This operation proved successful in relieving the patient. The case next described represents a group in which typical symp- toms of the disease were marked without a tendency to ulceration. A servant maid, twenty-two years old, kept under observation in hospital for more than a year, had for several years previously, as also while under treatment, suffered from symmetrical recurrent tylosis of the soles of the two feet only, the hands being spared. A dense, thick, yellowish-gray cast of the entire sole of each foot was regularly shed every four months, leaving behind a soft, tender, and CALLOSITAS. 377 irregularly mammillated epidermis. Persistent maceration of the feet for weeks at a time, poulticing, absolute disuse of the organs for months, mopping with from ten to thirty per cent, solution of caustic potash, applications of Hebra's diachylon salve, mercurial and tar ointments, were all futile in preventing the recurrence of the tylosis. After the cast of each foot was formed, the use of the organs was almost interdicted in the act of walking, on account of the pain which was induced. The nail of each toe of both feet was roughened, scabrous, friable, and tilted up from the matrix so as to approach the vertical position. The hands were the seat of a persistent hyperidrosis, being constantly clammy and macerated with the sweat that poured from them. The pulse was slow, ranging from fifty to sixty beats a minute. All other functions of the body were properly performed. In the group of cases to which reference is made above, there was always a symmetrical involvement of the entire sole or palm, either of both feet, or both hands and feet. The patients were young adults. The palms when involved never exhibited the translucent, yellowish, wash-leather-like appearance of the same condition of the soles, but rather suggested the dry, scaly features of the palms in certain forms of erythematous eczema of these parts, but always without itching, and always with coincident plantar tylosis. The soles, however, always presented the typical appearances of callositas throughout the entire region, the callosity reaching somewhat upward over the heel, and in some cases relatively sparing the instep. In some cases the nails were not involved. The feet were always as cold to the touch as in pernio. Pathology. — The disease is, without question, a trophoneurosis. Histological examination has shown destruction of the myelin and axis cylinder of twigs of nerves supplying the affected parts. Ac- cordiug to Messrs. Savory and Butlin, the sensory and nutrient fibrils of the involved nerves degenerate in consequence of pressure exer- cised upon them by increase of the endoneurium, the motor fibrils escaping, owing to their large size and thicker medullary sheath, a view plainly untenable for all cases. Diagnosis. — The diagnosis is between tuberculosis and simple cal- lositas, a distinction readily established by the evident neurotic phe- nomena seen in the so-called perforating disease of the foot. Treatment — Apart from the surgical interference called for by one class of cases, a roborant treatment, including the internal adminis- tration of iron and arsenic, has been followed by most favorable results. The Prognosis is doubtful. 373 DISEASES OF THE SKIN. Clavus. Lat. clavus, a nail. Clavus, or Corn, is a circumscribed callosity usually found upon the toes, due to epidermal hypertrophy, and provided with a conical spur of horny tissue beneath, which is projected into a corresponding depression in the corium. Corns are hypertrophies of the horny layer of the epidermis, with the peculiarity of presenting inferiority a coniform prolongation, which, being pressed from without inward upon the sensitive papillae of the corium, excites pain in various degrees. They vary in size from peas to large chestnuts, and are dense and callous when occurring upon those prominent parts of the foot where the boot, shoe, or gaiter, exercises its greatest pressure. When occurring upon the lateral face of a toe in apposition with another, the corn originates usually from pressure through the medium of the neighboring digits. It is then softer, from exposure to greater heat and moisture. Corns are often weather-sensitive, being unusually painful before, during, or after the occurrence of storms, and should therefore not be con- founded with gouty or rheumatic deposits below the skin. They are composed of superimposed, and often concentrically arranged, layers of epithelium, between which are occasionally found minute hemorrhagic extravasations. They are occasionally seen upon the palms of the hands. At the periphery of the corn the corium is unchanged, but at the point where its central cone is pressed into the deeper structures, the papillae are either atrophied or quite absent. Corns are rationally treated by disuse of the feet, or the adjust- ment of properly fitted coverings for the same. They usually fall spontaneously after an attack of paraplegia and in the case where the lower extremities are confined for a few weeks in surgical apparatus for relief of a fracture. They may be softened by prolonged macera- tion in water, poultices, or, best of all, oil, as in the treatment of callosities. Erasion and excision may be practised, if demanded by an exigency. Where the sufferer must necessarily continue the use of the foot, the simplest and best treatment is as follows : The part is thoroughly macerated for half an hour, with water as hot as can be tolerated. Then the projecting callous portion of the corn is gently removed by cutting or scraping, till, as nearly as may be, the surface is level with the plane of the adjacent skin. The part is then dried, and the entire surface, both of the seat of the corn and the adjacent integument, is completely covered with many narrow, short, and nicely adjusted strips of Maw's moleskin plaster. When the trifling operation and dressing are complete, the patient should bear firm pressure over the corn without flinching, and walk with perfect comfort. The plaster remains till it separates spontaneously, which is usually in the course of a few days. The corn is then macer- CORNU CUTANEUM. 379 ated at night with an oil poultice, as described above, and the dressing afterward reapplied, usually the second time by the patient. Persist- ence in this course is followed by complete relief if the coverings of the feet be properly fitted. Caustics, employed by many, are usually unnecessary when there is no ulceration of the hard corn ; and are in this situation frequent sources of great distress. They are chiefly valuable in the treatment of the soft variety ; but should always be applied with a skilled hand. For this purpose, the crayon of nitrate of silver or acetic acid may be employed. The proprietary "corn salves" sold in the shops commonly contain the ointment of the nitrate of mercury, which also is a useful application to the soft variety of corn. The latter should be protected by the interposition of absorbent cotton or wool from contact with adjacent digits. As a rule, the ringed corn-plasters sold in the shops are inferior to the dressing with the moleskin plaster described above, which is made to cover the entire corn. Anderson recommends the emplastrum salicylici for a similar purpose. Cornu Cutaneum. Lat. cornu, a horn. Cornua, or cutaneous horns, are circumscribed hypertrophies of the epidermis, forming irregularly shaped, spur-like excrescences of different sizes. Cylindrical, conical, straight or twisted, angular and otherwise irregularly shaped and sized corneous eminences, single or multiple, are occasionally seen projecting from the scalp, forehead, nose, lips, ears, penis, and extremities. They are named from their resemblance to the similar appendages in horned cattle, but widely differ from the latter, which are always implanted upon osseous tissue. They are formed of dense and massed columns of epithelia, often resting upon somewhat prolonged papilla?. Occasionally, on section, they exhibit the concentric arrangement of the epithelia seen in corns, but, unlike the latter, have reentrant basal depressions into which the papillae below penetrate. At times they are implanted in a dilated follicle, in which case the glandular elements participate in their formation. At times, also, they represent a corneous transformation of the epi- thelia which constitute warts. They are seen in all colors, but are often between a yellowish-brown and a brownish-black, with a fissured or wrinkled or longitudinally grooved exterior, like rough bark. They may be painless, or, like the other keratoses, become the seat of inflammation in various grades. They may be short or several inches in length. The largest specimen ever under the author's observation was seen by him iu France, on the forehead of a man, where it had existed for fifteen years. It measured three inches in length. A few cases have been recorded in Chicago. They may be shed spontaneously, never to return or shortly to reappear. They occasionally develop into epitheliomata, as has occurred once 380 DISEASES OF THE SKIN. under the author's observation, in a gentleman over sixty years of age, whose epithelioma developed from a horn on the dorsum of the right hand, projecting about three-fourths of an inch. Fig. 44. Varieties of cutaneous horns. At the meeting of the American Association of Genito-Urinary Surgeons in 1887, Dr. Brinton, of Philadelphia, exhibited an ante- riorly curved horn one and seven-eighths of an inch long and three- eighths of an inch in circumference, removed by him from the glans penis of an elderly patient, no member present having then seen a similar growth in that locality. Only fourteen cases are on record of a similar growth in this situation. In a horn growing from the lower lip of an elderly man exhibited at the author's clinic in 1886, the growth was longitudinally fur- rowed, and also at somewhat regular intervals transversely furrowed, presenting then the appearance of the joints of the sugar-cane. VERRUCA. 381 Pathologically, these hypertrophies are first developed either within a closed atheromatous cyst, or from remarkably elongated papillae of the corium. They are made up of cornified and hypertrophied epidermal cells. Horns may be removed by extirpation, after which the surface upon which they were implanted should be carefully and completely cauterized. Verruca. Lat. verruca, an excrescence. Verruca, or Warts, are pin-head to bean-sized and larger, soft or hard, cir- cumscribed elevations due to bypertropby of both the epidermis and papillae of the skin. Warts are cutaneous excrescences; sessile or pedunculated; pointed or flat ; smooth, rugous, or having a cauliflower appearance ; pig- mented in various shades, or of the natural color of the skin ; con- genital or developing after birth. They may be single or multiple, and occur upon the hands, feet, face, scalp, neck, genitals, and other parts of the body. They may develop slowly or rapidly, and per- sist for years, or disappear without apparent cause. They may be soft, dense, or even corneous to the touch. The several names given to the various forms of warts have chiefly a descriptive value. Verruca Acuminata (condyloma) is a filiform, papilliform, or cock's-comb-like vegetation. They are single or multiple ; at times hundreds coexist upon the genitalia and neighboring regions. In size they vary from a pin's point to a hen's egg, and may be larger. They are apt to be moist and secreting, being frequently covered with a puriform mucus of exceedingly nauseating odor. Upon the geni- tals, they are encountered upon the glaus, around the frsenum, and over the prepuce of men ; and in women, about the clitoris, labia, vagina, and anus. They are usually of a bright red color in these situations. When occurring upon the integument, they are firmer, drier, and exhibit a feebler tendency to luxuriant vegetation. In this form they may be recognized about the axillary regions, the umbilicus, the interdigital spaces of the feet, and even the face. Dr. Heitzmann once informed the author that he had seen them covering the side of the chin. Verruca Congenita and Verruca Acquisita are terms used to designate the lesions discovered at birth or later. Verruca Filiformis. — This variety of wart differs somewhat from the others, not only pathologically, as is noted below, but in its clinical features. They are slender, thread-like, often pedunculated masses, usually covered with a smooth and apparently unaltered epi- 382 DISEASES OF THE SKIN. dermis, occurring upon the neck, eyelids, chest, and ears of women. Kaposi ((includes that they represent minute fibromata. 1 Verruca Glabra i^ distinguished by its smooth surface. Yi:i;i:rcA PLANA is the flattened or globoid, smooth or rugous formation like a plaque or button, usually pigmented, and occurring upon the back. Verruca Senilis vel Plana. — These are bean- to coin-sized, smooth, aud softish growths developed upon the face, trunk, and extremities of persons of advanced years. They are flat, usually pigmented, and have a granular aspect. They are readily separable by the finger-nail, and are then found to rest upon a reddish granular base. As the result of external injury (caustics, traumatism) they may become the starting-point of an epithelioma. Verruca Vulgaris is the form most frequently seen upon the fingers aud hands, as pin-head to pea-sized, usually discolored, papill iform excrescences. Of the several varieties of warts it may be said, in general, that they are most frequently observed either on the hands or over the genital region ; that they are usually discrete but may be confluent aud form palm-sized and larger elevated plaques ; that they may be soft, hard, smooth, rough, pointed, flat, brush-like, or like the comb of a cock ; that they may vary from a pinkish to a blackish hue ; that they may persist, occur in crops, or spontaneously disappear ; and may grow with great rapidity [Verruca Acuminata] to a large size and involve any portion of the body. Dr. Fox, of New York, has figured an interesting case in which warts occurred in lines tattooed on the skin of a young man. Etiology. — The causes of warts are unknown ; but in early child- hood, a period in which they are most frequently encountered, it is reasonable to conclude that they result from external contacts. It is when the child begins to handle everything within reach, that they usually first appear, and then about the hands. The acuminate or condylomatous warts are chiefly induced in parts moistened with a blennorrhagic secretion, but unquestionably may originate from con- tact with the leucorrhceal or pathological, non-venereal discharges from the female genitals. They are rarely seen in virgins of either sex. The senile warts are more probably due to obscure changes in the nutrition of the integument. Pathology. — Warts on section exhibit, microscopically, an hyper- trophy of the papillary layer of the corium concerned in their growth, with corresponding development of the vascular loops rising from the superior vascular plexus of the corium. Above these papilla? the rcte is usually largely developed, the epithelia being multiplied not only on the sides of the prolonged papillae, but immediately over 1 See Dr. Taylor's observations as epitomized in the chapter on Fibroma. VERRUCA. 383 their apices. In all the dry varieties the stratum corneum is also hypertrophied, but this more especially over the summit of the excrescence. The filiform warts are composed chiefly of a slender fasciculus of connective tissue springing from the bundles below, Fio. Vertical section of the summit of a pointed wart, a, papilla containing vascular loop ; 'c, stratum corneum ; d, hypertrophied rete. (After Kaposi.) enclosing a vascular loop and covered with an epidermis which is not apparently altered. Beneath all forms of warts there may be a sub- stratum of sclerosed connective tissue, constituting the firm base upon which they rest. - The diagnosis of warts is usually readily made, but great care 384 DISEASES OF THE SK1X. must be had to distinguish the moist variety from syphilitic condylo- mata. In the latter there is usually a history of contagion with other syphilodermata upon the surface, such as mucous patches, palmar lesions, or papules of the face. Fibroma, or molluscum fibrosum, generally occurs in tumors of greater number, firmer con- sistence, and larger size. The tumor of molluscum epitheliale greatly resembles a wart, but the waxy-whitish appearance of the lesion and its dark punctum at one point or another, sufficiently distinguish it. Treatment. — Warts may be removed by excision, erasion, or caustics (nitrate of silver, alkalies, acids, perchloride of iron, corrosive sub- limate, etc.). The larger growths upon the genitalia are often highly vascular, and may demand the prior application of a ligature when they arc pedunculated. Even the slender filiform warts will be found to contain a small vessel in the pedicle which requires cauteri- zation after the excision. When the warts cannot be more readily removed by the knife or curved scissors, the Paquelin cautery may be used. The blackened eschar which is left prevents hemorrhage, serves as the best subsequent dressing, and is less apt to be followed by a return of the growth. In some cases, it is a useful expedient to transfix the lesion iu several directions with the long needles used iu gynecological practice, previously dipped iu a fifty per cent, solu- tion of chromic acid. By far the simplest and most elegant method of removal, however, is to transfix the base of the wart a sufficient number of times with a needle connected with the negative pole of a galvanic battery, the positive being connected with the body of the patient by the aid of a moist sponge. The formula, accord iug to which are made several of the proprie- tary "wart cures" sold in the shops, is as follows : R. Acid, salicylic. £ss; 2 Cannabis indie, extr. grs. v ; Collodion Jss; 16 Sig. To be painted over the wart with a camel's-hair brush. M. For patches of warts, Van Harlingen recommends attacking one part at a time cautiously with the following paste: R. Pulv. acid, arseniosi gr. vj ; (40 Ungt. hydrarg. ) aa q. B. ad 8 Emplast. hydrarg. j 5ij; M. For warts not requiring operative removal, local treatment often answers well. Those about the genital region often disappear if persistently washed with a solution of tannin in alcohol, one drachm (4.) to three ounces (96.), after which they are dried and thor- oughly dusted with boric or salicylic acid with lycopodium ; or burnt alum and rosin ; or, what is most popular, dry calomel. Alum and lead lotions may also be substituted for the tannin and alcohol, and for a time kept over the parts as a compress. VERRUCA. 385 Prognosis. — Warts are benignant growths ; and in childhood and early adult life need uot suggest grave sequelae. It is far different in advanced years, for, though these excrescences possess even then no malignant character, they are the too frequent precursors of epithelioma. While it may be urged justly that the early lesions in such cases were really epitheliomatous and not verrucous ; the fact remains that many warty formations of apparently benign character do in advanced years, especially under the teasing of frequent cauteri- zation, undergo a cancerous transformation. Multiple Cutaneous Tumor Accompanied by Intense Pruritus. — Under this title Dr. W. A. Hardaway/ of St. Louis, describes a rare disorder characterized by the occurrence of about sixty pea- to nut-sized, dense tubercles and tumors covered by a thickened, scaly, and excoriated, often hemorrhagic skin. In some situations coalescence had occurred, forming thus long and narrow plaques of nearly the width and half the length of the finger of an adult. The lesions were seen upon the outer aspects of the arms and legs, the palms and soles, the sides of the fingers, and around the ankles, wrists, and elbows. The accompanying pruritus was intense and intolerable ; and, having lasted for twenty-two years, was naturally associated with the degree of pigmentation often observed under similar conditions. The patient was an unmarried woman, fifty-one years of age, and declared that the lesions first appeared as "blisters." Specimens of these tumors, examined by Dr. Heitzmann micro- scopically, exhibited hyperplasia of the epithelial and connective tissues. The papillse were longitudinally elongated, branching, and provided with narrow capillaries. Numerous nests, greatly varying in size, and containing inflammatory elements with considerably enlarged bloodvessels, lay close beneath the papillary layer of the corium. These elements showed all stages of transition into basic substance. The deeper layers of the derma were built up of very coarse bundles of connective tissue and numerous elastic fibres. Papilloma. — This term has been loosely applied to a large number of cutaneous growths widely differing from each other, both histologically and clinically. It has been made to include the vegetations of syphilis, the neoplasms of naevus, and even the tuber- cles of lupus. The designation, papilloma, is properly limited here to such cir- cumscribed hypertrophies of portions of the skin as correspond with warts in their pathological significance. They may be defined as excrescences from the cutaneous surface, of a size considerably larger than all the varieties of the wart with the exception of the condy- loma, usually presenting a luxuriant vegetation composed of elon- gated papillse, bloodvessels, and enlarged rete, covered externally with a smooth epidermis like a pellicle, or, more commonly, branched 1 Arch, of Derm., April, 1880, p. 129. 25 386 DISEASES OF THE SKIN. and tufted with the cauliflower aspect, and (hen usually covered with a puriform mucus. The tumor increases rapidly till it attains a maximum size, and then indolently persists. It is benign in char- acter, and bears no relation to struma, carcinoma, syphilis, or lupus. It may occur upon any portion of the body. The cases observed by the author all occurred in women who were either pregnant or at the period of the menopause. Verruca Necrogenica. Verruca Necrogenica is a vesiculo-pustular or wart-like lesion situated usually on the hands, resulting from contact with the bodies of the dead, which may induce grave constitutional symptoms. This lesion, also known as the " Post-mortem Tubercle," " Dis- section Tubercle," or "Anatomical Tubercle," was first named by Wilks, 1 verruca necrogenica. It commonly occurs on the fingers of those engaged in the habitual handling or dissection of cadavers, and is said to result both from such habitual contacts, and also from dissection wounds. Cases are reported where the lesion has had a non-cadaveric origin. It begins at the site of an abrasion or wound as a vesico-pustule, with deep-seated base and reddish or reddish- purple areola. This is productive of a burning, smarting, or pru- ritic sensation. The lesion accomplishes a period of bursting and crusting, which may be followed by complete involution. But when the typical so-called "anatomical tubercle" forms, the tissue becomes indurated and horny, and a pigmented verrucous papule or tubercle very slowly forms, which may become fissured at one or more points. The characteristic lesion is the thickened, Fig. 46. indolent, more or less pigmented and fis- sured, split-pea to bean-sized wart, usually single, found on the finger of the auatomist. In other cases, grave symptoms result either in the involvement of the deeper tis- sues (subcutaneous, thecal, tendinous, peri- osteal), or in the production of erysipelas, 3p pya?mia, septicaemia, or gangrene. Surgeons divide these cases into mild and acute va- Jfl rieties, according to the symptoms exhibited. The records of the medical profession in almost every one of the larger cities of this 9 country contain the names of one or more of its emineut representatives whose lives have been sacrificed in this manner. It is probable that some one or more of the ptomaines, described on a preceding Model P a g e > may be responsible for some of the results here mentioned. Out of more than fifty-eight thousand cases of cutaneous diseases collected by the statistical committee 1 Guy's Hospital Kep., 3d series, vol. viii., p. 263. > ' 1 Verruca Necrogenica. Guy's Mus. 1935». NJEVUS PIGMENTOSUS. 387 of the American Dermatologieal Association, but one instance was reported of verruca necrogenica. This does not, however, exactly represent the frequency or, better, the infrequency of the lesion, since the majority of all such accidents occur in the persons of anatomists and surgeons, who destroy their lesions themselves without consulting others on the subject. The treatment of verruca necrogenica is destruction of the lesion with acid nitrate of mercury, nitric acid, or caustic potassa. The prognosis is not necessarily grave. Nsevus Pigmentosus. Lat. ncevics, a mask. Nsevus Pigmentosus is a congenital, circumscribed pigmentation of the skin, in single or multiple deposits, either with or without textural cutaneous change, or associated with the development of warts, plaques, tumors, or pilary hypertrophy. Abnormal congenital pigmentations of the skin vary in color from a light yellow or chocolate-brown to a blackish hue, and may be single, or multiple and very numerous. They are commonly termed Pigmentaey Moles. They vary in size from a pin-head to tumors of considerable volume ; and are either ovoid or circular in contour, or so irregularly shaped as to present a fanciful resemblance to parts of the figures of the lower animals, whence the popular belief as to their origin in maternal impressions. They occur in both sexes ; and upon the face, neck, trunk, thighs, buttocks, and external genitals. The term Nsevus Spilus is applied to those which occur in a smooth, and otherwise unaltered skin ; N^vus Verrucosus, to those which are irregular and wart-like; N^vus Pilosus, to those surmounted by a growth of shorter or longer, stiff or downy, dark-colored hairs ; and Nsevus Mollusctformis, or Lipomatodes, to the soft or firm, more or less elevated and projecting tumors. They may be, when multiple, symmetrically or asymmetrically developed upon the surface of the body ; and in either case may exhibit in their arrangement the controlling effect of the nervous system. In a case reported by myself 1 there were multiple mono- lateral pigmentary nsevi distributed over the left side of the trunk in the course of the intercostal nerves, and in such a manner as strongly to suggest to the eye their correspondence in site with the lesions of zoster of the same region. De Amicis 2 had previously reported a somewhat similar case. The course of pigmentary nrevi, after obtaining their full evolution, is to persist unchanged for a lifetime. Their increase in tender years is occasionally characterized by a relative rapidity. The author has seen a pilary mevus upon the cheek of an infant extend over nearly double its original area in the course of two years. 1 Chicago Med. Joum. and Exam., October, 1877. 2 Lo Sperimentale, March, 1876. 388 DISEASES OF THE SKIN. The lesions of this Bori seem to occur with equal frequency in the two sexes. It is possible that they may be acquired after birth, as claimed by some authors, but it is much more probable that such presumably acquired cases were instances of rapid development from minute congenital pigmentary moles. A case of unusually large congenital naevus lipomatodes associated with multiple pigmentary uaevi of several forms occurring in a child, was observed by the author in 1883, the report of the case made subsequently being illustrated by a chromo-lithograph. 1 (See frontis- piece.) Patholof/y. — Anatomically, pigmentary moles are readily separable into two classes: first, those in which the pigment only of the skin undergoes hypertrophy (naevus spilus) ; second, those in which both epidermis and corium are hypertrophied, forming verrucous, pilous, mollusciform, and other lesions. The distinction made by V. Baren- sprung, Gerhardt, and others, between these two classes and still a third, where the lesions are limited to the cutaneous regions supplied by one or several nerves (Nsevus Unius Lateris, Papilloma Neuropath - icum) is more apparent than real : for a close study reveals a tropho- neurotic influence exerted in all cases, even in the enormous tumors of a mollusciform type. According to Demieville, the pigment accumulation occurs in the corium as well as in the epidermis, in the form of ribands stretching along the lines of the bloodvessels. Pigmentary moles very rarely disappear spontaneously. Their removal may be accomplished by excision, or by destruction with caustics, with the Paquelin knife, or with the needle by electrolysis. The last-named method is applicable only to the smaller and more superficial growths of this class. Fox 2 calls attention, in connection with this subject, to the need of passing the needle no deeper than the epidermis, sufficiently deep merely to " blister the surface of the black spot." Xerosis. Gr. Zwpoc, dry. Xerosis is a congenital dryness and roughness of the epidermis accompanied by a moderate degree of furfuraceous exfoliation. Xerosis, also termed Xeroderma, is a term which has been applied to the disease sometimes known as xeroderma pigmentosum, or the melanosis lenticularis progressiva of Pick. In these pages that disorder is described, in accordance with the nomenclature of the American Dermatological Association, as angioma pigmentosum et atrophicum. The term xerosis, or xeroderma, has also been employed to designate a simple asteatosis. It is also used by some authors as practically equivalent to ichthyosis. It is sought here to limit its application to 1 Jonrn. of Cutan. and Vener Diseases, July, 1885. 2 Electricity iu ltemoval of Superfluous Hairs, etc., Detroit, 1886. xerosis. 389 the description of a distinct and easily distinguished morbid condition of the integument. Symptoms. — The sole symptoms found in xerosis are cutaneous. The skin of the body, in some regions more than others but at*times universally, is to the touch of another, dry, harsh, rough, and desti- tute of natural moisture and unguent. Closely inspected, the surface is seen to be scaly, the exfoliation being of the character described as furfuraceous. In some cases the hand passed briskly over the surface of such a skin will cause a moderate separation of a few of the scales in a scanty shower ; in yet others, while the surface seems quite fit for the furnishing of such free flakes of epidermis, one is surprised to note that the free flakes are more or less attached, and the clothing of the patient is not, as in some forms of psoriasic and pityriasic disease, covered with epidermal scales. In brief, there is not in progress a catarrh of the horny layer, as in some of the other disorders named j but merely an unusual keratinic transformation of the elements of that layer. The parts chiefly involved are the extremites, more particularly the hands, feet, forearms, and legs ; but all parts of the skin may be involved, including the face, temples, cheeks, and even the lips. The disorder is met with in all grades, from the mildest physio- logical dryness of the skin, almost suggestive of the so-called "goose- flesh," to that state in which the exhibition of the face only, suggests an abnormal condition of the skin. The color of the latter in well- marked cases is always of a dirty yellowish or dirty brownish shade, suggesting the unwashed condition of the integument, and in extreme cases of older patients becomes rather deeply pigmented. It is seen in both sexes and at all ages, being a congenital condition whose first appearance is only clearly indicated after variable periods of time after birth. Red-haired individuals perhaps furnish the larger number of well-marked cases. The general health is unaffected. Before puberty the affection, in northern latitudes, will often be inappre- ciable in summer, and distinct in winter. As maturity is reached, however, the condition becomes more or less permanent. This disorder may be, as described by some authors, a variety of ichthyosis simplex, but the following are excellent reasons for giving it a separate consideration : 1. The disease does not furnish the typical plate-like scales of ichthyosis. 2. One child affected with what appears at first to be merely xerosis, may exhibit a typical ichthyosis before puberty, while an- other will go through life, the xerosis of his childhood becoming simply the exaggerated xerosis of mature years, but never an ich- thyosis. Xeroderma may therefore be regarded in one sense as a variety of ichthyosis, but cannot be described as a stage of the latter disease. The disorder is congenital, and may be inherited from parents. It is readily distinguished from all furfuraceous scaling diseases of 390 DISEASES OF THE SKIN. the skin by the absence of inflammation. The treatment and prog- nosis are those of the disease next considered. Ichthyosis. Gr. iipdb?, a fish. Ichthyosis is a congenital deformity of the skin, developed first in early infancy, and manifested in a general scaliness, in the formation of regularly outlined polygonal plate?, or in the growth of larger masses of a corneous consistency. Symptoms. — The disorder, also termed the "Fish-skin Disease" and ''Xeroderma/' is one which displays a wide variation in its symptoms. To the extremes in either direction two names are given, ichthyosis simplex and ichthyosis hystrix. Ichthyosis Simplex. — The earliest and mildest form of ichthy- osis simplex is, by many authors, held to be the condition of xerosis, fully described in the preceding pages. It will be remembered, however, that such a xerosis may persist through life without the production at any time of the peculiar symptoms of the ichthyotic skin. In these earlier manifestations of the disease then, the skin of the patient can merely be described as unusually harsh to the touch, moistureless, and covered with adherent or exfoliating, fine scales. The latter are not massed, imbricated, nor displayed in plaques, and are usually of a dull yellowish-white color. It is rare that the prac- titioner is consulted for the relief of this disorder ; it is usually discov- ered when the skin is exposed for other purposes (exploration, vac- cination, etc.). In a still more advanced degree, the scales are massed together, forming grayish and whitish, polyhedral elevations or plaques, regularly outlined and closely set together, especially upon the extremities and certain portions of the trunk. Elsewhere the scaliness described above may be present in a more marked degree. Variations occur, in consequence of which the plaques, bordered distinctly by the natural lines and furrows of the skin, are even depressed, centrally or completely, or assume darker shades of color than those described, brownish and greenish-brown. Ichthyosis Hystrix. — With and without the symptoms detailed above, the hypertrophy of the skin may, in circumscribed patches or larger areas, produce irregularly shaped, verrucous, corneous, corru- gated, wrinkled, or rugous masses, usually much darker in color than the patches seen in the simple variety of the disease, aud more often also discovered in adult years. The resemblance is here rather to the rough bark of a tree than to the scales of a fish. In other still rarer cases, the excrescences assume a spinous, acuminate, or horn- shaped form. The hand passed over the surface perceives not only the excessive roughness, but also the dryness of the skin. Perspira- tion is imperceptible in the parts affected. The nails are friable and indurated ; the scalp scaly, aud covered with hairs of exceeding ICHTHYOSIS. 391 harshness. The palms and soles are often spared Kaposi described certain diffuse callosities occurring in the palmar and plantar regions differing from the ichthyotic patches elsewhere. The face is usually spared, but, when involved, only the slighter manifestations of the disease appear there, minute, superficial, scaly patches of a grayish tint. Ichthyosis is accompanied by insignificant subjective sensations. The skin, indeed, of these, patients seems inapt for the eczematous and other complications of the less diffuse keratoses. The author has treated four ichthyotic patients for syphilis, and noticed in all a decided tendency to the production of lesions of the mucous surface without cutaneous efflorescence. The extensor are usually more implicated than the flexor surfaces of the extremities. Singular variations from the types described above are noted by observers. Hilbert, 1 for example, in a case of congenital circum- scribed ichthyosis in a young woman, discovered a growth of thick hairs over the left shoulder and arm, one centimetre long. Weisse 2 exhibited to the New York Dermatological Society a boy, ten years old, with hemorrhagic fissures in an ichthyotic skin, double ectropion, corneous opacities, claw-like fingers, attachment of the ears to the sides of the head, and a generalized condition of the skin, which became very red when warm, some doubt, however, existing as to the diagnosis. The most exaggerated types of ichthyosis are seen in the so-called "Porcupine," " Rhinosceros," or " Hedge-hog" patients. In these unfortunate beings, the entire skin is converted into a rugged, bristling, warty, quilled, or horn-like envelope, suggesting the integu- ment of the animals named. Such conditions are represented by Mr. Henry Baker's case, described by Anderson. The terms, Ichthyosis Serpentina, Nacrea, Nigricans, are employed to designate those conditions respectively in which is recognized a snake-like appearance of the skin, silvery whiteness of the scales, or a dark pigmentation. Viewing the disorder as thus in various ways exhibited, it is seen to be a congenital deformity rather than a disease. It may be par- tial or general, though usually the latter, with intense manifestations over the extremities, especially over their extensor aspects, and relative immunity of the face, axillee, groins, flexor aspects of the limbs, the palms and soles, the glans penis, and prepuce. Like xerosis, the deformity is rarely visible at birth, but usually becomes apparent before the completion of the first year of life. It is first manifested in the region of election named above — i. e., over the elbows and knees — and here also, as in xerosis, may be for some years only apparent in this latitude in winter, disappearing almost wholly in the summer season. In maturity, the deformity has been known to disappear also temporarily under the influence of inter- 1 Virchow's Arctaiv, Bd. 99, Sept. 3, 1884. 2 Journ. of Cutan. and Yen. Dis., 1883, p. 49. 392 DISEASES OF THE SKIN. current disease (variola). One patient is said to have regularly cast a slough of his integument in the autumn. The general health is usually unimpaired. Ichthyosis Congenita. — This exceedingly rare deformity occurs as an intra-uterine modification of the skin of the foetus, which is usually brought into the world as a non-viable monstrosity. The skin is represented by a thick, horny cuirass, deeply furrowed, and resembling plates of armor. The ears, lids, and lips are usually wanting, and replaced by corneous folds suggesting in appearance the corresponding features of a mummy. The fingers and toes resemble talons and claws. Death usually occurs in the course of a few days from both inability to secure nutrition by the act of sucking, and by imperfect development of other organs than the skin. Etiology. — Ichthyosis is unquestionably a congenital disease, though its first manifestations are only apparent during the second year of life. It is said to be generally hereditary, but this should be accepted with some reserve for every individual case. One of my ichthyotic patients was married to his own cousin, and had by her five children entirely free from cutaneous disease. Xone of his parents or grandparents was similarly affected. The disease occurs equally in both sexes, and is liable to aggravation in cold climates and the season of winter. The general vigor and development of patients thus deformed are, as a rule, quite unimpaired. Kaposi says : " The cause appears to be a local anomaly of the nutrition of the skin, especially involving its epidermic and fatty elements;" but this scarcely meets the requirements of etiology. Thost 1 describes ichthyosis occurring in four generations. Ac- cording to the ascertained genealogy, the ancestor first known to have suffered from this affection had five male children who inherited it, while one girl and one boy were spared. One of these diseased children had himself five children, of whom three males showed the disease, while one boy and one girl remained free. Another brother, of the second generation, had five male and three female children; of these, four boys and two girls became affected. One of the latter (of the third generation) bore four children, of whom three girls inherited the disease, while the fourth, a boy, escaped. It appeared that the affection always showed itself within a few weeks after birth, in the form of a roughness of the palmar and plantar sur- faces. With the growth of the patient, the condition constantly increased in severity, the epidermis shedding in large shreds until the disease reached its maximum by the fourteenth year. There was a marked disposition to excessive sweating, particularly in the dis- eased localities; the sensibility of the skin remained normal. Micro- scopic examination showed, in addition to the hypertrophied papilla?, i Inaug. Diss. Heidelberg, 1880; CM. f. Chir., Xo. 10, 1881. ICHTHYOSIS. 393 great development of the sweat glands, with marked thickening of the ducts. Treatment failed to give more than partial relief. In the Molucca Islands and some other isolated regions, ichthyosis, on account of its unusual prevalence, has been regarded as an endemic affection. But instances of this kind are readily explained, without referring to climatic influence, by the operation of the laws of heredity with intermarriages. JFig. 47. Ichthyosis hystrix, vertical section ; a, masses developed from the stratum corneum ; 6, cones formed hy the rete ; c, hypertrophied papillae with dilated vessels ; d, dense connective tissue of corium, exhibiting numerous vessels transversely divided. (After Kaposi.) Pathology. — The diseased, or, better, deformed, skin is found microscopically to be hypertrophied in various degrees according to the development of the malady, the proliferation of its elements occurring in connective tissue, papillae, stratum corneum, and blood- vessels. In well-marked cases of ichthyosis hystrix, the elongated papillae are surmounted by dense cones of the horny layer of the epidermis, more or less concentrically disposed, with sclerosis of the connective tissue, and a relatively unchanged rete. Iu this last particular, the dense plaque of ichthyosis differs in texture from the wart. The polygonal ichthyotic plates are composed for the most part of 394 DISEASES OF THE SKIN. corneous epidermal cells, their long axes parallel with the surface of the skin, with an unusual accumulation of pigment granules between the strata. The interpapillary coues are enlarged; the horny layer greatly thickened, the hair-follicles indurated, the papillae elongated but not branching, and their bloodvessels dilated. The sebaceous glands are frequently converted into cyst-like bodies, the coil-glands distended, and the panniculus adiposus diminished in size. Diagnosis. — Ichthyosis not only presents features which are so characteristic as to be unmistakable, but also those which can be well- nigh perfectly portrayed in plates. In this respect it differs from a long list of cutaneous maladies. 1 Whenever necessary, aid of an important character can be gained in the history of the disease and in the entire absence of the lesions and lesion-sequela?, exhibited in the exudative *md scaling affections heretofore considered. The most conspicuous characteristic of ich- thyosis, as distinguished from psoriasis, lichen ruber, and pityriasis, is the absence of inflammatory phenomena. Treatment. — The younger the patient applying for relief, the larger are the chances of improvement and possible recovery. Ichthyosis hystrix of mature years is practically incurable. Internal treatment is valueless. External treatment is directed to softening, macerating, or anointing the skin, and, as fir as practicable, preserving it in a softer state. This is accomplished by frequent baths, alkaline, vaporous, or combined with the use of soap or green soap, and generally fol- lowed by an anointing with vaseline, dilute glycerine, or lard. The French, after the removal of the denser layers of the horny plates by the aid of soft soap and water, anoint the body by friction with the glycerolate of starch. Almond, cod-liver, neat's-foot and linseed oils, or lanoline may be used after the bath. Only by the most assiduous perseverance is a desirable result obtained and permanently secured. In the severer hystrix varieties, the most annoying projections and rugosities may be removed by excision, the Paquelin knife, or, less preferably, by the aid of caustics. Subcutaueous injections of one-third of a grain (0.022) of pilo- carpine have been practised in ichthyosis, in order to induce sweating, with a view to the maceration of the skin. Van Harliugen recom- mends the following for use when the epidermis begins to shed after the external application of soft soap: R. Potass, iodid. J}j ; 1 01. pedis bubuli ) .. ? , fl ;;;: Adipis Glycerin. 5j ; 4 M. Anderson recommends the wearing of pure vulcanized India- rubber garments, a method of treatment which the author has found too exhausting for all cases. Taking a general survey of the therapeutical management of ich- 1 Tho admirable representation of the ichthyotic Bkin in plate !•'. nf Duhring's Atlas, is faithful in its exactness. ONYCHAUXIS. 395 thyosis and its results, the course to be advised for the majority of patients is very clear. With but few exceptions 1 the subjects of this deformity are either entirely relieved, or greatly better in hot weather and moist atmospheres. Under these circumstances, and having regard to the essential fact that the deformity is life-long in duration, patients should always, when practicable, select for permanent resi- dence a climate most conducive to the comfort of the skin. There is no step which the ichthyotic patient can take at all comparable in value with the important selection of a suitable environment. Prognosis. — Having in view the facts set forth above, it will be clear that in no case can a favorable result be anticipated with respect to a "cure" of the deformity. Treatment, persistent, prolonged, and properly directed in connection with suitable climatic influences may do much to improve the condition of the skin. Onychauxis. Gr. bvv%, a nail ; av^eu, to grow. Onychauxis, or Hypertrophy, of the nails is an abnormal development of these appendages of the skin in any diameter. Symptoms. — The nail substance may be developed to an unusual extent either as an idiopathic or symptomatic affection, and in each case may be simply increased in volume, extent, or number, or exhibit such increase in connection with secondary changes. Thus the nail may develop to an extraordinary length or breadth, pre- serving its general character as regards texture, color, and position; or it may also be changed in auy particular, becoming opaque, dis- colored, dirty yellowish, aud blackish or brownish ; rugous, furrowed, horny, and rigid; thickened in one part and thin, vitreous, and ex- tremely fragile in another; tilted to one side or another on its bed ; or projected backward in recurved, irregular lines. Finally, the matrix may be inflamed, suppurating, hemorrhagic, and the seat of an excruciating pain. One or more of the nails may be affected; in some cases the entire twenty are similarly involved. The diseases in which these changes occur as symptomatic lesions are numerous, since it is evident that the matrix, from which the nail is produced, would scarcely enjoy immunity in the case of pro- found alteration of the skin in its vicinage. Thus eczema, lepra, psoriasis, lichen ruber, syphilis, scarlatina, perforating disease of the foot, variola, and other diseases are attended by changes of various grades of severity in both matrix and nail. The condition termed Paronychia, is that in which one or both lateral borders of the nail bury themselves deeply in the tissues adjacent, producing thus an exquisitely tender and painful state of the soft parts, which may suppurate or surround the attached limb of the nail with exuberant granulations. This is more frequently 1 While these pages are in preparation, the author has been consulted by an intelligent patient who positively asserts that her ichthyosis is always aggravated by warm weather. 896 DISEASES OF THE SKIN. observed in the nails of the toes, as the appendages of the skin are liable to injury from the pressure of ill-fitting boots, gaiters, and shoes. In the condition described as Onychia, the matrix is not only inflamed, bat the nail substance is, as a consequence, texturally changed. No strict line of demarcation, however, can be described between tli« L two conditions. The term Oxychogrypiiosis has been employed to describe the contorted deformities which cause it to resemble a claw. Onychomycosis is the name given to that condition in which the nail substance is invaded by vegetable parasites. In such cases, the nails become opaque, discolored, and thickened, with a noticeable friability at the projecting border. In Syphilitic Onychia, one or several of the nails may become affected, though it is quite characteristic of the disease to exhibit limitation to the extremity of a single digit. In such cases, there is usually a very marked involvement of the peripheral soft parts, which may be infiltrated with gummatous material. The bullous syphiloderm, of the congenital manifestations of the disease, will at times form beneath or quite near the nail, and thus endanger its integrity. In both forms, ulcerative results are common, with secre- tion of a foul discharge. In the affection termed perforating disease of the foot, all the nails of the feet may exhibit a characteristic onychauxis. Traumatism (constant or intermittent pressure of shoes) may augment the size of the nail in one or another diameter ; and the deformed talons resulting from gross and long-continued neglect (East Indian devotees, etc.) are illustrations of another type of hyper- plasia. Supernumerary nails may be found on supernumerary fingers and toes; or double organs on a single digit; or in unusual situations as over the scapula (Tulpius) ; or on a digital stump ; or in an ovarian cyst. With respect to onychauxis proper, two forms are recognized. In the first, the nail-cells are more closely set together and the resulting hypertrophy is declared, not in changes in bulk of the nail, but in a dense, thick, opaque, glossy, grayish-white transformation of the organ. It is perceptibly increased in weight and becomes so solid that it cannot be cut by ordinary implements. It may be also, though not changed in bulk, altered in shape, its free border curved downward or upward. The second form represents a visible hypertrophy iu bulk, the nail being enlarged in one or several diameters. Enlargement in a trans- verse diameter necessarily involves the soft parts adjoining. Vertical hypertrophy results in any one of the claw- or talon-like forms of onychogryphosis. Etiology. — Onychauxis may be congenital or acquired ; idiopathic or symptomatic ; and due to inflammatory changes in the corium or matrix of the nail ; to traumatism ; to defective hygienic care of the general surface of the skin including the nails; and, perhaps, in exceptional cases, to senile influences. ONYCHAUXIS. 397 Pathology. — According to Geber, there is in gryphotic nails a tolerably uniform consistence superficially ; and in the deeper strata a harder or softer substance arranged in fan-like layers. In the former region, the nail is made up of small, roundish, or flattened cells containing variously sized dark granules. These have a linear arrangement along the longitudinal axis, and, in places, as along the higher transverse ridges, are more closely aggregated. More deeply the cells are irregularly grouped. According to Virchow, they con- tain, centrally, horizontal masses of horn, which descend laterally, including the so-called " medullary spaces." These are sharply defined loculi filled with a homogeneous, lustrous, yellow, or finely granular mass ; and in them may be found epidermal cells in process of keratinization. When the nail is lifted off, the bed looks short, arched, and narrow. Beneath the epidermis accumulated upon the surface, the hypertrophied ridges, longitudinally arranged anteriorly, and the papillae more particularly, become visible, the latter containing large vascular loops surrounded by a small-celled infiltration. Treatment. — The treatment of the disorders of the nail described above, is largely that of the maladies in which they occur. Arsenic and iron are often indicated in these affections ; and their influence upon the nutrition of the nail cannot be questioned. In syphilitic onychia, the constitutional treatment of the disease is essential. The cutting, scraping, and trimming of the nail by the aid of the useful instruments found in the chiropodist's case, supplied by most surgical instrument makers, are important measures in many cases. The treatment of ingrowing toe-nail varies with the extent of the disease. In mild cases, soft threads of charpie are insinuated between the offending border of the nail and the tender granulating surface upon which it presses. Counter-pressure by plaster and the local use of the crayon of nitrate of silver, may be at times employed with advantage. In severer cases, the nail may be removed, though this is generally unwise. The method of treatment devised by Agard, of California, often produces the speediest results. The soft parts are, by him, completely removed from the side of the nail by means of a thin-bladed bistoury ; and the nail permitted to grow down upon one side of the extremity of the distal phalanx, thus protecting the cicatrix and radically preventing the recurrence of the disease. The proper dressing of the feet in onychauxis of the toes is a matter of great importance. The shoes and socks, or stockings, should be adjusted both as to texture and shape to the special requirements of each case. After the hypertrophied tissue is largely removed by cutting or scraping, the phalanx may be enveloped in a plaster-mull or salve-muslin of diachylon ointment, or with mercurial plaster, and the whole covered with a leather or rubber cot. The Prognosis in these disorders of the nails rests entirely upon the nature of the malady in which they occur. Idiopathic and localized changes, as also those occurring in transient cutaneous dis- eases (e. g. the exanthemata), often terminate favorably. In severe 398 DISEASES OF THE SKIN. constitutional or grave cutaneous diseases, the outlook is less promis- ing. The diseases of the nail are usually more obstinate and less amenable to treatment than the similar affections of the softer parts. In cases where there is congenital disease of the nails, a prognosis should be made with reserve. Hypertrichosis. Gr. birkp, in excess; 0p\%, hair. Hypertrichosis is a development of the pilary filaments, exaggerated as to size or Dumber, or unusual either with respect to the location of the growth, or the age, or sex, of the individual in whom it is displayed. Hypertrichosis, Hypertrophy of the hair, Hairiness, or Hirsuties, may be congenital, and this in various grades. It is sufficiently common to see infants at birth provided with extremely long hairs of the hairy parts of the body, such a growth being usually replaced later by shorter filaments. Universal congenital hirsuties is a rare deformity, the entire body being then covered with longer or shorter downy hairs of various colors. Acquired hirsuties may be partial or universal, much more com- monly the latter. Thus the hairs of the scalp or beard may acquire an enormous vigor and length, reaching fully to the ground when the figure is in the erect position; or the hypertrophy of the hairs may affect the face of the child or woman, and in this sex, either the upper lip, chin, cheeks, or all [tortious of the body usually covered by hairs in mau, be provided with a vigorously and symmetrically developed pilary growth. Remarkable instances of universal congenital hirsuties are occa- sionally observed. The so-called "Russian dog-faced mau" (Andrian Jeftichjew) and his son, lately on exhibition- in this country, were noteworthy illustrations of this anomaly. In most cases the influence of heredity is usually distinct and often accompanied by defective dental development, such as entire absence of molar or canine teeth. In all cases of hypertrichosis, whether congenital or acquired, the parts normally unprovided with hair, such as the palms, soles, ungual phalanges, prepuce, glans penis, upper eyelids, and vermilion border of the lips, are not the seat of the pilosis. As the growth of the beard in man is more or less associated with the maturity of the sexual organs, so we often find the hypertrichosis of women and children related to a precocious, perverted, or arrested function of the generative organs. The reported instances of men- struation in female infants and children usually include a description of abnormal pilary development about prematurely developed pudenda ; and after the climacteric period, when some women con- spicuously begin in external appearance to resemble individuals of the opposite sex, either isolated, thick, bristle-like hairs develop over the chin or lips ; or the extreme hirsute condition may be reached. HYPERTRICHOSIS. Duhring 1 has reported one such case, which is illustrated by an excel- lent lithograph representing the face of a woman provided with a superb beard. Fro. 48. The Russian "Dog-faced Man." The influence of the sexual organs in the hypertrichosis of women is well demonstrated in the following case coming under the author's observation. A married woman, thirty-three years of age, weighing one hundred and fifty pounds, mother of three healthy children, applied, in 1883, for relief of a general and facial hirsuties which had resulted in the growth of a full beard and moustache. She had not menstruated for more than a year, and had been pronounced by an expert past the climacteric. During the years 1884 and 1885 the author removed in successive operations the hairs of the face by the electrolytic method described below. Menstruation began while she was subject to the influence of the galvanic current in the operating-chair, and continued thereafter irregularly, at times with intense pain and even menor- rhagia. In 1886, after the last of the operations on the face, she rather suddenly lost in weight, decreasing to one hundred pounds, and began to menstruate regularly and painlessly. The hyper- trichosis of the general surface then disappeared by a simple fall of hair. In the latter part of the year she again conceived, and in 1 Arch, of Dermatology, April, 1877. 400 DISEASES OF THE SKIN. March, 1887, beiug then quite free from any form of hirsuties, she brought a healthy male child into the world. As the result of the local application of stimulating and oily lini- ments persistently and over a single region of the body (scapula, sacrum, sciatic notch, etc.) a growth of long and numerous hair- i- often produced. Care should be had in the management of cases of acne and rosacea in the persons of dark-skinned young women with luxuriant hair upon the head, lest this growth be precipitated upon the chin, cheeks or nose. In cases of hypertrichosis the hair- may be variously colored, and the hypertrophy of downy hairs be purely numerical, or result in increase in the actual size of the shaft of the individual filaments. In neither case do the hairs present any anatomical peculiarities of structure. The localized congenital form of hirsuties is often charac- teristic of certain moles, known as N.evi Pilosi ; and the surface of pigmentary moles (N.evi Pigmextosi) is often very extensively covered with hairs of a dark color. Singular anomalies have been figured by a number of dermatologists where extensive regions (one or several limbs, the entire back, even the greater part of the body) were the seat of enormous pigmented moles, covered with warts, fibromata, and other benign tumors, and clothed with a thick covering of longer or shorter hairs. 1 All such cases exhibit a striking development in either symmetrically or asymmetrically disposed areas of distribution of cutaneous nerves. Under the name Plica Poloxica was formerly described, a condi- tion supposed to be a disease peculiar to the Poles (whence its name), but which has long been recognized as a result merely of persistent neglect, filth, the invasion by parasites, and consequent exudative dis- orders of the scalp. When it exists, the hairs form a huge matted mass on the crown of the head. Hebra has devoted some interesting- pages to the superstitious awe with which this accumulation of hairs, lice, and filth has been regarded. Dr. H. M. Bannister, lately con- nected with the U. S. station in Alaska, informs me that he has seen a number of cases of plica among the natives of that region. A typical case of this curious deformity was lately presented at the author's clinic. Under the title Xeukopathic Plica, Le Page 2 describes a case in which tangled "lumps" and "festoons" of hairs, flat, curled, looped, and intertwined, appeared on one side of the head of a girl seventeen years old, who had previously suffered from neuralgic pains in the site of the growth. Etiology. — The causes of hypertrichosis are practically unknown. It is clear that whatever determines the blood in excess to any one region of the body, may be indirectly the cause of hypertrophy of the hair, a fact demonstrated in the patients who, after applying sinapisms or liniments for years to the skin over the seat of a rebel- 1 See the author's case of nrcvns lipomatodes in a child, the pilary growth being at that age unde- veloped. Journal of C'utan. and Ven. Diseases, July, 1885. 2 British Medical Journal. January 20, 1884, p. 160. HYPERTRICHOSIS. 401 lions neuralgia, exhibit an abundant growth of hair, often several inches in length, over a scapula or a buttock. In women, whose sex renders the anomaly most deforming and distressing, it is chiefly noted as has been observed, in precocious, perverted, or arrested activity of the sexual function. The neurotic conditions accompanying certain varieties of hirsuties may be inappreciable ; or evidently due to traumatism ; or exhibited in paralyses, muscular atrophy, etc. Treatment — To Hardaway, of St. Louis, Americans are indebted for the popularization of the method of removing superfluous hairs by electrolysis, first devised by Michel, of his city. 'After him most American dermatologists have with success removed extensive pilary growths without subsequent reproduction of the hairs. A fine needle is introduced into the hair- follicle and pushed well down to the papilla at its base. This instrument is connected with the negative pole of a galvanic battery containing six or more elements, the posi- tive pole of which is in connection with a sponge electrode held in the patient's hand ; the latter being thus enabled to make or break the circuit at will. When the current is passed, a few minute bubbles of gas escape from the orifice of the follicle, and, when the hair-papilla is destroyed, the hair itself is readily extracted. The dexterity acquired by practice is requisite for the proper performance of the operation, with a view particularly to the insertion of the needle at the proper angle into the follicle. Few patients complain of pain. The number of hairs removed at a sitting varies with the sensitiveness of the patient's skin. The resulting scar is either quite imperceptible or far less disfiguring than the hirsuties, sug- gesting the appearance of the male beard after shaving. Transitory maculae, papules, pustules, and wheals occur at the site of puncture. Care should be taken not to insert the needle too deeply in the par- ticularly vascular regions of the face, as an aneurismal tumor might be produced as a consequence. Every detail of this exceedingly simple operation has now been carefully studied by American operators, and the results, as con- firmed by the author's experience, may be given as follows : 1. As to the battery, any good galvanic battery may be employed. The author uses habitually the forty-cell stationary battery made by the Mcintosh Galvanic and Faradic Company, whose switch- board is so arranged that any number of any selected cells may be brought into the circuit. The number of cells employed should be different for different individuals, different parts of the face, and on different days with the same individual — e.g., a smaller number is required when a patient previously operated upon returns after a somewhat long period of rest. Two to four cells only may be tolerated over the tip of the nose or upper lip near the septum nasi. Twelve to twenty may be well borne, after some experimenting, on an insensi- tive chin. 2. The best needle is a carefully selected, exceedingly fine jeweller's broach, its shaft and point annealed by rapid passage through the flame of an alcohol lamp. It is often useful to have the point also 26 402 DISEASES OF THE SKIN. well rounded on an emery-wheel. The irido-platinura needles are useful, but inferior for general work to the well annealed, carefully selected broach. 3. The needle-holder should be simply a convenient insulated handle, sufficiently long to protect all the points of the operator's right hand from the current. The author employs Prof. White's long handle. Duhring's 1 is of the shape of a thin lead pencil or pen- holder, and is about four inches in length. The handle or stem is of hard rubber, through which passes a metallic rod, acting as a con- ductor for the transmission of the current. The needle is inserted into the needle-holder proper, which is slolted, the needle being clamped immovably by means of a screw-nut. On the other end of the stem there is an insulated inserting-pin attached to the cord leading to the battery. The instrument is of proper weight, conve- nient to handle, and altogether well adapted for the operation. 4. As to further details of the operation it is well (a) to make the connection only after the needle is in situ; (b) to introduce the latter with a gentle manipulation acquired only by skill — it is well charac- terized by Hard away as a "catheterization" of the hair-follicle — observing a certain degree of parallelism with the hair-shaft as the needle enters ; (c) to operate leisurely, making sure that the current is not broken by the separation of the hands of the patient, before the hair is completely free in the follicle. This last can be ascertained by gentle traction on the shaft in from ten to twenty seconds after the insertion of the needle ; (d) to operate in succession upon con- tiguous hairs when practicable, not selecting one here and one there, the latter course being productive of greater pain ; (e) never to use the positive pole in connection with the needle, an error which results in the production of unsightly pigmented blemishes on the surface of the skin. The previous employment of preparations of cocaine both hypo- dermatically and by inunction — c.r/., the oleate of cocaine — in order to relieve or diminish the pain of the operation, may be followed by exceedingly unpleasant consequences. The author has seen a derma- titis thus induced present for months. Dr. Prince, of Boston, 2 lays stress upon the accurate regulation of the current by the aid of the absolute galvanometer, which the author has found in his practice useful but not essential. Dr. Fox, 3 of New York, reports a gradual decrease in the number of hairs returning after operation, proportioned to the improvement in the instruments and skill of the operator. There can be no question that the percentage of such returns varies with these conditions. All patients affected with hirsuties are not to be advised the opera- tion. The author has declined to operate in many cases which were not deemed to belong to the class in which the best results of the 1 Amer. Journ. of the Med. Sci., July, 1881. 2 The exact measurement of the electric current, and other practical points in the destruction of hair by electrolysis. 3 The usl> of electricity in the removal of superfluous hair, etc. Detroit, 18S0. H YPERTRICHOSIS. 403 operation may be expected. Young and vigorous women, usually unmarried, may point out hairs to be removed which are merely fully developed filaments of a thick downy growth, all of whose individuals are rapidly pushing to equal maturity. Here the opera- tion itself, by inducing hyperemia of the skin, may simply hasten the hypertrichosis actually in progress, and thus aggravate the. dis- order. In most cases when an operation is undertaken, both parties should fully understand the possible issue. It may also be a ques- tion whether it lies within the legitimate sphere of the physician to remove superfluous hairs from the habitually covered breast and arms of women. Hairy naevi are best removed by complete excision. Depilatories for the removal of superfluous hairs operate by the destruction of the filament without obliteration of the papilla. The consequence is that the hairs are reproduced in the course of about a fortnight. Most of the compounds used for this purpose contain either the sulphate of calcium, sulphate of arsenic, or sulphide of barium, made into a species of paste with hot water. This is applied over the surface with a spatula, and permitted to remain till it dries, a period usually requiring ten minutes. It is then rapidly removed by scraping with the spatula, and the surface thoroughly cleansed with warm water, after which it is anointed with cold cream, or other similar unguent. Of these depilatories Duhring recommeuds the following : R . Barii sulphis. 3ij ; 8 Pulv. oxid. zinc. ) ._ ,_... 12 Pulv. amyl. j aa dllJ ' • - M. The following are formula? devised by French authors. R. Sodii sulphat. Siij; 12 Amyli pulv. j aa 3x ; 40 M To be finely triturated, and when used, to be made into a thin paste with water. (Boudet.) R. Calcis 3j; 4 Sodii carbon. 5jss; 6 Cerat. adipis gj ; 32 M. To be applied as a depilatory in the manner of a paste. All of these require caution in their use, and should never be intrusted to unprofessional hands. Shaving may be practised upon the hirsute face of women, and, with a similiar end in view, epilation also ; the latter, particularly in cases of hypertrophy of the hair, limited in extent. Partial suc- cess has attended the thrusting into the follicles of needles, pre- viously dipped in various caustic solutions, or heated in various degrees, but these methods are all far inferior to electrolytic destruc- tion of the hair-papilla. 404 DISEASES OF THE SKIN. 3. Of Connective Tissue. Sclerema Neonatorum. Gr. oK/>jpi}Q, hard ; vkov, lately; yewou, to bring forth. Sclerema Neonatorum is a disease of early infancy, induced by changes in the capillary circulation, accompanied by a progessive fall of temperature, and characterized by blanching, oedema, and even mummification of the skin. Symptoms. — The disease occurs, as a rule, iu from three to six days alter birth, and is characterized by a progressive cooling of the surface of the body, with an increasing- and extending- oedema, first most notice- able in the lower extremities. The skin is blanched, marbled, mottled, or more rarely of a yellowish, reddish, or violaceous hue, pits upon pressure, and later is indurated, firm, tense, and shining. The con- dition becomes more or less rapidly noticeable over the other parts of the body, the face, upper extremities, and trunk. As a consecpuence, motion is impeded, the features are stiffened, suction of the nipple is rendered difficult or impossible, and the infant reclines helpless, motionless, rigid, cold to the touch, and displaying the signs of a waning vitality merely by its moans and superficial respiration. Death usually occurs within a brief time. The respiratory and circulatory systems are in such cases always at fault. The disorder is common after capillary bronchitis, the pneu- monia of infants, and the gastro-intestinal disorders which prevail in premature, imperfectly nourished, and neglected infants of a tender age. Etiology. — The causes of the disease, whose cutaneous manifesta- tions seem to be largely symptomatic, are to be sought in every sys- temic disorder of early infancy which is accompanied by retardation of the respiration and circulation. For several years the author had the opportunity of studying the changes which precede a fatal issue in a large proportion of the abandoned and diseased foundlings cared for in the infirmary of the Chicago Home for the Friendless, and in several were distinguished unmistakable symptoms of sclerema neonatorum. Three of these waifs had been, significantly, abandoned at the door of the institution in very cold weather, and had there remained for several hours exposed and unnoticed. In none was it necessary to seek for causes any more profound than those which the history of each case suggested. Authors have, however, regarded the disease as produced by atelec- tasis pulmonum, cardiac disorders, and unknown constitutional con- ditions. Pathology. — Post-mortem, there is discovered no hypertrophy of the cutaneous elements. The tissues are simply distended with yel- lowish-white serum — in other words, are cedematous. This fluid, often SCLERODERMA. 405 containing fat globules, flows forth after incision of the parts, more or less stained by the coloring matters of the blood, which was during life in a state of partial stasis. The stearine-like deposit found in the panniculus adiposus, is mere coagulated lymph, whose movement has been arrested and whose temperature has been lowered simultaneously with that of the blood. The subcutaneous tissue is usually so infil- trated that it is readily separable from the fascia? and aponeuroses beneath. The brain, lungs, kidneys, and serous membranes are often found coagulated and infiltrated with fluid. Diagnosis. — The disease is readily recognized by its characteristic features exhibited in very early infancy, and in subjects suffering from any cause which strongly depresses the respiratory and circul- atory activity. It is to be distinguished from sclerema adultorum, in which there is a hide-bound condition of the integument of very slow progress and rarely generalized. The latter disease is due to a true hypertrophy of the cutaneous elements. Treatment. — The treatment should be exclusively directed to the restoration of warmth, the stimulation of the respiratory and cir- culatory centres, and the proper alimentation of the little patient. Massage and cutaneous frictions, with artificial heat applied exter- nally, are serviceable. The prognosis is grave. Infants are said to have been saved after exhibiting these symptoms. The author has seen none such recover. In the discussion, however, of a case pre- sented by Dr. JRobinson to the New York Dermatological Society in 1883, several cases of recovery were reported. Scleroderma. Gr. GKA?]p6£ ; hard; dspjia, the skin. Scleroderma is a chronic affection, characterized by a circumscribed or rela- tively diffuse induration, rigidity, fixation, and subsequent atrophy of the skin, the affected parts being yellowish-white, waxy, or pigmented in color, and either elevated or depressed, the disease-process enduring for a series of years, and, in certain cases, terminating fatally after the induction of marasmus. The disease, also termed Scleriasis and Sclerema, is manifested either as a partial or general change in the structure of the skin. The former, much more commonly encountered, is termed by French authors, solereme en placards. There can be little question to-day that niorphoea and scleroderma are different names for one and the same disease, though the two have been separately considered by many authors. In the following pages, adhering to the nomenclature of the American Dermatological Association, the conditions indicated by each name are for the present separately described, a temporary provision looking to more exact knowledge of the entire subject. Under the title, Morphoea, will be, therefore, found a description of the localized forms of scleroderma, to which that name has long been applied. 406 DISEASES OF THE SKIN. Symptom*. — In both the partial and generalized forms, the disease is first manifested in irregularly defined roundish or ovalish, coin of palm-sized patches, in elevated or depressed, yellowish-white or waxy, ribbon-like bands, or in a more extensive and uniform involvement of the skin, usually that of some part of the upper segment of the body. The affected areas in both of the forms named maybe ele- vated slightly above the level of the adjacent normal integument, or to an equal extent depressed below it, or both, the depressions being irregularly distributed among the elevation-, or, especially in the ribbon-like form, bordered on either side by dense ridges. In all fully developed cases, the most prominent feature is the sclerosis, the skin being shining, indurated, brawny, tense, pigmented, and immov- able upon, because adherent to, its underlying structures, as the muscles, aponeuroses, and periosteum. For this reason, there is at times interference with the movements of the trunk in respiration, as also of the lips and other parts of the face in the expression of the emotions, and of the fingers in the grasp of the baud. The disease, in short, produces the condition often described as "hide-bound." The skin of the affected parts is usually yellowish-white, dirty, yellowish, waxy, or like alabaster in color; is often slightly desquamating, and may be pigmented iu various shades from yellow to brown and bronze. There is usually no alteration iu the subjective sensations, temperature, glandular secre- tion, uor, in the early stages of the disease, in the general health of the patient. The malady begins insidiously, but may, however, be rapid in its development, and accompanied by pyrexic or rheumatoid symptoms. Iu its subsequent progress, it always pursues a chronic course. There is no strict line of demarcation between the sclerosed and unaffected portions of the skin. The # temperature of the affected part may be at times slightly subnormal. After the complete evolution of the disease, when the sclerosed patch has attained a maximum of induration and thickening, the disease may disappear by resolution, or marked atrophy result. This atrophic process may involve both the skin and its underlying struc- tures. A dead-white, thinned, pinkish, slightly pigmented, or dirty- yellowish membrane may then be seen tightly stretched over a joint or a projecting osseous surface. The course, therefore, of the disease may be either toward definite resolution, persistent cutaneous atrophy, or the final induction of a fatal marasmus. But little is known of the concluding stage of the affection, patients, before arriving at that term, usually drifting from the observation of practitioners. Nearly twenty fatal cases are, however, on record. The skin may be entirely restored to its normal condition, but often such restoration is succeeded by a return of the disease in the part originally affected, and by the involvement of new The sites usually involved are: the head, trunk, and upper ex- tremities, including the mamma of women. It is occasionally of SCLEEODEEMA. 407 symmetrical development. When occurring upon the face, an ex- ceedingly characteristic symptom is the resulting immobility of the features, head, thorax, digits, and even the limbs. Its lesions are accompanied at times by other cutaneous disorders, such as eczema, erysipelas, melanoderma, canities, anidrosis, morphoea, zoster, and acne. Exaggerated forms of the disease have been noted by several authors, where, to a varying extent, the surface of the lateral half of the face has been involved, the resulting condition being described as Hemiateophia Facialis. Here not only the subcutaneous tissue, but the aponeuroses, periosteum, and bones may participate in the atrophy, a fact well illustrated in the case of Robinson's patient, 1 whom the author had the opportunity of examining. In this instance there was also a distinct sclerodermatous lesion on the face of one thigh. Scleroderma is exceedingly rare ; and the preceding description is based upon the notes of the few cases which have fallen under the author's observation. In one male patient, the surface of the entire chest was symmetrically involved to the extent of inducing marked dyspnoea, and the general condition was that of decided asthenia. His skin was tightly bound in undulating ridges to the ribs beneath, and colored in a dirty-yellowish shade. The other patients were much less seriously affected; one had symmetrical scleroderma of a part of the skin of the thorax in irregular patches ; another, a band- like deep yellow depression between dense ridges which fastened a part of the forehead firmly to the frontal bone ; the fourth, a limited whitish patch at the back of the neck ; and the fifth, a diffuse sclero- derma of the cutaneous envelope of the left mamma, the patient dying in a neighboring State one year after my examination of her person, of what her physician pronounced to be "sarcoma" of the lung. Finlayson 2 has observed in one case symmetrical gangrene of the extremities, a complication related without doubt to the " symmetrical asphyxia of the extremities" described by a number of English authors. The so-called "Glossy Fingers" and the "Sclerodactylia" of symmetrical distribution may belong to the same category. In many of the asymmetrical forms of the disease, and in others also, the sclerosed patches occur in the areas definitely supplied by certain nerves, or in the lines of nerve trunks. The lilac-tinted border, described more fully in connection with morphoea may dis- appear as the disease progresses. In exceedingly advanced stages the pigmentation may be deep and extensive. The complications of such stages are naturally associated with circulation disturbances ; and may be erysipelatous, gangrenous, or ulcerative. Amyloid degeneration of the viscera may also complicate any case. Etiology. — The causes of the disease are obscure. It is observed in about two-thirds of all cases in the female sex, a fact which certainly points to some other cause than rheumatism as effective in 1 Amer. Jcrarn. of the Medical Sciences, Oct. 1878. 2 Med. Chronicle, Jan 1886 408 DISEASES OF THE SKIN. its production, since men arc more exposed than women to changes in atmospheric temperature and humidity, which agents are generally admitted to have an etiological importance in rheumatism. The disease occurs at all ages, chiefly, however, in adults. Cruse observed one ease in a child two years old. The etiological importance of the nervous system is, in the explana- tion of many cases, too obvious to require demonstration. This is much more distinct in the localized manifestations of the disorder where a region supplied by a single nerve or traversed by a nervous trunk is solely involved. Harley, Schwimmer, and others have recognized cardiac and gastric disturbances ; AVestphal and Eulen- berg, central and peripheral changes in the nervous system ; Heller demonstrated in one case a closure of the thoracic duct. Bancroft 1 repeatedly recognized filarise in large numbers in the blood of a young girl in Australia affected with a characteristic scleroderma. The disease is regarded to-day by the greater number of observers as a trophoneurosis. Pathology. — The confusion which has existed in relatiou to the question of the identity of scleroderma and morphcea is due to various causes. By several authors similar symptoms are described under each of the two names : and the symptoms described as peculiar to each are occasionally seen either simultaneously or successively in the same individual. Microscopical examination of the tissues involved in the disease has proved unsatisfactory. The connective tissue of the skin has been fouud, according to Kaposi, condensed and thickened ; its elastic fibres multiplied at the expense of the panniculus adiposus ; its muscular tissue hypertrophied ; the pigment in the rete and corium increased ; the sweat glands dilated ; the lumen of the blood- vessels diminished, and their walls ensheathed in accumulations of what he terms " lymphatic cells." Schwimmer and Bates found vascular changes including a narrow- ing of the vessels, thickening of the tunica media and intima. In the atrophic sequel* of the disease the new elements disappear. Diagnosis. — A differential diagnosis between scleroderma and morphcea involves, as has been already shown, chiefly a distinction between the partial and general manifestations of the disease. Scleroderma is occasionally symmetrical, usually insidiously developed, void of subjective sensations, and indeterminate in out- line. Morphcea is usually asymmetrical, often accompanied by pain or tingling, and exhibits a particularly well-defined contour. Scleroderma may affect large areas of the integument which are at some time densely rigid and firm, and may not exhibit to the eye a structural change. Morphcea is of much less extensive development, produces a soft, somewhat elastic or " cushiony " feel to the touch, and alters the skin so that the eye can take cognizance of the change. The former commences as a cutaneous sclerosis ; the latter as a patch of altered color, the change of hue being due to a greater or less 1 Lancet, Feb. 28, I8SG, p. 380. MORPHffiA. 409 degree of vascularity. Lastly, in scleroderma there is no telangiec- tasis, nor punctate atrophy. Treatment. — The treatment of scleroderma, though empirical, should be persistently enforced in the hope of improvement. Locally, baths (cold, hot, sea, vapor, Russian), massage, frictions with fat and oils, and possibly the hypodermatic injection of pilocarpine (Besnier, Doyon) may be advantageously tried. The inunction of mercurial and iodized unguents has proved futile. Internally, quinine, iron, arsenic, cod-liver oil, and the usual hygienic and tonic regimen, are in different cases severally indicated. In some cases the galvanic current has been employed with marked benefit, applied locally to the patches of disease, and in the direction of the trunks of nervous supply, and over the nervous centres. Rasmussen applies locally an ointment of the black oxide of copper, two grains (0.133) to the ounce (32.). Prognosis. — The outlook for the patient affected with extensive scleroderma, especially of the trunk, is decidedly unfavorable. Much more limited expressions of the disease may be regarded as less grave. Recovery in cases is said to have been perfect. Atrophy once estab- lished, is final. Contracture of mouth, fingers, or costal region may prove serious. Patients yielding to marasmus are naturally those to whom little can be promised. Even after slight manifestations of the disease, the future may be portentous. Morphcea. Gr. fiopcpfj, by metathesis, form. Morphcea is a cutaneous disease characterized by the occurrence of one or several discrete, well defined, firm, and smooth points, patches, lines, or bauds, often slightly elevated or depressed, and surrounded by a delicate violaceous or lilac-tinted halo, whose involution may be followed by macular, punctate, or striate atrophy of the skin. Symptoms. — This disease, once known under the misleading title of "Addison's Keloid," is to-clay best regarded as a local manifesta- tion of scleroderma. The following is a brief description of the most typical form of the disease observed by the author : The patient was a vigorous, well-nourished girl, sixteen years old, with a patch upon the outer face of the left thigh, as large as a breakfast plate and almost as perfectly circular. It was slightly elevated in its centre above the adjacent level, and thence declined to the periphery by a gentle curve quite perceptible when viewed from the side. It was firm but not indurated, feeling to the finger like a densely padded cushion set in the skin. With some difficulty it could be gathered up between the fingers. Sensibility was slightly impaired over its surface. Its outline was so distinct that its limits could have been traced by a pen. The surface was exceedingly smooth, and colored in a shade between alabaster and yellowish wax. Regularly dispersed over the surface of this circular cushion, were 410 DISEASES OF THE SKIN. discrete, slightly pigmented, atrophic puncta, separated from each other by an inch or less of the shining substance constituting the patch. About it was a delicate, elegant, and very regularly dis- played halo of a violaceous tint, which on close inspection could be .-ecu to be produced by a plexus of minute capillaries. Of the few cases of this rare disease which the author has had the fortune to see, no one was comparable with that described above, as respects the size of the patch, and the classical type of the features. In another case, observed lately in private practice, a female child exhibited a small hen's egg-sized patch on the left temple, the in- volved part projecting to a marked extent above the level of the sur- rounding skin. The same violaceous halo surrounded the part, made up, as was evident on close examination, of a delicate vascular plexus. Other forms in which the disease is manifested are one or more coin- to palm-sized patches approximately circular, either at the general level of the integument or slightly depressed below it, in which the tissues are either natural, or unusually firm, tense, and sug- gestive of a tightly stuffed cushion. The surface may be rosy pink, whitish, yellowish, lardaceous, purplish, mottled, or pigmented. It may resemble marble, alabaster, wax, bacon, or a piece of tanned leather. Occasionally there is superficial desquamation. Often minute bloodvessels ramify over its surface, or in the areola, beyond which also the skin may be pigmented in various shades. The centre is often partly anaesthetic. After existing for months and even years, these lesions may undergo involution, leaving an unaltered integu- ment where once they existed, or, more commonly, a contracting cicatriform atrophy of the skin and often also of the subcutaneous tissues, the resulting scar becoming agglutinated to the structures lying beneath it. The lesions may often also be first observed as punctate or striate atrophic depressions. An exaggerated form of the latter is the more or less broad, grooved streak, or furrow, in the sunken floor of which is a glazed, white, firmly attached, and insensitive epidermis, bounded on either side by hypersemic, pigmented, or otherwise altered, smooth edges or ridges. Whether, however, in the form of patches, puncta, stride, furrows, or broad grooves, these changes must in many cases be sequela? of the insidious deposition of lardaceous material to a corresponding extent, whose resorption has been unnoticed. As in the case of stria? et macula? atrophica?, many of these lesions are mingled with, or surrounded by, variously colored, pigmented, hyper- a?mic or telangiectasia patches, streaks, lines, or mere shadows. Often a delicate, yellowish, or violaceous streak cau be distinguished in the immediate proximity of these curious lesions, and the most careful scrutiny will fail to define either its outline or character. The disease occurs asymmetrically, and often unilaterally, upon the face, back of the neck, surface of the trunk, including the breast of women, the belly, the arms, and the thighs. It is said, also, at times to select the areas supplied by certain nerves, a feature by no means distinctive of the disease. Tilbury Fox, for example, writes that MORPHEA. 411 " when morphoea occurs on the forehead, it takes the course of the supraorbital nerve ; " but I have certainly seen one perfect frontal groove, with pigmented, yellowish edges, terminating fully an inch from the supraorbital notch. Etiology. — The causes of the disease are unknown. It rarely occurs in men, a large proportion of all patients being women. I have, however, seen an oval patch two inches in length upon the back of the neck of a young man. All my patients, one child only ex- cepted, were individuals in early adult life, though it is said to occur at all ages. The subjects of the disease are both vigorous and weakly. Pathology. — The studies thus far made of the^ microscopical anatomy of the disease have neither sufficed to demonstrate its iden- tity as distinguished from scleroderma, nor to explain satisfactorily the polymorphism of the affection. Duhring, in one case, established shrinkage of the upper and condensation of the lower layers of the corium ; while Crocker, 1 beside noting the usual phenomena of mul- tiplication of the elements of the derma and secondary changes in the rete and skin glands, thought there was also a fibrous metamorphosis of the protoplasm, lending color thus to the view of Fox, that the disease is essentially a fibroid degeneration of the skin. The neurotic explanation of the disease, suggested by Hutchinson and others, may be said to have generally commended itself to late observers. Morphoea, in fact, is a localized scleroderma, and its position will probably be one day fully established among the tropho- neuroses of the skin. Diagnosis. — For the distinctive differences between morphoea and scleroderma, when such are recognizable, the reader is referred to the details presented in connection with the diagnosis of the last-named disease. From the patches of vitiligo those of morphoea are readily distinguished by the entire absence of all structural cutaneous changes in the former, aud their characteristic milky-white color, the hairs of the part being also blanched. Both the pigmented macules and atrophic patches of lepra are remarkable for their anaesthetic condi- tion, and their coincidence with, or sequence from, other readily recognized symptoms of the disease, such as tubercles, bullae, ulcers, and involvement of the hairs, nails, eyes, and other organs. Treatment. — In many of the milder cases of morphoea, especially those existing upon portions of the surface concealed by the clothing, there is no indication for treatment. The patient's general health is unimpaired, and the local disorder unproductive of either present discomfort or a menace for the future. When the disorder is facial, and atrophy has already occurred, the resulting disfigurement may be regarded as remediless. For the earlier stages of the disease upon the face, and for those lesions in other situations which, from their size, number, or progress, are portentous, general and local treatment may be required. The former includes the use of iron, quinine, arsenic, cod-liver oil, strychnia, and phosphorus, with the usual 1 Lancet. November 22, 1S70. 412 DISEASES OF THE SKIN. roborant regimen and diet. The latter involves the application of the various simple stimulants, frictions with oil, spirits, and soaps, singly <»r in combination ; lotions with the mercuric bichloride, mas- sage, and the employment of the galvanic current. In pregnant women treatment should he deferred till after delivery, when involu- tion may be more speedily obtained. Young girls, chlorotic, anaemic, and suffering from .menstrual derangements, should be taken from the school -desk and the piano-stool, and sent to the riding-gallery, the gymnasium, or the dairy-farm, where they can swallow a goblet full of pure, fresh milk after each meal. Prognosis. — The disease may terminate by spontaneous and perfect restoration of the part. Adherent atrophic stria? or patches are remediless. The progress of the disease is exceedingly indolent, and may continue for a lifetime. Occasionally grave sequela? may be anticipated. Elephantiasis. Gr. el£$ag, elephant. Elephantiasis is a chronic disease of the cutaneous and subcutaneous tissues, usually limited to certain regions of the body, preceded by the occurrence of some inflammatory process in the blood- and lymphatic vessels of the affected part, and resulting in an enormous increase in its volume, with hypertrophy of the structures of which it is composed. Symptoms. — This disease, long known as Elephantiasis Arabum, Pachydermia, Bucnemia Tropica, and Elephant Leg, or Barbadoes Leg, is encountered more frequently in and near the tropics, but sporadic cases occur in all countries. Perfectly typical instances of the malady have been noted in almost every part of the United States. Fig. 49. Elephantiasis of the foot and leg. Its most frequent seat is the lower extremity of one side, where it involves the foot and leg, though the thigh of the same limb may ELEPHANTIASIS. 413 also enlarge. The penis and scrotum of the male, the labia and clitoris of the female, the upper extremities, the face, and portions of the trunk may likewise become involved. The disease is insidious in its approach, and remarkably chronic in its career. Usually, localized inflammations precede, as an erysipelas or a dermatitis, with or without some involvement of the lymphatic vessels and glands. At the same time there is a condition of general fever. To this succeeds a defervescence, with abatement of the local inflammation ; its sequelae becoming manifested in a more or less persistent oedema of the part lately inflamed. After intervals of days, weeks, or months, the pyrexia recurs with still greater involve- ment of the swollen tissues which, with each access of fever, increase in volume and gain in density. When the elephantiasic condition is fully developed, the skin is found to be tense, glossy, and blanched or discolored in various shades. Pressure upon the oedematous part is followed by pitting, but the tissue beneath is felt to be brawny and indurated. The parts beneath the skin are perceptibly increased in volume, especially the subcutaneous tissue ; and the circumference of a limb thus diseased may be several times larger than that of its fellow. A lymphangitis is usuallly declared by painful, cordlike, linear indurations of the part, associated with adenopathy of the Fro. 50. Elephantiasis scroti. nearest ganglia. In older cases, the skin loses its glabrous aspect, and exhibits eczematous, verrucous, papillomatous, seborrhoeic, and even ichthyotic changes. Pigmentation, even to a blackish tint, may ensue; scaling, Assuring, and furrowing are common; and the accum- ulation of altered sweat and sebum in these depresssions is the 414 DISEASES OF THE SKIN. source of an offensive stench. During the course of the disease almost all of the elementary lesious of the skin may be displayed by the skin, maculae, vesicles, papules, tubercles, pustules, blebs, ulcers, crusts, scales, excoriations, and fissures. Warty growths form as large as those seen in ichthyosis hystrix, and in some cases reddish- colored tumors spring from the hypertrophied integument. When fully developed in the lower extremity, the unwieldy limb with the foot, ankle, and leg massed into one huge, cumbrous cylinder, bears a striking resemblance to that of the elephant, from which circumstance the malady first received its name among the Arabs. Locomotion is then greatly impeded, or rendered impossible. No less striking is the similar deformity induced in the female labia or male scrotum, the latter at times hanging far below the knees. In its rugous folds the penis disappears, and the urine is passed along a gutter formed of skin transformed into quasi-mucous mem- brane. As a consequence of the fissures and excoriations which form, the lymphatic channels are finally opened, and a true lymphor- rhoea results. After similar processes the ear may become largely pendulous by the side of the neck. Subjectively, the disease may be regarded as productive of less discomfort than would be suggested by its formidable features. Pain is occasionally experienced, and, during the exacerbations accompa- nied by pyrexia, there is corresponding malaise. The chief subjective sensations are those induced by the weight and consequent tension, inseparable from the enormous masses of hypertrophied tissue. Etiology. — The causes of elephantiasis are exceedingly obscure. Predisposition of races or individuals, heredity, climatic influences, malaria, fatiguing labor with the feet and legs immersed in water, aud filth in connection with "misery," have all been cited as favor- ing conditions. To these should be added the local disorders especially common in the lower extremities, which have in cases proved to be the points of departure of the elephautiasic hypertrophy, such as obstruction to the blood or lymphatic currents by pressure of tumors, pregnancy, or neoplasms ; ulcers, cicatrices, and the presence in the blood of the filaria sanguinis hominis. Lewis and others have demonstrated the presence of embryos aud filaria, adhering to the walls of both lymphatic and bloodvessels in elephantiasis of the tropics ; but the occurrence of the malady where such parasites do not exist is to be explained on other grounds. The. disease is especially prevalent in the East and West Iudies, Egypt, Arabia, Abyssinia, Africa, Malabar, Barbadoes, Brazil, Mexico, aud parts of China. Pathology. — Even macroscopically, the elephautiasic mass is seen to be built up of hypertrophic elements representing all the tissues of which the part is composed. The knife with difficulty divides the homogeneous, whitish, and lardaceous mass, from which on pressure exudes a fluid of similar color. The subcutaneous connec- tive tissue is found relatively much more enlarged and sclerosed than the epidermis and derma ; though when the section is made through ELEPHANTIASIS. 415 the rugous aud warty skiu described above, all the elements of the papillary layer, rete, and stratum corneum are seen to participate in the changes described in connection with the pathology of verruca. Here and there are loculi filled with a fluid lymph. The sheaths of the bloodvessels, lymphatics, and nerves, the bones, muscles, and aponeuroses are also thickened, solidified, and occasionally aggluti- nated, so as to be almost indistinguishable in the mass of uniformly sclerosed tissue. The pigmentation of the derma is marked : the nuclei of the connective-tissue cells are multiplied ; and the cutaneous glands intact, hypertrophied in their epithelial linings and invest- ments, or, at a later stage, atrophied. It is evident that in many cases, as Virchow has pointed out, the earliest of the changes to be noted occur in the lymphatic glands and vessels, the whitish and yellowish lymphatic fluid which then accu- mulates in the tissue, resulting from obstruction of some of the lymph channels. In some of the remarkable cases on record the lymphatic obstruction is the prominent feature of the disease ; and the elephanti- asic enlargement subordinate in gravity to the former condition. Such are, for example, the noteworthy instances in which the lymph distends multiple cutaneous vesicles, after rupture of one or more of which that fluid streams away to a dangerous extent. For a fuller description of this interesting class of cases, the reader is referred to Busey's careful monographs on Occlusion and Dilatation of the Lymph Channels. Diagnosis. — The striking deformity, which characterizes elephanti- asis, will always suffice for its recognition. In the earliest stages of the disease, when merely an erysipelatous or eczematous condition of the skin can be determined, it would be difficult, if not impossible, to decide as to the future of the disorder, especially in a locality where only sporadic cases occur. A symmetrical hypertrophy of both legs and both feet developing in this country, even though described as " elephantiasis," should be most carefully studied before a diagnosis is made of the particular disease here considered. The same might even be said of elephantiasis of but one inferior extremity. The author was once requested to examine a patient with extensive deforming induration and enlargement of the right leg and foot, ac- companied by pigmentation and a well-marked warty condition of the skin, who had been pronounced the victim of idiopathic elephantiasis Arabum. It was discovered that the patient had had a fracture of the upper third of both bones of the same leg during the previous year, and had since constantly worn a tight bandage, encircling the limb at the seat of the injury. The deformity rapidly disappeared under the application of a roller bandage extending from the toes upward. A peculiar and rare, though characteristic, deformity of the labia majora of women — most commonly the labium majus of one side — results from a tertiary, syphilitic, gummatous infiltration which must be distinguished from elephantiasis. In such cases the history of the disease and the relative inferiority as to bulk of the affected organ, 416 DISEASES OF THE SKIN. points to the nature of the disease. The syphilitic labium rarely exceed- the size of a large fist. Treatment. — In the early -tap's of elephantiasis, the febrile condi- tion of the patient and the localized cutaneous inflammations, are to be treated by the measures appropriate for the relief of these condi- tions. Quinine, especially in malarial districts, is of the highest importance. When the elephantiasic development is established, if the genitals are involved, the knife of the surgeon offers the best prospects. The result of such interference, both in the genitalia and extremities, has been in many cases brilliant indeed, though the mortality of such severe operations is necessarily great. When the lower extremity is involved, it should be maintained in a horizontal position, it- ulcer- if possible healed, its excresceuces removed, its circumscribed inflammations resolved, aud then elastic compression be carefully and skilfully maintained by means of the rubber bandage. The toes are first separately enveloped; then the foot and ankle; and lastly the leg. The results are sometimes highly satisfactory. Ligation and digital compression of the main artery supplying the elephantiasic leg, have been occasionally followed by transient improvement. Instrumental compression has at times resulted in severe ulceration, and a reawakening of the erysipelatous affection. Multiple punctures and incisions, made with a view to giving exit to the fluids contained in the mass, have been attended by no greater success. The main obstacle in all these surgical procedures, is the lymphangitis which so frequently complicates the situation. None of them promises so well as nerve stretching, which, in a few isolated cases, has been followed by noteworthy results. Excision also of a portion of the sciatic nerve has been followed by satisfactory changes. The use of the galvanic current has, when long continued, accom- plished resolution of engorged masses of tissue. Elastic compression in the horizontal position for all cases not warranting nerve stretch- ing, may be regarded as the wisest course when the extremity is involved. For the local treatment of the pachydermia proper, green soap, mercurial ointment, and bathing in hot or cold lotions, may be advantageously employed. For patients whose disease is acquired in countries where the deformity is prevalent, a change of climate is of the highest importance; and, having in view the social surround- ings and habits of most victims of the disease, it is scarcely necessary to call attention to the need of a proper hygiene, diet, and tonic regimen. Prognosis. — The future of a patient affected with the disease may be regarded as most favorable when the latter exhibits an early tendency to respond favorably to appropriate treatment, and when circumstances permit of a resort to the best therapeutic measures which can be adopted, such as change of residence, persistent and careful dressing of the affected part, and the removal of any exciting cause of the disease, such as a neoplasm, indurated cicatrix, etc. In the severer cases, a fatal result may be precipitated ; but usually life is prolonged, burdened by the inconvenience of the enormous ROSACEA. • 417 elephantiasic mass in comparison with which the rest of the body ofteu seems to serve as a mere appendage. Lymph Scrotum, Varix Lymphaticus, or Nsevoid Elephantiasis, fully described by Wong, Carter, Fayrer, Manson, and other East Indian observers, is that condition in which the inguinal and femoral glands become large and soft, and the scrotum covered with vesicles and distended with dilated lymphatic vessels all filled with coagu- lable lymph. As in elephantiasis of other organs, there may be preceding fever, chills, erysipelas, and other localized inflammations. The disease is produced solely by the filaria sanguinis hominis, and may be associated often with chyluria on the one hand, and elephan- tiasis of other organs on the other. Rosacea. Lat. rosa, rose. Rosacea is a chronic cutaneous disorder, chiefly of the face, characterized by irregularly disposed, rosy or reddish maculations often produced by telan- giectasis of the skin capillaries, or forming split-pea sized and larger hypertrophic nodules most commonly seated upon or about the nose. The condition of telangiectasis described under this title, is almost identical as regards its clinical features with acne rosacea (Gutta Rosea, Copper-nose), to which the reader is referred. In what fol- lows, it is attempted to portray the affections of this class which may be properly described as hypertrophic in character ; relegating the acneiform cases to the chapter devoted to Acne Rosacea. [A.] Erythematosa. Symptoms. — The eruption is usually displayed in middle life or later, and chiefly upon the face of both sexes. In these, the nose (tip, alse, root), brow (especially near the root of the nose), chin, cheeks, temples, or lips, may be the seat of reddish or rosy blotches. The effect is a marked unsightliness for which chiefly or only the advice of the physician is sought. These maculations are usually unproductive of subjective sensations, or of objective feeling of heat. They may be so numerous as to implicate all the regions named above to a great degree, or be limited to one or two adjacent regions, or, lastly, be spread very profusely over the entire face in minute blem- ishes not more developed at one point than another. The very greatest irregularity may be noted as to their contour, the spots being pin-point to nail-sized, roundish, radiating, stellate, linear, tortuous, or in any fantastic outline. The colors vary from a delicate rosy pink to a deep purplish crimson. Viewed with care all are seen to be produced by a double process of dilatation, and new formation of the skin capillaries. This condition is subject to marked aggravation, or at least tran- 418 DISEASES OF THE SKIN. sient change of features after the operation of any cause tending to congest the vessels of the head, such as dietetic stimulation, coughing, laughing, sneezing, active exertion, the application of hot water to the surface, exposure to the sun, etc. Alter such occurrence, the blood will visibly distend the vessels of the face, the color deepen and spread, and all features of the disorder become decidedly con- spicuous. Often a coexisting acne, or seborrhea faciei participates in these changes. The disease is seen with almost equal frequency in both sexes, but women rarely exhibit the succeeding stage of the disorder next described. [B.] Hypertrophica. After a longer or shorter continuance of the condition described above, a new formation of connective tissue with cell infiltration proceeds pari passu with the telangiectasis. In this way small or large pin-head to egg-sized tumors are developed, more particularly about the tip or aire of the nose, reddish or purplish in color, till the stage is reached which is elsewhere described as rhinophyma. The absence of inflammation is in these cases marked. The nose is often cold to the touch when bright red in hue, and may be of a pecu- liarly oily or greasy appearance in consequence of a seborrhoea oleosa of the part. The so-called "brandy-drinker's," "wine-drinker's," and "whiskey-drinker's," noses are of this class. Etiology. — The disease in its milder manifestations is common to both sexes, the hypertrophic forms being rarer and practically limited to the male sex. The causes of the disorder are numerous, but always operate by producing at first active or passive distention of the bloodvessels of the upper portion of the body. Among these effective causes may be named gastric dyspepsia (especially though not exclusively associated with intemperate use of alcoholic stimu- lants, including brandy, whiskey, wine, and beer); articles of clothing, surgical apparatus, tumors, etc., compressing the larger vessels at the root of the neck; the long-continued action of heat and cold upon the face, as also the local effect of chemicals, and the influence of certain trades and occupations of life tending to produce congestion of the face, as, e. g., among cooks, cab-drivers, swimming teachers, etc. In some cases there is a distinctly inherited tendency to dis- tention of the capillaries of the skin of the face; in yet others, the rosaceous blemish is congenital. Disease of the uterus and other viscera may be the remote sources of the trouble. Pathology.— The hypersemia usually begins as a transitory phe- nomenon in the more deeply seated plexus of vessels and, after per- manent distention has resulted, the vascular elements of* the more superficial strata of the corium, and those surrounding the sebaceous glands and hair-follicles become involved. In the hypertrophic lesions, there are new formation of connective tissue, enlargement of all portions of the corium, hyperemia and telangiectasis of the ves- sels, and dilatation of the sebaceous glands. FRAMBCESIA. 419 Diagnosis. — Acne rosacea is to be distinguished from uncompli- cated rosacea by its characteristic lesions, comedones, papules, pus- tules, crusts, etc. In uncomplicated rosacea, there is only a macular lesion due to hyperemia or telangiectasis. The two disorders, thus artificially distinguished, are often found the one complicating the other, an acne being the origin of the hyperemia, which is the first rosaceous stage. The hypertrophic lesions of rosacea are also often thus associated with acneiform symptoms. Lupus, carcinoma, and syphilis of the regions affected by rosacea are commonly productive of ulcerative or destructive consequences which point to the nature of those affections. Treatment. — The treatment of rosacea is practically the same as that of acne rosacea, to the chapter devoted to which the reader is referred. The vessels producing the rosaceous blemish are to be destroyed, preferably by electrolysis; but the result may also be accomplished less elegantly and perfectly by incisions, followed by cauterization ; by curetting, by the Paquelin knife, by Brun's sharp spoon, Vidai's lancet, or B. Squire's multiple scarificator, the last- named instrument being only available for the larger lesions. The hypertrophic forms of rosacea are best remedied by the plastic opera- tions of modern surgery. Prognosis. — The lesions of rosacea, limited in extent, even though quite numerous, may be elegantly and permanently removed by electrolytic methods. The scars left after operations upon the larger lesions are usually superficial, and not disfiguring. The prognosis, after ablation of the largest hypertrophic lesions, is proportioned to the resources of surgery. In no case does general disease result. Framboesia. Fr. framboise, raspberry. Framboesia is a disease of the African race chiefly, manifested in pin-point to egg-sized and larger papulo-tubercular lesions, appearing mostly on the face, resulting in discharges and crusts, and in cases followed by systemic symptoms. This disorder, termed by Charlouis, Polypapilloma Tropica, is encountered chiefly among the negroes residing along the African coasts, in the West Indies, and in South America, where it is also known as Yaws and Pian. By Alibert it was termed Mycosis Frambcesioides. The contributions to the literature of this sub- ject have been made chiefly by Drs. Milroy, Nicholls, and Imray, of Dominica, and Dr. Bowerbank, of Jamaica. The malady is .said to be characterized at first by the occurrence of brownish-red, pin-head to pea-sized, flat maculo-papules. In these, one or more yellowish or whitish puncta become visible, which gradually develop into roundish papules or tubercles, resembling pea-sized and larger pus- tules of yellowish-red color. When the integument which covers 420 DISEASES OF THE SKIN. these gives way, a fetid, sero-purulent fluid exudes, aud a dirty- yellowish, Bpongy mass projects from the reut, aud enlarges subse- quently, till it appears as a yellowish-red, crusted vegetation, an inch or more in diameter. This may degenerate into an offensive ulcer, whose destructive processes are accompanied by progressive emacia- tion and systemic disturbance. Instead of this retrogressive meta- morphosis, the tubercle may shrivel iuto a dark-colored, crusted, aud withered excrescence, yielding a fetid and ichorous discharge. The eruption occurs upon the face, neck, extremities, auo-genital region, and, rarely, upon the trunk. The lesions are seldom the seat of subjective sensation. They have been considered contagious, and not susceptible of transmission by heredity. The course of the disease usually extends through from two to four months. It is also said to occur at all ages and in both sexes, one attack conferring immunity against another. The constitutional symptoms of the malady include fever, osteo- copic pains, gastro-intestinal distress, arthritic troubles with ulcera- tions about the joints resulting in deformity, and eventually cachexia. The disease is both inoculable and auto-inoculable. Iuoculatiou results in the formation of a crust-covered ulcer, followed in from seven to fifteen days by a general eruption. The result is rarely fatal, the disease being concluded in most cases after a period of from three to four months duration. Most of the authorities who have personally studied the disease as it occurs in the African race, believe that frambcesia is a disease sui (/corn's. Certain it is that in both syphilitic aud non-syphilitic sub- jects, who have never visited the countries where it is claimed that the disease is endemic, similar symptoms have been recognized and described. An interesting case of framboesioid lesions in a syphilitic woman is reported by I)e Amicis; 1 and the author has personally treated three patients whose lesions corresponded very closely to those described above, no one of whom was syphilitic. It can be readily understood that a vegetation occurring upon the filthy skin of an unwashed negro in the tropics, might assume features which would be scarcely recoguized as classical, in the clientele of most practitioners in this country. It is safest at present to regard the term frambcesia as largely descriptive in scope, and as including certain papillomatous and other vegetations projecting from the surface of the body as a result of filth, syphilis, tropical temperatures, and possibly of other uufavorable agencies operating upon the skin of a negro. A sufficient commen- tary upon these considerations is afforded by the admission of the West India surgeons, that mercury aud the iodide of potassium are regarded as specifics for the disease as it exists in those islands, aud that cleanliness is of prime importance. 1 Cf. a translation of his paper by the author in the Archives of Derm., October, 1879, p. 39. FRAMBQESIA. 421 Parangi. Kynsey has presented a report upon the nature of the disease which is thus designated in Ceylon, where it prevails. It appears to present mixed features of syphilis, land scurvy, yaws, pellagra, lupus, leprosy, scrofula, and less severe disorders, existing as an endemic in certain provinces of the island. It is clear, from the description of the symptoms recorded, that the nature of the disease has not yet been recognized. It was first described by Loos in 1868, and is now regarded as due to numerous causes, such as mal- nutrition induced by impure food and water, wretched hygienic sur- roundings, and infection from the discharges from ulcers. There is, according to Christie, 1 an incubation period of from two to eight weeks, followed by the appearance of an ulcer over any bony prominence — the initial sore. This is followed by malaise and pyrexia, the premonitory fever lasting from two to eight days, and followed by the exanthem which appears first over the face, and later on the body. This eruption may be vesicular, pustular, pustulo- tubercular, or squamous, superficial ulcerations forming which become subsequently crusted. JRupioid, furuncular, and psoriasiform features are common in the course of the malady. Condylomata may appear at the anus. Ulcerations succeed later of a more formidable char- acter, involving the nose, palate, and cheeks ; the digits may be lost by gangrene; blebs occur; pricking pains are experienced; there may be anaesthesia of some part of the surface, associated with bronzing and glazing of the skin. The patient may perish of some inter- current disorder or from exhaustion. The duration of the disease is said to be from two to eight years. Treatment has been successful with the cautious employment of mer- cury and the iodide of potassium, and strict observance of the rules of hygiene. Donda Ndugu ("brother ulcer," or "ulcer that clings") is a disease existing in Central and Eastern Africa. Dr. James Christie, 2 who first described it, believes it to be identical with that from which Livingston suffered in 1870. The disease is confined to the lower extremities, and occurs among the natives chiefly in the rainy season after a march toward the coast. It is characterized by the appearance of whitish papules springing from a boggy swelling, seen often near the toes, heel, or dorsum of the foot. When incised, an extensive, deep-seated slough is found beneath the healthy tissue, bathed in an ichorous discharge. Severe rapidly -spreading ulcerations and death may ensue. Livingston ex- tracted the ova of a species of maggot from such lesions in his own person; but Christie failed to discover them in his cases. The treat- ment is local, by the use of antiseptics after incision. 1 See Anderson's Treatise on Diseases of the Skin. 2 Loc. cit. 422 DISEASES OF THE SKIN. CLASS V. ATROPHIES. 1. Of Pigment. Absence of the pigment of the skin, giving rise to conspicuous disfigurement, is naturally most frequently encountered in those races of mankind whose skins are most abundantly provided with such pigment. The absence of pigment may be congenital or ac- quired, and partial or universal. Some confusion has been produced by the arbitrary distinction established by authors between the names intended to designate these several varieties of achromatia or leuco- pathia. In the following pages, leukoderma is the name employed to designate the pigment atrophy which is partial and congenital ; albinismus, that which is universal and congenital ; vitiligo, that which is acquired. Leucoderma. Gr. Ievko-, white ; depua, skin. Leucoderma is a partial congenital absence of pigment in the skin, most commonly observed in the colored races, and characterized by whitish patches or bands having an irregular border, the evidences of disease in such parts being limited to the changes in hue of the skin and hairs. Symptoms. — In these cases, the patients being most often of the colored races, one or several whitish or rosy-whitish patches or bands, varying as to size, outline, or situation, may be seen at birth unprovided with pigment. These may have a symmetrical arrange- ment, in which case they commonly observe the areas of distribution of one or more cerebral or spinal nerves, or be asymmetrical in dis- tribution. They are usually of circular outline, and may be fouud upon the scalp, face, nipples, breast, and genital region. The hairs found upon such parts are equally destitute of normal color, being usually white. Negroes thus marked are generally termed "pie- bald," and the integument similarly affected in persons of other races has long been recognized as the "pied" or "piebald skin." These blemishes, when symmetrical, like pigmentary naevi, exhibit a striking analogy with the symmetrical arrangement of the spots, bands, and stripes to be recognized in the furs of many of the lower ALBINISMUS. 423 animals. The outline of the patch may be abrupt, or may gradually shade into that of the adjacent integument. At times, islands of pigmented skin are visible within the non-pigmented areas. The changes in these patches daring later life may be insignificant, or they may individually increase in size with age, or even multiply. Rarely they regain pigment in later life. Iu no case is there an excess of pigment deposited at the border of the patch. This condition is practically remediless. Albinismus. . Lat. albus, white. Albinismus is a congenital cutaneous achromia, characterized by universal defect of pigment, unaccompanied by textural changes in the skin. Symptoms. — The term albinismus is limited to the congenital con- ditions of achromia induced by universal failure of cutaneous pigment. This deformity is peculiar to individuals known as Albinoes, isolated instances of this anomaly occurring in all races, but more frequently among those having normally a hyperpigmentation of the skin, such as negroes. In the subjects of this anomaly, the skin has a milky-whitish, transparent, or rosy- tinted hue, and is usually of delicate texture; the hairs are silky and yellowish, whitish, or snowy-white in color; the iris, transparent or pinkish ; and the pupil, in consequence of the defect of pigment in the choroid, is also reddish or pinkish. There is, as a result, nyctalopia and heliophobia with frequent nictitation, pupillary variations, and the semblance of myopia. The pinkish hue of the skin is, in these individuals, due only to its translucency and vascularity. In no other respect, save as to pigment anomaly, does the skin of the healthy albino indicate disease ; but the majority of persons thus deformed are far from vigorous. In albinismus the defective condition of the pigment is usually unchanged throughout life. The causes of the deformity are unknown. The few cases of inherited albinismus on record are not sufficient to establish a law of inheritance in the face of many instances where such transmissibility has not occurred. The union of a male or female albino with an individual of normal color has been repeatedly followed by offspring without pigmentary peculi- arities. The condition is remediless ; though it is probable that transfusion with the blood of a vigorous black-skinned African would largely modify the color characteristics of the pure albino. 424 DISEASES OF THE SKIN. Vitiligo. Lat. vitium, a blemish. Vitiligo is an acquired cutaneous achromia, exhibited in single or multiple, variously shaped and sized patches, unaccompanied by textural change in the >kin, and usually bordered by tissues exhibiting pigmentary excess. Symptoms. — The disorder is one observed among the several races, often in the negro, and not rarely among those of Aryan descent. It commonly occurs without the slightest appreciable disorder, subjective or objective, save that betrayed to the eye in the discoloration of the skin. One or several roundish, or very irregularly shaped, smooth, and well-defined, pale, or milky-white lines, streaks, or disks appear, often bordered at the periphery by an integument which assumes a light or dark brown or chocolate shade, this hue being by contrast most noticeable immediately at the contour of the patch, and imper- ceptibly fading into the normal color of the outlying integument. The hairs or lanugo filaments growing from the affected area may or may not be blanched. Most commonly they are; a condition par- ticularly conspicuous when, as is not rarely observed, a vitiligiuous disk extends from the back or side of the neck, well into the scalp, in which case the outline of that portion of the scalp involved is clearly defined by the whitened pilary growth. Lesser describes a condition termed by him " Poliosis Circumscripta Acquisita," in which the hairs were thus blanched in a single area of an unaffected scalp, an observation which the author has confirmed in a single case. The surfaces thus blanched are otherwise unchanged. In point of subjective and objective sensation, secretion from the follicles, and the condition of both epidermis and corium, aside from the dyschromia there is no departure from a normal standard. The disease may progress by the coalescence of relatively small areas of involvement till a large portion of the trunk, thighs, or buttocks is involved. Hall 1 reports the case of a dark mulatto who became " perfectly white" with the exception of a patch on the chin. Levy 2 reports three instances of total disappearance of pigment. It is then, as Kaposi has well shown, that the eye of the observer is struck no longer by the unusual whiteness of the involved patches ; but this whiteness being generalized and apparently that proper to the person, by the intermediate peripheral belts of a deeper and unusual color. The greater portion of the surface of the body may be finally thus involved. The most common seats of the disease are the face, the neck, the backs of the hands, and the extremities ; and in these, since the course of the disease is exceedingly slow, there may be 1 Louisville Med. News, 1880, x. p. 148. - Receuil de Mem. de Med. de Chirurg et de Pharm. mil., 1865. VITILIGO. 425 Fig. 51. for years no apparent extension of any involved area. Upon the backs of the hands the disfigurement is usually more conspicuous at some seasons of the year than at others, a circumstance which probably ex- plains the reported instances of recurrence and total disappearance of the disease in suc- cessive years. These changes are probably due to the influence of the sweat in washing the pigment to the surface. Such an effect would, of course, render the hyper-pigmented peripheral zone of a vitiliginous disk much the more conspicuous. The health of the subjects of this disorder is usually unimpaired. A morbid mental condition is often produced when the disfig- urement involves the facial region, especially in women of middle life. As in several of the other pigmentary dis- orders of the skin, the patches of vitiligo may be symmetrical in distribution, with their outlines limited to the areas supplied by certain nerves. Lesser, however, attrib- utes this peculiarity to the symmetrical ana- tomical relations of the skin in symmetrical regions of the body, an explanation which will not suffice for all cases. The course of the disorder is evidently toward increase even where all the pigment is not removed from the surface. Generally a term is reached beyond which the atrophy does not progress. In exceptional cases the parts which have lost their pigment again acquire it. Patients of lymphatic temperament and blonde complexion (often they are women in early adult life) will occasionally apply to a physician for relief of dark patches on the skin of the face. Examination of these faces often discloses faint lines, ribbons, or streaks of pigment about one or both cheeks, the temples, or the lips. But a yet more careful scrutiny recognizes an undue whiteness of the skin, with exceedingly faint and irregular outline near or next to these pigmented portions of which complaint is made. I am inclined to set all these cases down as instances of vitiligo, even though they rarely exhibit the definite roundish contour of the typical patch of the disease. In some patients vitiligo is most conspicuous in summer ; in others, this occurs in winter. These peculiarities may depend upon changes either in the pigmented or unpigmented portions of the skin. Vitiligo in a Negro boy. Piffard's case. 426 DISEASES OF THE SKIN. Etiology. — Vitiligo occurs in both sexes, and in individuals of all complexions and ages ; though it is commonly observed in early or middle life. It is at times coincident with scleroderma, morphcea, lepra, variola, and other diseases with similar cutaneous symptoms, though it occurs independently of all such. Its etiology must be regarded as obscure, unless the strong probabilities in favor of its occurrence under the influence of perturbed innervation be accepted as conclusive. I am strongly inclined to believe that the disorder is of more frequent occurrence than dermatological statistics tend to show. Many persons who are the subjects of vitiligo of an incon- spicuous part of the body, do not consult a physician with regard to the nature of the disease, as it occasions no physical distress. Close observation of the people with whom one comes in contact in public will often verify this fact. Pathology. — The pathological anatomy of vitiligo may one day be described in the changes which occur in the trophic nerves supplying the skin. At present, the cutaneous changes alone are recognized; and these are, probably, as regards the pigment, neither strictly atrophic nor hypertrophic. It is true that there is an apparent atrophy in one portion of the skin, and an apparent hypertrophy in another; but this may be merely in cases falling short of complete pigment atrophy, a dystrophia or ataxia of the epidermis, a disturb- ance of arrangement and distribution, as of the blood in the face, in certain cardiac diseases, when the skin is temporarily streaked or mottled by the irregularity in the distribution of the circulating fluid. Under the microscope no change is recognized in the skin beyond the absence of pigment. Diagnosis. — Mr. Hutchinson, of London, has devoted an entire chapter in his valuable Lectures on Clinical Surgery 1 to the impor- tance of the diagnosis between leucoderma and white leprosy ; yet it seems incredible that the symptoms characteristic of a systemic disease could be confounded with those described above, where there is no cutaneous anaesthesia or structural change in the integument. This latter is, in fact, the basis of discrimination between all purely pigmentary and all non-pigmentary changes in the skin-color, separ- ating them widely from parasitic diseases (tinea versicolor), morphcea, lepra, and syphilis. From the chloasmata, which are always accom- panied by hyper-pigmentation, vitiligo is readily differentiated. Treatment. — Much chagrin will be saved both physician and patient, by practically regarding vitiligo as not amenable to treat- ment. Patients occasionally recover while under treatment; the latter has, however, generally contributed but very little to the result. Arsenic and iron internally, recommended highly by some authors, have repeatedly failed to accomplish any appreciable results as regards dyschromia. By efforts directed to the removal of the hyper- pigmentation in the border of the achromic patches, the disfigurement may be somewhat lessened. The method of arriving at this end is i Churchill, London, 1878. CANITIES. 427 described in connection with the treatment of chloasma. It is pos- sible that further experimentation with hypodermatic injections of pilocarpine, which have in a limited number of cases been followed by disappearance of the disease, may warrant a less unfavorable view of the results of treatment. Prognosis. — The health of the subject of the malady is not im- paired. The disease is practically incurable, progressing usually till it has obtained a maximum of development ; and then, as a rule, remaining unchanged throughout life. Canities. Lat. canus, white. Canities is that condition of the hairs in which they become in various degrees decolorized as the result of atrophy of their pigment. Symptoms. — In Canities, or Poliosis, hairs appear in all shades of whiteness, from dirty-gray to silvery- white, and this either as a general or partial, congenital or acquired, physiological or pathological, prematurely, rapidly, or gradually acquired condition. General congenital whiteness of the hairs is seen in albinismus, where pig- ment has never been supplied to the filaments. Partial congenital whiteness is occasionally seen, in meshes limited in size, varying in color from a pure white to a deeper hue, which from birth refuse to receive pigment in due proportion, and thus contrast strangely with the pigmented filaments by which they are surrounded. Physiological decoloration of the hairs in variable shades is the well-known result of advancing years. When premature, it may be considered as resulting from pathological causes, or due to other indi- vidual or inherited peculiarities. It may occur gradually or sud- denly ; in the former case, the hairs usually pass through varying shades of gray to white, and this at any period after puberty though usually after middle life is reached. Recurrence to the darker shades is rarely noted. Leonard, of Detroit, 1 cites a number of curious instances in which changes of this sort have occurred. Generally, however, canities of advanced years is progressive and permanent, occurring earliest on the temples and the beard of man, then involving the vertex of the head. Finally, the hairs of the entire surface undergo a similar pigmentary loss. It should be remembered that the coloring of the hairs of the head is, to a greater extent than is commonly appreciated, subject to vari- ation from the operation of external causes. Thus washing the hair with alkaline solutions has a bleaching effect, while profuse sweating, inunction with fats, subjection to smoke, and the temperature changes of the summer, have the contrary influence, the last named being possibly due to the increased sweating in the hot season. Cases of sudden blanching of the hairs, occurring, for example, in a single night, are sufficiently numerous and well authenticated to be i The Hair, etc., Detroit, 1880. 428 DISEASES OF THE SKIN. admitted as among the rare possibilities of a clinical experience. Nervous disorders, both centric and peripheral, such as long-con- tinued mental depression, melancholia, paralysis, neuralgia, and traumatism of nerves or of nervous centres, may be followed by more or less rapid, general or partial, and permanent canities. The same result may follow wasting disorders, such as typhoid fever, in which cases, as distinguished from the others, properly pigmented hairs often replace eventually those which were white. It is well known that the first hairs springing from a patch of alopecia areata where repair is in progress, are often white or whitish, and replaced later by those of normal color. Laudois has shown that many instances of suddenly occurring canities depend solely upon the rapid appearance of air-bubbles in the shaft, in excess of the average number. Hairs whitened in alternate patches, rings, nodes, or spots have been described by Landois, Karsch, Riehelot, Spiess, and others. Etiology. — Whitening of the hair may be senile in origiu, in which case it is customary to declare it to be physiological ; or be due to heredity; to deficient nutrition or innervation of the hair-follieles ; to functional or organic nervous affections (fright, facial atrophy, etc.) ; or to local chemical action upon the hairs. Premature canities in young adults is often associated with the occupations of life, being much more common in men who from necessity have the head habit- ually covered, and who yet lead sedentary lives. Pathology. — The pigment substance of the hairs is both cellular and intercellular in its distribution, and is supplied by the papilla. De- coloration of the hairs may be due to failure of supply or removal of pigment ; to unevenuess of the hair surface (by which the light is refracted) ; or to air-bubbles between and within the fibre-cells. In senile and presenile decolorations, there is commonly actual diminu- tion of pigment, which has been ascribed to failure of the papilla to produce it. Sudden canities is ascribed to the sudden appearance of air-bubbles in quantity in the shafts of the hairs. Alternations of color in the hairs are ascribed to successive periods of activity and rest in the pigment-producing function of the follicle. Treatment. — McCall Anderson, while admitting that the treatment of canities is unsatisfactory, suggests, in cases of accidental presenile blanching, strict attention to the general health, arsenic internally, and local stimulation, as in alopecia simplex. But the chief means of remedying premature canities is by the action of dyes, and these are, in the main, compounded of solutions of nitrate of silver, acetate of lead, and the sulphate of iron. The chief objections to their use are the disagreeable coloring of the scalp which results from incautious use of the dye, and the consequent liability to irritation of the surface. When applied to the hair alone, these substances are not known to have a deleterious effect upon the health. Kaposi gives the following formulae for hair dyes : ALOPECIA. 429 To obtain a black color — R . Argent, nitrat. gr. xv ; 1 Ammon. carb. grs. xxij ; 1 Unguent, adipis §j ; 32 R . Argent, nit. gj ; 4 Plumb, acetas gr. xv ; 1 Aq. Cologn. gtt. xv; 1 Aq. ros. ad f^iij ; 96 M. M. To obtain a brown shade — R. Acid, pyrc-gall. gr. xv; ll Aq. Cologn. 3ss; 2 Aq. ros. gjss; 48 1 M. Anderson first applies a lotion of the bichloride of mercury, two grains to the ounce (0.133-32.), and follows this with a solution of the hyposulphite of sodium, one drachm to the ounce (4.-32.), for the production of a jet-black shade. 2. Of Hair. Alopecia. Gr. alunriZ, a fox. Alopecia is a physiological or pathological, symmetrical or asymmetrical, partial or complete deficiency of hair. Alopecia, Calvities, Defluvium Capillorum, or Deficiency of Hair, may be due to arrested pilary development at birth, or to any cause interfering with the regular physiological process by which hairs are constantly shed and replaced by new filaments. Congenital Alopecia. — In rare cases, there is a partial or com- plete absence of hairs at birth, in consequeuce of an arrested develop- ment of the pilary system. Generally, however, these appendages of the skin are merely of tardy appearance, their eruption being extraordinarily delayed, as in cases of retarded dentition. When this condition persists to adult years, as is very rarely the case, neither hairs nor teeth may be formed, as in Danz's observa- tion. The author has had a child seven years of age presented at his clinic, with only a wisp of white hairs upon the vertex of the In localized congenital alopecia, hairs rarely develop after matu- rity, and here also abnormalities of teeth may be coincident features. In a case examined by Schede, the sebaceous glands were found opening on the free surface of the skin. In the deeper part of the cutis, straight or convoluted hair-rudiments were visible in the tubules, without perceptible internal cavity, which corresponded to the external root-sheath. 430 DISEASES OF THE SKIN. Senile Alopecia. — The baldness of old age, whet her occurring upon the vertex, so as to produce a tonsure like that of the priest, or whether limited to the frontal region, or so extensive as to involve nearly the entire calvarium, leaving a fringe of hairs at the occiput and temples merely, is always remarkable for its symmetry. There is hence a certain degree of dignity added to the appearance of the head, which an asymmetrical loss of hair could not produce. It may occur at varying ages of advanced life, and is quite frequently trace- able to an early seborrhoea sicca or alopecia furfuracea. It is much more common in men than in women; and this largely because of the difference in the manner of covering the head in the two sexes, women usually wearing an exceedingly light dress for the head, while men encase the latter with tight-fitting caps or hats which interfere with proper aeration of the scalp. Individuals of the male sex, also, in consequence of their usually wearing the hair short, bestow far less time upon the care and dressing of it. In uncivilized races, where these differences are less marked, and where men pay great attention to the ornamentation of the scalp, senile baldness is of less frequent occurrence. The bald surface is, as a rule, smooth and shining; it is occasion- ally the seat of a seborrhoea oleosa. The hair-follicles, with their accessory sebaceous glands, and occasionally the skin itself are often in a state of atrophy, though there may be dilatation of the sebaceous glands. There is commonly some blanching of the hairs, which are gradually shed, as also of those which remain, though this is not constant. These conditions are much less frequent upon the surface covered by the beard, and pubic and axillary hairs, where, according to Michelson, the hairs in advanced years are often denser than at other periods of life. Premature or Presenile Alopecia, or premature calvities, is that form of acquired baldness which occurs in individuals who have not attained advanced years. It may be either idiopathic or symptomatic. The idiopathic variety does not originate in the diseases of the scalp or of the general economy which are recognized as effective in the production of other forms of baldness. It is, as with senile alopecia, more common in men than in women, and is, in the former sex, decidedly prevalent among those leading sedentary lives. The loss of hair may be produced either rapidly, or, more commonly, slowly, and at any period after the. puberal epoch. The pilary growth may gradually and evenly recede from the forehead, or, what is more frequent, recede on either side of the median line, leaving a more vigorous crop extending centrally toward the root of the nose, or produce the effect of the tonsure described above. It is always symmetrical, and usually remediless, partial calvities being the per- manent result of the process. In many families, there is a predis- position to this premature loss of hair, which may be recognized in the males of succeeding generations. ALOPECIA. 431 Symptomatic premature alopecia is the frequent result of a series of local and general disorders which vary in their gravity. Sudden and gradual symmetrical thinning of the hairs or complete baldness, is sufficiently common as the result of seborrhoea sicca, psoriasis, and other cutaneous affections of the scalp; the asymmetrical forms being more common in asymmetrical scalp diseases, such as those resulting from the destructive action of the vegetable parasites. Rarely, how- ever, asymmetrical seborrhoea, occurring in patches upon the side of the head, may produce such disfigurement. Among the systemic disorders which have this effect, may be named almost all severe febrile processes, including the exanthemata, profound disorders of the nervous centres, lepra, and syphilis. In the last-named disease it may occur as a precocious or tardy symptom, the former being always symmetrical, variable as to the degree of loss, rarely so severe as to cause baldness, and, occurring as it does usually in early adult years, generally quite remediable. The tardy form, on the other hand, is usually associated with the evolution or destructive involution of gummata of the scalp, and the resulting baldness is often permanent. The forms of alopecia described above as encountered upon the scalp, may involve also other hairy portions of the body, as of the axillae and pubis; and these also in variable degrees. Pathology. — In senile and premature alopecia, a fibrous endarteritis is described by Michelson as first occurring to narrow the lumen of the vessels, which starves the follicular and peri -follicular tissues till an atrophy results. The epidermis becomes thinned ; the derma contracts ; the hair-follicles shrink, while their funnel-shaped orifices, occupied with loose horny masses or lanugo hairs, remain patulous. Convolutions of pigmented, roundish nuclei, aborted results of hair- formation, may rarely be recognized at the base of the empty hair-sacs. The coil- and sebaceous glands and muscles are but slightly altered. Treatment. — The treatment of alopecia in general, is that which stimulates the nutrition of the hair-follicle by producing in its peri- phery a species of transitory and artificial hypersemia. This is usually accomplished by friction of the scalp with a brush, aided by the local employment of one or more alcoholic, oily, alkaline, and other stimulating applications described below. The general health must in such cases receive special attention. A large number of individuals suffering from premature baldness have a distaste for fat ; and the ingestion of cod-liver and other nutritious oils, fat meat, or linseed and linseed oils, as recommended by Sherwell, is for such patients advisable. Iron, strychnia, tar, phosphorus, and arsenic, often meet the indications presented. A scanty crop of short, soft, downy hairs may, however, push for a time to the surface, but soon yield before the inactivity of the follicles in which they are implanted. Inasmuch, however, as excep- tionally brilliant results arc occasionally obtained by treatment, the latter is always deserving of a trial. When the alopecia is symp- tomatic of some local disease of the scalp, the latter of course is first to be relieved by the measures, appropriate for each, as, for example, 432 DISEASES OF THE SKIN. the use of parasiticides in those of parasitic origin. The total or partial symmetrical losses of hair occurring in the course of systemic disorders have a much more hopeful prognosis. Exception, how- ever, is to he made of the tardy syphilitic alopecia associated with local scalp lesions or profound cachexia. In all forms of syphilitic alopecia, local as well as constitutional treatment is indicated. Local treatment may often be preceded by shampooing with either the Sarg fluid soap, or combinations of glycerine, alcohol, and sapo viridis to meet the requirements of individual cases. The scalp, after all such shampooings, should be anointed with lanoliue, plain or salicylated ; vaseline; the oil of benne; or scented castor oil. In obstinate cases the nail-brush may be vigorously used over insensitive scalps at the time of the shampooing. The salve used may be often advantageously medicated with sulphur, chrysarobin, tar, cantharides, or mercury. Formulae for lotions and salves to be used in this way, are appended : R. Fo Hydrarg. chlorid. corros. Spts. vin. rectif. Glycerin. Aq. ros. r external use over the scalp. grs. v ; |ij; svj; 64 16 192 33 M. B Picis liquid, [vel. ol. rusci] 01. lavendul. 01. pin. sylvestr. aa3j; 5vj; 4 192 M. [Piffard.J R Hydrarg. chlorid. init. Hydrarg. amnion, chlor. Vaselin. Bij; ad Ij ; 5| 2 66 32 1 M. [Bronson.] R 01. sabinse gtt. Spts. vin. rectif. v-xxx ; 3J; 133-2. 32j M. [Pincus.] R Hydrarg. bichlorid. Cantharid. tinct. Medull. bovis. 01. rosar. gr. ss ; f3j; q. s. ; 1032 4 16 M. [Van Harlingen.] R Acid, chrysophanic. Glycerin. Vaselin. gr. x; n\.xl; 3vij; 166 266 .28| M. [Anderson.] R Sulphur, prsecip. Ungt. aq. ros. | Vaselin. j 3j; aa 3ss ; 4 16 M. Andre is said to have induced an abundant growth of hair in an obstinate case of total baldness by hypodermatic injections of the muriate of pilocarpine, from one-eighth to one-fourth (0.008-0.016) of a grain being injected on each occasion. The treatment of alopecia is that also of alopecia furfuracea, and alopecia areata. ALOPECIA. 433 Alopecia Furfuracea, or Pityriasis Capitis, or Alopecia Pityrodes Capillitii. Under this title is included that loss of hair, varying greatly in degree from moderate thinning of the growth to considerable symmetrical bald- ness, usually of the vertex, which, at the onset, is scarcely distin- guishable from alopecia simplex, alopecia prematura or prsesenilis, and seborrhcea of the scalp in some of its forms. It is exceedingly common, especially in men. The disorder, essentially chronic in course, is usually first mani- fested in early adult life, though persons of both sexes, from twelve to fifteen years of age, may at these ages display typical forms of the disease. After some months or years, the subject of the affection discovers a relatively large loss of hairs from the scalp producing thinness of the growth upon the vertex, near the brow or over the temples. The hairs, when examined in situ upon the scalp, are shortened and rebellious to the comb and brush, projecting stiffly from the brushed surface, being also harsh, lustreless, and rarely well anointed with sebum. Those shed from the scalp, especially of men, are found to be nearer in type to the lanugo or downy hairs than those which fall physiologically from a vigorous growth of hair in a healthy subject; that is, they are short, thin, pointed, and often with an indistinct medulla. At the same time the scalp is in process of incessant desquama- tion, the scales being of pityriasic type, and exceedingly abundant so long as the alopecia is not complete, after which, the epidermal catarrh promptly disappears. The mealy, bran-like scales are shed in a fine shower upon the clothing of the patient, and, the disease being more common in men than in women, its traces are often dis- tinct upon the collar of the coat after the fingers have been passed through the scalp. The same flour-like, whitish and grayish scales are distinct and plentiful among the hairs to which they cling, and also can be recognized over the scalp surface when the latter is inspected with care. Greasy conditions of this product of secretion upon the scalp are due to complications with a seborrhea of this region, and the reader is urged to consult the chapter devoted to that malady in order to study this subject from its several pathological sides. According to Pincus, three-fifths by weight of the scales fur- nished by the scalp in this condition, are inspissated products of sebaceous secretion. Often, however (and it is this important feature which justifies the separate consideration of alopecia furfuracea and seborrhoea capitis), the scales are true squamse; dry, corneous, and epithelial, rather than fatty and seborrheic. The subjective sensations are then usually marked ; the scalp is often scratched and torn by the nails, and is, in some cases, reddened and thickened. There may be also decided general cachexia. Among women the patients are often nervous and sallow, with a long history of distressing headache, 434 DISEASES OF THE SKIN. uterine hemorrhage, or hepatic disorder. These are simply states in which there is malnutrition of the scalp. The scalp may or may not he the seat of perspiration. Eczema, of pustular type, occasionally complicates these cases. Etiology. — The disorder may be due to inheritance, to any systemic affection impairing the bodily vigor, to long-continued neglect of the hygiene of the scalp, or to such diseases of women as are accompanied by menstrual irregularities. The confinement necessitated by seden- tary occupations of life; those trade- and professions which permit or require the constant covering of the head of men ; and the wearing of heavy hats or bonnets interfering with the aeration of the scalp, all furnish conditions for the occurrence of the disease. In 1882, Lassar and Bishop produced alopecia by rubbing upon the sound surface of the skin of animals the epidermic detritus and hairs furnished by a patient affected with the disease. This lends color to the possibilities of contagion which should not be ignored. Pathology. — According to Pincus, the vessels of the scalp are unaltered, but the corium beneath the affected surface is thinned in proportion to the severity of the disease. Nothing characteristic can be discovered in the hairs removed from an affected patch. Diagnosis. — The disease is distinguished from seborrhoea of the scalp by the epithelial character of a great part of the dry discharge occurring symmetrically from the scalp surface, coupled with the symmetrical and largely vertical alopecia. The asymmetrical greasy patches of pure seborrhoea capitis, pasting the hairs to the scalp, which may be limited to the occipital or temporal region of one side, are strikingly different. Michelson and Pincus place reliance in establishing a diagnosis, upon the firmer attachment of the scalp and the discovery upon four successive days of a proportion of one-eighth of pointed hairs to the entire pilary loss, with an average length of thirteen centimetres. Treatment. — The general and local treatment of alopecia furfuracea is practically that of alopecia simplex, alopecia areata, and seborrhcea of the scalp. Pincus applies upon compresses the sodium bicarbonate in solution sufficiently concentrated to stimulate but not redden non-hairy por- tions of the skin. Sulphur, tannin, the oil of savin, the bichloride of mercury, tar, naphthol, resorcin, the peroxide of hydrogen (in two volumes), and iehthvol have all been successfully employed in the management of these cases. Each is best preceded by the shampoo- ing described in the preceding chapter. Schmitz, Schiiller, and Andre have all reported excellent results from hypodermatic injec- tions twice weekly of one-twelfth to one-sixth of a grain (0.005- 0.010) of the muriate of pilocarpine in distilled water. No remedy has a higher and more established value in the local management of these cases, whether in an early or late stage, than sulphur. In the strength of from one-half to one drachm (2.-4.) of precipitated sulphur to the ounce (32.) of vaseline or lauoline, it should be well rubbed into the scalp after each shampooing. When ALOPECIA AREATA. 435 there is marked improvement of the pityriasic catarrh, one of the stimulating lotions may be used that are described in the pages devoted to the other varieties of alopecia. Alopecia Areata. Lat. area, a vacant space [arere, to wither, Fox). Alopecia Areata is a disease of the pilary follicles characterized by the sudden occurrence of general and symmetrical, or partial and asymmetrical bald- ness, the latter exhibited in distinctly circumscribed, smooth, whitish patches, which are, in typical cases, completely destitute of hair. Symptoms. — This disorder, which is more common than is gener- ally believed by physicians, may be, at its outset, preceded or accom- panied by symptoms of ill-health, such as headache, malaise, inappe- tence, loss of flesh, or malnutrition. In yet other cases, cephalalgia, paresthesia, pruritus, aud formication of the skin of the scalp and other regions indicate some disturbance of the nervous centres. Often, however, the patients of this class are in sound health, the disease then manifesting itself by the sudden and complete loss of hair over a circumscribed patch, usually upon one side of the scalp, so rapidly effected that they often describe a first discovery of the fact at the toilet of the morning. After a variable period of time, other patches of baldness may occur, all of the hairy portions of the body being liable to the affection, the scalp first in order, next the beard, then the genitalia, axilla?, brows, eyelids, and the general sur- face of the body. In early childhood cases occur in which the closest scrutiny with a glass fails to detect a single filament of hair upon any portion of the skin. The patches may be roundish, ovalish, or irregularly shaped, and may vary greatly in size, from that of a small coin upward. They may be so numerous as to disfigure greatly the entire scalp ; and though these touch at the borders when thus numerous, they can scarcely be said to coalesce, as the individual elementary areas are usually recognizable. Their surface is smooth, whitish, and often perfectly destitute of hairs; it is rarely tumid, and slightly reddened. The hairs at the periphery are usually of full length and fixed in situ, but are occasionally fragile, and readily withdrawn from their follicles. Stumps of such friable hairs may be at times seen at the margin of the patch. In point of abnormal subjective sensations, temperature, or disease of the surface from which the hairs have fallen, there is, as a rule, complete absence of symptoms. The skin, when the evolution of the disease is complete, is usually normal to the touch, and pliable. Occasionally it is anaemic, thinned, and more movable over the corium than in the scalp which is not the seat of the disease. In incomplete evolution and in periods of repair, downy hairs may appear upon the surface, at times considerably differing in color from those springing from unaltered regions of the scalp. The loss of hair from the surface may be : rarely, gradual ; pre- ceded by mild pruritus (Besnier et Doyon); or followed by anses- 436 DISEASES OF THE SKIN. thesia (Neumann). Its apogee once attained, the course of the disease is variable; it may persist for periods without apparent change; or new patches may form while those of an older date either proceed to exhibit wholly or in part the pilary growth; or, this latter accom- plished, suffer a fresh loss by relapse. Shifting areas of the disease may, without question, in this manner invade the entire surface of the scalp, which yet at any one moment of time may exhibit a loss of but the half of its hirsute covering. There is some reason for believing that the disease has a relatively fixed period of evolution, though the exact limits of the latter are not known. Few individuals suffer less than one year ; the most are relieved within a period of two years. These remarks, however, apply to the asymmetrical forms of the disease in the relatively young. The symmetrical alopecia areata of the middle-aged is, in my experi- ence, a far more formidable affection. Few diseases are the source of greater mental distress than those of the class now under consideration. The prominent deformity thus occasioned debars the subject of the malady from social relations of many kinds, and this intensifies the morbid feeling which every reflected view of the head awakens. This is particularly true of women. The successful management of these cases calls often for the supporting assurances of the practitioner. Etiology. — The causes of the disease are obscure. It is not trans- mitted by heredity nor by contagion; and it is not due to the presence of a parasite. It occurs with ecpiial proportion in the two sexes ; and among these, irrespective of social condition. Of the partial and asymmetrical forms, the larger number of cases occur in young subjects, from childhood to early adult life. The severe and generalized forms are more often encountered in middle-aged persons. In the latter class especially, it is occasionally observed to follow the obscure disorders of the nervous centres due to sudden or prolonged undue excitation. In young subjects one may often dis- cover a peculiar repugnance to the ingestion of fat and meat, a point to which attention is called in considering alopecia simplex. The neurotic explanation of this disorder is more geuerally accepted as facts accumulate bearing on its etiology. The nervous symptoms which often precede or accompany the appearance of the bald patches are strikingly suggestive, and led Von Barenspruug to announce his theory of "inherited innervation " as a cause of the malady. Further, the occurrence of the disease after shock of the nervous centres is significant. Collier 1 cites two cases in which alopecia areata followed a blow upon the temporal region, and Sir Dyce Duckworth reports the case of a gentleman who sustained an injury to the head in a fall from a dog- cart, who suffered as a result from permanent loss of hair. OveraP has reported a similar instance; Joseph 3 has produced the disease by section of nerves in a cat. 1 Lancet, Amer. Ed., August, 1881, p. 130. - Alien, and Neurol., St. Louie, 1886 3 Ontralb. f. meil. Wissenscliaft , 1880, No. 11. ALOPECIA AREATA. 437 On the other hand, v. Sehlen, 1 in 1885, exhibited in the Medical Congress at Strasbourg, micrococci about the sheaths and roots of the hairs, which he claimed to have demonstrated to be the cause of the disease. Pathology. — The anatomical lesions which produce alopecia areata have not been recognized. The hairs fallen from the surface, when examined with the microscrope, are seen to be atrophied in the bulb and shaft, though Rindfleisch describes in certain cases a node-like enlargement of the hair-shaft after its escape from the follicle. Fracture of the shaft is in some cases also noted, evidently an acci- dent of the process. No parasite can be discovered in uncomplicated cases. I have in one instance detected spores and mycelia of the trichophyton in the hairs, a coincidence of two disorders which has been observed by others. In default of all positive knowledge on the subject, the majority of dermatologists have assumed the disease to be a trophoneurosis, a view sustained by the etiological history of certain cases. Michelson, however, regards the vasomotor nerves as presiding over the nutritive changes determining the loss of hairs. Schultze recognized some thinning of the scalp in sections examined by him. Future investigation may establish some difference other than that of degree between the partial asymmetrical disease of the young and the more general symmetrical affection of middle life; in which the entire scalp, lids, brows, pubes, and axilla? are completely shorn of their filaments. It is, however, held to-day that all forms of alopecia are parasitic in origin and are therefore all related. Diagnosis. — Alopecia areata is to be distinguished from vitiligo of the hairy portions of the surface by the preservation of the pilary growth in the disease last named, the filaments, moreover, having usually a blanched and whitened look, due to the absence of pigment. From ringworm aud favus of the scalp the disease in question is readily differentiated, by the suddenness of its onset ; the absence of all stumps of hairs, scales, crusts, and evidences of irritation in the involved area ; the whiteness, smoothness, and complete baldness of the latter; and, above all, by the failure to detect with the micro- scope the evidence of the presence of a vegetable parasite. The asymmetrical patches of seborrhoea of the scalp are recognized by the presence of the fatty plates pasting the hairs to the surface, as well as by the slow and very gradual onset of the disorder. Other forms of baldness than those named above are all of gradual and, in their early stages, of symmetrical development. Those re- sulting from traumatic injuries of the scalp, with cicatricial results, are easily determined as having such an origin. Treatment. — One must necessarily view with some distrust all treatment for that disease which in the course of months or years usually terminates in spontaneous recovery, and in the meantime may bid defiance to each and every therapeutic measure. Neverthe- 1 Anna], tie Derm, et de Syph., June, 1886. 438 DISEASES OF THE SKIN, less, persistent and hopeful management of even the apparently desperate cases is occasionally rewarded by such brilliant conse- quences that, however slight may be the foundation for a belief in the value of the therapy employed, it deserves recognition and trial. The hygienic management of every ease is a matter of great importance. Tobacco should in every form be denied to subjects of the disease addicted to its use. Iron, quinine, mix vomica, cod- liver oil, phosphorus ami the hypophosphites, arsenic, and strychnia are often indicated, and used with great benefit. The indication for local treatment is to increase the physiological afflux of blood to the hair-follicles. With this end in view, the affected part- are to he bathed daily in water as hot as can be toler- ated, then dried, and scrubbed with a stimulating lotion. The articles usually employed are alcohol, ether, turpentine, ammonia, camphor, cantiiarides, carbolic acid, oil of mace, croton oil, tincture of mix vomica, tincture of capsicum, tincture of aconite, castor oil, tar, iodine, sulphur, and the mercurials. All frequently fail. Several of these in combination seem at times to be of service. The following is a formula, the ingredients of which may be varied to suit the indications in different cases : R. 01. ricini f£ss; 16 Acid, carbolic. 3j ; 4 Cantharid. tinct. ^ss; 16 01. rosmarin. gtt. xv; 1 Spts. vin. rectif. adf|iv; 128 M. Sig. For external use over the scalp with friction. The formulae containing chrysophanic acid and the bichloride of mercury, given on a preceding page in connection with the treatment of alopecia furfuracea, are well worth trying. Dr. Nevins, of Liverpool, mops the entire surface with strong liquor ammonias. The speediest return of hair the author has ever observed in a patch of alopecia areata, followed a single application of pure creasote to the surface, resulting in moderate vesication. The spirit of turpentine has been similarly employed. Faradization of the scalp with a stiff wire brush, pushed to the point of producing moderate hyperemia, has been followed by excel- lent results. Wilson recommends: M. R. 01. amygd. dulc. «8; 32 Capsici tinct. f3ij ; 8 Liq. amnion, fort. flj; 32 Spts. rosmarin. f5v; 160 01. limon. f3j; 4 Here is another stimulating application : M. 01. terebinth. ) 01. ricini { aa f,5ss ; 16 Origan i tinct, f3j; 4 01. camphorat. f.5J; 32 Liniment, volatil. ad f.^iij ; 96 M. Sig. For external use with a brush till the scalp is irritated. ALOPECIA AREATA. 439 Repeated blisterings of the scalp with cantharidal collodion, the spirit of green soap, and petroleum have also been employed exter- nally with success. The ointment of chrysarobin has the disadvantage of staining not only the remaining hairs, but often the face in conse- quence of the frequency of its transmission to that locality by the medium of the hands. When patients, however, consent to its use, it is worthy of a trial, as its application has been speedily followed by a vigorous growth of new pilary filaments. Andre employed ten hypodermatic injections of muriate of pilocarpine in one-eighth grain (0.008) doses, which resulted, in the case of a middle-aged woman affected with total symmetrical baldness, in an abundant growth of hair. Lassar and Bishop 1 operated by first vigorously shampooing the entire scalp daily with a strong solution of tar soap for fifteen minutes ; rinsing next with an irrigator, by the aid of warm water, followed by cold water, and subsequently drying. Then a corrosive sublimate wash (1. : 300. adcle spts. cologniens., glycerin., aa 100.) was applied, and the head again dried ; then a solution of naphthol (naphthol, 0.5; spts. dil., 70.; aq. dest., 30.) was rubbed in. Lastly, carbolized oil, 1J per cent., was poured slowly over the scalp, entering the cleansed and expanded orifices of the glands, so that seven drachms (28.) could be employed at a time. This was pursued daily for eight weeks. Prognosis. — From what precedes, it will be justly inferred that, as regards the relief of the baldness, the asymmetrical development of the patches in youth is much more favorable than the symmetrical general disease of middle life, the latter being often remediless. The prognosis of the same affection of the beard is quite favorable. In all cases, the practitioner should actively persevere to the end. In no case should any encouragement be given as to complete relief within the year, though such exceptionally short careers of the dis- ease are at times observed. The disease, when limited to the regions of the beard in young men, usually concludes its stadium in the course of about one year, with a favorable termination. Shaving should be regularly prac- tised, as the deformity is thus rendered somewhat less conspicuous, and the bald surface should be frequently stimulated with one or several of the topical applications named above. Alcoholic solutions of the mercuric bichloride, half to one grain (0.033-0.066) to the ounce (32.) are to be well rubbed over the patch or patches once or twice daily. The disease in this locality may coexist with benig- nant syphilis, the latter disease pursuing a career considerably shortened by vigorous treatment, while the former, none the less, endures from twelve to fourteen months, long after the syphilitic cachexia has been relieved. At the end of this time, recovery occurs precisely as in those cases which have presented no history of in- fection. 440 DISEASES OF THE SKIN In all eases of implication of the head, where the scalp is involved in either sex, and where the peculiar hypochondriasis of the disease is developed, a wig should be worn for the sake of its moral effect upon the sufferer. For such, however, its use should be limited to social occasions, visits, etc., as the persistent wearing of a perruque indoors seems to lengthen somewhat the course of the disease. Alopecia Neurotica. — Under this title Michelson includes all cases of loss of hair, (1) coincident with or following traumatism of cerebral or peripheral nerves ; (2) those associated with diseases of the nervous system due to internal causes. As to the first class, instances of alopecia are given above, where, as in the case reported by Sir Dyce Duckworth, the loss followed a fall upon the head. Todd, Schultze, Fischer, and Michelson have also made observations of this character. In the second category are the local and general losses of hair reported as associated with melancholia, migraine, neuralgias of persistent type, and facial and other paralyses. In some of them the skin and panniculus adiposus have wasted, the hairs falling in stripes or ribbon-shaped streaks, with partial or complete canities of those left in the follicles. Atrophia Pilorum Propria. Atrophy of the hair may be either symptomatic or idiopathic. Illustrations of the first named condition are observed in phthisis, syphilis, seborrhcea, ringworm of the scalp, and almost all general diseases interfering with the nutrition of the pilary growth. The filaments then become dry, lustreless, friable in both longitudinal and transverse diameters, and diminished in each dimension. There are several recognized forms of idiopathic atrophy of the hair. One of these exists in those long hairs which are seen to be irregularly thinned or flattened in the shaft, and split at the point into two or more recurving fibrillffi, a condition noted, for the most part, in few hairs scattered among those of full development and vigor. This especially localized atrophy seems to be peculiar to one or more follicles merely ; and is quite analogous to the condition in which there appears among the vigorous pigmented hairs of early life, a single blanched filament. Under the title "An Undescribed Form of Atrophy of the Hair of the Beard," Duhring 1 gives the details of an exceedingly interesting . 18, 1882, p. 188. ANGIOMA. 469 ductiou of any results worse than the original disfigurement, often with complete success. The method of Sherwell 1 is by multiple puncture with a set of fine needles in a holder similar to that described above. These are dipped in a twenty-five to fifty per cent, solution of chromic acid, and then made to penetrate the part to be attacked. The bleeding is readily arrested by pressure, and then the patch is to be covered with several superimposed layers of flexible collodion. This pro- cedure is of value in circumscribed patches of superficial character and relatively limited area. By it, the author has succeeded in re- moving port-wine marks in three patients, with the result of pro- ducing a somewhat irregular cicatriform tissue much less disfiguring than the original blemish. One of these patients was repeatedly exhibited at the clinic during the progress of the case. Squire's operation is done upon previously frozen patches by the aid of an instrument which destroys the vessels by making numerous crossed and closely spaced linear incisions, parallel to each other and in a plane obliquely directed to that of the integument. Here also bleeding is arrested by pressure, exerted before the circulation is re- stored. The operation has been, in hands other than his own, at- tended at times with unsatisfactory results. Sodium ethylate, a compound in which the radical ethyl in ethylic alcohol is united with sodium, is a caustic recommended by Richard- son 2 in the treatment of nsevus. It is applied by means of a glass rod. A first application usually results in the formation of a dense crust under which the nsevus contracts, and repeated applications are made at intervals of a few days till the desired result is obtained. The sodium ethylate should be pure, and the crusts should not be disturbed till they fall spontaneously. In one case observed by the author, there was a persistent redness of the resulting scar which was decidedly open to objection. Other methods employed are the ligature when practicable ; punc- ture with hot needles; the topical application of caustics other than those named above, such as hydrate of potassium, nitric and carbolic acids, and corrosive sublimate; and total excision, the latter being practicable in relatively small growths. The galvano-cautery and the thermo-cautery are both valuable in the destruction of the capillaries, and have repeatedly proved successful in my hands. For telangiectases and naevi no larger than a pea, the Paquelin knife is an efficient resort. The old method of multiple vaccination about and upon the involved area is frequently followed by the best of results, and whether in consequence of the retraction of tissue under the influence of the inflammation excited, or of the destructive re- sults of the suppuration induced, or of an indefinite caustic effect, is not, as Kaposi suggests, quite clear. These results may be partly imitated by the induction of superfi- cial pustulation and suppuration through the medium of tartar emetic and crotou oil, methods which certainly should be considered i Archives of Derm., Oct. 1879. " Lancet, November 9, 1878 470 DISEASES OF THE SKIN. clumsy in the light of recent successes, obtained by more manageable expedients. Injections with carbolic acid and the perchloride of iron, though in very few cases followed by fatal results, are often brilliantly suc- cessful. Coombs 1 has lately modified somewhat the method most in vogue, by passing fine silver wires through nsevous growths, and connecting the extremities with a Bunsen's battery. When the wires are heated, the circuit is broken, and the ends of the wires disconnected from the battery and united to each other, being then left in situ and covered with lint and plaster. The current can then be passed repeatedly without reinsertion of the needles, and the latter need be withdrawn only when the cure is complete. The treatment of angioma cavernosum mauifestly requires surgical interference. The prognosis in any case of augioma will evidently rest upon the method of treatment adopted for its removal. In the larger number of cases, the lesions having attained a maximum development, persist without further pathological change, constituting a deformity rather than a disease. Physiological alterations in the color of such lesions occur under the influence of changes in the circulation. Lymphangioma. Lymphangioma of the skin is an ectasia or new growth of lymphatic vessels of the corium, spontaneous or traumatic in origin, producing usually cysts containing lymph. New growths of lymphatic vessels in the skin have been noted as constituting a cutaneous disease proper, by Hebra and Kaposi, Pos- pelow, 2 Van Harlingen, 3 and a few other writers. By the authors first named, the disease is termed Lymphangioma Tuberosum Mul- tiplex. The lesions in these several cases were multiple, pea- to bean-sized, smooth, roundish, reddish, lilac-tinted or bluish, firm or compressible tubercles, implanted in the skin, and occurring first in early life, about the neck and trunk. Some of these were quite reducible under pressure, aud transparent. In Van Harlingen's case, the lesions were destitute of fluid contents, and also interspersed between telangiectases. Anatomically, roundish or oval spaces appeared in sections, recognizable as distended lymphatic vessels by the characteristic endothelium with which they were liued. Kaposi distinguishes these tubercles from all subcutaneous cavernous tumors constituted of new-formed dilated lymphatic vessels reaching toward the skin, by the limitation in the former of the neoplastic growth to the superior parts of the corium. In comparing these with the large number of cases of congenital i London Lancet, 1881. 2 Viertel.j. f. Derm. u. Syph., Hft. 4, 1879. 3 Paper read before the Amer. Dermat. Association, September, 1881. Phila. Med. Times, September 24, 1881. EHINOSCLEROMA. 471 and acquired dilatation of the lymph channels, collated in the valu- able monographs on these subjects by Dr. S. C. Busey/ of Wash- ington, D. C, a further special difference between the two becomes apparent. In the latter, when the lymph-filled vesicle, papule, or tubercle, which appears upon the integument is ruptured, there at once supervenes an exhausting drain from the body, of pure, coagu- lable lymph, a feature which is not described by the dermatological authors named, as of occurrence in their cases. Most of the diffuse forms of lymphangioma, those of the class last described, constitute firm or lax tumors of such size as to be termed Elephantiasis Lymph an giectatica or Pachydermia Lymphangiectatica. These contain often large lymph-filled sacs or lacunae, enveloped in hypertrophied muscular and connective tissue, and an cedematous integument. Some of the elephantiasic deformities of this character are fully as enormous as the extreme distortions of elephantiasis proper. Lymphadenectasia is a name given by Virchow to tumors usually in the axillary or inguinal regions where the lymphatic vessels in the lymphatic glands dilate or multiply so as to form large tumors. The lymph-scrotum due to the presence of the filaria sanguinis hominis is elsewhere described. Lymphangiomata may be congenital or appear soon after birth. Their cause is unknown. Anatomically the lesions are found to consist of greatly developed lymphatic vessels, lined with endothelium and enveloped in small-celled connective-tissue stroma. The treat- ment, of the larger lesions only, is surgical. Rhinoscleroma. Gr. pig, or plv, the nose ; and onlripSg, hard. Ehinoscleroma is an infectious granuloma affecting the skin and mucous mem- branes of the nose and contiguous parts, characterized by the formation of exceedingly dense, elastic, and painful, flattened or elevated plaques, nodules, or tubercles, which may be isolated or confluent. Symptoms. — A knowledge of this rare disease, first described by Hebra and Kaposi in 1870, 2 has been obtained solely from a study of some forty cases chiefly observed by these authors. The following is a concise statement of their description of the malady : The disease commonly begins in the septum or a single ala of the nose without inflammatory symptoms. The involved parts slowly enlarge, and become finally as dense as ivory. The individual lesions 1 Congenital Occlusion and Dilatation of the Lymph Channels (Amer. Journal of Obstetrics, January, 1877, et seq.) ; Narrowing, Occlusion, and Dilatation of Lymph Channels, Acquired Forms (New Orleans Medical and Surgical Journal, No. 3, 1876, to No. 8, 1878, inclusive). See, e. g., history of Berkley Hill's patient, p. 101; of Zambuco's, p. 120 ; of Carter's, p. 103 ; of Oholmley's, p. 136 ; of Jackson's, p. 173, and many others. 2 Wien. med. Woch., No 1, 1870. 472 DISEASES OF THE SKIN. are Hat patches, or elevated and circumscribed nodules, papules, and tubercles, painful upon pressure, movable to a certain extent over underlying tissues, and covered either by a normal integument, or a light or dark red, shining, vascular epidermis. Neither hairs nor glands are discernible over the lesions. As the disease progresses, the aire become enlarged, flattened, and so indurated that they cannot be pressed together, while respiration may be impeded by stenosis of the nares. The process may extend to the neighboring parts, involving thus the upper lip, gums, velum, epiglottis, and larynx, the teeth meanwhile falling from their sockets and the soft palate becoming in some cases perforated. Involution of the process has not been observed, as the lesions do not degenerate by ulceration. Mas Zeissl, 1 however, reports a single case in which there had been ulcerative destruction of the entire left nostril, as well as the tip and right ala of the nose. Occasionally superficial excoriations have occurred, but very rarely a diminution in the consistency of the mass. The disease is exceedingly chronic, requiring years for its develop- ment ; and though the affected parts are painful on pressure, they are otherwise not the seat of subjective sensation. Etiology and Pathology. — The disease is observed between the fifteenth and fortieth years in persons of all social conditions and individuals of both sexes, free from syphilitic, strumous, tubercular, and other cachexia. Kaposi originally observed, as anatomical lesions of the disease, a dense infiltration of the corium, and its papillary layer, with small* closely packed elements, which he recognized as a true new-formation. He considered this as analogous to the small-celled sarcoma, iuasmuch as Mikulicz, Geber, and Billroth have seen some of the elements of the neoplasm transformed into osseous formations sufficiently common in sarcomatous tumors. More lately, however, A. v. Frisch, after examining tissue removed from lesions of rhinoscleroma in twelve patients, found in the cells and between them in the interpapillary fissures of the connective tissue, bacteria distinctly rod-shaped, one and one-half times longer than they were broad. These germs were successfully cultivated, but experimental inoculations with culture fluids thus obtained were negative in results. Neisser in a single case found no bacteria ; nor did Davis have better success in studying sections removed from his patient, the first reported as occurring in Egypt. 2 Dreschfeld, 3 however, found in sections of tissue obtained from Payne's patient numerous bacilli less slender and smaller than those occurring in tuberculosis with slightly thickened extremities. These were unlike those exhibited by Paltaup, at the Berlin Congress, who regarded them as similar to if not identical with Friedliiuder's pneu- mococcus. Barduzzi, Pellizari, and others have added to the evidence in favor of the parasitic nature of the disease. i Wien. med. Woch., 1880, p. 021. 2 Brit. Med. Journ , May 29, 188tS. 3 Brit. Med Journ., October 24, 1885. LUPUS ERYTHEMATOSUS. 473 Diagnosis. — The disease can hardly be mistaken for another in consequence of its situation, the disfigurement it occasions, the ivory- like elasticity and induration of the affected parts, and the rarity of ulcerative degeneration. As distinguished from syphilis, it is known to be entirely unaffected by specific medication. From the variety of acne rosacea of the nose, known as rhinophyma, it is readily differentiated by the softness and compressibility of the latter, and its evident vascular and glandular composition. The ulcerations of epithelioma have a more circular outline, a more elevated edge, and occur in persons of a more advanced age. Keloid, if found in the situation of rhinoscleroma, does not ulcerate. Treatment. — The method of relief thus far employed is a total or partial extirpation of the neoplasm. Kaposi speaks of dilatation of the nares by means of laminaria and compressed sponge, where there is actual or threatened nasal occlusion. Both excision by the knife and destruction by caustics have, however, been found to secure merely temporary benefit, as the growth is reproduced with some rapidity. Prognosis. — The future of the patient is grave. The disease not only persists and recurs after operative interference, but may endanger life by obstruction of the nostrils. Zeissl's case 1 proved fatal in ten years after the disease first appeared. Lupus Erythematosus. Lat. lupus, a wolf. Lupus Erythematosus is a cutaneous new growth, displayed to the view in well-defined, slightly raised, discoid patches, often with a depressed or atrophied centre, colored in various shades of hyperemia, covered with adherent, yellowish-gray scales, and terminating, after a favorable involu- tion, by the production of a persistent scar. This disease was first described by Biett under the title Erythhne Centrifuge. Hebra, in 1845, described it among the seborrhoeas as Seborrhoea Congestiva. Its present title was given by Cazenave in 1850. It is also termed Lupus Erythematodes, Lupus Sebaceus, Lupus Superficialis, and " Scrofulous Ringworm." Symptoms. — The disease is first exhibited in one or several rape- seed to bean-sized, reddish maculae, slightly elevated from the surface, and covered with a peculiar glistening epidermis, or with an adherent scale. When but a single patch is formed, the primary lesion described above enlarges its periphery, in the course of months or years, by a slowly continuous development. Its reddish outer rim is then distinctly elevated, while its centre is depressed, showing either adherent, yellowish-gray scales, or a glistening appearance of the unbroken epidermis. It may thus attain the size of a small coin or a large saucer, and occur in this form symmetrically or asymmetri- cally about the cheeks, nose, eyelids, forehead, ears, scalp, mouth, i Wien. med. Woch,, 1880, p. 621. 474 DISEASES OF THE SKIN. hands, and feet. The disks or patches arc very well defined in out- line, and of a eolor varying with the complexion of the patient, from a rosy-pinkish to a deep purplish hue. The shape is usually circular, oval, or in figures representing combinations of these outlines. The scales, too, vary in color, being at times of a clear white or whitish- yellow, and again, often from concurrence of comedones, of a leaden or brownish tint. The latter are usually scanty and adherent, but are also, rarely, abundant. They can be occasionally seen firmly fastened to the orifice of the excretory duct of a sebaceous gland. When such a patch spreads symmetrically over the brow and cheeks, its figure has been likened by Hebra to the open wings of a butterfly. The disease is never accompanied by the occurrence of other cutaneous Pig. 58. Lupus erythematosus of the face (fr. f the author's patients). lesions; nor is it ever displayed in symptoms of moisture and dis- charge. When the macuhe originate as multiple lesions, the evohition of the disease may be accomplished by increase in the number of the former, rather than, as just described, by the peripheral extension of a single patch. The disease is then apt to be manifested, not only in the regions named above, but over the trunk and extremities, where it is likely to assume atypical forms, and be complicated by accesses of a febrile or neuralgic character, and by various cutaneous accidents, such as erysipelas, dermatitis, etc. LUPUS ERYTHEMATOSUS. 475 The disease is remarkably chronic in its course, lasting in cases for a quarter of a century, and throughout not interfering with the general health. So-called " galloping" cases are described by French writers, where visceral complications were the causes of a fatal result. The disease varies in the subjective sensations it produces; being at times accompanied by excessive itching, and often by no discomfort. It is much more common in women than in men, and is a disease of adult years. Kaposi reports a single case in one child three years of age. The scars left by the affection are indelible and characteristic. They are generally uniform and superficial ; can be readily pinched up between the thumb and finger ; are of a dull, whitish tint, and rendered punctate in a peculiar manner, suggesting the action of the engraver's tool in what is known as the " stippling " process. They are never pigmented, puckered, radiate, stellate, corded, or deeply attached. According to some authors there are two varieties of erythematous lupus, the first, the so-called discoid form, described above ; second, a disseminate form. In the latter, graver in type, the disease begins with numerous efflorescences of the character already described which multiply without marked enlargement of any single disk until very extensive surfaces are involved including the trunk, extremities, and, in generalized forms, almost the entire body. There is often coinci- dent fever or erysipelatous complication, and the result may be a typhoid condition with fatal result. These cases are not known in America and Great Britain. Boeck has described two cases of this sort observed in Norway. Lupus erythematosus of the hands, observed rarely in France and Germany, more often decidedly in England and America, occurs not only in the generalized forms referred to above when large areas of the body are involved, the hands included ; but also when the lesions are exclusively manual in situation. These cases have been described by Hutchinson, Sir Erasmus Wilson, and others, including the author. 1 The lesions are not to be mistaken for chilblains on the hands. Very rarely they are seated upon the glans penis. Etiology. — The causes of lupus erythematosus are unknown. Much has been said and written to prove that the disease is of scro- fulous origin, but inasmuch as an immense number of scrofulous patients in all parts of the world never exhibit traces of the disease, it is needless to say that the proof has not been obtained. In by far the larger number of patients actually displaying characteristic disks of erythematous lupus, the usual concomitants of scrofuloderma (which see) are actually wanting. In many patients, the most careful investigation fails to discover any other evidence of ill health. Yet inasmuch as many young women, after the puberal epoch, suffer from the chlorosis, ansemia, and menstrual irregularities common to their sex and age, these conditions may concur. As for tuberculosis, 1 See his resume of these cases in the Journ. of Cutan. and Vener. Dis., Nov. 1884. 476 DISEASES OF THE SKIN. adenopathy, and malnutrition, cases of erythematous lupus occur in subjects affected with such symptoms to an extent which may pos- sibly be the result of coincidence. Considering the remarkable rarity of the disease, and the no less significant frequency of sebor- rhea, the wonder is not that they should occasionally concur, or be transformed, the latter into the former, but that such phenomena are not more conspicuously and frequently noted. The disease is more common in women than in men, usually ap- pearing first in the third decade of life, in this particular presenting a contrast with lupus vulgaris. It is reported to have followed acne, seborrhcea, variola, erysipelas, vesication with cantharides, and the traumatism of leech-bites. The author has seen it in one case appear when the curette had been employed in a patient with a characteristic patch elsewhere on the face. Pathology. — The disease -process originates either in the peri- glandular tissues of the sebaceous or sudoriparous follicles and their ducts, or in some part of the panniculus adiposus; in other words, from any point in the superficial or deep strata of the cutaneous or subcutaneous structure. Under the microscope, the elements of both the epithelia lining the glands and of the connective tissue without are seen to be multiplied and largely commingled with the ordinary products of an inflammatory process. Thin 1 fouud enormous distention of the capillaries in the papillae, their loops of venules being choked with red blood-disks, and in this state almost completely occupying the digitation. The same was observed in the perifollicular plexuses, while yet the rete and glands were quite unaffected. Such alterations would, without ques- tion, ultimately follow as the result of the vascular trouble ; but the observations are of interest as lending color to the supposition that the primary changes in lupus erythematosus are chiefly vascular. Similar vascular dilatations, papillary and perifollicular, have been noted by Kaposi and others as concurrent with structual alterations in other portions and appendages of the skin. In consequence of the new growth thus formed, there are moderate elevation of the initial macule of the eruption and a thickened rim to its centrifugally developing patches. Central resorption or atrophy of the same material in the epidermis and corium of such a patch explains the wasting and depression so frequently observed in each. By the destruction of the glandular and connective tissue elements in the course of a retrograde metamorphosis, a loss is pro- duced which is made good by the peculiarly punctate form of the cicatrix which results. Veiel classes the disease among the superficial inflammations of the skin. Diagnosis. — The facies of the patient, with lupus erythematosus of that region, is usually so characteristic that the disease is there i Mod. Clin. Trans., 1S75. LUPUS ERYTHEMATOSUS. 477 recognized with ease. When the hand and other portions of the body are involved, the diagnosis is somewhat less readily established. In the former situation, the disease has a predilection for the dorsum, and invades the palm usually only by extension to it from behind. From lupus vulgaris it may be recognized, by its occurrence originally at a later period of life ; by its greater tendency to sym- metry; and by the absence of nodules, ulceration, and extension to the deeper portions of the skin or underlying structures. In eczema, there is usually some history of moisture; in ery- thematous lupus, never. In eczema, also, the itching is a more per- sistent and distressing symptom; but the acuteness of even chronic eczema, as compared with lupus erythematosus, will suffice to dis- tinguish the two diseases. Psoriasis is rarely, if ever, limited to a single patch on the face; it is also characterized by more lustrous and more readily exfoliating scales. Its patches are, furthermore, uniformly well covered with scales, and of equal flatness in all parts, while those of lupus erythematosus are irregularly squamous, the scales being often clustered at the orifices of the ducts of the sebaceous glands, while the rim of the patch, is elevated and the centre depressed. In acne rosacea, there are marked telangiectases and papulo-pus- tules or nodules which are not found in erythematous lupus. In tinea circinata, there may be a clearing, but never a cicatriform centre of the circular disk. The circular serpiginous syphiloder- mata of the face occur usually with other manifestations of lues, are characterized by a much darker hue of the dense infiltration, and exhibit distinct signs of ulceration in most cases. Cicatrization or atrophy of the skin without preceding ulceration, is the sign and seal of typical erythematous lupus. Treatment — The internal treatment of this affection is not highly satisfactory. Often none is indicated or required. Anderson 1 highly recommends the trituration of twenty-four grains (1.6) of iodine with a little water, adding to this one ounce (32.) of starch, till a uniform deep blue, almost black color is obtained, after which the iodide is dried by gentle heat. A large teaspoonful is given in a little gruel three times daily. The administration of the iodide of potassium, arsenic, and iodoform has also been followed by note- worthy results. In general, however, cod-liver oil and the chary - beates will be found most serviceable, in connection with such hygienic regimen and diet as are in each case specially indicated. The local treatment of the patches of disease is of importance. Inasmuch as the affection is one whose involution is occasionally accomplished under the influence of mild topical applications, and is succeeded very rarely by grave sequela?, it is evident, that the simpler measures should be first adopted. Of these, green soap, applied as a plaster, or in the form of the spiritus saponis viridis, is most ser- viceable. It not only cleanses the patch of its scales, but stimulates i Brit. Med. Journ., May, 1880. 478 DISEASES OF THE SKIX. the surface, often to the extent of inducing a reparative process. The patch may he briskly rubbed, either with the soap or the spirit, in combination with hot water, after which an ointment may be ap- plied, preferably sulphur, in the strength of two drachms (8.) to the ounce (32.) of petroleum ointment. When a decided effect is pro- duced, the spirit may be discontinued, and the hot water and unguent for a time employed alone. A decided and beneficial effect can be noticed at times after the topical application of very hot water alone, sopped on the parr for twenty minutes at a time with a small sponge mounted on a handle. The following is a gentle stimulant: M. ZiiK-i sulphat. J aa 3ss • 2 Potassii Bulphuret. J Spts. vin. rectif. ffcuj; 12 Aq. rosar. f^hjss; 312 To be diluted as required for external use. [Dubrin The following is a formula for a stronger lotion : M. Cbrysarobin. Sijss; 10 Acid, salicylici } -- _ „ Calami nis pulv Athens f3j ; 4 Collodii flex. f^v; 20 Sig. To be applied with a brush. M. For this may be substituted pyrogallol, in the strength of half a drachm (2.) to the ounce (32.) of salve. Other substances for local applications are: the tars, iodized phenol, iodized glycerine, the iodide of sulphur, iodide of potassium, iodine in fine powder and tincture, naphthol, ichthyol, and chloracetic acid. Ohrvsarobin and pyrogallol have a decidedly favorable effect, subject, however, to the inconvenience of staining the skin, a promi- nent objection in the majority of eases where the disease is displayed upon the face. Upon the hands the author has employed chrysarobin with the effect of producing a typical cicatrix in the course of a month when the disease had lasted for two years. Erasion by the dermal curette, in accordance with the method pro- posed by Dubini, of Milan, and popularized by Volkmann, of Halle, has been successfully practised by many operators; as also the treat- ment by multiple punctures. These have not met with the favor in lupus erythematosus which has been accorded them in lupus vul- garis; while multiple incisions by the lancet, or the instrument devised bv Balmanno Squire 1 have been rewarded with greater success. The instrument of the latter makes sixteen simultaneous superficial incisions in the patch previously frozen by the ether spray. Vidal 2 lays stress upon attacking in this way the peripheral zone of the lesions. In exceedingly obstinate cases, those especially where the elevated rim of the erythematous disk refuses to yield to the simple measures i British Medical Journal, May, 1880. * Le Praticien, Nov. 14, 1881. LUPUS VULGARIS. 479 described, a solution of caustic potassium in distilled water, one part to two or four, may be gently applied with a camel's-hair brush, and the alkali immediately neutralized by the addition of dilute muriatic acid, as soon as the desired effect is produced. That effect, it must be remembered, is superficial cauterization only. AYhen the sero- sanguineous exudation and reactive effects disappear, the rim is seen to be flattened and to have lost in part its violaceous blush. After such severe application, which should never be trusted to the hand of one unskilled in its use, an anodyne cerate should be spread over the part, containing morphia or opium. Vesication with cantharides, recommended by Anderson, has been endorsed as valuable by several authors. The same may be said of the mercurial plaster, of which Kaposi speaks highly j while he and others agree that carbolic, salicylic, nitric, chromic, and sulphuric acids, the chloride of zinc, the other mercurial preparations, and arsenical pastes, are of less value. I have used electrolysis with benefit in a few cases, passing the needle connected with the negative pole of the battery deeply into the involved tissue. Among other useful applications may be named pure creasote, white precipitate salve, Unna's gutta-percha plaster- mull of pyrogallol, iodoform, and the zinc oxide pastes (see p. 82). Prognosis. — A favorable opinion with respect to the future of the disease can never be safely given ; though, as regards the general health and comfort of the patient, there can rarely be question. At the same time the affection is capricious in its course, and may on occasions, after long periods of obstinate persistence, very rapidly improve under the simplest treatment. It is liable to relapse, though not to frequent recurrence. Lupus Vulgaris. Lat. lupus, a wolf. Lupus Vulgaris is a neoplastic growth in the skin or contiguous mucous mem- brane, manifested in the production of slowly developing, reddish-brown nodules, whose involution, in certain cases, is succeeded by ulceration and the production of a cicatrix. This disorder has also been termed Lupus Exedens, Lupus Vorax, and Scrofulide Tuberculeuse. Late discussion of the question of its extent, nature, and relations to other diseases, has been prolific in the production of an enormous mass of literature devoted to the subject, of which there is not space in a treatise of this scope for more than the briefest conclusions. Symptoms. — The disease is characterized at its outset and throughout its career, by the development of numerous, softish, isolated, sub- epidermic nodules, varying in size from a millet-seed to a hemp-seed, encompassed by the derma, and betrayed to view in the epidermis by punctiform maculations of a reddish-brown color, which fade under pressure with the finger. It is the subsequent evolution of these elements in each lupous 480 DISEASES OF THE SKIN. eruption, often, indeed, somewhat difficult to appreciate, which fur- nishes each variety of the disease. Thus they may be disseminated irregularly as in segments of circles (Lupus Disseminatus, Lupus Serpiginosus) ; or developed in bulk to the size of papules or tubercles (Lupus Tuberculosus); or proceed to involution by atrophy and desquamation (Lupus Exfoliativus) ; or by ulceration (Lupus Vorax, Lupus Exedens); or be the seat of proliferating vegetation (Lupus Vegetans, Lupus Hypertrophicus); or of corneous and papillomatous growths (Lupus Verrucosus). Fig. 59. Lupus vulgaris of the face (from a photograph of one of the author's patients). Under the title of Lupus Sclerosus (Lupus Sclereux), Vidal, in 1883, described a form having a cicatricial centre, a circinate outline, and a firm elevated border, located often upon the hands. A number of other names are employed to designate unessential features of the disease, according as its lesions appear in lines, with well-defined margins, or display elephantiasic, acute, chronic, and other phenomena. The disease is quite rare in this country, and when seen is usually in papular or tubercular phases. The lesions are then commonly agglomerated in patches; and vary in consistency, size, and depth of involvement of the derma and subcutaneous tissues, though often distinctly circumscribed in outline. If involution occur, the papulo- tubercles flatten by atrophy, and the shining, tense, and imperfectly formed epidermis with which they were covered, exfoliates, leaving a cicatrix beneath. When ulceration of the patch occurs, a suppurative, and often painful inflammation precedes; the ulcer, if the secretion it furnishes LUPUS VULGARIS. 481 be permitted to dry upon its surface, very slowly spreading beneath the crust. The lupous ulcer has a dirty, purplish-red, indolently granulating or hemorrhagic floor ; a generally circular outline ; soft, neither elevated nor undermined edges ; and a discharge which is sufficiently abundant to drip freely from an exposed surface, or to dry in peculiar, broad, flat, rather uniformly homogeneous crusts. The nose is the most frequent seat of lupus, and this organ it may reduce eventually to a mere atrophied miniature of its former size, or utterly destroy by exteusive ulcerative invasion of its integument, mucous membranes, and cartilages. It occurs also upon the cheek, chin, ears, lips, lids, scalp, neck, genitals, buttocks, and extremities. At times, two or more distant regions are affected. The author has at preseut under his charge a young Englishman with a palm-sized lupous patch upon and beneath the chin, and a large platter-sized exulceration on the right buttock and thigh, both of which have tormented him from his earliest childhood. One of the most conspicuous features of lupus vulgaris is its essen- tially chronic course. Compared with other chronic infectious diseases it requires far more time for its complete evolution than either syphilis or carcinoma ; and in this point is best compared with lepra. For a quarter of a century, a lupous patch may be limited to a space no larger than the palm of the hand ; and exhibit some evidence of activity during the greater part of that period of time. A form of lupus vulgaris, not very rarely observed, produces extensive changes in the skin (more particularly of the face) without ulcerative effects. Here a large portion of the skin of the head (cheeks, lips, nose, lids, chin, ears, brow, and neck) becomes altered by the lupous new growth. The resulting thickening produces a marked and characteristic deformity reducing the openings of the mouth and lids to narrow slits, interfering with vision, speech, and mastication, and producing a marasmus from these causes alone before there is ulceration at a single point. The ravages of the disease are at times frightful in severity ; not merely in consequence of the destructive ulceration to which it tends, but from the deformity left by its awkward attempts at repair. The entire head may be thus converted into a hideous travesty of humanity, while yet its possessor is left with all his vital organs and functions apparently unimpaired. Etiology. — Lupus vulgaris is generally first seen between the third and sixth years of life; after the thirtieth year practically never, unless there have been prior symptoms of the disease. It is not congenital in origin, nor limited to either sex, nor to individuals of any social grade. It occurs in the anaemic and the asthenic ; in the scrofulous, the tuberculous, and those free from such disorders. It is much rarer in this country than abroad, occurring here with nearly the frequency of lupus erythematosus. It is in no way related to either acquired or hereditary syphilis. The author is in practical agreement with Neisser, who believes the disease to be a " partial manifestation of tuberculosis." Though 31 482 DISEASES OF THE SKIN the actual demonstration is yet wanting, the proofs at hand point conclusively to the feet that lupus vulgaris should be classed with the infectious granulomata. The author has elsewhere called atten- tion to the striking fact that the disease is commonly first manifested at the early period of life, when the habit is not yet established of keeping the soiled hands away from the face. Infection of the skin with the bacilli of lupus would thus produce, as is the fact, facial lesions in tin- majority of all cases and lesions of other exposed parts of the body (bare legs of children) in the order of ease with which they might become the .-eat of infection. 1 Fig. 60. d d Section of .1 lupous nodule. 6, normal curium ; «, reticulum with lupous elements in groups; c, d, giant cells. (After Kaposi.) Pathology. — For a knowledge of the microscopic characters of lupus vulgaris we are largely indebted to the Germans, whose opportunities for the study of the disease are unequalled. Virchow, Auspitz, Bill- roth, Lang, Kaposi, Klebs, Stilling, and Thin, of England, have amply contributed to the subject : and the result of their investiga- tions may be concisely stated as follows : 1 Relations of Lupus Vulgaris to Tuberculosis, Journ. of Cutan. and Vener. Dis., Nov. 1885. LUPUS VULGARIS. 483 The more recent nodules when divided exhibit at different depths of the corium roundish masses, comparable to a nidus or nest, above which spreads an unaltered epidermis. These foci of the disease are well denned in outline, and of a reddish-yellowish tint. Around them is woven a network of connective-tissue bundles ; with larger Fig. 61. Section of lupus of face. X 750 and reduced. (Delafield and Prtjdden.) and smaller interspaces containing vascular elements, and also cells and nuclei, probably masses of protoplasm originating in the rever- sion of the connective-tissue elements to the embryonal state, lletrogression is marked by a diminished vascularity ; while the elements disappear by resorption, or by the destructive process of ulceration followed by the cicatrix. Both Kaposi and Lang agree that the vascular and fibrous elements of the lupous mass are capable of developing new connective-tissue which later undergoes retraction. This is curiously in accord with the clinical result of Squire's treat- ment by multiple linear scarification, in which the lupous growth, after replacing the normal elements of the derma, becomes itself the source of the new material of repair. When the disease is extending, the lupous growth, spreading along the vascular elements of the derma, involves finally the rete and the 484 DISEASES OF THE SKIN. panniculua adiposus. Tlie nest-like agglomerations disappear; there is in their stead an irregularly diffuse infiltration, producing subse- quently hypertrophic, atrophic, desquamative, suppurative, or ulcera- tive sequelae. Finally, the glands of the skin may become involved, the hairs falling from their follicles, the sebaceous glands either becoming obliterated, or having their acini stuffed with epidermal masses which distend them in milium-like bodies grouped about a cicatricial pedicle. When, as observed by several authors, there is coincidence of lupus vulgaris and epithelioma, the latter is developed from epithelial cones, described by Kaposi as penetrating downward and in other directions from the coil-glands and the root-sheaths of the hairs. The discovery of bacilli in lupous tissue, first made by Koch, has been since verified by Doutrelepont, Weichselbaum, Meisels, Schiiller, Lustig, and others. The striking resemblance first shown by Vir- chow between a caseous miliary tubercle and a lupous nodule had, even before his discovery, pointed to an identity of origin. The result of inoculation of culture fluids has given positive results. Lenz, Hiiter, Schiiller, aud others, have produced tuberculosis in rabbits, by introducing within the eye granulations taken from lupous patients. The bacteria of lupus are rod-shaped, and in length from one- fourth to one-half the diameter of a red blood-corpuscle. They are usually found within the cells, aud commonly but one is visible in a single cell. They are, however, also found free in the lupous tissue. Some contain roundish or oval spaces. They are more abundant in recently formed lupous nodules exhibiting some pathological activity. Diagnosis. — Epithelioma, though rarely resembling lupus vul- garis, is more often designated by that than by any other false title. Great confusion has arisen from the looseness with which several surgical authors have furnished illustrations of " lupus exedens," which were really pictures of cancer. But the latter is rarely a disease of early life, and when of such early occurrence never per- sists to adult years ; while lupus is such exactly in the vast majority of all cases. The nodules of lupus are absent in epithelioma, and the evolution of the disease slower, less painful, and, in its earlier periods certainly, of deeper situation. The ulcer of epithelioma is more often defined and single; its edges whitish, indurated, and everted ; its floor uneven and glazed ; its secretion scanty and occa- sionally fetid ; its base a mass of indurated tissue. Lupous ulcers are often ill-defined and multiple ; their edges, soft and incon- spicuous, neither everted nor undermined ; their floors granulating aud flattened ; their secretion relatively profuse and generally odor- less ; their bases soft and pliable, though occasionally indurated. Tubercular, serpiginous, and ulcerative lesions of syphilis may at times resemble certain forms of lupus. In any doubtful case a history of infection, of other types of cutaneous disease, of mucous patches, of adenopathy, of abortions in the female, etc., should aid in the recog- LUPUS VULGARIS. 485 nition of syphilis. The suspected lesions should be carefully ex- amined for the purpose of distinguishing characteristic lupous nodules in the patch itself or in the periphery of any exfoliating area. In the case of an adult, a long history of lupus can be often obtained; and it is worthy of note that syphilis with exceeding rarity displays for long periods of time a single exanthematous lesion or aggregation of such lesions in one part of the body exclusively. The lupous ulcers, often multiple and isolated, insensitive, rarely of well determined outline, never reniform or horse-shoe shaped, with supple, low edges and reddish, smooth, hsemorrhagic granulating floor, covered with crusts like soiled parchment of uniform thickness, do not resemble those of syphilis. The latter are often painful, single, circular, and clean-cut in contour, with firm, raised, infiltrated margins, and with offensive greenish and blackish crusts, resembling oyster shells. The cicatrices of syphilis are elegant, smooth, delicate, superficial, cir- cular, and, after pigmentation has disappeared, dead-white in color. Those of lupus are irregular, indurated, deforming, yellowish-white, and reddish-yellow. Acquired syphilis is a disease of adult life ; lupus begins in childhood. The disks of psoriasis are distinguished from flat exfoliating patches of lupus vulgaris by the relatively large number of the former, the nacreous lustre of the scales, the reddish hemorrhagic surface beneath, and the sites of election of the disks, usually on the extensor faces of the limbs. Lupus erythematosus is even more readily distinguished by its characteristics ; including the absence of nodules, ulcers, and crusts, the superficial character of the disease process, the scaliness, and occasional symmetry of the patch. Cases are described of interme- diate forms between lupus erythematosus and lupus vulgaris, but I have never been able to persuade myself that these really occur. The two diseases, unfortunately somewhat similar in name, are unques- tionably distinct in character. The so-called intermediate forms shown to me have been in every instance cases of flat and scaling epitheliomatous infiltrations going on to ulceration. In acne and rosacea with a bulbous condition of the tip of the nose, the redness is vivid; and the telangiectasia complications with the seborrhoeic flux, are conspicuous points of difference from lupus vulgaris. There is further no ulceration nor scarring, and the patients have usually suffered from the disease ouly after arriving at maturity of life. The mucous surfaces are also spared. Lupus of the Face. — Here the first manifestations are the so- called primary efflorescences, exhibited on one or both cheeks, nose, or cheek and nose, as a dull-colored maculation, or minute nodule, often long unnoticed, or a finger-nail sized, purplish thickening of the skin. Extension may then occur by multiplication of lesions, or by spreading of the single patch, the central parts wasting or cica- trizing. The contracture of the irregular scars thus resulting may 486 DISEASES OF THE SKIN. produce au ectropion of the lid or lip, and with this is often seen the " bouffissure" of the features already described. Crusting and ulceration may be conspicuous or well nigh absent features. Gradu- ally the subcutaneous tissue becomes involved. The nose, as already stated, may, after absorption of the lupous tissue, become shrunken and retracted to a miniature of its former dimensions, its tip being noticeably reduced to a sharp poiut. In other cases (one such is now under the author's care), the point becomes bulbous, flattened, livid, and knobbed, with a thickened septum and distorted alse, an isolated patch or two of lupus infiltra- tion showing in the neighborhood of the cheek on one or both sides. The last described condition may lead by degenerative processes to the first, but is more commonly noticed as a less severe and more localized involvement of the face which may terminate, in favorable cases, without the severe mutilation first described. The upper lip, when involved, becomes first swollen, fissured, hemorrhagic, and crusted, aud a granulating surface indicates exten- sion of the disease to the adjacent mucous surface. Later, if the ulcer heal, the mouth, by contracture, is reduced to a repulsive looking slit or chasm in the face, permanently retracted, aud either open or closed. The gums, lining membraue of the lips, velum, and hard palate may be also granulating, eroded, or whitish, when the exfoliated epithelium is in situ. Ulceration and cicatrization here also produce deformities interfering with the function of the parts, aphonia, for example, resulting from the operation of these causes in the larynx. Lupus Vulgaris of the Ears may be symmetrical in develop- ment, or affect but one auricle. As in eczema, a favorite point of election is the lobule, which, with or without tumefaction of the whole organ, becomes a pyriform, purplish, dependent tumor, agglutinated speedily to the cheek. Later, when ulceration occurs, the auricle may disappear, or be reduced to a shrunken shell of its former state, the external auditory meatus being, by the same process, occluded. Lupus of the Trunk is, as a rule, more extensive and less destructive than lupus of other parts. Giant areas over the loins, hips, and belly may be involved in superficial serpiginous ulceration, the centre healing as the peripheral ring spreads. In these cases, it is even more difficult than in others to insure cicatrization. Lupus of the Genital Region may occur in both sexes ; aud then, as a rule, has extended thither from affected areas of the adjacent integument. "Lupus of the genital region" in women, so called, beginning in adult years, and strictly limited to incoercible ulceration of the mucous surfaces without marked involvement of the groins, pubic region, or cutaneous surface of the labia, is usually syphilitic in origin. LUPUS VULGARIS. 487 Lupus of the Extremities is remarkable for its interference with the mobility of the smaller bones of the hands and feet, as a result of rigid cicatrices ; and also for the production of caries and osseous necrosis. Mutilating effects are thus produced by loss of phalanges, and also by shortening of the hand or foot after destruction of cen- trally situated bone. Elephantiasic enlargements of such organs as the hands and feet thus correspond to the livid tumefaction seen occa- sionally in the face. Thickenings, ridges, knobs, nodules, warty excrescences, ulcers, crusts, and callosities are often commingled, and in patients of mature years strongly resemble some forms of vege- tating and ulcerating epithelioma. Lupus of the Mucous Membranes means, for the most part, extension of the disease from an affected adjacent integument. The lupous nodule, in consequence of warmth and moisture, is here trans- formed into a moist papillary outgrowth, or externally granulating patch which may ulcerate and cicatrize. The borders of such an affected area are well defined, and its surface is of a dirty grayish- white color, where the investing epithelium is loosened but not yet detached. Treatment. — The internal treatment of lupus vulgaris is practically that indicated by the condition of the patient; inasmuch as no medi- cament is known to be capable, after ingestion, of relieving the victim of his local ailment. Of the articles in this category none will be more often indicated than cod-liver oil, the chalybeates, the bitters, the preparations of iodine, and possibly phosphorus. Arsenic and mercury are powerless to prevent the extension of the disease. With these, it is needless to add, a diet of the most generous character is to be supplied, and the rules of hygiene enforced. Iodoform and the iodide of potassium have been recently freshly recommended by Neisser, who employs the former in pills each con- taining half a grain (0.033). Thehypophosphites are useful in many cases. The local treatment of lupus vulgaris by the aid of parasiticides is based upon the infectious character of the disease ; and in many cases is brilliantly successful. Dr. White, of Boston, 1 with a view to its parasitic action, applies to the lupous patches rags soaked in solutions of the bichloride of mercury, one to two grains to the ounce (0.066- 0.133 to 32.), and also applies ointments containing the same quantity of metal in the ounce of salve-basis. The favorable results obtained by him have been again and again verified by the author, who is in the habit of freely painting lupous ulcers with a solution of corrosive sublimate in the tincture of benzoin of the strength named. Salicylic acid two to four per cent, solution in castor oil and in ointments, half to one drachm to the ounce (2.-4. to 32.) ; sulphurous acid (Hutch- inson) ; .pyrogallol (Neisser) in ten per cent, ointments, spread on 1 Boston Med. and Sugical Journ., October 29, 1885 488 DISEASES OF THE SKIX. linen rags and covered with impermeable tissue; and iodoform, have all been successfully employed with the same object in view. [^i'lM .V modification of the Dubini-Volkmann method (that namely by multiple linear scarification) deserves mention here, as it is claimed with some justice to have changed the prognosis of the disease. It is somewhat doubtful whether anything is to be gained by either a pre- liminary freezing of the part, or the use of the cutting instrument of niauy blades devised by Squire, of which mention is made in the preceding article. The incisions are best produced with a delicate bistoury held in the fingers like a pen. They should be in parallel lines, closely set together, and crossed ; should extend completely through the depth of the lupous growth ; and this is determinable after some practice by the cessation of the creaking resistance which the blade fails to discover in normal tissue. Further, they should extend laterally beyond the borders of the lupous patch into the sound peripheral zoue. The bleeding is trifling, and readily arrested by firmly pressing small pieces of fine sponge, lint, or absorbent cotton over the part. The edges of the incision unite either by granu- lation or first intention ; and in both cases seem to serve as starting- points of the reparative process, the material for which, as already pointed out, seems to be supplied from the lupous nests themselves. Subsequent operations, when needed, require a previous freezing of the affected surface. Less efficacious, more painful, and much more disfiguring in its results, is the method of erasion by the dermal curette. This instru- ment is a sharp-edged spoon with a fenestrum in the bowl to permit escape of the debris. With it, the frozen lupous growth may be completely scraped away, and, if necessary, caustics subsequently applied. The method of treatment by multiple punctures instead of incisions is efficacious, though less satisfactory. Schiff, 1 and Auspitz, have combined puncture with the introduction of iodized glycerine (one part of the former to twenty of the latter), the first named operator using a tubular needle filled from a rubber pipette. The author has on several occasions, both in public aud private, employed the Paquelin knife without anaesthesia and with good results. The finer blades, especially manufactured for the purpose, are thrust at a red heat again and again through the lupous tissue until it is destroyed in its depth. Over the whole, the lower blade is firmly passed and pressed, the blackish coal resulting being the best subse- quent dressing after the serous exudation ceases. Americans are generally credited, abroad, with a preference for erasion followed by the galvano- or thermo-cautery. Treatment by chemical cauterization alone is now somewhat obso- lete. The various acids and alkalies, Cosine's paste, nitrate of silver, arsenical, mercurial, and zinc compounds, have all been thus em- ployed, and each, in suitably selected cases, may be productive of fairly satisfactory results. For the cases which do not require surgical or other operative i Vierteljhsft. f. Derm. u. Syph., Xos. 2 and 3, 1880. SCROFULODERMA. 489 interference, simple local applications may be made, such as oily and fatty substances for the softening of crusts ; stimulating dressings of tar, iodated glycerine, thymol, ichthyol, carbolized glycerine, iodized phenol, naphthol, chrysarobin, and iodoform ; as also the carbolated unguents appropriate for the reparative phases of the ulcer left after the destruction of the lupous growth. The author's dernier ressort in the local management of ulcerative and rebellious forms of lupus vulgaris is creasote. It is applied with a brush in a pure state ; is exceedingly painful, and often followed by uncomfortable reactive effects. It should be applied only by the practitioner. Cicatrization of exceedingly indolent and obstinate ulcers has followed this application. Bartarelli applies, in similar cases, equal parts of resorcin and vase- line. Gerhardt, 1 of Berlin, claims to have had good results in the local management of lupus by the use of ice-bags. Gartner and Lustgarten 2 claim to have better results in the employment of electro- lysis in lupus, by using as an electrode a flat silver plate attached to the negative pole of the battery, the plate being set in a hard rubber ring. They employ a current of from five to eight millamperes. Prognosis. — The future of most lupous patients treated with skill and in this country is quite satisfactory. Generalized tuberculosis or cachexia may complicate a small proportion of cases. The local process may result in grave deformity or disfigurement. But even in cases where this last issue seems of severest grade, if there be no recurrence of lupous nodules in the cicatrix, the latter, in course of time, becomes less and less conspicuous. One of the author's patients affected with disfiguring ectropion which several distinguished oculists failed to relieve by operative interference, completely disguised his deformity by the aid of a flesh-tinted silver plate covering the lid, and fastened by the aid of a slender arm to the bridge of a pair of spectacles. Scrofuloderma. Lat. scrofa, a sow. Scrofuloderma is an affection characterized by indolent hyperaemic, granu- lating, and degenerative changes in the skin and subcutaneous tissue, asso- ciated with adenopathy of the contiguous lymphatic ganglia, and otfen with other evidences of a systemic vice of nutrition. Symptoms. — The term Scrofula, or Struma, has been long and loosely applied in general medicine, for the purpose of designating a number of diseases whose real significance was unknown, and whose points of resemblance to each other were greatly outnumbered by their specific differences. The researches of the last twenty years have been steadily and continuously restricting this list, in almost every department of medicine. Many of the disorders once supposed to be scrofulous are now known to be syphilitic. Rickets, for i Medical Times, November 7, 1885. 2 Wien. med. Wochenschrift, No?. 27 and 28, 1880. 490 DISEASES OF THE SKIN. example, is properly recognized to-day as a manifestation of hereditary lues. In orthopaedic surgery, a number of joint affections once believed to be incontestably of strumous origin, are known to be producible by traumatism exclusively. And in dermatology, no less, a broad advance has been made since the day when eczema, psoriasis, aod acne were described as evidences of scrofula. It should, however, not be forgotten that there are few fast and hard lines in the economy of nature. The requirements of a scien- tific classification of diseases are often too rigid for the phenomena both of good and ill health. It cannot be questioned that the scrofu- lous may become both eczematous and psoriasic; that, in short, .struma may coexist with other diseases. The coexistence of cutaneous with other diseases proves nothing as to the essential character of either, or the relation of the one to the other. The author has at this moment in his charge two patients who have been psoriasic for years, each of whom has lately contracted syphilis, one with the addition of a blennorrhagia. The distinction between these disorders is admitted beyond a peradventure ; and yet when the strumous patient gets eczema, acne, or lupus, it is difficult and often impossible to establish in the mind of some observers the conviction that there is no essential connection or relation between these disorders. It is only by comparing such cases with the multitude of others where no such concomitance can be recognized, that a just estimate of the truth can be made. This much premised, it may be added that the term, scrofuloderma is here strictly limited to those cutaneous changes which occur in distinctly scrofulous subjects, and which are themselves stamped by the peculiar imprint of the disease. Billroth's description of the scrofulous diathesis may here be recalled. By this term he recognized that condition in which there occurs at any point in the body where irritation has been induced, an indolent inflammation wdiich persists after such irritation has ceased, which frequently terminates in sup- puration and caseification, and which subsequently rarely pursues an hyperplastic career. If with this be conjoined inflammation and caseous infiltration of the lymphatic ganglia or of the subcutaneous connective tissue ; amyloid degeneration of one or several of the viscera ; tumefaction of the belly ; chronic keratitis, ophthalmia, otorrhoea, or coryza ; a chronic arthritis (white swelling) ; a pasty,