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BY THE SAME AUTHOR.
Eczema and its Management, a practical treatise based on
the study of two thousand five hundred cases of the disease, pp. 344.
$3.00.
Neumann's Handbook of Skin Diseases, translated with
notes, pp. 467. $4.00.
Archives of Dermatology, a Quarterly Journal of Skin and
Venereal Diseases. Vol. I. to VIII. (current.) Vol. I.-IV., $3 per
year ; Vol. V. to VIII., $4 per year.
The Skin in Health and Disease. Health Primer, pp. 148.
Fifty cents.
The Use and Value op Arsenic in the Treatment of
Diseases of the Skin. Fifty cents.
In Preparation.
Principles and Practice of Dermatology : A theoretical
and practical treatise on Diseases of the Skin, 8vo.
MANUAL
OF
DISEASES OF THE SKIN
WITH
AN ANALYSIS OF EIGHT THOUSAND
CONSECUTIVE CASES
AND
A FORMULARY
BY
L. DUNCAN BULKLEY, A.M., M.D.
ATTENDING PHYSICIAN FOR SKIN AND VENEREAL DISEASES AT THE NEW YORK HOS-
PITAL, OUT-PATIENT DEPARTMENT; DERMATOLOGIST TO THE HOSPITAL FOR
RUPTURED AND CRIPPLED ; LATE PHYSICIAN TO THE SKIN DEPART-
MENT, DEMILT DISPENSARY, NEW YORK; AUTHOR OF " ECZEMA
AND ITS MANAGEMENT " ; EDITOR OF THE " ARCHIVES OF
DERMATOLOGY " ; PERMANENT MEMBER OF THE
AMERICAN MEDICAL ASSOCIATION ; FEL-
LOW OF THE NEW YORK ACADEMY
OF MEDICINE) ETC., ETC.
J •* ■* ^ J •* ^
V ■» •* y* J <j ^
J •* >j ^ ^ J ^ J
^ ^ ^ ^ J •* <J ^ ^ •*
NEW YORK
G. P. PUTNAM'S SON^
27 AND 29 West 23D Street
1882
Copyright,
1882,
By G. P. PUTNAM'S SONS.
TO
THE GOVERNORS
OF THE
NEAAT YORK HOSPITAL,
WHOSE KIND APPRECIATION AND ASSISTANCE OF THE
AUTHOR IN HIS CLINICAL WORK IN THEIR INSTITU-
TION HAVE DONE MUCH TO ENCOURAGE HIM
AND TO PROMOTE THE INTEREST OF
^ THE PROFESSION IN THE
BRANCH OF
DERMATOLOGY,
THIS LITTLE WORK IS INSCRIBED.
PREFACE.
The following pages represent an attempt to pre-
sent the subject of Diseases of the Skin concisely,
and yet with sufficient details to be of practical
value to the student and practitioner. They are
offered as an introduction to the study of a branch
which is of great importance, and yet which is not
readily grasped, owing to many reasons, such as the
large number and variety of affections of the skin,
their difficulty of recognition and the confused and
unwieldy nomenclature often employed.
The present little work has been largely prepared
for those following my clinics at the New York
Hospital, and has indeed grown out of a Skin Phar-
macopoeia arranged for their use. The aim has
been to make it thoroughly practical, and it par-
takes much of the style of class room conversations
upon the various diseases as they appear clinically.
Pathology is introduced but briefly, and no attempt
has been made to enter the literature of the subject,
or to present or discuss doubtful questions. Differ-
ential diagnosis has not been fully entered on, for
want of space, but in connection with each erup-
tion mention is made of those with which it may
vi PREFACE.
be confounded. In order to present the relative
frequency and importance of different affections in
the briefest space possible, a chapter is devoted to
the analysis of eight thousand skin cases.
The nomenclature and classification employed
correspond in the main to those used by many;
the nomenclature being Latin, and the diseases be-
ing mostly grouped on a pathological basis. In this,
as in other matters, the desire has been not to pre-
sent new or startling features, but to harmonize,
as far as possible, the views of dermatologists in
various countries. It is hoped that the very com-
plete index will be of much service.
- The matter of therapeutics has been dwelt on
more largely than might be expected in a small
" manual "; it is hoped, however, that this, with the
*' formulary,*' may be of a practical value to the prac-
titioner, while they serve as a guide to the student in
becoming acquainted with remedies. While this
portion represents to a certain degree the treatment
recommended by others, the actual application "of
remedies refers rather to their employment in my
own practice.
Acknowledgment is here made of aid derived from
the writings of Hebra, Kaposi, Neumann, Duhring,
Piffard, Wilson, Fox, Anderson, Hardy, and others,
to the study of whose works it is hoped that the
present may be a further incitement.
I East 33RD Street, New York City.
CONTENTS.
CHAPTER I.
PAGE
On the Study of Dermatology i
CHAPTER II.
Anatomy and Physiology of the Skin 5
CHAPTER III.
Nomenclature and Classification of Diseases of the Skin 18
CHAPTER *IV.
Relative Frequency of Diseases of the Skin : Statistics of Eight
Thousand Cases 25
CHAPTER V.
Diagnosis » 32
CHAPTER VI.
Etiology 42
CHAPTER VII.
Class I. Morbi Cutis Parasitici — ^Vegetable Parasitic Affections 46
CHAPTER VIII.
Class I. Morbi Cutis Parasitici — Animal Parasitic Affections
(continued) 63
CHAPTER IX.
Class II. Morbi Glandularum Cutis — Glandular Affections. ... 73
CHAPTER X.
Class III. Neuroses — Neurotic Affections 90
• •
Vll
*.
viii CONTENTS,
CHAPTER XL
PAGB
Class rV. Exsudationes — Exudative or Inflammatory Affections loi
CHAPTER Xn.
Class IV. Exsudationes — ^Exudative or Inflammatory Affec-
tions (continued) : 117
CHAPTER XIII.
Class IV. Exsudationes — Exudative or Inflammatory Affec-
tions (continued) — of Internal or Local Origin 138
CHAPTER XIV.
Class IV. Exsudationes — Exudative or Inflammatory Affec-
tions (continued) 164
CHAPTER XV.
Class rV. Exsudationes — Exudative or Inflammatory Affec-
tions (continued) 193
CHAPTER XVI.
Class V. HemorrhagisQ — Hemorrhagic Affections 209
CHAPTER XVII.
Class VI. Hypertrophise — Hypertrophic Affections 212
CHAPTER XVIII.
Class VII. Atrophiae — Atrophic Affections 235
CHAPTER XIX.
Class VIII. Neoplasmata — New Formations 245
CHAPTER XX.
Diet and Hygiene of Diseases of the Skin 267
- CHAPTER XXL
Therapeutics of Diseases of the Skin 275
Index. 299
MANUAL
OF
DISEASES OF THE SKIN
CHAPTER I.
ON THE STUDY OF DERMATOLOGY.
While it is not possible for every one to become
proficient to the highest attainable degree in every
branch of medical practice, there is no reason why
all who enter the profession should not acquire a
fair knowledge concerning the diseases which affect
the integument. There are indeed many reasons
why accuracy should be cultivated in this rather
than in many other departments of medicine ; and
it may be fairly said that he who understands the
branch of diseases of the skin well, is better fitted
for general practice than he who is master of any
other one specialty.
Dermatology is an especially inviting field, be-
cause all the lesions of disease are exposed to view,
and pathological changes can be studied on the skin
as nowhere else in the body. Here inflammatvcyci
I
2 MANUAL OF DISEASES OF THE SJCIN
and its processes and products can be watched while
taking place ; hypertrophy and atrophy occur here
in their fullest extent ; and these, with new forma-
tions, constitute the richest field of pathological
research, both in their gross features, and in their
histological elements. And finally the study of
vegetable parasites as they affect the integument
has led to researches in other fields of pathology.
But, again, dermatology is inviting because there
is no branch of medicine, surgery not excepted,
where accuracy of diagnosis can be obtained more
surely and in a larger percentage of cases than in
that of affections of the skin. In no class of dis-
eases, moreover, are the results of treatment so
plainly visible ; the ill effects of wrong measures are
at once seen, and the benefits from proper treat-
ment are no less apparent, both to the patient and
physician.
The study of dermatology, therefore, is not to be
underrated because so many of the diseases com-
ing under its domain do not endanger life, and are
found in those in apparently excellent health. For
not only do disorders which may appear to be in-
significant cause much distress to those affected, but
not a few of the diseases of the integument are
very important from their bearing upon the general
health and usefulness both of the sufferer and of
others. As illustrations of this last assertion may be
mentioned the relations of certain diseases of the
ON THE STUD V OF DERMA TOLOG Y. 3
skin to the gouty state, of which they are often pre-
cursory signs; also, the parasitic affections, which
may sometimes spread through an entire school or
community from carelessness ; and, above all, the
great importance of early recognizing every mani-
festation of syphilis should be borne in mind, both
for the welfare of the patient and as a preventive
of the spread of the disease to others. It must
further be remembered that many diseases not al-
ways reckoned as belonging to the province of der-
matology, such as small-pox, scarlet fever, measles,
erysipelas, and others, exhibit skin phenomena
which may at times be difficult of diagnosis, and
may be closely simulated by quite different affec-
tions of the skin.
The relations of dermatology, therefore, to the
practice of general medicine are most intimate and
important, and a clear understanding of this branch
is essential for general success. The close observa-
tion and the appreciation of minute features wjiich
are called for in the study of diseases of the skin,
are also elements in medical practice the cultivation
of which cannot be too strongly insisted upon ;
while the effect of remedies, external and internal,
which can be clearly observed in the treatment of
these diseases, teaches much in regard to the thera-
peutics of diseases of other organs.
The error has often occurred of isolating derma-
tology too much from the ordinary practice of
4 MANUAL OF DISEASES OF THE SKIN.
medicine, and of regarding it as a department quite
separate, and one difficult to understand and grasp ;
whereas, in pointT of fact, this branch cannot be
rightly understood except by those thoroughly ac-
quainted, theoretically and practically, with medi-
cine as a whole. Skin diseases are not separate and
distinct affairs, having relations and conditions quite
different from those affecting other portions of the
body, but must be studied on the same principles
as diseases of other organs. They depend largely
upon the same class of causes, and many of them
resemble other maladies very closely ; almost all of
them have relations reaching further than the skin
itself. With this view or thought in mind, we will
briefly enter upon the study of the subject.
CHAPTER II.
ANATOMY AND PHYSIOLOGY OF THE SKIN.
The skin is the largest, and in some respects the
most important emunctory organ of the body, and
upon a proper performance of its functions depends,
to a great extent, the health and well-being of the
individual. While its apparent purpose is merely
as an outer investment, for the object of giving
shape and symmetry to the human form, and of
enabling it to resist external agencies which would
injure or destroy more delicate structures, it has
also functions of its own to perform which are most
important. It furnishes the means of exhaling a
large proportion of the fluid given off from the
body, and is the chief, fneans for maintaining ani-
mal heat at an equable point.
To fulfill its many duties, the skin is composed of
a number of different elements, all united in a har-
monious texture ; it contains excretory glands and
organs of sensation, and has, as appendages, the
hair and nails, all to serve definite purposes. In
certain localities^ it undergoes changes in structure
according to the necessities of the case; thus on
the palms, soles, and buttocks it is thick and re-
5
6 MANUAL OF DISEASES OF THE SKIN.
sisting; while it is thin and delicate on the eyelids,
penis, and certain other regions. On the scalp, face,
and elsewhere it produces hairs, which are but modifi-
cations of its epithelial elements ; and on the ends
of the fingers and toes, another variation in epider-
mal development gives rise to the nails. At the
orifices of the body, as at the nose, mouth, urethra,
vulva, and anus, its anatomy is altered to conform
to the requirements of the parts, and the mucous
membranes result, which are indeed but altered
skin, whose diseases are often closely allied to or
connected with those of the outward integument.
The skin is composed in the main of two layers,
quite different in their structure and composition.
The lower or deeper one is called the corium, cutis
verUj true skin, or dermay and the outer one is named
the epidermis (Greek, epi, upon, and derma, skin).
The derma or corium, the inner or deeper portion,
which constitutes the leather of commerce, is com-
posed of densely interwoven connective tissue fibres,
firm and elastic, which interlace and form a texture
resembling felt. At the deepest part of this corium
or true skin, the fibres are separated, and between
them are found masses of fat globules, constituting
th^panniculus adiposusy or adipose tissue; in the outer
portion the fibres are closely matted together, and
the surface externally rises into minute prominences,
called the papillae of the skin, this portion having
the name of the papillary layer, ox pars papillaris.
ANATOMY AND PHYSIOLOGY OF THE SKIN 7
The epidermis^ cuticle, or scarf skin, has no fibres,
but is composed of roundish elements called cells.
The deeper cells are more rounded or many-sided, and
succulent, and compose what is known as the rete
mucosum or rete Malpighii; this rests directly upon the
papillae, and dips down into the interstices between
them. In the cells of this deepest layer is found
the pigment or coloring matter, normally in the
colored races and in certain regions of the white
body, as about the areolae of the breasts and else-
where ; it also occurs in this layer pathologically in
certain diseased states, hence the difficulty of re-
moving pigmentary deposits in the skin. The outer
layers of cells of the epidermis are more flat, and as
they approach the exterior they become still more
flattened, hardened, and lifeless, only waiting to be
thrown off or removed by friction.
The corium, or true skin, contains a number of
elements which demand closer consideration. These
are blood-vessels, nerves, lymphatics, muscular fi-
bres, hair follicles, sebaceous glands, sweat glands,
and nails.
The blood and nerve supply of the skin is ex-
ceedingly abundant, and is of the utmost impor-
tance in its relations to its diseases. Its very great
richness in these elements may be judged from
the fact, that even a fine needle cannot be intro-
duced into the skin without drawing blood and
causing pain. The blood-vessels coming from be-
8 MANUAL OF DISEASES OF THE SKIN.
low anastomose very freely in the skin and rise into
the papillae.
The nerves of the skin serve the purposes of pre-
siding over its nutrition, of providing general sensa-
tion which shall protect the parts from injury, and
of furnishing the sense of touch. In the main the
larger nerves are confined to the corium, but nerve
elements have been also traced beyond the true skin
even into the second or third layer of cells of the rete
Malpighii ; also in the sheaths of the hair follicles,
and in the sebaceous glands. Within the papillae
are found what is known as the tactile corpuscles ;
these consist of a mass of nucleated cells, mingled
with connective tissue, into which the medullated
nerve fibre is seen to run and apparently to termi-
nate. It is thought that in them lies the sense of
touch. The nerves which preside over nutrition,
the trophic nerves^ have not yet been demonstrated,
and very little is also known with regard to the
vaso-motor nerves in the skin ; but that both these
are exceedingly important in their relations to skin
diseases cannot be doubted, from the structural
changes, the functional glandular derangements,
and also the congestion and inflammation which oc-
cur so readily in the integument.
The lymphatics of the skin are very numerous, and
undoubtedly of importance in connection with its
oathology. They have been recently demonstrated
' very abundant, both throughout the skin and
ANA TOMY AND PHYSIOLOGY OF THE SKIN 9
in connection with the sebaceous and sweat glands
and the hair follicles. As yet we know little of their
real relations to the diseases of the skin, although
in certain affections, as elephantiasis, morphoea,
lymphangioma, erysipelas and others, they proba-
bly play an important part. We see the lymphatic
element exhibited in the multiple adenopathy of
syphilis; also in the buboes connected with chan-
croids, and the milder glandular swellings accom-
panying prurigo and also inflammatory conditions
on the lower extremities ; likewise in the enlarged
glands in the back of the neck, in pustular eczema
and other diseases of the scalp.
Muscular fibres exist in the skin in two forms
or conditions. First, there is a small amount of
smooth muscular tissue running horizontally, which
is more developed in certain localities than in others.
In some animals there is a considerable amount of
striated or voluntary muscular fibre throughout the
entire skin, whereby they are able to move it to a
slight degree, and thus to assist in shaking off dust,
insects, etc. ; the dartos of the scrotum somewhat
resembles this, but here the movements are almost, if
not quite, entirely involuntary, and these frequently
interfere materially with the treatment of eczema
in this region. The greatest development of the
muscular fibre in the skin of man is found in the sec-
ond form of distribution, in connection with the seba-
ceous glands and hair follicles, next to be described.
10 MANUAL OF DISEASES OF THE SKIN.
Hair and hair follicles. — The relations of the
hair follicles to the integument can be best under-
stood by imagining the lower or fibrous portion of
the skin to be soft and plastic, and the upper or
epidermal layers to be pushed down into it without
breaking, around a penetrating hair ; the sheaths
of the hair are thus seen to be cellular, and to a
certain extent to correspond to the layers in the epi-
dermis. Quite a number of separate layers of cells
have been made out and described, but the practi-
cal point to be remembered is, that they are cellu-
lar, reaching down into a fibrous structure; this
will be found to be of importance in reference to
the vegetable parasitic diseases. At the bottom
of the hair follicle thus formed, which in the case
of larger hairs extends through the extreme thick-
ness of the skin, the fibrous elements of the corium
rise and form what is known as the hair papilla^
from which the hair is supposed to take its growth.
This contains blood-vessels and extends up into, and
is embraced by the lower portion of the hair. The
hair itself is composed, like the epidermis, of cells ;
at its deepest portion, within the follicle, these cells
are seen to be quite round or polygonal, and are soft
and succulent like those of the rete Malpighii. Those
further outward are more flat and compressed, until
finally all the cells are so flattened and condensed
together that they appear like fibres, and these con-
stitute the entire length of the hair, however great.
ANATOMY AND PHYSIOLOGY OF THE SKIN, n
Hairs exist over almost every portion of the sur-
face of the body, with a few exceptions, as in the
palms and soles, the internal surface of the prepuce,
and the glans penis, though in some situations they
are so fine as to be hardly discernible with the na-
ked eye. The number of the hairs is exceedingly
great, varying vastly in different individuals. Be-
tween seven and eight hundred have been counted
on a square inch, and the total number on the scalp
has been estimated at between ninety and one hun-
dred and twenty thousand. Hair is very strong,
and yet very elastic ; a single hair has supported a
weight of over two ounces, although such strength
is undoubtedly exceptional ; repeated instances have
occurred where the scalp has been torn from the
head by means of the hair, so firmly is it attached,
and yet in disease it may fall with the slightest
touch or break with the gentlest traction. Hair is
so very elastic that it may stretch almost one third
of its length, and regain its former dimensions.
Sebaceous or sebiparous glands. — These are irregu-
larly shaped masses of glandular structure, belong-
ing to the variety known as racemose glands, and
with a single excretory duct ; they are almost in-
variably connected with hairs of some size. Upon
hairy parts, as the scalp, they form appendages to
the hairs, and discharge their secretion into the hair
follicles. Generally there are two to each hair, situ-
ated on opposite sides ; but in some situations large
12 MANUAL OF DISEASES OF THE SKIN.
hairs have a number, even from four to eight, situ-
ated around them, forming a sort of collar about
the hair. In other places, where the hairs are fine
and rudimentary, the sebaceous glands are large,
and the tiny hair appears there as an appendage to
a comparatively large gland. All the sebaceous
glands, however, are very minute affairs, and mostly
situated in the outer portion of the corium. The
secretion -from these glands is of an oily nature, and
when in a healthy condition, it is perfectly fluid at
the temperature of the body. The quantity of the
secretion is not very great in health, and its main
function appears to be to keep the skin and hairs
in a flexible state ; although the amount of solid
matter thrown off thus must be of some importance
in the economy. When these glands fail to act, we
have a dry harsh condition of the skin, known as
xeroderma ; and when the secretion becomes blocked,
it forms comedo, both of which states will be treated
of in connection with acne. Sometimes the secre-
tion is great, and appears as an oily coating on the
skin ; or it may dry, forming coarse scales or greasy
crusts, representing seborrhoea or acne sebacea.
Neither of these conditions in which the secretion is
observed represents the normal state of the seba-
ceous material.
The muscles of the skin, which are connected with
the hair follicles and sebaceous glands, the arrec'-
tores pilorum^ play a part which it is important to
ANATOMY AND PHYSIOLOGY OF THE SKIN. 13
understand. These are attached to the lowest por-
tion of the hair follicle, and, running diagonally,
are inserted in the upper portion of the corium ;
they thus embrace the sebaceous glands connected
with the hairs, so that each time they contract,
pressure is made upon the glands, and their con-
tents more or less forced out. On the parts of the
body, such as the face, back, and chest, where the
sebaceous glands are very large and the hairs very
insignificant, the glands lose this aid to the expul-
sion of their secretion and very readily become
clogged, thus furnishing one of the reasons for the
prevalence of acne upon these parts. When these
muscles contract under the influence of cold or men-
tal emotions, the surface presents minute transitory
elevations, cutis anserina^ or " goose skin ; ** ^lis may
be produced at will on entering a bath, by allow-
ing the exposed surface to become a little chilled,
while dry, when the hairs are seen to become
erected, especially on the arms.
Sweat or sudoriparous glands. — These are in the
form of minute tubes, which are coiled up in the
deepest portion of the corium, or even in the subcu-
taneous adipose tissue, and then extending through
the entire thickness of the skin, and after making
several spiral turns within the epidermal portion, they
open directly upon the outer surface. These glands
are very numerous in some portions ; on the sole of
the foot and palm of the hand there are about 2700
14
MANUAL OF DISEASES OF THE SKIN.
in the square inch ; on the legs there are about 550
in the same space, and on the forehead about 1250.
According to careful computation their total, num-
ber amounts to almost 2,400,000 ; the total length
of all of these minute tubes when uncoiled has been
variously estimated at from two to eight miles.
The action of these little glands is not intermit-
tent but continuous, and sweat is incessantly exhaled
in the form of vapor or insensible perspiration. It is
only when the body becomes much heated, as by
exercise or otherwise, or in disease, that the per-
spiration manifests itself to the eye or touch. The
total quantity of the fluid exhaled by the skin is
subject to the greatest variations, according to tem-
perature, moisture, exercise, quantity and quality of
food an4 drink taken, etc. The average person in
health gives off through the skin ordinarily be-
tween one and two pounds or pints of fluid daily,
a quantity almost equal to that excreted by the kid-
neys. When animals are completely covered with
an impermeable coating, as by varnishing the sur-
face, death always takes place; and the story is
current among physiologists, that a child who was
covered with gold leaf in order to represent an
angel in the ceremonies attending the coronation
of Pope Leo X., died a few hours after the coating
had been applied.
Nails. — The nails resemble the hairs very closely
in many respects, and are but altered portions of the
ANATOMY AND PHYSIOLOGY OF THE SKJN. 15
epidermis. We speak of the root and the body of
the nail, the root being that portion toward the
trunk, and situated beneath the skin. The body of
the naily which represents the section of the hair
within the folHcle, is the remaining attached por-
tion, while the free extremity of the nail, which
custom and convenience remove frequently, corre-
sponds to the free extremity of the hair. The
matrix of the nail is that upon which the nail rests,
and to which it is firmly attached. Nails grow from
their roots just as do the hairs, and only slide over
their matrix or bed, so that injuries to the matrix
need not cause a disfigured nail, other than of the
portion directly injured, whereas injury or disease
at its root will generally cause a destroyed or de-
formed nail.
PHYSIOLOGY OF THE SKIN.
The physiology of the skin is important to re-
member, both in its relations to dermatology and to
general medicine. As a great emunctory organ, it
shares very largely with the lungs and kidneys the
office of removing the superfluous water from the
system. The skin and kidneys each excrete some,
where between one and two pounds of liquid daily,
while the lungs, perhaps, not over one half or two
thirds as much. It can be readily understood, there-
fore, how ** a check of perspiration " can act harm-
l6 MANUAL OF DISEASES OF THE SKIN.
fully by throwing extra work upon other organs.
These three great agents for removing or eliminat-
ing water from the system act in harmony, and in-
terchange their duties to a greater or less degree.
Thus, an cold weather, when the skin perspires less,
the kidneys are more active, as are also the lungs ;
in summer, again, when the perspiration may be pro-
fuse, it is a common observation to find the urine
more scanty. This vicarious action of these organs
is frequently taken advantage of in medicine, as
when, in kidney disease, we cause the skin to act
profusely and remove water which threatens dropsy ;
also in pneumonia, where power for work of the
lungs is seriously impaired, the action of the skin
is excited in like manner. Again, in many diseases
of the skin great advantage results from remedies
which increase the action of the kidneys and bowels.
The results of physiological research show that
very considerable impression may be made upon
the general system by simply acting upon the skin,
as by baths, the cold pack, etc. ; advantage may
often be taken thus of the absorbing power of the
skin for the introduction of remedies through this
channel, and nutrition also may be greatly affected
by fatty inunctions. Failure in the action of the kid-
neys, bowels, lungs, and liver, deranges the balance
of the system, and may result in disease of any
organ which has work thrown upon it which it
cannot perform ; we must believe, therefore, that
ANATOMY AND PHYSIOLOGY OF THE SKIN. 17
the skin undoubtedly may become diseased in the
effort to produce its secretions from imperfectly
elaborated blood, as well as from attempting to
take its nourishment from that which has been
insufficiently prepared in other portions of the
economy.
The beneficial effects often observed in skin dis-
eases from the use of mineral waters in bathing and
drinking, must not be attributed to their action upon
the diseased tissues alone ; the skin as an organ is
often affected favorably, and performs its work
better, and the kidneys and bowels are stimulated
to action by the mineral ingredients. Even when
used externally alone, other organs are more or less
influenced by the mineral water, as it has been
definitely shown that the urine can be affected,
both in its liquid and solid elements, by means of
baths and wet packs.
CHAPTER III.
NOMENCLATURE AND CLASSIFICATION OF DISEASES
OF THE SKIN.
Very much confusion, and much of the difficulty
attending the study of dermatology, has resulted
from the number and variety of terms which have
been applied to these diseases, by different authors.
Many affections have been called by quite different
names, and often the same designation has been
given to diseases which are quite distinct ; not only
has every author or teacher felt at liberty to coin
new terms, or to propose changes, but in some in-
stances they have not even faithfully adhered to
one name, but have made repeated changes, both
in those employed by themselves and others.
Happily at the present time this error of past
study is appreciated by the majority of those who
write and teach this branch, and the desire is becom-
ing more and more fixed and manifest to use der-
matological names that are not only plain, but such
as can be adhered to by those of every nation and
school. It would be useless to attempt to enter
upon, much more to give severally, the various
views which have been promulgated in times past.
CLA SSIFICA TION OF DISEA SES OF THE SKIN.
19
and the different names and systems which have been
put forward, only to last until the death of their
producer, or not to find acceptance beyond his im-
mediate circle. . The dermatology of to-day looks
back upon the heaps which have been piled up, only
to endeavor to avoid the repetition of such follies ;
and all who have this branch deeply at heart, are
seeking for unity of thought on this subject.
Inasmuch as different names may be given to dif-
ferent diseases in various countries, the Latin lan-
guage has become more and more adopted for the
expression of exact science ; and in order that many
of the names which have been used and known from
antiquity may not be changed, the older Greek
terms are retained as far as possible, while the Latin
ig further used for secondary names and expletives.
The following of this plan in various countries, to-
gether with the publication of photographic and
other representations of diseases, will soon har-
monize dermatological thought, and render the
study of cutaneous maladies much more easy.
The classification of diseases of the skin, while
not of the utmost importance, still often serves as
an aid to the understanding of the branch. Vari-
ous efforts have been made at forming a clinical
classification ; but the plans have varied so much,
according to the views of the writer, that no two
have very greatly resembled each other, and few
authors have quite agreed upon the subject. With
20 MANUAL OF DISEASES OF THE SKIN.
the study of pathological anatomy, however, dis-
eases of the skin, as well as those of other organs,
have come to be placed in certain groups according
to the pathological changes which have taken place.
In a very rough way, this was first proposed many
years ago by Plenck, and followed by Willan and
others, who divided skin diseases according to the
gross features exhibited, and arranged them in
eight orders, as follows :
I. Papulae. V. Pustulae.
II. Squamae. VI. Vesiculae.
III. Exanthemata. VII. Tubercula.
IV. Bullae. VIII. Maculae.
But the insufficiency of this plan becomes manifei^
when it places in the same group diseases which not
only have no relation to each other but which are
widely dissimilar in appearance. Thus, scabies and
variola appear together, because both exhibit pus-
tules; varicella and eczema, because vesicles may
be seen in both ; acne and lupus, because tubercul-
ous masses are developed in each, and so on.
In 1845, Hebra published his attempt at. a classi-
fication of diseases of the skin on a basis of patho-
logical anatomy, and his plan, simplified by himself
and others, has since been followed more and more,
until now a considerable portion of the dermatologi-
cal world acknowledges it as the best basis upon
CLA SSI PICA TION OF DISEA SES OF THE SKIN. 2 1
which to arrange dermatological thought. The fol-
lowing classification is based entirely upon this plan,
although considerably simplified from that first pro-
posed by Hebra, and that given in his text-book.
CLASSIFICATION OF DISEASES OF THE
SKIN.
Class I. SCorbi cutis paxasitici. Parasitic Affections.
II. SCorbi grlandolaxiixxi cutis. Glandular Affections.
III. Neuroses. Neurotic Affections.
IV. Szsudationes. Exudative or Inflammatory Affections.
V. HaBmorrhagiflP» Hsmorrhagic Affections.
VI. Hypertrophiaa. Hypertrophic Affections.
VII. Atropliied. Atrophic Affections.
VIII. Neoplasxnata. New Formations.
Glass I. SCorbi cutis parasitici. Parasitic Affections.
A. Vegeta-
ble.
'corporis (or tinea circinata).
capitis (or tinea tonsurans),
barbs (or sycosis parasitica),
cruris (or eczema marginatum).
B. Animal.
z. Tinea trichophytina
(or ringworm)
I Parasite — Tricho^
\Phyton tonsurans),
*• Jr°^^^^^ (Jarasite—Achorion Sckoenleinu).
'' Si'^tJriSsteJsicolor) (/arasite^Microsporon/ur/ur),
"^r^Sosis) \"^^f\ (Parasite^Pe^icuius),
2. Scabies (or itch) (parasite— -A carus scabiei).
Glass H. SCorbi grlandalarum cutis. Glandular Affections.
A. Diseases
OF THE
Sebaceous
Glands.
I. Due to
faulty
secretion
or
excretion
of
sebaceous
matter.
( oleosa
■< cerea
( cornea
(
z. Acne sebacea •{ cerea >• (or seborrhcea).
.Acne punctata { °}^,<?^rifu'^.
3. Acne moUuscum (or molluscum sebaceum).
II. Due to inflammation of the ( 4. Acne simplex (or vulgaris),
sebaceous glands with sur— < k. Acne indurata.
rounding tissue.
Acne rosacea.
22
MANUAL OF DISEASES OF THE SKIN.
B. DiSBASBS
OP THB
Sweat-
Glands.
I. As to quantity of ( x. Hjrperidrosis.
secretion. ( a. Amdrosis.
n. As to quality of ( 3. Bromidrosis.
secretion. ( 4. Chromidrosis.
III. With retention of j 5. Dysidrosis.
1 6. - - ■
secretion.
Sudani ina.
Class m. Neuroses. Neurotic Affections.
X. Zoster (herpes zoster or zona).
9. Pruritus.
3. Dermatalcla.
4. Hyperaesthesia cutis.
5. Anaesthesia cutis.
6. Dystrophia cutis (or trophic disturbances).
Olass rV. Ezsudationes. Exudative or Inflammatory Affections.
X. Rubeola (or measles).
3. ROtheln (or German measles).
3. Scarlatina.
4. Variola.
5. Varicella.
6. Vaccinia.
A. Induced by Infection or
Contagion.
7. Syphilis.
8. Ristula malinia.
9. Equinia (or glanders),
xo. Diphtheritis cutis.
XX. Erysipelas.
B. Of Internal
or Local
Origin.
I. Erythematous.
II. Papular.
III. Vesicular.
X. Roseola.
2. Erythema
3. Urticaria.
4. Lichen
5. Prurigo.
6. Herpes
( simplex.
-< multiforme.
( nodosum.
simplex,
planus,
ruber,
scrofulosus.
febrilis.
iris.
progeni talis,
gestationis.
rV. Bullous.
V. Pustular.
7. Hydroa.
8. Pemphigus { S-^'-
9f Pompholix
(or cheiro-pompholix).
xo. Sycosis (or folliculitis pilorum).
XX. Impetigo.
X3. Impetigo contagiosa.
X3. Ecthyma.
CLASSIFICA TION OF DISEASES OF THE SKIN. 23
B. Of Internal
OR Local
Origin. —
Continued.
VI. Multiform, i. e.^
eiythematous,
papular, ves-
icular, pustu-
lar, etc.
VII. Squamous.
VIII. Phlegmonous.
IX. Ulcerative.
14. £czema.
15. Dermatitis
' calorica.
venenata,
traumatica,
medicamentosa.
z6. Dermatitis exfoliativa
(or pityriasis rubra).
17. Psoriasis.
x8. Pityriasis c^itis.
19. Furunculus (funmculosis).
ao. Anthrax (or carbuncle).
3x. Abscessus.
33. Hordeolimi.
j 33-
1^-
Onychia.
Ulcus
(si
simplex,
venereum.
Class V. Haemorrhairisd. Hsemorrhagic Affections.
( simplex.
X. Purpura < rheumatica (or peliosis rheumatica).
( haemorrhagica.
3. Hsmatidrosis (or blo^y sweat).
3. Scorbutus.
Class VT. Hy];>ertroplii8a. Hypertrophic Affections.
A. Of Pxgment
•I
X. Lentigo.
3. Chloasma.
3. Melanoderma.
4. Morbus Addisonii.
5. Naevus pigmentosus.
B. Of Epider-
mis and
Papillae.
X. Ichthyosis.
3. Keratosis pilaris (or lichen pilaris).
3. Comu cutaneum
4. Clavus.
5. Tylosis (or callositas).
6. Verruca
vulgaris,
senuis.
ne<yo^enica.
. acummata.
C. Of Connect-
ive Tissue
D. Of Hair.
E. Of Nail.
■\t
Scleroderma.
Morphcea.
Sclerema neonatorum.
X. Hirsuties.
X. Onychogryphosis.
4. Elephantiasis (Arabum).
5. Dermatolysis.
6. Framboesia (or yaws).
3. Nsevus pilosus.
3. Onychauxis.
Class Vn. AtrophisB. Atrophic Affections.
X. Albinismus.
A. Of Pigment. | ^ Canities
a. Leucoderma (or vitiligo).
B. Of Corium.
( propria.
X. Atrophia cutis •< linearis (or stris atrophicae).
I maculosa (or maculae atrophies).
3. Atrophia senilis.
24 MANUAL OF DISEASES OF THE SKIN.
i X. Alopecia. a. Alopecia areata.
C. Op Hair. •< 3. Trichorexis nodosa. 4. Fragilitas crinium (or atrophia
( puorum propria).
D. Of Nail. Onychatrophia.
^ Olass VJJJ.. Neoplasxnata. New Formations.
I. Benign Nbw Formations.
A. Op CoNNRcnvB ( z. Keloid. a. Fibroma (or moUuscum fibrosnm).
Tissue. ( 3. Xanthoma (xanthelasma or vitiligoidea).
B. Op Fatty Tissue. Lipoma.
C. Op Granula- j _ t ,,-.„. j erythematosus. a. Scrofuloderma.
TioN Tissue. \ '* *-»*P»" \ vulgaris. 3. Rhinoscleroma.
D. Op Blood ( x. Nsevus vasculosus.
Vessels. ( 3. Telangiectasis (or angioma).
E. Of Lymphatics. Lymphangioma cutis.
F. Op Nerves. Neuroma cutis.
II. Malignant New Formations.
osa >
tlca )
^maculos^C
tuberculosa )■ (or elephantiasis GraBComm).
anaesthetlca
a. Carcinoma.
3. Epithelioma,
c J idiopathicum.
4. sarcoma -j pigmentosum (or melanosis).
CHAPTER IV.
RELATIVE FREQUENCY OF DISEASES OF Til K SKIN:
STATISTICS OF EIGHT THOUSAND CASI':^^.
The relative frequency and importance of the
different diseases of the skin may be in a mcai>urc
judged from statistics, although they often fail to rep-
resent the true frequency of the affections record^-d.
Thus, very few of the febrile diseases of the aUin ap-
pear here, such as measles, scarlatina, and sin:iU-|)ox,
because they comparatively seldom fall under the
observation and care of the specialist ; and n)any of
the more trivial skin disorders occur al^>o in much
fewer numbers than in reality, as such cases rarely
apply for treatment. Again, certain of the most
common diseases, eczema and acne, are not a«
largely represented as they might be, inasmuch as
many cases of eczema arc left untreated, and acne
is very generally disregarded.
The statistics here presented are from eight
thousand cases observed by the writer in private
practice, and in the Demilt Dispensary and the
Out-patient Departments of the New York and
Bellevue Hospitals. It was thought best to exclude
a large number seen in other institutions, as records
2 25
26
MANUAL OF DISEASES OF THE SKIN.
of them had not been kept with sufficient uniform-
ity and accuracy.
Analysis of 8,000 Skin Cases.
Disease.
Abscessus
Acne
Adenoma . .
Alopecia
Anthrax
Atrophia cutis
Bromidrosis
Cacatrophia cutis
Canities .'
Carcinoma cutis
Cellulitis
Chloasma
Clavus
Congestio foUiculorum . . .
Comu cutaneum
Dermatalgia
Dermatitis
Dysidrosis
Ecthyma
Eczema
Elephantiasis Arabum . .
Ephilide
Epithelioma
Erysipelas
Erythema
Excoriationes
Folliculitis capitis
Furunculus
Haemophilia
Herpes
Hydroa
Hyperaesthesia cutis
Private Practice.
•a
us
150
46
5
2
I
370
3
i2
I
I
22
2
529
26
3
16
15
28
5
23
I
2
I
I
I
2
30
I
520
69
6
4
I
I
2
2
I
14
I
I
349
I
I
19
3
24
13
19
I
32
2
36
3
I
878
I
I
45
6
40
28
47
6
Public Practice.
US
9
169
4
13
3
2
2
69
I
10
873
24
31
27
2
I
58
I
56
2
2
•a
. 7
284
I
7
2
I
3
2
10
4
3
i2
16
453
5
20
5
2
73
3
7
928
17
54
61
65
55
I
3
3
10
7
I
I
142
4
17
r,8oi
2
41
85
88
3
I
123
I
III
3
2
1-3
17
973
5
89
II
6
3
I
3
5
3
42
7
I
2
2
178
7
18
2,679
3
I
86
91
128
3
I
151
I
158
9
2
FREQUENCY OF DISEASES OF THE SJCIN. 2/
Analysis of 8,000 Skin Cases. — Continued.
Disease.
Hyperidrosis
Hypertrichosis
Ichthyosis
Impetigo
Impetigo contagiosa
Impetigo herpetiformis. . .
Keloid
Lentigo
Lepra
Leucoderma
Lichen
Lupus
Lymphadenoma
L3nnphangioma
Macula pigmentosa
Miliaria
Morbilli
Morphoea
Naevus
Neuroma
Onychatrophia
Onychia
Papilloma
Papulo-vesicular eruption.
Paronychia
Pemphigus
Phlegmon
Phthiriasis
Pityriasis
Pompholix
Prurigo
Pruritus
Psoriasis
Purpura
Rhinoscleroma
Private Practice.
•3
•a
I
5
I
10
3
I
4
9
29
II
23
77
9
3
23
5
5
2
4
2
8
15
21
I
3
4
12
8
12
» •
I
17
54
2
I
3
o
H
8
24
15
7
2
7
3
4
17
44
32
I
4
5
16
10
II
17
4
I
40
131
II
I
Public Practice.
II
2
2
43
7
I
3
2
2
6
2
I
I
2
I
4
•a
a
8
6
8
12
I
61
30
231
14
• • • •
55
• • • •
• • • •
57
• • • •
• • • •
112
92
no
202
12
• « • •
16
• • • t
28
....
3
^
19
13
13
19
2
3
104
37
2
2
I
I
3
10
2
2
II
2
T
5
7
I
386
18
O^
27
24
28
13
26
2
II
3
6
20
148
69
I
2
2
I
5
8
26
2
2
17
5
I
5
17
I
397
35
4
I
152
333
39
I
28
MANUAL OF DISEASES OF THE SKIN.
Analysis of 8,000 Skin Cases. — Continued,
Disease.
Roseola
Rothcln
Ruguc
Sarcoma
Scabies
Scarlatina
Scleroderma
Scrofuloderma
Strophulus pruriginosus
Sycosis
Syphilis
Syphilophobia
Telangiectasis
Tinea
Trichorexis nodosa ....
Tumor
Tylosis
Ulcus
Urticaria
Vaccinia
Varicella
Varicella prurigo
Variola
Varioloid
Verruca
Xanthoma
Xeroderma
Doubtful diagnosis
Private Practice.
15
92
87
4
8
14
3
4
5
2
4
2
I
8
61
I
37
6
30
1,320 1,263
3
o
H
II
I
2
10
I
3
3
15
153
I
124
4
14
44
14
6;
6,
3
Public Practice.
^
:«
I
66
14
12
344
142
88
62
2
9
2
I
30
I
2
4
2,583! 2,577
V
1
52
I
13
I
• • •
302
I
I
94
2
I
79
93
• • • •
II
3
2
4
2,840
6
I
I
118
I
27
I
12
646
I
I
236
3
I
167
155
2
15
2
I
41
4
4
8
5,417
6
12
I
3
128
I
4
30
I
27
799
I
2
360
4
3
I
181
199
2
21
2
5
I
55
10
10
II
8,000
Eczema is seen to come first in point of frequency,
it occurring in 2,679 of the 8,000 cases, or 33.48 per
FREQUENCY OF DISEASES OF THE SKIN. 29
cent, of the whole ; the real frequency is probably
even more than one-third of all skin affections as
presented to the general practitioner, since the many
cases of infa,ntile eczema of family practice do not
find their way into the statistics of the specialist ;
certainly far more than one half of the eruptions in
small children (excluding eruptive fevers) are eczema.
Acne is the next common disease here presented,
with 973 cases, or 12.16 per cent. ; here again statis-
tics fail to give the correct proportion, owing to the
general neglect of this eruption. Acne formed more
than one-fifth of the private cases.
Syphilis comes next in frequency, forming about
ten per cent, of all the cases, the proportion being
somewhat larger in public than in private practice.
The next name on the list, as to point of numbers,
is phthiriasis, giving 397 cases, or nearly five per
cent, in which the lesions were caused by lice ; there
were only eleven among the 2,5CX) private cases,
showing how seldom the condition occurs among
the upper classes.
The eruptions due to vegetable parasites appear
next in frequency, in almost the same proportion in
private and public practice, namely, forming four
and a half per cent, of all cases ; of these, two-thirds
were caused by the parasite trichophyton tonsuranSy
giving rise to the various forms of ringworm, while
there were only thirty-one cases of favus in the
entire 8,chdo.
30
MANUAL OF DISEASES OF THE SKIN.
Psoriasis appears next, and sixth on the list, with
333 cases, or a percentage of but 4.16, showing it to
be much less common than is usually supposed ;
the proportion of cases in private and public prac-
tice was about the same.
Urticaria is probably much more common than
these statistics indicate, inasmuch as many patients
with other diseases will give a history of being sub-
ject to this eruption, for which they will seldom
seek relief; it formed but 2.49 per cent, of all cases.
The remainder, even of the more commonly
known eruptions, appeared in still smaller propor-
tions, under two per cent., and a number of cutane-
ous maladies occurred but once or twice among the
entire number of cases analyzed.
Zoster or shingles formed but a trifle over one per
cent, of the 8,000 cases, although the eruption is so
startling and often so painful that those affected
generally apply for relief. Scabies was very rarely
seen, but 118 times in public and ten times in private
practice ; lupus formed but 0.86 per cent. ; purpura
but 0.49 per cent.; ichthyosis, 0.35 percent.; naevus,
0.33 per cent. ; leucoderma, 0.25 per cent. ; pemphi-
gus, 0.21 per cent. ; keloid, 0.14 per cent. ; morphoea,
0.10 per cent. ; and scleroderma but 0.05 per cent.
In regard to sex the patients were remarkably
evenly divided, 3,897 males to 4,103 females in the
total numbers ; but in individual diseases great dif-
ferences will be found. Thus in acne the females
FREQUENCY .OF DISEASES OF THE SKIN, 31
are double the number of the males, while with
alopecia there were twice as many males as females.
Chloasma is seen to be almost exclusively an affec-
tion belonging to females, there being forty cases to
two of males, while sycosis belongs to the male sex.
In eczema the sexes are pretty evenly divided, 1,402
males to 1,277 females ; with lupus the females were
almost three times as many as the males. Psoriasis
presented almost an exactly equal number of both
sexes, 169 males, 164 females.
CHAPTER V.
DIAGNOSIS.
The diagnosis of individual diseases of the skin
will be treated of in connection with each affection,
but a few general rules or considerations may be
here noted. Diseases and lesions of the skin should
always receive very careful inspection and study,
for, however simple the case may appear at first
sight or in any of its elements, it is quite possible
for other portions of the eruption to exhibit quite
different features ; and unless disease is taken as a
whole, and also unless it is understood in each and
all of its parts, no perfectly correct diagnosis will be
arrived at, and consequently no intelligent thera-
peusis.
The first consideration, therefore, has to do with
the examination of the patient. This should always
be made in a very general and complete manner ;
the practitioner should never be satisfied with in-
specting only a portion of the eruption present, but
must insist upon viewing the whole of the diseased
surface, and it is also important to examine the
neighboring healthy skin as well. It is, likewise,
32
DIAGNOSIS.
33
very necessary to observe and note carefully the
distribution of the eruption, for, as will be developed
elsewhere, different affections have different seats
of predilection, and modes of development and ar-
rangement of their elements, which will often aid
very considerably in the study of the case. As in-
stances maybe mentioned the proneness of eczema to
affect the flexor surfaces ; while psoriasis, ichthyosis,
and lichen are found by preference upon the ex-
tensor surfaces of the body. In studying the dis-
tribution of the eruption it is also well to bear in
mind the tendency which certain eruptions have for
a particular form of distribution; thus, the inclina-
tion to circular arrangement of the lesions of syphilis,
the disposition of the vesicles of zoster along the
lines of nerve tracts, and the peculiar grouping of
the vesicles of herpes febrilis and preputialis, are all
very striking, while the rather symmetrical develop-
ment of tinea versicolor, and the circular form and
irregular location of patches of ringworm are like-
wise characteristic.
It is important always to discover the primary
lesions of an eruption, the form in which it makes
its first appearance ; for, although when well devel-
oped it may or may not haVe characters which are
distinct, the earlier phases of its evolution will very
generally point towards the proper diagnosis. The
primary elements are generally discoverable near or
outside the main line of eruption, if at all, although
2»
^A MANUAL OF DISEASES OF THE SKIN,
occasionally they will reappear very characteristically
in portions already traversed by the disease. Some-
times the earliest stages are not present at the time,
all of the lesions having passed into a more fully
developed or retrograde state; but the previous
condition may then be generally learned by very
accurate questioning.
In making the diagnosis of an eruption, there are
two methods by which the end can be arrived at ;
these should be employed together, in order to at-
tain any true accuracy. The first is by recognizing
the actual characters or features of disease present,
and their likeness to a well known lesion or malady
of the skin ; the second is by exclusion, namely, by
considering other eruptions which the one present
might be mistaken for, and excluding each in turn,
by the absence of some particular, distinctive fea-
ture belonging to it. As remarked before, both
methods must be employed where the case is at all
doubtful; indeed, until one is familiar with the sub-
ject, this process of mental logic should be asso-
ciated with every case.
There is nothing really so very special or peculiar
in the lesions which are found upon the skin, or in
the diagnosis of the dise*ases which affect the integu-
ment. The pathological processes which occur here
are precisely the same as those which take place in
other portions of the body ; congestion, inflamma-
tion, the results of altered nutrition, as hypertrophy
DIAGNOSIS, 35
and atrophy, together with the development in the
tissues of new formations, as cancer, etc., constitute,
with the alterations caused by parasites, the lesions
which are found upon the skin. The variety of the
changes produced by these processes, results in con-
siderable confusion to one unaccustomed to look
upon them ; but a little careful observation will soon
distinguish the elements of disease belonging to the
various eruptions and processes, and by thus analyz-
ing and separating the lesions found upon the skin
a diagnosis can generally be made with certainty.
True it is, that the gross features and grouping of
elements seen in some skin diseases enable the prac-
ticed eye to make a probable diagnosis in many
instances at first sight ; but as successful treatment
depends absolutely upon accuracy of diagnosis, the
greatest care should be exercised in determining this
exactly.
Various agencies effect certain pathological
changes in the skin structure, which have received
the name of lesions; each of these exhibits to the
eye, and often to the touch, features which are dis-
tinctive, and which, if recognized, establish with
more or less of certainty the nature of the disease
process present. It is essential, therefore, to fix
firmly in the mind the elemental lesions, and to
connect them with the various diseases with which
they are associated.
We will first give a few brief definitions of the
i
36 MANUAL OF DISEASES OF THE SKIN.
terms used to express the parts or elements of
which eruptions are composed ; these are spoken
of as primary lesions^ and secondary lesions^ the first
the direct results of disease, the second, a more or less
consequent condition.
Of each of these there are eight, as follows :
Primary Lesions. Secondary Lesions.
1. Macula ; spot, macule. i. Tinctura ; stain.
2. Papula ; papule. 2. Squama ; scale.
3. Vesicula ; vesicle. 3. Crusta ; crust.
4. Bulla ; bleb. 4. Infiltratio ; infiltration.
5. Pustula ; pustule. 5. Fissura ; fissure.
6. Pomphus ; wheal. 6. Excoriatio ; excoriation.
7. Tuberculum ; tubercle. 7. Ulcus ; ulcer.
8. Phyma ; tumor. 8. Cicatrix ; scar.
First, of the primary lesions of the skin^ eight in
number.
I. Macula. Spots or macules are of various
sizes^ colors, or shapes ; not elevated or depressed.
These may be congestive, hemorrhagic, pigmentary,
or from extraneous causes.
Congestive maculae are seen in dermatitis^ eczema
erythematosumy erysipelas, erythemay leprosy, ncBvus
vasculosusy roseola, rotheln, rubeola, scarlatina and
syphilis: hemorrhagic maculae occur in purpura,
scorbutus, and insect bites : pigmentary maculae are
found in Addison's disease, chloasma, ephelis, leuco-
derma, melanoderma, morphoea, ncevus pigmentosusj
scleroderma, syphilis, and xanthoma: maculae from
DIAGNOSIS.
37
extraneous cause are seen in nitrate of silver stain-
ing, and from parasites in tinea trichophytina and
tinea versicolor.
2. Papula. Papules or pimples are sniall solid ele-
vations of the skin, inflammatory or neoplastic.
Inflammatory papules occur in acne, dermatitis,
eczema papulatum, lichen, phthiriasis, prurigo, pur-
pur a, scabies, syphilis, urticaria papulosa, and variola :
neoplastic papules are seen in keratosis pilaris.
3. Vesicula. Vesicles, or small water blisters, con-
sist of small elevations of the epidermis, with clear
fluid contents.
Vesicles appear in dermatitis, dysidrosis, eczema,
herpes, scabies, sudamina, varicella, variola, and zoster.
4. Bulla. Blebs, or larger water blisters, are so
called from their resemblance to bubbles on the sur-
face of agitated water. Blebs may be of any size
from that of a split pea upward.
Bullae are observed in hydroa, leprosy, pemphigus,
pompholix, scabies, and syphilis infantile.
5. Pustula. Pustules represent small, round ele-
vations of the epidermis, containing pus.
Pustules are seen in acne, dermatitis, eczema,
ecthyma, equinia, furunculus, impetigo, impetigo con-
tagiosa, phthiriasis, pustula maligna, scabies, sycosis,
and variola.
6. Pomphus ; a wheal. The flat, solid, slightly
elevated lesions of urticaria or nettle rash are called
wheals, or pomphi.
38 MANUAL OF DISEASES OF THE SKIN.
In addition to urticaria, wheals may also appear
about the bites of insects,
7. Tuberculum ; a tubercle. This term, which has
no relation to tubercles of the lungs, refers to small
solid elevations of the skin, larger than papules.
Tubercles occur in acne, carcinoma, clavus, epithe-
lioma, fibroma, lepra, lupus, lymphangioma, rhinoscle^
roma, sarcoma, scrofuloderma, syphilis, and verruca.
8. Phyma; a tumor. This is a large swelling in
or upon the skin, and may be of any size above that
of a tubercle. Generally masses larger than a cherry
are spoken of as tumors.
The following diseases may present lesions classed
as tumors : carcinoma, dermatolysis, elephantiasis,
fibroma, keloid, lepra, lipoma, rhinoscleroma, sarcoma,
and syphilis.
The secondary lesions of the skin, eight in number,
are as follows :
1. Tinctura ; 'a^ s\,2AXi. A discoloration of the skin
more or less permanent, left after a preceding le-
sion.
Stains may remain for a varying period after all
inflammatory affections; they are most commonly
seen after acne indurata, ecthyma, furunculus, lupus,
phthiriasis, psoriasis, and purpura, and after certain
lesions of syphilis, and ulcus they are apt to be per-
manent.
2. Squama ; a scale. A portion of the epidermis
more or less diseased and detached.
DIAGNOSIS.
39
Scales occur in dermatitis exfoliativa, eczema,
ichthyosis, lupus, pemphigus foliaceus, pityriasis^
psoriasis, rubeola, scarlatina, syphilis, tinea favosa,
tinea trichophytina, and tinea versicolor,
3. Crusta ; a crust. A dried mass, generally of
pus and epidermis, the product of some disease of
the skin.
Crusts follow inflammatory and destructive le-
sions ; they are principally seen in dermatitis, eczema,
ecthyma, favus, furunculus, herpes, hydroa, impetigo,
lepra, lupus, pemphigus, phthiriasis, scrofuloderma,
sycosis, syphilis, vaccinia, variola, and zoster.
4. Infiltratio ; infiltration ; a thickening and hard-
ening of the skin from disease. In this the nontial
suppleness and elasticity are lost, and the skin
readily breaks with each movement of the part.
Infiltration and hardening of integument is seen
in eczema, epithelioma, lepra, morphcea, rhinoscleroma,
scleroderma, and ulcus.
5. Fissura; a fissure, or crack in the skin, con-
sequent upon previous infiltration.
Fissures appear principally in connection with the
infiltration occurring in eczema, lepra, psoriasis, and
syphilis.
6. Excoriatio ; excoriation and ulceration of the
surface, generally caused by scratching.
Excoriations or scratch marks are observed in
connection with eczema, phthiriasis, prurigo, scabies,
and urticaria ; also in consequence of bites of insects.
40
MANUAL OF DISEASES OF THE SKIN,
7. Ulcus ; an ulcer. An excavation in the skin
made by disease. Ulcers generally extend deep into
the true skin, and leave a scar.
Ulcers may occur in anthrax y carcinoma^ chancroid^
dermatitis^ eczema, ecthyma, epithelioma, equinia,
furuncle, herpes preputialis, lepra, lupus, onychia,
pustula maligna, sarcoma, scleroderma, scrofuloderma,
syphilis, and from traumatic causes and varicose
veins.
8. Cicatrix ; a scar. A new growth made up of
hard, fibrous tissue, which replaces that lost by dis-
ease or injury.
Scars may follow ulcerative lesions in the diseases
just mentioned, and are also seen in acne, atrophia
cutis, favus, sycosis, vaccinia, varicella, variola, and
zoster.
All the lesions occirrringon the skin, will be found
to be made up of these elements, sometimes of a sin-
gle one alone, far more often of several combined.
Especially do we continually find those belonging
to the two classes intermingled, namely, primary-
lesions combined with their results, or secondary
lesions of the skin, and the one may be quite as
characteristic of the disease as the other. Thus,
the pearly, imbricated scales of psoriasis, and the
yellowish greasy scales of seborrhoea are both suffi-
ciently pathognomonic. The crusts of impetiginous
eczema and of syphilis, the ^cars of certain diseases,
DIAGNOSIS,
41
and the infiltration of eczema, all point clearly to
the affections to which they belong. In certain af-
fections we see little except the secondary lesions,
as in phthiriasis, where the scratch marks or excori-
ations are almost pathognomonic ; and in favus the
entire external lesion is made up of crusts and
scales. It will be observed that many diseases ap-
pear under several of these lesions, according to the
variety or stage of the eruption.
To observe diseases of the skin satisfactorily, it is
necessary that there should be good light ; for this
purpose daylight is almost essential, and plenty of
it, preferably from a northern exposure. It is almost
impossible to judge correctly of the color and char-
acter of skin lesions by artificial light.
CHAPTER VI.
ETIOLOGY.
The etiology of various diseases of the skin has
always been a matter of considerable difference of
opinion among writers, but the subject is being
cleared up more and more under the light of modem
science and accurate study, and many points are now
placed beyond the reach of controversy. In former
periods it was supposed that all cutaneous disorders
were manifestations of an internal poison or evil, a
fnateries morbid seeking exit by this channel : hence
the general name given to this class of affections
was eruptions (from the Latin e-rumpo, I burst
forth), as is also signified in the Greek term, eczema
(from iKByioo^ I boil over). This idea has by no
means entirely disappeared, either from the public
or professional mind ; in few, if any instances, how-
ever, is it' correct.
Modern study has demonstrated a certain group
or number of diseases of the skin to be entirely due
to the local effect upon the integument, or its ap-
pendages, of vegetable parasites which find a habitat
there ; certain other lesions on the skin are wholly
due to other local irritants, as the burrowing of the
42
ETIOLOGY.
43
scabies insect, or the scratching practiced for the
relief of pediculi, or from other causes. Still other
conditions recognized as disease are the direct re-
sults of heat and cold, or mechanical and chemical
irritants, as injury, dye stuffs, poison ivyy etc.;
another group of affections are known to be purely
local alterations in the skin tissue, such as fibroma,
epithelioma, keloid, and the like. Yet other diseases
have most intimate internal relations, such as acne,
eczema, and urticaria ; others, finally, as syphilis
and the exanthemata, are the result of specific poi-
sons.
It will be impossible, therefore, to enter here fully
into the subject of the causation of diseases of the
skin, but the matter will be briefly referred to in
connection with each malady. A few general con-
siderations, however, may be of value.
While some diseases are definitely due to a local
cause, as a parasite, and others to a specific poison,
in regard to a large number the etiology is by no
means fixed, and both internal and external causes,
as also individual and family tendencies, are of im-
portance in their production. These may be briefly
alluded to.
I. Internal Causes. — Food, which is wrong either
in quantity or quality, is a frequent cause of skin
disorder, as will be dwelt upon in the chapter on diet
and hygiene. Derangements of the internal organs,
as indicated by dyspepsia, constipation, and urin-
44
MANUAL OF DISEASES OF THE SKIN,
ary disturbance, likewise sexual disorders and ner-
vous derangements, are frequently very closely con-
nected with skin lesions ; and the permanent cure of
the latter often depends upon the successful relief
of the former. Debility is also an important element
to consider in this connection ; and infancy, denti-
tion, puberty, pregnancy, and the menopaus have
all relations to cutaneous maladies. The internal
administration of some medicines, as quinine, iodide
and bromide of potassium, and copaiba, and other
drugs, is sometimes followed by eruptions of peculiar
nature.
2. External Causes, — Parasites, animal and vege-
table, heat and cold, chemical and vegetable poisons,
and mechanical irritation, as by friction, harsh un-
derclothing, and above all by scratching, are fruitful
causes of skin lesions, and must all be looked for.
In some instances they are the sole efficient cause,
and the eruption fades away when they are re-
moved ; in other cases they are but a single factor,
and the real cause is found in the internal or indi-
vidual state. Thus, local agents may excite an
eczema in one predisposed thereto ; but the same
irritation practiced upon a dozen other individuals
will excite but a temporary inflammation of the skin.
The lesions of late syphilis are frequently deter-
mined as to their seat by a local injury.
3. Individual and Family Tendencies, — Some indi-
viduals are far more prone to have skin affections
ETIOLOGY.
45
than others, even as the lungs or kidneys are more
often affected in one person than in another ; those
with light complexion and hair are more inclined to
skin diseases than the dark. Again, families present,
the same peculiarity ; some affections are hereditary
to a greater or less extent, such as syphilis, leprosy,
cancer, and psoriasis ; eczema sometimes appears
to be inherited, but in reality this is rarely the case.
The gouty, strumous, and nervous habits or states,
whether hereditary or acquired, are of importance
in connection with this subject.
Other elements to be taken into consideration as
bearing upon etiology, are the seasons, climate, oc-
cupation, age, and sex, as will be developed in later
pages.
CHAPTER VII.
CLASS I. MORBI CUTIS PARASITICI. — PARASITIC
AFFECTIONS.
The first class of diseases in our classification em-
braces eruptions having a well recognized and easily
defined cause : namely, the existence in or upon the
skin of parasites, whose presence and irritation cause
the phenomena of disease. These parasites are rec-
ognized to be of two kinds — ^vegetable and animal.
The first group embraces three distinct kinds or va-
rieties of disease ; the second, two.
The vegetable parasites producing the three dis-
eases are supposed to be distinct one from another ;
they have not been found to be interchangeable in
causing disease. The three vegetable parasites are
the trichophyton tonsurans^ causing the varieties of
tinea trichophytina or ringworm, the achorion Schon-
leinii^ causing tinea favosa or favus, and the micro-
sporon furfur, inducing tinea or pityriasis versicolor.
The action of these parasites is a purely local one ;
that is, the lesions are produced by the local action
of the vegetable growth upon and in the elements
of the skin, and not by absorption or by any action
of the parasite upon the blood or the system at large.
46
PARASITIC AFFECTIONS.
47
When the eruption is communicated to another per-
son, or develops elsewhere on the same individual,
it is always by direct or indirect transference of the
germs of the parasite to and upon the affected spot.
I. Tinea trichophytina. Synonym : Ringworm,
The growth of the parasite trichophyton produces
quite different appearances as it affects the different
portions of the body, and four distinct varieties of
eruption from it are recognized : Namely, tinea tri-
fhophyton corporis^ — capitis^ — barbcBy and — cruris^
affecting respectively the general surface and extrem-
ities, the scalp, the bearded face, and the genital
region. Although they are really the same disease,
they will best be described and treated of separately,
so different are the appearances at times presented.
Tinea trichophytina corporis. — Synonyms:
Ringworm of the body; Tinea circinata; Herpes circina^
tus. This includes the eruption due to this parasite
upon all parts other than the hairy scalp, the bearded
face, and the genital region ; it is very commonly
seen upon the face and hands of children. It is
characterized by the development of a small red
spot which enlarges peripherally with considerable
rapidity, so that in two or three days or a week it
may attain the size of a circle half an inch or more
in diameter ; as it increases at the border, it has a
tendency to clear in the center. The margin is
sharply defined, slightly raised, of a well marked
48 MANUAL OF DISEASES OF THE SKIN.
red, and covered with a small amount of easily re-
moved scales. Sometimes, in delicate skins, a few
minute vesicles will form on a large spreading bor-
der (herpes circinatus) ; this, however, is rare. When
at all well developed, the center of the patch is of a
dirty yellowish color with more or less scaling.
There may be one or several patches ; I have counted
as many as one hundred and three on one child ;
they may attain some size, and by coalescing may
form larger patches, or, the center clearing, gyrate
forms may be produced by the red margins. They
generally give rise to but little physical discomfort
other than a slight itching.
Diagnosis, Tinea circinata is most likely to be
confounded with psoriasis^ squamous eczema^ syphi-
lis, and erythematous lupus. The history of the case,
and the rapid development of the circles of ringworm,
with a tendency to clear in the center, will differ-
entiate them. The diagnosis is established with cer-
tainty in all the forms of ringworm by the discovery
in the scales and hairs, of the parasite trichophyton
tonsurans. The examination is best made by scrap-
ing the surface with a dull knife and placing the
debris in a little liquor potassae and glycerine, upon
the slide of a microscope, and examining it with a
power of from two to three hundred diameters. The
mycelium appears as minute, slightly greenish tubes
with parallel sides and rounded extremities, often
branching, and the spores as minute rounded bodies.
PARASITIC AFFECTIONS, 49
of even size, refracting the light strongly: some
little care is necessary to distinguish the latter from
fatty globules.
Tinea trichophytina capitis. Synonyms: Ring-
worm of the scalp; Tinea tonsurans; Herpes tonsurans;
Trichophytosis. Ringworm of the scalp is not always
as easy of recognition as might be supposed, and in
cases which have lasted any length of time the diag-
nosis may be very difficult. The eruption begins,
as upon the face and body, with a small red point,
which increases peripherally in a more or less circular
form, until it has attained almost any size. When
first presented there are commonly seen one or more
patches with a diameter of from half an inch upwards,
upon which the hairs are broken and stubbed, and
the surface covered with a dirty grayish scaling;
the history will be given that these were noticed
quite recently, and mainly by the loss of hair.
Sometimes instead of these dried patches there is
an inflamed condition, and each point of attack of
the parasite will be marked by a small pustule or
mass of inflammation, surmounted by a crust ; but
generally other non-inflamed patches will also be
visible.
Sometimes the tendency to inflammation will be
so great, that in place of single small points, the
entire patch, half an inch or more in diameter, will
become inflamed, boggy, slightly elevated above
the skin, and teijder upon pressure. When the dis-
50 MANUAL OF DISEASES OF THE SKIN
ease has lasted a length of time, each hair is seen
to stand in a little well of pus, from which it can be
extracted without pain ; and a gummy, purulent
fluid exudes from the hair follicles on moderate
pressure. This form or condition of the disease has
received the name of tinea kerion.
On attempting to extract the hairs from a non-in-
flamed patch of ringworm, the stump readily crum-
bles in the forceps without drawing the root with it ;
if the patch is scraped with a dull knife, many broken
bits of hair will be found with the scales, which are
seen to be filled with the spores of the parasite.
This broken condition of the hair which is seeti on
these patches, may be readily discovered by passing
the finger lightly over the surface at a slight dis-
tance from the scalp.
In certain old cases the distinctive features of ring-
worm may be lost, and the scalp is moderately scaly,
with thin hair, and among the long hairs may be
found many which are broken and stubbed, as in the
patches previously described.
Diagnosis. — Ringworm of the scalp may be mis-
taken for eczemay psoriasis^ seborrhceay and perhaps
syphilis. The stubbed and broken condition of the
hairs, and the presence of the parasite, are sufficient
for the diagnosis.
Tinea trichophytina barbae. — Synonyms :
Ringworm of the beard ; Parasitic sycosis ; Barber* s
itch; Tinea barbae ; Sycosis parasitica. In theearli-
PARASITIC AFFECTIONS.
51
^^H'.est stages of ringworm of the beard, the eruption
^^^ does not differ essentially from that observed else-
P where on the body; there is first a small red point,
' which extends peripherally in circular form, while
the center tends to clear, and becomes covered with
a moderate amount of scaling. The eruption may
remain in this condition without giving rise to much
irritation, but in long standing cases, it occasions
deep seated inflammation of the follicles of the
part, with the production of boggy masses, corre-
I spoading to that condition just described as tinea
kerion.
L Diagnosis. — The sharply defined ring, or portion
^^M of a ring, which can often be made out, red and
^^■.more or less scaly, with the history of an increase
^^^^.from a small point, indicates the character of the
^^H eruption, together with a discovery of the parasite
^^^K'by a microscopic examination of the scales and
^^^■'Ibairs. But the eruption may be confounded with
^^^^gcsema, true sycosis, seborrhea, and pityriasis, also
^^^B , possibly with psoriasis, acne, or syphilis. Eczema
^^^P always manifests its character of an imperfectly de-
^^^ fined margin, shading out into healthy tissue, and
without the tendency to clear in the center, and
generally exists elsewhere, or spreads out on to the
neighboring parts. True sycosis presents single iso-
lated pustules surrounding hairs, rather than the
I large boggy masses of the parasitic disease.
Tinea trichophytina cruris. — Synonyms:
52
MANUAL OF DISEASES OF THE SKIN,
Ringworm of the thigh and genital region; Chinese^
Burmese^ and Tokeleau ringworm; Eczema margina-
tum. The fourth and last variety of the eruption
due to the presence and growth of the trichophyton
tonsurans, is that about parts which are kept warm
and moist, as in the genital region and axillae, and
presents features which at times render it very diffi-
cult of recognition. But the development of the
eruption here is the same as elsewhere; namely,
from a small point which enlarges peripherally, with
a tendency to clear in the center. When presented
for treatment, however, one seldom sees small points
or even rings ; but generally there is a more or less
reddened surface with a sharply defined margin,
which is red, slightly elevated above the skin, and
from which a few scales can be scraped. This mar-
gin, which is generally not more than a line in width,
is of a reddish color, while the surface behind is of
a brownish, dirty yellow hue, sometimes quite red
and inflamed from previous treatment ; occasionally
small, newly developing points will be found within
the larger area or outside of the main line of dis-
ease. On the male the eruption on the scrotum
exactly corresponds to that upon the thigh ; gen-
erally the two thighs and the sides of the scrotum
are affected unequally. In the region around the
anus, and upon the buttocks where the parts come
in contact, the eruptions on the opposing surfaces are
seen to correspond to each other, and to present the
IKARA Sine AFFECTION'S. 5 3
sharply defined margin, and soggy, perhaps whitened
tissue within.
The itching from ringworm in the genital region is
generally most intense, and the suffering may be
very great. These cases often last a great length of
time, being relieved by treatment but not cured
until the accurate diagnosis is made.
Diagnosis. — The eruption in this location is mainly
liable to be mistaken for eczema^ and intertrigo;
often the two eruptions are combined, either being
first developed ; the sharply defined margin, and the
more or less tendency to clear in the center, should
always attract attention. Eczema in this region is
worse towards the crotch, and tends to become
lighter towards the periphery; simple chafing or
erythema intertrigo has the character of eczema in
a lighter degree.
Prognosis, — The prognosis of all the forms of ring-
worm is good ; there is a definite local cause, and if
it can be removed the disease will surely get well.
But the prognosis varies a good deal, with the form
and location of the disease, and the individual pa-
tient. Ringworm of the body always yields more
or less readily. On the scalp and beard it frequently
remains uncured for months and years, because of
the great difficulty of reaching the parasite, deep in
the follicles ; in the genital region, if properly treat-
ed, it is perfectly manageable.
Treatment, — This is comparatively simple, al-
54 MANUAL OF DISEASES OF THE SKIN.
though the details are difficult of execution in some
cases. A number of home remedies are of value in
ringworm of the body, such as laying a penny wet
in vinegar on the spot, ink, iodine, castor oil, etc.
Any of the mercurial ointments, preferably the red
precipitate or citrine ointment (Formulae 90, 92, 93,
98), well rubbed in, will suffice for the removal of
the disease on the body. Oleate of mercury in five
or ten per cent, solution is also valuable, but there is
a possibility of salivating with the too free use of it.
Sulphurous acid, if thoroughly applied, is one of
the best and most cleanly parasiticides ; to be of
value, however, it must be absolutely fresh, for by
contact with the air a portion of the sulphurous acid
evaporates, while the remainder is converted into
sulphuric acid, which is irritating to the skin and
useless to destroy the parasite. For this purpose
an unopened package should be obtained, and a
small bottle repeatedly filled therefrom. It is to be
applied thoroughly to the skin, two or three times a
day, undiluted, unless it appears too irritating, and
the effect may be heightened by covering the part
with oiled silk. Sometimes additional local stimu-
lation is necessary, as with the compound tincture
of green soap (Formula 39) ; if too much irritation
has been set up, soothing treatment will be required.
(Formulae 25, 26, 83, 84, 85). Ringworm in the gen-
ital region is similarly treated.
Ringworm of the scalp and beard, when recent,
PARASITIC AFFECTIONS.
55
may be removed by the means previously described,
but when deep seated, it is very difficult for the
remedy to reach the fungus in the follicles, and the
extraction of the hairs becomes necessary. If, how-
ever, we attempt to pull out the hairs from a tolera^
bly well developed patch of ringworm; they break
off, and considerable care will be necessary to insure
their removal ; they must be drawn perpendicularly
to their axis, and repeated attempts will often be
made before success is obtained. When depilation
is practiced, it is always well to rub into the sur-
face afterwards a solution of bi-chloride of mercury
(Formula 45) ; but this should not be intrusted to the
patient, for serious accidents have been reported
from the careless use of this remedy. In older
patches, where the hairs have less tendency to
break, and where large surfaces are to be treated,
the method of wholesale depilation described under
favus may sometimes be resorted to with advantage.
The plan of destroying the parasite by inflaming
the skin, which has recently found many advocates,
consists in powerfully stimulating the scalp with such
irritants as croton oil, repeatedly applied until an ar-
tificial tinea kerion is produced, and a muco-purulent
fluid exudes; the loose hairs are then easily ex-
tracted and the inflammation is allowed to subside
under soothing treatment, j^vhen the disease is fre-
quently found to be cured. This plan must be
adopted with caution, as it is not safe to treat too
56
MANUAL OF DISEASES OF THE SKIN.
large a portion in this manner, and sloughing has
occurred from its careless employment.
The internal treatment of ringworm may be briefly
disposed of. As moss does not grow upon the bark
of perfectly healthy trees, with plenty of air and
sunlight, so parasitic diseases seldom flourish upon
individuals in perfect health, as has been repeatedly
shown by failures in attempts at inoculation. It is
always desirable, therefore, especially in cases which
have lasted any length of time, to investigate most
carefully the general health, and to prescribe intel-
ligently therefor. Arsenic will not cure the disease,
but may be required as a nerve tonic, or as an im-
prover of nutrition, in connection with other reme-
dies ; the same may be said of many other agents.
An eczematous habit or diathesis will often be
found in ringworm cases ; in eczema marginatum
constipation aids the congestion and slight irritation
of those parts \vhich give the proper nidus for the de-
velopment of the parasite ; see treatment of eczema.
Tinea favosa. Synonyms: Favus ; Porrigo fa-
vosa ; Crusted ringivorm ; Honeycombed ringworm.
The second vegetable parasitic disease is due to
the growth in and upon the skin of the achorion
Schonleinii. This is a comparatively rare affection in
this country ; it occurring only 31 times in our 8,000
cases. The parasite may affect any and every part
of the surface of the body, but is more commonly
PARASITIC AFFECTIONS.
S7 .
seen or recognized upon the scalp. Here it is really
often severe and obstinate, because of the great size
and depth of the hair follicles into which the fungus
penetrates. Upon the rest of the surface, where
there are no large hairs, the eruption is very super-
ficial, and much more easily cured. The charac-
teristic lesion of favus consists of a slightly raised,
circular, cup-like mass, of a bright yellow sulphur
color, commonly seated around a hair, with a de-
pression in its center. When first appearing, the
little cups are exceedingly minute, perhaps not
much larger than the head of a small pin ; but if left
undisturbed, they may grow to the size of a quarter
of an inch or more in diameter; they are easily
dislodged, and the surface beneath presents a red,
glazed appearance. The mass thus removed is found
to consist entirely of the spores and mycelium tubes
of the parasite, which may be readily recognized
under the microscope, when ground up with a little
water or glycerine, and magnified 300 diameters.
But this characteristic cupped appearance of favus
is not seen in every case as presented for treat-
ment ; more commonly there are yellowish masses,
having somewhat the appearance of dried pus,
around and among the hairs, which may become
darkened by dust or blood. In cases which have
existed for some time a large portion of the scalp
may become affected, and exhibit the disease in
various degrees of severity, in cups or simply dried
3*
58 MANUAL OF DISEASES OF THE SKIN.
scaling. This superficial development, however,
is by no means the only portion of the disease ;
the parasite penetrates the hair and along its root-
sheaths, so that when greatly affected, the hairs may
be very easily extracted, and do not readily break
off. The disease is far more destructive in its tend-
ency than tinea capitis, and may not only destroy the
growth of the hair, but also the follicle itself, and
the eruption may be followed by great cicatrization ;
in old cases patches of scar tissue of greater or less ex-
tent are always found, slightly reddened, and perhaps
with some scattered hairs upon them. The disease
always interferes very greatly with the nutrition of
the hair, and renders it dry and harsh.
Favus sometimes appears on other parts than the
scalp, and if left undisturbed yellow cups will form,
and around them there is generally a ringed, erythe-
matous, scaly surface, very closely resembling ordi-
nary ringworm. In rare cases a large portion of the
body may be affected with favus. Favus is always
seen in those exhibiting ill health, and generally oc-
curs in strumous subjects. It is questionable, how-
ever, whether the disease itself, although purely a
local one, has not something to do with lowering of
the health and vitality of the individual.
Diagnosis. — This is not ordinarily difficult. No
other disease exhibits the characteristic cups ; and
if doubt exists the microscope will always decide.
Pustular eczema of the scalp, some cases of syphilis^
FAKASITIC AFFECTIONS.
59
and psoriasis are the only diseases with which it
can be confounded.
Treatment. — The treatment of favus differs with
its situation ; upon the scalp, owing to the great size
of the hairs and depth of the follicles, it is gener-
ally most rebellious, unless the treatment be very
thoroughly and faithfully persisted in until perfectly
cured.
External applications if lightly applied are of very
I little service, because they will not penetrate the
depth of the follicle ; and although the external mani-
festations are removed, it will crop out again when left
to itself. Two methods of treatment are therefore
applicable : the one of removing the hair and allowing
k the parasiticide to penetrate into the open follicles ;
I the other of causing an inflammation, which, by its
intensity, shall destroy the life of the parasite. De-
pilation is most to be relied upon, and if thoroughly
and efficiently performed is followed by success.
The hairs may be extracted by the forceps, but this
is a slow procedure when a large surface is involved ;
and the methcd recently employed by the writer for
extracting the hairs en masse is a much more ready
and more certain method. This consists in having
sticks prepared of a very adhesive material (Formula
20), which are made to adhere to the hairs, and then
pulled off. The hair should be cropped to about one-
eighth of an inch long, over the part to be treated ;
the sticks are then melted on the end in a spirit-lamp,
6o MANUAL OF DISEASES OF THE SJCIN.
and applied with a slight rotary or twisting motion,
to work the short hairs into their substance. After
they have cooled, they are removed by bending them
over and pulling the hairs in succession, with a slight
twisting motion. The sticks are prepared for fur-
ther use by burning the hairs in the flame and wip-
ing the end firmly upon a sheet of paper.
After depilating by this or other means, a solu-
tion of bi-chloride of mercury (Formula 45) is to be
well rubbed into the skin by the operator. To be
very effective depilation should be practiced every
day or so until all the affected hairs are removed ;
it is well to give the patient an ointment (Formulae
92, 93, 102), to be well rubbed into all the affected
parts night and morning.
In epidermic favus the cups are simply picked out
and the surface well rubbed with pure sulphurous
acid, the oleate of mercury 5 per cent., or one of
the mercurial ointments (Formulae 92, 93, 102).
Most cases of favus should also have some internal
treatment of a tonic character (Formulae 52, 53, 58,
59), in order that the general health may be raiised
to the standard which will resist the development of
the parasite.
Tinea versicolor. Synonyms: Pityriasis versi-
color ; Chloasma?; Liver-spots; Chromophytosis.
The third and last vegetable parasitic disease of the
skin is that due to the presence of the microsporon
PARASITIC AFFECTIONS, 6l
furfur. This is seen first and mainly on the chest, in
the form of yellowish-brown, slightly scaly patches
of various sizes and extent. Sometimes the erup-
tion consists of very many small points, at other
times of patches which may cover a very considera-
ble area. The back is almost always affected at the
same time, though to a less degree, and the eruption
may occasionally spread under and upon the arms,
and even upon the neck and face ; and in rare cases
upon the lower limbs. Usually it is quite symmet-
rical; when there is much sweating the surface
will be almost free from scales, and may be quite
red. There is often slight itching accompanying it.
Upon scraping the patches and placing the scales
beneath a microscope, groups or masses of round
spores are seen and more or less mycelium among
the epidermal scales.
This eruption has considerable tendency to recur,
and in many cases it lasts for years, being partially
removed by treatment, and then relapsing, owing to
the failure to entirely reach and destroy the para-
site.
Diagnosis. — This is comparatively easy ; the erup-
tion may be mistaken for chloasma^ leucoderma,
ringworm, erythematous eczema, and seborrhoea.
This eruption was formerly called chloasma, but this
term is now given to a pigmentary affection, having
no connection with the one now described, nor has
the present eruption any connection with liver dis-
62 MANUAL OF DISEASES OF THE SKIN.
order. True chloasma occurs on the face, and sel-
dom, if ever, in a manner to tesemble tinea versi-
color. In leucoderma there are white patches upon
a yellowish or brown base, whereas in the parasitic
disease now described we have yellow patches upon
a normal skin. Seborrhoea of the chest presents cir-
cular patches, which are more red in color; the
scales are very greasy, and the parasite is not found
under the microscope.
Treatment. — The treatment is often ineffectual in
permanently removing the eruption, because not
persisted in long enough. It consists of the appli-
cation of a parasiticide, of which there are many of
value. Sulphurous acid in solution will remove the
eruption very quickly, also Vlemingkx' solution
(Formula 37), and a few sulphur vapor baths will aid
greatly; preparations of mercury, as the oleate,
citrine ointment diluted, and others, are also effec-
tual; also solutions of corrosive sublimate, four
grains to the ounce, with a little ammonia; like-
wise tarry preparations, well rubbed into the skin,
such as the compound tincture of green soap, or
the liquor picis alkalinus (Formulae 39, 40, 42). It
is also well to have the patient wash the surface very
freely, and for this purpose even yellow bar soap
may be used to advantage.
CHAPTER VIII.
CLASS I. MORBI CUTIS PARASITICI. — PARASITIC
Animal Parasitic Affections.
Two distinct diseases of the skin are recognized
as due to animal parasites, although there are a
number of parasites which may at times attack the
human integument. These two principal ones are
phthiriasis and scabies.
I. Phthiriasis. Synonyms: Pediculosis ; Morbus
pedicularis ; Lousiness. Three distinct forms of
pediculi are found upon the human skin, occupying
severally and chiefly the body, the head, and the
pubis. Hence we speak of three forms of this affec-
tion or condition, n^sixAjy phthiriasis corporis^ phthi-
riasis capitis j difxA phthiriasis pubis.
Phthiriasis corporis. — ^The body louse has as
favorite seats of occupation the regions about the
shoulders and hips, and here the greatest number of
skin lesions will be usually found. These consist of
inflamed and torn papules of various sizes, together
with abundant scratch marks or excoriations. There
63
64 MANUAL OF DISEASES OF THE SKIN.
is also a curious lesion seen, which is caused by the
manner in which the insect obtains its nourishment ;
this consists of a very minute red point, not elevated
above the surface of the skin, and is in reality the end
of a small plug of blood occupying a dilated follicle,
into the bottom of which the insect has penetrated
with its proboscis in order to suck blood. On strip-
ping the patient with phthiriasis corporis, one gen-
erally finds none of the parasites upon the body,
but they may commonly be found in the folds of
the clothing about the parts affected, and here like-
wise are laid the eggs or nits, which may be seen by
careful inspection, as minute, oval, whitish bodies,
adherent to the fibres of the clothing. In debilitated
subjects and in long standing cases the itching may
give rise to so much scratching that very considera-
ble lesions result ; even ulcerated points, covered
with thick crusts.
Phthiriasis capitis exhibits many of the re-
sults of scratching and inflammation upon the scalp,
in the form of excoriations covered with more or less
crusts. The itching is generally quite considerable,
and the patient unconsciously tears off the crusts,
continually making the eruption worse. In severe
cases a large portion of the scalp may be the seat of
inflammatory action, and the hairs, accordingly, may
be matted together by the exudation ; the glands of
the back of the neck become enlarged, and the scalp
emits a fetid odor. The pediculi may generally be
PARASITIC AFFECTIONS. gj
seen moving upon the hairs, and their nits are found
attached to the same.
Phthiriasis pubis.— The true cause of itching
about the pubis will sometimes pass long unrecog-
nized. In some cases there will simply be a moderate
amount of itching about the genital region, with
the occasional development of scratched papules,
but in other instances all these parts may be very
much torn, and a considerable eruption exist. The
pediculiis pubis or crab louse differs from the preced-
ing varieties in being much smaller and more round ;
it holds very firmly by means of its crab-like claws
to the hairs, and is generally found firmly attached
to the hair, near its exit from the follicle, and with
its body in close contact with the surface. Thus it
may readily escape recognition, and appears more
like a little scab or crust than a living insect.
When it is dislodged, it still holds firmly to the
hair, and is with -some difficulty removed. It de-
posits its eggs or nits upon the hairs of the part,
and generally they can be found, as minute white
specks, attached to them. This crab louse may
also infest the hairs of the axillae, eyebrows, eye-
lashes, and even the hairs of other parts, as the
beard.
Diagnosis, — Upon the scalp the eruption jresem-
bles eczema^ pustular syphilis^ and possibly psori^
asis; but the inflammation caused by lice, and the
resulting crusts and the itching, are generally far
66 MANUAL OF DISEASES OF THE SKIN.
greater than those in these eruptions. In some
cases, however, very few lesions will be seen, and
the scalp may be kept so clean that no pediculi
can be discovered. But, however great care is exer-
cised, some nits may almost always be found on the
hairs when the eruption is due to lice. Phthiriasis of
the body may be mistaken for many eruptions, ec-
zemUy scabies^ pustular syphilis^ also iox pruritus and
prurigo ; but the peculiar locations of the principal
lesions over the region of the shoulders and about
the loins should excite suspicion ; and a careful ex-
amination will generally reveal the marks of the
finger nails in the torn papules and streaks, and
great care will reveal the hemorrhagic specks al-
luded to. Phthiriasis pubis may also resemble sim-
ple eczema and scabies ; but the finding of the
parasite renders the diagnosis clear.
Many of the cases of phthiriasis of the body and
genital regions were formerly called pruritus and
prurigo; these terms, however, belong to entirely
distinct diseases ; pruritus, or itching, is a symptom
of phthiriasis, as also of many other skin affections.
Treatment. — For phthiriasis of the scalp simple
cleansing alone does not suffice, but some agent
must be employed which is directly a parasiticide.
The most effective and sure application is that of
ordinary petroleum or kerosene oil, the commoner
the better, as it contains a larger proportion of the
volatile elements, which are destructive to the life
PARASITIC AFFECTIONS. 6^
both of the parasite and its nits. The head should
be thoroughly soaked with it two or three times
during a day, and left wrapped up in a cloth for
twenty-four hours. At the end of this time it is
thoroughly washed, and if there are any excoria-
tions, they may be treated with a little zinc or white
precipitate ointment (Formulae 83, 84, 85, 91.) One
such thorough application is generally sufficient for
the complete cure of the disease ; the nits will then
be found to be loosened upon the hairs, and to come
out with tolerable readiness ; it is never necessary
to cut the hair in these cases. Other treatment may
be used, as an infusion of stavesacre, as also white
precipitate ointment in full strength. Lotions of bi-
chloride of mercury should not be entrusted to pa-
tients for this purpose, as they are more or Iqss
dangerous.
Phthiriasis corporis is very easily remedied. The
patient is simply to take a warm bath with soap and
water, after which fresh clothes, which have been
thoroughly boiled and ironed with extra care, are
put on ; the parasites adhering to the clothing are
thus removed, and the clothes which are taken off
should be thoroughly baked or boiled. Some care
should also be exercised that other articles of cloth-
ing which the patient has worn be similarly treated,
lest lice develop anew from the nits attached to
them, however carefully removed from other gar-
ments.
68 MANUAL OF DISEASES OF THE SKIN,
Phthiriasis pubis is sometimes a little difficult of
removal because patients do not make sufficiently
thorough applications. Any of the mercurial oint-
ments (Formulae 90, 92, 93) are quite sufficient for
the destruction of the parasites, as also ammoniated
mercury well dusted on ; the danger of salivation
should always be borne in mind when the simple
unguentum hydrargyri is employed. In very rare
cases it is necessary even to shave the parts affected
with pediculi pubis ; but this need seldom be the
case if care is exercised.
It need hardly be stated that none of the varieties
of pediculi can by any possibility appear beneath
the skin, or affect the system at large, as is so often
popularly supposed. They are air-breathing insects,
and remain wholly upon the surface of the body,
and the lesions caused are due to the irritation from
them and the consequent scratching.
2. Scabies. Synonym: The itch. This affection,
quite different from the conditions just described,
is due to the boring into the skin or rather beneath
the epidermal layer, of a minute insect, the acarus
or sar copies scabieu The female does the mischief,
she burrowing for the purpose of laying her eggs,
which may be found in a little track which she
leaves behind her, called the ctiniculus or furrow.
The male is said never to penetrate the skin. This
little track which the female leaves forms the path-
PAJ^A SI TIC AFFECTIONS, 69
ognomonic sign of the disease ; it consists of a minute
brownish black line, generally curved, which appears
as though a bit of dark colored sewing silk had been
run beneath the surface. If the skin is washed or
wiped, this, instead of being removed, will stand out
still clearer, and will be seen to terminate at a point
of inflammation, a papule, vesicle, or pustule, or to
pass over the surface of one of these. The point of
inflammation is caused by the presence of the insect,
and she will be found at that extremity of the cuni-
cuius or furrow ; behind her a number of oval eggs
in various degrees of development may be observed
microscopically, and between them minute black
particles, which latter arc supposed to be the faeces
of the insect. Very recent cases may not present
cuniculi, if time has not elapsed for a sufficient bur-
rowing of the insect, but papules or vesicles may
form immediately on her penetrating the epi-
dermis.
The lesions of scabies are peculiarly multiform,
exhibiting papules, vesicles, and pustules often of
some size, also scratch marks and crusts, each case
varying greatly according to its duration and the
condition of the individual in regard to health,
cleanliness, etc. In light cases, or in very healthy
subjects, papules predominate, with a few vesicles
when the skin is delicate ; whereas in broken down
constitutions and in children, very severe inflam-
matory lesions may result, with large pustules ; or,
70
MANUAL OF DISEASES OF THE SKIN.
these may be scratched, and large, superficial, raw
patches form, covered with, more or less crusts.
There are certain places of predilection which aid
very greatly in recognizing the disease. The first in
importance is the region about the fingers, especially
where they join on the back of the hand; next, on
the inner surface of the wrists, also the soles of the
feet, and about the malleoli in children. In males
there will almost invariably be found one or more
lesions about the penis and scrotum, partaking of
the same inflammatory character; and often cuni-
culi or furrows of the insect may be found here very
perfectly developed. In the female the region of
the nipple is very often affected, also the flexor sur-
face of the forearm and the fold in front of the axilla
in both sexes ; the face and head generally escape.
The itching of scabies may be quite severe, but is
generally of a mild form, and bearable ; it is even
pleasant compared to that in severe eczema. There
will almost always be found the history of contagion
in scabies, and rarely will one member of a family
be attacked alone, especially if there are children.
Scabies is becoming a comparatively rare disease
in this country ; among the 8,CXX) cases analyzed it
only formed 0.39 per cent, in private, and 2.18 per
cent, in public practice. Occasionally it appears in
public institutions, and many cases are seen together,
and the disease may be difficult to eradicate. In
some countries, as in Scotland, it is much more fre-
PARASITIC AFFECTIONS,
71
quently met with, and in statistics from Glasgow it
forms about twenty-five per cent, of all cases of skin
disease. During our late war it was quite common,
and was often spoken of as the " army itch."
Diagnosis, — ^As may be judged, the eruption of
scabies may be confounded with very many affec-
tions of the skin; eczema, lichen, pkthiriasiSy pru-
rigo, pruritus, and urticaria papulosa ; between pap-
ular and vesicular eczema of the hands, and mild
recent scabies, the diagnosis is often very difficult.
Prognosis, — ^This is good ; of however long stand-
ing, the disease may be rapidly and thoroughly
cured if proper and complete treatment is carried
out. The system is never affected, and there is no
harm in removing the disease as quickly as possible.
Treatment, — ^This is accomplished purely by ex-
ternal means. As an indication of the plan to be
followed we may mention the rapid cure of the dis-
ease practiced in the Hopital St. Louis, in Paris.
The patient is first very thoroughly rubbed all over
from head to foot with soft soap, especial attention
being paid to the regions most apt to be affected :
this process occupies about half an hour. The pa-
tient then takes a warm bath, remaining in it for
half an hour or so, in the meantime scouring the
skin thoroughly. On coming out of the bath, he is
thoroughly rubbed from head to foot with an oint-
ment containing sulphur (Formulae 100, loi), and this
process also takes half an hour at least, particular
72
MANUAL OF DISEASES OF THE SKIN.
attention being given to the portions mentioned as
most commonly affected. The clothes, which have
been thoroughly baked while the patient was in the
bath, are now put on, and it is expected that the
disease is thus entirely cured. The idea of the first
friction is to open the furrows, as far as possible re-
moving the eggs which would hatch out ; these,
with the male insect which could be thus reached,
the bath then removes from the skin. The sulphur
ointment being then thoroughly rubbed into all the
parts, enters the open cuniculi and completes the
destruction of the insects. The clothes having been
baked at a high temperature, all the insects which
may have lodged upon them are destroyed.
Sometimes cases of scabies are over-treated, or
are so severely irritated by the measures used for
the destruction of the parasite, that an artificial
papular eruption results, which more or less imitates
the disease. In such cases a soothing treatment
may be employed for a few days, such as is suitable
for an eczema, and the case is then left a little with-
out treatment. If there are still the elements of
scabies remaining they will then become apparent.
CHAPTER IX.
CLASS II. MORBI GLANDULARUM CUTIS. — GLANDU-
LAR AFFECTIONS.
The diseases belonging to this group are divided
into two classes, namely: those relating to the
sebaceous glands, and those affecting the sweat
glands.
The diseases of the sebaceous glands comprise six
distinct varieties, several of which may often be
found more or less associated in the same individ-
ual. Of the sebaceous diseases we find two orders :
First, those due to faulty secretion or excretion of
the glands: acne sebacea, acne punctata^ acne mol-
luscum ; and second, those exhibiting inflammation
of the sebaceous glands with the surrounding tissue :
acne simplex^ acne indurata, acne rosacea.
I. Acne sebacea. Synonyms: Seborrhoea ; Se-
borrhagia ; Steatorrhoea ; Fluxus sebaceus. Three
distinct forms of this variety of functional sebaceous
disorder are recognized : acne sebacea, or seborrhoea^
oleosa, cerea, and cornea.
Acne sebacea oleosa. — In this the skin is more
oily than natural, and has a greasy, shiny appear-
4 73
74
MANUAL OF DISEASES OF THE SKIN.
ance. When the scalp is affected the hair has an
unctuous appearance, and emits a nauseous odon
Upon the face and the forehead it may exist to such
an extent that the oily secretion will stand in drops
upon the skin.
Acne SEBACEA CEREA. — This dry form of sebor-
rhoea is characterized by the presence of greasy
masses of scales or crusts, of a yellowish or greyish-
brown color, which tend to adhere to the skin.
Upon the nose and cheeks it may present a very
disagreeable and annoying coating : upon the scalp
the secretion may either remain quite greasy and
accumulate, so that it can be removed as a yellow-
ish, crusty mass, with the finger nail ; or, it dries into
scales, which fall continually upon the clothing, and
thus constitutes a large share of the cases ordinarily
called dandruff or dandriff. Commonly a large por-
tion of the scalp is affected, and loss of hair ensues
to a greater or less extent. Seborrhoea of the scalp
often resembles closely a dry scaly eczema^ a pityru
astSy or psoriasis.
Acne SEBACEA cornea is characterized by the
development, principally upon the face, of horny
sebaceous masses and concretions which, when forci-
bly removed, are found to have projections into the
orifices of the sebaceous glands ; sometimes their re-
moval causes slight bleeding. This condition may
remain, especially on elderly persons, for a length of
time, and may result in epithelioma.
GLANDULAR AFFECTIONS, 75
Treatment. — ^The constitutional treatment of these
functional subaceous disorders is essentially that of
inflammatory acne to be described later. Locally
stimulating and astringent applications are called
for; on the scalp tannin and white precipitate oint-
ment (Formulae 87, 90, 91) are most serviceable, with
an occasional shampoo with tar soap, or green soap
in solution (Formula 38) ; later, inildly stimulating
lotions are called for, and still later those with
cantharides (Formulae 49, 50, 51). The local treat-
ment of seborrhoea of the face is practically that of
the other forms of acne ; with the addition of a bis-
muth and white precipitate ointment (Formula 91).
2. Acne punctata. Two forms of disease are rec-
ognized which are due to retention of the sebaceous
matter, namely: acne punctata nigra^ or comedo, and
acne punctata albida, or milium.
Acne punctata nigra, or comedo, represents
the little black specks seen upon the face, commonly
called black-heads, worms, or grubs. These consist
of hardened plugs of sebaceous matter contained
within the cavity and ducts of the glands ; the black-
ened end is probably due to dust from the atmos-
phere, although this has been disputed of late.
The foundation for the popular idea that these
plugs, which can be squeezed out, are themselves
worms or insects, lies in the fact that there is in
reality a very minute animal which infests the se-
76
MANUAL OF DISEASES OF THE SKIN,
baceous glands ; it is, however, by no means of such
a size as one might imagine. It is called the demo-
dex or steatozoon folliculorum^ and is exceedingly
small, being in length from y|^ to -i^ of an inch,
and in breadth about i\-^ of an inch ; but this ani-
mal is perfectly harmless and entirely innocent of
the disease ; a number may be found in a single
plug, or again several masses may be examined
without finding one.
Acne punctata ALBIDA. — Synonyms: Milium;
Grutunt; Strophulus albidus. Milia are the little
white specks or bodies often seen in the neighbor-
hood of the eyes, and upper part of the face, and
occasionally on other parts of the body. They con-
sist of small collections of sebaceous matter, which
may have undergone alteration and calcification,
situated beneath a very thin layer of skin ; they
cannot be squeezed out, as can comedones, and do
not always come out, even when the skin is punc-
tured over them.
<
7>^^//«^;^/.T— Comedo calls for the internal and
external remedies suitable for ordinary acne, and in
addition the expulsion of the contents of the glands
by means of firm pressure made over them by
means of a small tube with rounded edges and an
aperture of sufficient size to admit the plug.
3. Acne molluscum. Synonyms : Molluscum se-
baceum; Molluscum contagiosum. Some little dis-
GLANDULAR AFFECTIONS.
77
pute has arisen with regard to the real nature of
this disease, but the weight of evidence seems still
to connect it with disorders of the sebaceous glands.
It is, however, quite a rare affection, and is seldom
associated with the other forms of sebaceous dis-
ease. It is more common in children than in adults.
It consists of small, pearly, or slightly reddened,
globular masses, projecting a little from the skin,
generally with an opening in their center, from
which can be squeezed a cheesy or milky substance.
Their common seat is about the face, eyes, and tem-
ples, although they may be seen on any part of the
body, as on the shoulders and back, and about the
geniftd r^on.
These little lesions often appear to be contagious,
hence the name, molluscum contagiosum ; but the
real cause of the contagion has never been demon-
strated, and inoculations have generally proved
fruitless. The prognosis is good, as they may gene-
rally be quickly and easily removed.
Treatment. — This consists in removing the little
tumors with the curved scissors, the base being
afterward thoroughly burned with a stick of nitrate
of silver.
Sebaceous cysts or wens belong in this group,
and appear as small, globular, movable tumors, with
semi-fluid contents, projecting slightly above the
surface, covered with normal or slightly reddened
skin. It is not sufficient to evacuate their contents,
78 MANUAL OF DISEASES OF THE SKIN,
as the sebaceous sac will pretty certainly refill ; they
should be removed entire or enucleated, or when
already opened, the sac can be drawn out with the
forceps, and by a little care can be entirely re-
moved.
The next three varieties of acne are due to im
flammation of the sebaceous glands and surround-
ing tissue, namely, acne simplex^ acne induratay and
acne rosacea. These, although defined and classified
as separate eruptions, are really but varieties of one
and the same affection, and their nature and treat-
ment will be considered together ; they are also
very clojsely associated with the two forms of acne
first described. These five varieties of sebaceous
diseases are constantly seen variously intermingled,
and occasionally all of them may be distinctly made
out on the same individual.
4. Acne simplex. Synonyms: Acne vulgaris;
Acne disseminata ; Acne jiauenilis. This represents
the eruption commonly seen upon the faces of
young people, consisting of scattered papules or
pustules, generally associated with the black points
of acne punctata, or comedones. The disease pre-
sents different degrees of severity in different sub-
jects, from a few, irregularly scattered papules or
pustules, to a very badly marked face. The nature
of the disease is undoubtedly inflammation about
GLANDULAR AFFECTIONS.
79
sebaceous glands, which is generally the result of
hardened sebum retained in them ; often the end of
the sebaceous plug will be seen in the center of an
inflamed point, which subsides as soon as it is ex-
pressed. Quite as often this is not seen externally,
but the cavity of the gland is blocked, and when
the point is freely opened a minute solid mass
escapes with the blood and pus.
5. Acne indurata. This name is given to cases
where the lesions are larger, forming indurated mass-
es, from the size of a small pea even up to that of a
small chestnut, generally of an indolent character,
purplish, and slow to suppurate. While the acutely
tender points of acne simplex have to do, as a rule,
with but a single blocked and inflamed gland, in
acne indurata a series of glands and circumscribed
masses of tissue are involved, and the single ele-
ments partake rather of the characteristics of dermic
abscesses than of the lesions ordinarily recognized
as acne. These are often very indolent, lasting
weeks or months, and giving little or no pain upon
pressure ; as a rule they have not pustular sum-
mits, but require to be lanced before pus is discov-
ered ; when they are opened the contents are found
to be of a grumous character, and sometimes fetid.
6. Acne rosacea. Synonyms : Gutta rosea ; Cou-
perose. The preceding forms of acne are almost al-
80 MANUAL OF DISEASES OF THE SKIN.
ways seen in young persons, whereas this form of
sebaceous disease belongs to older periods of life.
The characteristic location of the eruption is about
the central portion of the face included in a line
dropped from the external angles of th.e eyes to the
chin ; the surface is more or less evenly reddened,
perhaps with some dilated blood-vessels, and with
many or few separate papules or pustules. There is
a heat and burning in the part, with redness and
flushing upon the slightest excitation, also after eat-
ing and drinking, or on entering a hot room.
Acne simplex and indurata may affect the back,
shoulders, and chest, as well as the face, and in some
instances may cause very great scarring ; acne rosa-
cea affects only the face.
Diagnosis, — While it is usually easy to recognize
acne, in certain instances the diagnosis may be diffi-
cult. Acne simplex may resemble a papulo-pustular
syphiloderniy papular eczema^ intpetigOy and also erup-
tions produced by iodine and bromine ; acne indurata
may be mistaken for a tubercular syphiloderm and
furunculus ; and acne rosacea is sometimes difficult
to distinguish from an erythematous and papular
eczema^ a flat tubercular syphiloderm^ and lupus
erythematosus and vulgaris.
Etiology, — The causes of acne are found always in
a lowered vitality, very commonly associated with
constipation and assimilative disorders, and in fe-
GLAXDULAR AFFECTIONS. 8 1
males with sexual disturbances. Acne frequently
improves greatly after marriage, although it is not
rare to find quite severe cases in those who are mar-
ried and have had children.
Treatment, — ^To be successful, the treatment of
acne must embrace both constitutional and local
measures. The constitutional treatment includes
diet, hygiene, and internal medication. Certain ar-
ticles of food almost invariably produce acne in
some individuals ; the articles having this special
tendency are, buckwheat, pastry, hot bread, nuts,
cheese, chocolate, fried substances, and excess of
sweets and starches ; it is generally necessary to cut
off many of the so-called luxuries of life : among
them, wines and beer, also sweet and rich articles of
food. Exercise is all-important, and the proper care
of the skin by bathing and otherwise, must never be
neglected.
There is no one internal remedy which will have
any great and permanent effect upon all cases of
acne ; arsenic will not cure the disease. The meas-
ures to be used are those directed principally to
the restoration of perfect health, and to the removal
of assimilative and nutritive debility often shown by
constipation and dyspepsia, and sexual distubances.
The constipation is to be met by measures which in-
duce healthful activity of the chylopoietic viscera,
and not simply by repeated pugatives or by min-
eral waters; the pill of aloes and iron (Formula
4*
82 MANUAL OF DISEASES OF THE SKIN,
66) will be found of great service, if used care-
fully and intelligently, as described in connection
with eczema. For the dyspepsia, the most varied
measures may be required; a cup of hot water,
taken half an hour before eating, will often be of
the greatest assistance. In a large number of
cases of acne, however, alkalies will be found to
yield the best results, combined with various vege-
table remedies (Formulae 53, 55, 56, 57). In a
certain number of cases, the acne will depend
almost entirely upon pure debility, and powerful
tonics will be called for (Formulae 52, 58, 59). Ar-
senic may act ^as an adjunct, later in the treatment
of the disease ; but it is almost useless to give it
until other elements have been treated. In some
cases uterine disturbances will seem to be the cause
of the continuance of the eruption, but in quite a
share of these instances the removal of the portal
congestion, which may give rise to both the uterine
derangement and the acne, will be all sufficient to
remove the disease.
The local treatment of acne is varied, and ofttimes
the measures which are suitable to one case will
prove harmful or of no avail in another. If stimu-
lation is resorted to, it should be active, sharp, and
perfect, followed by suitable soothing remedies.
In a large share- of the cases, slightly astringent
and soothing lotions will be found of the greatest
service (Formulae 33, 34, 35, 36) ; it is well where
GLANDULAR AFFECTIONS. 83
there is much inflammation, to begin with a very
mild application (Formulae 25, 26), using the sul-
phur preparations when in a less active condition.
The greatest benefit is observed in all the inflam-
matory forms of acne from the local use of very hot
water, conjoined with other treatment. The water
should be employed as hot as the face can bear, ap-
plied by means of a handkerchief; this is dipped in
the water and held for a few moments to the part,
the operation being repeated two or three times,
lasting altogether not more than from three to five
minutes; after this the suitable lotion is applied
and left on all night. The hot water should be used
but once a day, but the lotions or other applications
may be kept freely applied with advantage. Much
gain can also be had by removing the comedo plugs
as described, and freely lancing all the inflamed
points, the bleeding being encouraged by bathing
with tepid water ; a single thorough operation can
accomplish more than a week or two of other local
treatment. Where the disease is indolent, stimula-
tion is required, as with caustic potassa (Formula 16),
followed by a soothing ointment, as of zinc (For-
mulae 83, 84). It is also advantageous to touch the
spots carefully with the acid nitrate of mercury.
DISEASES OF THE SWEAT GLANDS.
Three varieties of disorder of the sweat glands
are recognized; i. As to quantity of secretion;
84 MANUAL OF DISEASES OF THE SKIN.
2. As to quality of secretion ; and, 3d. With reten-
tion of secretion. The quantity of secretion may
be either augmented or diminished ; to the former
state the name of hyperidrosis^ and to the latter
anidrosis is given.
I. Hyperidrosis. Synonyms: Ephidrosis ; Exces^
sive sweating. This condition may be either general
or partial ; general sweating is observed, in certain
cachectic diseases^ as phthisis, with which dermato-
logy has little to do. The local fdrms of sweat-
ing are very annoying at times, and are frequently
presented for treatment ; the most common loca-
tions are the palms and soles, and axillae, although
other parts of the body may be affected. Hyperi-
drosis of the palms is readily recognized : on the
feet, however, the condition may be quite peculiar.
The patient will complain of tenderness of the soles,
with more or less burning, which may increaise to
such an extent that walking and standing become
very painful. The sole and the region of the toes is
seen to be reddish or pink, and to have a soddened
condition ; not much moisture can usually be found,
as it is readily absorbed by the socks and shoes.
Etiology, — The true causes of increased sweating
are not determined, but there is little doubt that it
always indicates debility, and generally of a nervous
form.
Treatment. — This is both internal and local ; in-
GLANDULAR AFFECTIONS, 85
ternal treatment should include every measure cal-
culated to restore nervous and general vigor, es-
pecially including strychnine, quinine, and arsenic.
There is one remedy which has been found to exer-
cise a very marked control upon the secretion of
sweat, but which has to be used with caution ; this
is atropine given internally, and I have seen jj^rth
of a grain at a dose exhibit this power to a striking
degree. After a time, however, it seems to lose its
effect. Sulphuric acid alone, or administered with
quinine is also of very considerable service.
The local treatment consists of astringent reme-
dies, and the local application of belladonna ; for
sweating of the hands a certain amount of benefit
can always be obtained by rubbing half a teaspoon-
ful of the tincture well into the palms. Excessive
sweating of the feet can very commonly be con-
trolled by a thorough and constant application of
the unguentum diachyli (Formulae 94, 95) ; this
should Jdc spread on muslin and worn upon the soles
night and day continuously for a period of at least
from ten days to three weeks, the dressings being
changed once or twice daily. Foot baths of infu-
sion of white oak bark, also powders containing sali-
cylic acid (Formula 79), well rubbed into the soles
and sprinkled in the socks, are of service.
2. Anidrosis. Diminution or arrest of sweating
is indicated by a dry, harsh state of the skin (xero-
86 MANUAL OF DISEASES OF THE SKIN.
derma), with more or less exfoliation. It is found
in certain cachectic diseases, as in chronic nephritis
and cancer, also in ichthyosis, and in general chronic
eczema ; it is likewise sometimes presented for treat-
ment unconnected with any other apparent disturb-
ance of health. No cause is known. The patient
should always be treated in accordance with indica-
tions present, as with tonics, more or less alkalies,
and the best diet and hygiene. Alkaline baths (For-
mulae I, 2, 3), followed by inunction with oils, the
glycerite of starch, or cosmoline (Formula 104), will
generally succeed in relieving the condition, though
very often perfect restoration of the skin to a
healthy condition is almost impossible.
3. Bromidrosis. Synonyms : Osmidrosis; Offen-
sive sweating. This is generally associated with the
first variety of sweat disorder, namely, hyperidrosis ;
although sometimes there will be an unnatural odor
to the perspiration without any apparently great
increase. The entire body may emit an offensive
smell, but more commonly this is confined to cer-
tain locations, more particularly the feet, axillae, and
genital regions. The same measures which are of
value in excessive sweating, are generally of service
in this condition.
4. Chromidrosis. Synonym : Colored sweating.
This is a curious state, which has been described by
GLANDULAR AFFECTIONS. 8/
a number of observers, but it is* exceedingly rare.
Blue and yellow sweat have been recorded, and a
number of instances^ where the sweat appeared red.
This latter condition, however, is in reality due to a
hemorrhage from the sweat glands, and will be de-
scribed under hemorrhages, by the name of hcBmati-
drosis. Nothing is known with regard to the etiol-
ogy, and little with regard to the treatment of
chromidrosis. These cases have usually been ob-
served in nervous and hysterical subjects, generally
females, and there is strong reason to believe that
in some of the instances deception has been prac-
ticed.
5. Dysidrosis. Some ten years ago Dr. Tilbury
Fox described, under this name, what he regarded as
a peculiar disease, which he believed to be due to re-
tention of the sweat within the ducts of the follicles,
giving rise to vesicles. The condition was observed
most frequently upon the hands, and especially upon
their backs and between the fingers. The lesions
were described as minute vesicles, very deeply seated,
and without the surrounding inflammation seen in
eczema and scabies. Appearing when fully devel-
oped like minute grains of boiled sago beneath the
skin, in rare cases this condition continues and in-
creases to such a degree as to form bullae of some
little size ; there is always more or less itching with
the disease. Shortly afterward Mr. Jonathan Hut-
88 MANUAL OF DISEASES OF THE SKIN.
chison described iinder similar terms, an aflfection
to which he gave the name of cheiro-pompholix
(See Pompholix), and one of the cases which was
figured in his atlas was also one of those upon
which Dr. Fox had based his description of dys-
idrosis. Discussion has followed and the subject is
by no means yet definitely settled. In regard to
certain of these cases there is little doubt but that
such a disease as dysidrosis really exists, consisting
of the closure of the sweat follicles and retention of
sweat within them. This condition may be ob-
served on the hands in warm weather, also upon the
tips of the fingers at other times ; it is likewise seen
about the face as a more chronic affair. Those
points upon the face especially may last for a very
considerable length of time ; when punctured they
give exit to a clear, serous, alkaline fluid.
Diagnosis. — ^This is sometimes very difficult to es-
tablish ; the eruption especially resembles vesicular
eczema^ scabies^ 2XiA pompholix.
Treatment, — Dysidrosis seems to be very definitely
connected with nervous depression, and the cases
are always more or less controlled by the internal
administration of arsenic. Other remedies may also
be called for to meet indications, inasmuch as dys-
pepsia and other conditions may possibly give rise
to the eruption. Locally there are no particular in-
dications for treatment other than those called for
by the state present. In some cases a considerable
GLANDULAR AFFECTIONS, 89
amount of inflammation attends the disease, when
soothing and astringent lotions (Formulae 25, 26) are
of real service. In the more chronic cases, the
diachylon ointment (Formulae 94, 95) spread on lint
and kept upon the parts will assist greatly in check-
ing the progress of the disease
6. Sudamina. Synonym : Miliaria. By this term
is indicated an acute affection of the sweat glands,
characterized by retention of secretion, which is seen
especially in connection with certain febrile condi-
tions. It is most characteristically exhibited upon
the abdomen during the course of typhoid fever and
rheumatism, as minute vesicles with a very delicate
covering and perfectly clear contents ; there is
usually no inflammation around them, and they ap-
pear studding the surface as though very small
drops of water had been sprinkled upon it. The
condition is one which calls for little or no treat-
ment.
CHAPTER X.
CLASS III. NEUROSES. — NEUROTIC AFFECTIONS.
There are six aflFections of the skin which are
classed as neurotic, because in them a nerve element
largely predominates ; these are zoster y pruritus^
derviatalgiay hyper cest/iesia cutis, atuBSthesia cutis, and
dystrophia cutis. Additions might be added to this
group of such eruptions as erythema, urticaria, ec-
zema, and others presenting nervous phenomena^
but these are more properly and definitely .arranged
in other classes.
I. Zoster. Synonyms: Herpes zoster ; Zona; Cin-
gulunt ; Shingles. This is an acute inflammatory
affection, characterized by the formation of groups
of vesicles upon an inflamed and very sensitive sur-
face corresponding to a definite nerve tract, accom-
panied by more or less neuralgic suffering. Con-
siderable pain may precede the eruption, and this
is very frequently supposed to be simple neuralgia ;
counter-irritation, as by a mustard plaster, will be
applied to relieve this, and the eruption will appear
shortly after, quite independent, however, of the
skin irritation. Zoster is peculiarly and essentially
90
NEUROTIC AFFECTIONS.
91
a neurosis, as the eruption is found to be confined
to the area of distribution of certain cutaneous
nerves ; and post-mortem examinations have dem-
onstrated most conclusively, in many instances, dis-
ease of the nerves supplied to the part. The nerve
trunk is found reddened and inflamed, and the
posterior or sensory ganglion is congested, softened,
and succulent.
The eruption of zoster is generally confined to
one side of the body ; on the chest (zoster pector-
alis) or abdomen (zoster abdominalis), it will be
found to reach in a band from the middle line pos-
teriorly to the middle line anteriorly. The vesi-
cles are usually in groups, and may run together,
forming large bullae, but generally do not exceed
the size of a small split pea. They are quite pecu-
liar, and different from those seen in any other af-
fection, being flat, and having but slight tendency
to rupture. The surface between them is reddened
and often exquisitely painful to the touch, some-
times presenting papules which have not yet devel-
oped into vesicles. When the nerve lesion is seated
in the lowest portion of the spinal axis, the eruption
will. occupy one or the other lower extremity (zoster
femoralis). When the nerve inflammation is seated
higher up, near the neck, the band of lesions will
extend down the arm (zoster brachialis), and may
even reach to the tips of some of the fingers. When
still higher up in the cerebro-spinal axis, the erup-
92
MANUAL OF DISEASES OF THE SKIN.
tion will be seated on the head, extending behind
the ear (zoster coUaris), or upon the occiput ; occa-
sionally the Gasserian ganglion is affected, and the
eruption is distributed over one or more branches
of the tri-facial nerve. The supra-orbital branch
is most commonly affected, and the eruption then
extends upon one side of the forehead, reaching
into the hair (zoster ophthalmicus). Sometimes
there are groups of vesicles upon the side of the
nose or cheek; very rarely the inferior maxillary
branch is involved, and the lesion is distributed
over the chin.
The peculiarity of the eruption of zoster, which
is pathognomic, is that it is confined to one side or
half of the body. Popular tradition says that if the
eruption extend so as to reach around the entire
trunk, the disease proves fatal : the reason for this
superstition rests on the fact that ordinarily the
eruption cannot thus extend because it occupies
only well-defined nerve tracts, which extend only to
the median line on either side. In very rare cases
there is a simultaneous occurrence of zoster in two
regions, and two distinct eruptions may sometimes
be observed on the same side of the body, or on
opposite sides ; if by chance these should occur at
the same level, the body might be encircled as has
been observed a number of times. As a rule,
herpes zoster occurs but once during life, but
cases have been recorded where it has recurred, in
NEUROTIC AFFECTIONS,
93
one instance, as often as nine times in the same in-
dividual.
Etiology, — The immediate exciting cause of zoster
is probably exposure to cold, but there seems to be
some reason to believe that there is a deeper causa-
tion, which at times renders the disease almost an
epidemic. Certain it is that numbers of cases will
often be observed in close succession or at the same
time, and then a considerable interval may elapse
before other cases are met with. As previously
stated, the skin lesions are the direct result of nerve
inflammation, involving the posterior or sensory root
of the spinal nerves ; they have also been observed
as a result of injury of nerve trunks by disease or
otherwise.
Diagnosis. — The markedly one-sided character of
the eruption, the pain, the hyperaethesia of the re-
gion, and the flat, grouped vesicles are quite suffi-
cient to distinguish this from all other eruptions.
Treatment, — Zoster is a self limited affection,
the eruption tending to disappear within a week
or two weeks. Treatment, however, may be of
considerable benefit in shortening the duration of
the eruption and lessening the distress from it. In-
ternally, phosphide of zinc with nux vomica (For-
mula 71) given as early as possible, and repeated
every three hours, diminishes the pain and appears
to shorten the attack. The internal use of the ci-
trate of iron and quinia in large doses seems also to
94
MANUAL OF DISEASES OF THE SKIN.
be of service. Locally, the greatest relief is ob-
tained by the application of a muslin baad, thor-
oughly dusted with starch, and sewed firmly around
the affected portion of the body, the diseased sur-
face being first dusted also with powdered starch.
This muslin is applied to the part in such a manner
as to make a tight covering over which the clothing
plays, and is left untouched until the eruption has
disappeared. The comfort afforded by the protec-
tion from friction which this gives is very great, and
ordinarily no other local treatment will be required ;
flexible collodion, containing a little morphine,
painted over the part, also makes a comfortable
dressing. If the pain is sharp, considerable benefit
may be experienced from the use of the galvanic
current, the negative pole being applied with a
moist electrode over the affected surface, and the
positive on the spinal column ; a mild current, from
four to eight cells of a battery of ordinary strength,
is all that is required. In some cases electricity will
be required for a period after the disappearance of
the eruption, to combat the excessive neuralgic pain
which remains.
2. Pruritus. Itching occurs as a symptom of
many diseases of the skin, and may exist as an in-
dependent affection either confined to definite areas,
or affecting the entire surface. It is in the latter
sense that the term pruritus is here employed, to in-
NE URO TIC AFFECTIONS. 95
dicate a functional disturbance in the sensory nerves,
exhibited alone as itching, without any apparent
changes in the skin except those caused by scratch-
ing, or by the means employed to give relief.
Pruritus hiemalis.— This name is given to a
form of itching of the skin which occurs principally
in winter ; generally beginning in the autumn, and
increasing with the cold, it continues until the ad-
vent of warm weather. It may return year by year,
and sometimes is the occasion of the severest suffer-
ing, the pruritus being generally aggravated to-
ward night. The chief places of itching are the ex-
tensor aspects of the arms, the inner surfaces of the
thighs, and the calves of the legs ; in a case which
has lasted some time, numerous scratch marks will
be seen.
Pruritus senilis is the name given to the tend-
ency to itch which exists upon the senile skin, and
which is dependent in a measure upon the atrophy
taking place in the structure of the skin in elderly
persons.
Pruritus vulvae. — This will cause the patient
to rub and scratch the parts violently in efforts for
relief, without seeming to reach the seat of difficulty ;
often, on examination, nothing will be seen but a
chafed and dry surface, the result of rubbing.
Pruritus scroti and pruritus ani may also
occur unconnected with other diseases, and give
very great distress, no skin lesions being presented.
^ . MANUAL OF DISEASES OF THE SKIN.
While, however, itching occurs idiopathically in the
region of the anus and genitals, it is more com-
monly found to be only a sign of a more or less
slightly developed eczema, which may have existed
unrecognized for years.
Diagnosis, — Considerable care should be exercised
in differentiating pruritus as a disease from pruri-
tus as a symptom : itching is a feature of very many
diseases, and when lesions on the skin are seen, other
than those caused by scratching, their real nature
should be determined accurately ; itching may occur
as a symptom of eczemay lichen^ phthiriasis, prurigo^
psoriasis f , scabies ^ seborrhcea, syphilis f, tinea cruris^
(eczema marginatum), and urticaria. Prurigo is re-
cognized as a distinct, papular disease, entirely sep-
arate from pruritus.
Etiology, — No one cause can be assigned for pruri-
tus ; it is a functional affection due very frequently
to other elements than those existing in the part it-
self. Pruritus of the vulva is often associated with
uterine disease, or with irritating vaginal secretions.
Pruritus of the anus may arise from intestinal
worms, and, together with pruritus of the scrotum,
is often dependent upon oxaluria. The most careful
investigation should therefore be made, and every
possible means of correcting all aberrations from
health employed.
Treatment. — This must vary with the individual
and the case. General itching is often benefited by
NEUROTIC AFFECTIONS.
97
mercurial cathartics (Formula 65), followed by nitric
acid in full doses ; quinine will be of much service
when in malarial subjects. Gelsemium internally, as
mentioned under eczema, gives relief, and chloral
and bromide of potassium may be required to induce
sleep. Diet seems to exercise some influence over
pruritus, and all articles which " heat the system "
will pretty certainly aggravate the sufferings of the
patient. Alcoholic and fermented liquors, also
spices and hot drinks all increase the itching for the
time, and probably have more or less influence in
prolonging the trouble ; tea, when taken in excess,
may act prejudicially. Harsh underclothing aids in
keeping up the irritation, as also the excessive use
of friction to the skin, as by flesh brushes ; in a
number of instances I have observed that those suf-
fering from general pruritus have previously in-
dulged in Turkish baths to excess.
Locally great comfort is experienced in all forms
of pruritus from alkaline baths (Formulae i, 2, 3),
followed by the application of carbolic acid in
ointment (Formula 104). Sponging the surface with
carbolic acid lotions with glycerine (Formula 44), or
with the liquor picis alkalinus (Formula 42), diluted
from ten to twenty times, also lotions with acetic
acid and alcohol, give much relief. Electricity, both
the direct and induced current, is often of great ser-
vice.
In pruritus of the vulva very many local applica-
q8 manual of diseases of the skin.
tions will be found of more or less service, and
again many may fail utterly. Vaginal injections
with carbolic acid, half a drachm or more to the
pint of tepid water, are frequently of great value ;
likewise lotions containing borax, morphia, bella-
dona, aconite, conium, and hydrocyanic acid (For-
mulae 27, 32, 43). An ointment composed of cam-
phor and chloral also gives relief in many instances,
likewise ointments containing tar (Formulae 105,
106).
Care must be exercised in attempting to relieve
the itching not to excite inflammation of the skin ;
it not infrequently happens that stronger and
stronger agents are employed, until an artificial
eruption is excited which is both distressing and
delays the proper treatment. Many of the measures
of service in eczema are equally applicable in pru-
ritus.
3. Dermatalgia. Pain confined to the skin is a
rare affection, but is occasionally met with. The
skin is generally sensitive to light pressure, but the
positive neuralgic pain, which may last or may be
quite transient, is sometimes relieved on deep, firm
pressure; no visible signs of disease are noticed
externally. Very little is known with regard to
its causation, and little with regard to its treat-
ment. Like other neuralgias, it indicates a lowered
nerve condition and calls for powerful nerve tonics
NEUROTIC AFFECTIONS.
99
and arsenic ; locally, galvanism gives considerable
relief.
4. Hyperesthesia cutis. Excessive sensibility
of the skin is a condition seen in hysterical and
nervous patients, and is also an accompaniment of
certain diseases of the brain and spinal cord. The
patient complains of very considerable pain or dis-
tress from even slight contact with the skin, of the
air, bed clothes, etc. The condition is to be treated
upon general principles.
5. Anaesthesia cutis. Diminished or absent
sensibility may exist in the skin, either generally or
as a local manifestation. It commonly has connec-
tion with internal causes, and is observed during
the occurrence of leprosy, and also not un frequently
during the eruptive period of syphilis, as analgesia
or loss of sensibility to pain; when it exists in
syphilis a pin may be thrust through a fold of
skin without causing pain. As a local manifestation
it occurs as the result of injuries or diseases of cer-
tain nerves or nerve centers.
6. Dystrophia cutis. This term is employed to
designate certain changes which occur upon the
skin as trophic disturbances, due to disease or in-
jury of certain nerve trunks. There have been quite
a variety of lesions described as thus dependent, a
number of them having been observed during our
late war in connection with gunshot and other
IC» MANUAL OF DISEASES OF THE SKIN.
wounds of nerves. The most commonly known
form is the erythematous state or ^^ glossy skin**
seen after injuries of nerves, whereby a part, as,
one or more fingers, will become red, glossy, and
shrunken at their ends, with an atrophic condition
of the nails, as a result of injury of a nerve trunk in
the arm. In certain cases where the nerve injury
has been severe and prolonged, vesicles have de-
veloped, and in certain other instances distinct gan-
grene of the skin has resulted from profound nerve
injury.
No particular line of treatment can be marked
out for these cases, as this must be conducted on
* general principles, and little can, as a rule, be done
to modify the skin lesions present.
CHAPTER XI.
CLASS rV. EXSUDATIONES. — EXUDATIVE OR IN-
FLAMMATORY AFFECTIONS.
This great class, which includes a large share of
the diseases of the skin ordinarily met with, has
two general subdivisions : (A) Those affections
which are induced by contagion or infection ; and
(B), those of internal or local origin. Eleven differ-
ent diseases are met with in the first, and twenty-
four in the second group.
The first group embraces those which have gene-
rally been known as the exanthemata, such as
measles, scarlet fever, and small pox, together with
certain others whose positions will be defined later.
Some of these will be very briefly alluded to, inas-
much as they belong more properly to general medi-
cine than to dermatology ;. but they are all intro-
duced here because they are at times of very great
interest from a diagnostic point of view. Syphilis
appears in this group for reasons which will be ex-
plained later.
I. Rubeola. Synonyms: Measles; Morbilli;
Rougeole ; Maseru. Measles is an acute, infectious dis-
lOI
102 MANUAL OF DISEASES OF THE SKIN.
ease, exhibiting inflammatory or febrile phenomena,
accompanied by symptoms of mucous irritation,
and the appearance upon the body of a maculo-
papular eruption. The eruption of measles is of a
mottled character, consisting of patches of a dull
red or raspberry color, showing considerable ten-
dency to assume crescentic shapes.
In from one to two weeks after exposure there
occur languor, back-ache, running from the nose,
sneezing, and coughing, with congested eyes. After
about four days of this, the eruption appears, first
upon the forehead, then upon the cheeks and neck,
and so on down, until by the end of the third or the
fourth day it has covered the body, and is fading
from the hands. By the end of the fourth day of
its completion, or the eighth day of its appearance,
all traces are generally gone except a moderate
scaling.
Diagnosis. — The diagnosis of measles is usually
not a difficult one, as the general and catarrhal
symptoms point to its true character. In certain
cases, however, it may resemble other eruptions,
namely, scatlatinay roseola^ rotheln (or German
measles), and the erythematous syphilide^ also possi-
bly small poXy the eruption from copaiba^ and that
from quinine^ and finally certain cases of scattered
erythema^ and superficial erythematous eczema. The
eruption which is sometimes called black measles
is undoubtedly, in most if not all cases, haemor-
INFLAMMATORY AFFECTIONS. 103
rhagic small pox, under which name it will be de-
scribed.
Treatment, — ^The patient should be put to bed, and
kept in a warm and even temperature until some
time after the complete disappearance of the erup-
tion. The diet should be light and unstimulating ;
broth, milk, and warm drinks should be given at
first until the eruption is fading. Little or no inter-
nal treatment is necessary, although it may be re-
quired to meet complications. There is little doubt
but that inunction, or greasing the surface, is of
much benefit, both in measles and in scarlet fever, and
should be generally practiced ; it gives great com-
fort to the patient, reduces the fever, and diminishes
the danger of communicating the disease. It is
very readily accomplished with cosmoline or with
almond oil. A good method, common among many,
is to soak a piece of fat bacon in water, in order to
remove the salt, arid then placing it in the oven, and
allowing it to melt a little, to rub it well over the
body. This may be repeated night and morning or
oftener.
2. Rotheln. Synonyms: German measles ; Epi-
demic roseola. This name is applied to an acute, in-
fectious disease, exhibiting hyperaemic, red blotches,
often very closely resembling those of measles, but
less sharply and clearly defined, without the ten-
dency to assume the cresentic shape ; the eruption
is also more irregular in its course and development
104 MANUAL OF DISEASES OF THE SKIN.
than that of true measles, and is not accompanied
by the coryza and the indications of mucous irrita-
tion observed in the former, though it is often asso-
ciated with some throat symptoms. There is but
little constitutional disturbance, and patients are
often up and around during its entire continuance.
The rash more often resembles that of scarlatina
than that of measles ; it may be, however, of much
shorter duration than either of these affections, and
in light cases disappears within two or three days
after its first manifestation. The eruption is liable
to be confounded with the same as were mentioned
in connection with measles.
The prognosis is always favorable, and generally
no treatment whatever is required. The disease is
supposed to be moderately contagious ; it certainly
very frequently appears as a mild epidemic, and
that more frequently during a time when measles
or scarlatina are prevalent.
3. Scarlatina. Scarlet fever is a far more seri-
ous disease ,than either of the two preceding, and
occasionally proves terribly fatal. The period of
incubation is not definitely fixed, and may vary
between one or two days and a week, or a little
more ; the sickness usually commences with more
or less of a chill, often with vomiting, headache,
sore throat, and general prostration. The eruption
appears on the second day of the fever, first upon
INFLAMMA TOR Y AFFECTIONS, 105
the face and then spreads rapidly down the chest
and reaches the lower extremities on about the
third day ; shortly after this it is at its height, and
by the fifth or sixth day begins to decline ; by the
ninth or tenth day desquamation is well established
and proceeds for a week or more. The rash has a
peculiar scarlet color, whence the name of the dis-
ease ; in the beginning it is punctate, but when at
all general it forms more or less of an evenly red-
dened surface, hot and tens.e. The other symptoms
always form a striking portion of the disease, and
may prove very serious, the sore throat being a
prominent and often dangerous feature. The
tongue is coated in the middle, but red at the end,
and covered with prominent papillae ; the fever runs
high, and the sufferings of the patient are generally
very great.
Diagnosis, — ^This is usually not very difficult if the
entire history of the patient, and the character and
course of the eruption, are taken into consideration.
Certain cases may resemble measles, and the erup-
tions mentioned in connection with that disease.
There is also a punctate form of erythema which
closely resembles the eruption of scarlatina, but is
unaccompanied by the constitutional symptoms ; it
is more uncertain in its distribution, and does not
pursue the regular course followed by scarlatina,
but may desquamate and considerably resemble
the rash of scarlatina in this respect; it is very
I06 MANUAL OF DISEASES OF THE SKIN.
apt to appear most markedly on the wrists and
abdomen.
Prognosis. — This is always doubtful. Cases vary
greatly in their severity ; some are so moderate as
to hardly seem to require the patient to take the
bed, while others are fatal at the outset ; others still
are fatal after a long continuance of the disease.
After the eruption has entirely disappeared the
dangers are by no means past, for the sequelae of
this affection are among the most serious known.
The kidneys are almost always affected to a greater
or less degree, and if care be not taken the founda-
tion of serious renal disease may then be laid ; the
dangers in this respect are peculiarly great during
the period of desquamation. Other sequelae such
as ear disease, paralysis, etc., may also give great
trouble.
Treatment. — The proper and complete treatment
of scarlatina cannot be here discussed. Mention,
however, may be made of the very great value of
inunction practiced several times daily, as described
under measles, both as a means of modifying the
fever, giving comfort to the patient, and of protect-
ing others from infection. The greatest care must
be exercised to prevent the spread of the contagion
of scarlatina ; disinfection cannot be too complete,
and the patient should be kept from mingling with
others for at least a month after convalescence.
INFLAMMATORY AFFECTIONS.
107
4. Variola. Small-pox is an acute infectious dis-
ease characterized by a pustular inflammation of
both the cutaneous and mucous surfaces. The
period of incubation varies very greatly, different
writers placing it at from six to twenty days. The
patient then feels languor and lassitude, with shiv-
ering, pains in the back, limbs, and head ; there is
often nausea and vomiting, constipation and general
distress ; the pain in the back may be very great.
After about two days of these symptoms small
red points appear, first upon the forehead and
about the mouth, then upon the rest of the face ;
this soon proceeds to the neck and arms, then down
the trunk to the lower extremities, and the entire
body may be more or less affected by the end of
twenty-four or forty-eight hours. These little
points, which are diffused, small, and red, soon
become conical and shotty ; and by the next day a
minute vesicular point may generally be observed
upon them. Within the next two days they en-
large, become indented or umbilicated, and their
contents, which are at first transparent, become
whitish and milky. By the sixth or seventh day
the contents appear as pus, and the vesicles become
of a darker color and begin to show signs of drying,
which by the seventh or eighth day is quite appa-
rent. As the eruption appears, the febrile symp-
toms lessen and the patient may be comparatively
comfortable when the eruption is in full vigor. By
I08 MANUAL OF DISEASES OF THE SKIN.
the eighth day the eruption has attained its height
on the parts first affected, namely, about the face,
and is less and less marked toward the toes. Thus
many phases of the eruption are present at the same
time.
About the period when the eruption has at-
tained its height, the secondary or suppurative
fever occurs, and continues several days, until
many of the pustules burst, or dry into scabs and
crusts. The entire process of the formation and
separation of the crusts may not be completed be-
fore the twentieth day or even later.
There are various forms or varieties of small pox
mentioned, which it is not necessary to dwell partic-
ularly upon. When the separate pustules occur
thickly together, a large, extended surface may be
involved in one mass of inflammation, and what is
known as confluent small pox results. When small
pox appears in those who have undergone vaccina-
tion, it is generally in a greatly modified variety,
and is hence named variola modificata or varioloid.
In certain cases the disease assumes a terrific form
known as variola maligna^ or hemorrhagic small pox ^
which often passes under the name of blcu:k measles.
Here the eruption does not exhibit the typical ap-
pearance, but the surface may have a dark, purplish
color from extensive capillary hemorrhages, and
only the greatest care will demonstrate any papules
or vesicles upon it. The course and development of
INFLAMMATORY AFFECTIONS,
109
this form is varied ; but the disease generally proves
fatal ; the intensity of the poison seems to disinte-
grate the blood, it exudes through the capillary ves-
sels everywhere, and hemorrhages from the mucous
membranes in all portions of the body occur, which
are often frightful in character. The patient seldom
survives the fifth day, generally dies by the third,
and the eruption rarely displays any of its ordinary-
features.
Diagnosis. — When the disease is fully developed
it is not difficult to recognize, but in mild, sporadic
cases, and very early in its course, it may readily be
mistaken for other eruptions. The papulo-pustular
syphilodertn frequently resembles it very closely ; it
is also occasionally quite difficult to distinguish be-
tween mild cases of small pox and varicella ; in the
very earliest phases the eruption may resemble
measles y scarlatina , acne, papular eczema^ and some
forms of erythema.
Prognosis, — The prognosis of small pox depends
greatly upon the case, and no brief statement can
be made with regard to it. In milder cases it is al-
most invariably good, while more severe ones not
infrequently prove fatal.
Treatment. — The measures to be employed also
vary very greatly with the case. The disease being
self-limited, no particular remedies are required to
mfeet it, but the patient must be managed according
to the indications occurring from time to time.
no MANUAL OF DISEASES OF THE SKIN.
The most important dermatological point in this
connection is in regard to the possible prevention of
the disfigurements which so often result from the
lesions, the much dreaded " pitting " of small pox.
Various methods and plans have been advocated
from time to time for its prevention, all in the main
having the same end in view. The cause of the
cicatrices which so frequently occur is undoubt-
edly found in the ulcerations which result from
disturbing the pustules during their normal course ;
upon those parts of the body where they are not
interfered with, the scarring is generally slight, if it
occurs at all, so that we can believe that if the pus-
tules were left undisturbed they would oftener run
their course without causing much if any destruction
of skin tissue. The plan, therefore, which secures
protection of the surface from friction and irritation,
and which modifies the inflammatory action, is that
best suited to accomplish this end. For this purpose
the eruption should be kept covered with some
bland application of a mildly astringent character,
calculated to soothe and diminish the congestion of
the surface. This is found in such applications as
vaseline, or better still in a very weak zinc or cala-
mine ointment (Formulae 83, 84, 85) carefully spread
upon the face. If there is itching there is no objec-
tion to the addition of a little tar or carbolic acid to
the ointment, as used for eczema. If greasy appli-
cations are not agreeable a lotion may be used, as
INFLAMMA TOR Y AFFECTIONS. 1 1 1
that of calamine, or others which contain a protect-
ive powder (Formulae 25, 26), which may be allowed
to dry upon the skin ; a small amount of carbolic
acid may be added to this if there is much itching.
It is generally acceded that it is better to exclude
the light ; care must always be taken that the pa-
tient does not pick or scratch off the crusts too soon,
but allow them to take their full time for maturation
and. suppuration. The severe ectrotics which have
been employed have not appeared to yield advan-
tages commensurate with the pain and trouble at-
tending their use, if indeed they have ever succeeded
perfectly.
5. Varicella. Varicella or chicken pox is a mild,
infectious disease, characterized by an eruption of
small, isolated vesicles, often irregularly disposed,
accompanied by a very moderate constitutional dis-
turbance. The period of incubation ranges between
four and seventeen days, and the patient then com-
plains of a little fever and lassitude ; but the consti-
tutional symptoms are generally very insignificant,
and frequently among the poor, children are brought
to the out-patient clinics with varicella. Often the
first sign of disease noted is the appearance of a few
points, which are very quickly converted into small,
quite distinct vesicles, which are remarkably trans-
parent, and with but little surrounding inflamma-
tion.
112 MANUAL OF DISEASES OF THE SKIN
The vesicles, which are always of small size, gen-
erally appear first upon the face, but frequently
attention will be first called to their existence upon
the back and chest. Their appearance here is gen-
erally very conclusive, and the whole back should
always be examined in making the diagnosis. The
small spots of inflammation are seen to be oval in
shape, directed across the body; the congestion is
very superficial, easily disappearing on pressure, and
the whole is surmounted by a minute, clear vesicle,
which soon dries up into a scab. A peculiar feature
of varicella is the successive eruption of the vesicles,
which appear in crops, often a hundred or so new
spots appearing each night for four or five days.
There is usually a considerable amount of itching,
and children, if not prevented, will not infrequently
tear the surface, and often cause considerable scar-
ring, which does not commonly take place where the
eruption is undisturbed. The vesicles may come on
any and all parts of the body, and I have seen a per-
manent scar left on the eyelid by a varicella vesicle.
Diagnosis. — The most common disease with which
varicella is confounded is small pox in its milder
forms ; the regular progress of small pox from above
downwards, compared with the irregular and succes-
sive development of the elements of varicella ; the
superficial character, oblong shape, and quick vesi-
cation of the latter, compared with the inflamma-
tory papule of variola, proceeding to suppuration ;
INFLAMMATORY AFFECTIONS.
"3
together with the general symptoms of small pox,
should suffice to distinguish them. The only other
lesions which could be mistaken for chicken pox are,
an acutely developing papular syphiloderniy which
sometimes vesicates, and a multiform erytheTua^
which may at times present small or large vesicles.
Prognosis, — ^This is invariably good, unless the
patient suffer from some great complication.
Treatment. — ^The mildest laxative and diaphoretic
treatment renders the patient more comfortable,
but no remedies can alter the normal course of the
disease. Some care should be exercised to prevent
those with varicella from scratching the face, and a
mild zinc ointment with a few drops of carbolic acid
in the ounce (Formulae 83, 84) will assist in allay-
ing any irritation and preventing scarring.
6. Vaccinia. This is an acute, infectious, vesicu-
lar disease of the cow, which when communicated
to man (usually in the process of vaccination) pro-
tects from small pox.
The process and results are familiar to all, and it
does not come within the scope of the present writ-
ing to enter on the subject, except from a derma-
tological point of view.
The accidents attending vaccination are numer-
ous, but fortunately they very rarely occur, and in
the vast majority of instances, the process pro-
gresses normally, the sore heals, and little or no
114
MANUAL OF DISEASES OF THE SKIN',
sensible effect is produced upon the patient's life or
health.
Vaccinal syphilis. — Groups of cases have been
observed, and also very rarely separate instances,
which demonstrate that the syphilitic virus has been
and can be conveyed in the process of vaccination ;
but compared to the numbers vaccinated, the cases of
syphilitic inoculation are infinitely rare. The prog-
ress of the disease is the same as when it is commu-
nicated in any other manner, and the same phe-
nomena may be manifested, unless interrupted by
treatment. The vaccination sore may take fairly
and exhibit sufficiently well the characters of vacci-
nia. Within two weeks, however, the site of inser-
tion of the virus hardens, and refuses to heal, and is
transformed into a chancre, which, unless properly
treated, may last several weeks longer, and the evo-
lution of constitutional syphilis follows, as described
elsewhere.
It IS not yet absolutely determined in what
method the syphilitic poison is conveyed ; some
have held that the vaccine lymph, if taken perfectly
clear, cannot transmit syphilis. It is pretty certain
that the intermingling of blood from a syphilitic in
an active stage of the disease, renders the giving of
syphilis probable; whether pus, epithelial debris,
etc., as existing in crusts from vaccine vesicles,
could convey syphilis, is not yet decided. Safety
lies in the use of good animal virus when possible,
INFLAMMA TOR Y AFFECTIONS. \ \ 5
or in the securing of only perfectly clear lymph,
from a healthy vaccinifer. The possibility of coii-
vejdng the disease by other means, as by a fi>ul
lancet, or soiled fingers, etc., must never be forgot-
ten ; it could also be conveyed from mucous patches,
through the saliva, if used to moisten vaccine mat-
ter, which improper practice is sometimes indulged
in.
Vaccinal erysipelas. — Sometimes in addition
to the very considerable amount of inflammation
ivhich may accompany vaccination, an erysipelatous
action will take place, which may spread to very
considerable extent, and prove a troublesome com-
plication. Generally it remains confined to the
arm, but in rare instances may extend to the body.
This is far more apt to occur subsequent to the use
of bovine virus than from perfectly healthy human-
ized Ijonph.
FURUNCULAk INFLAMMATION,— Besides a deep
inflammatory action, which may result from harsh
treatment of vaccination sores, it happens that in
persons of a lymphatic temperament, or in those
much run down, a furuncular state is developed,
which may sometimes be the cause of very great
trouble. At the seat of vaccination there may be
deep seated inflammation, involving the cellular
tissue, and ending in considerable scarring. In cer-
tain rare cases the purulent infection seems to go
further, and cutaneous abscesses occur elsewhere,
1 16 MANUAL OF DISEASES OF THE SKIN.
and this condition seems even to be communicable
to others.
Other than the above mentioned states, disease
cannot be communicated by vaccination. Eczema
may be excited in one predisposed thereto, or even
psoriasis, but they cannot be communicated from
one person to another by this means, nor is it proved
that any disease except syphilis can be thus trans-
ferred.
In regard to the vaccination of persons suffering
from diseases of the skin, it may be stated that if
carefully done, and if the sore is properly guarded
afterwards, little if any harm can result : as a rule it
is not well to vaccinate one suffering acutely from
eczema, but in a sub-acute or chronic stage it may
be successfully practiced without influencing the
disease prejudicially. In those with irritable skins
it is always well to employ the recently introduced
vaccination shields to prevent undue violence being
done to the pock.
CHAPTER XII.
CLASS IV. EXSUDATIONES. — EXUDATIVE OR INFLAM-
MATORY AFFECTIONS — {Continued).
7. Syphilis. Synonyms: Pox; Lues. Syphilis
is a chronic infectious disease, exhibiting a variety
of inflammatory and neoplastic lesions which may
affect every organ of the body, pursuing a more or
less definite course, and capable of transmission by
inheritance ; as a rule it can be acquired but once
during a life time. It is placed here among the dis-
eases induced by infection or contagion, because as
a disease it resembles those previously described, in
its nature and also in many of its earlier lesions
of the skin and mucous membranes ; the later
manifestations are to be looked upon as its se-
quelae.
Syphilis is one of the most important diseases
which affects the human race, and the value of a
quick recognition of its every phase, and a careful,
proper, and thorough treatment cannot be overesti-
mated. Syphilis occurs in an individual in only
one of two ways, by inheritance or by contagion ;
and, although the exact mode and time of acquisi-
tion is sometimes difficult to determine, there can
117
1 18 MANUAL OF DISEASES OF THE SKIN.
be no question but that the disease is always one
and the same, transmitted in one way or the other,
and never developed de novo. The subject of the
acquired disease will be first considered, and inher-
ited syphilis will be treated of subsequently.
The primary lesion of syphilis, or point of entry
of the virus into the system, is called a chancre,
known also as an initial lesion ; it is also spoken of
as a hard sore, from the commonly observed, hard or
parchment-like induration accompanying it, in dis-
tinction from the soft sore or chancroid, which is
a local affection, contagious, but not capable of in-
fecting the system. The period at which the chancre
makes its appearance after inoculation is uncertain,
varying from ten to almost one hundred days ; in
contrast to this stands the chancroid which has an
incubation of but a few days, or even hours.
The initial lesion of syphilis may vary consider-
ably in appearance, according to the location, health
of the patient, amount and activity of the poison
imbibed, etc. ; in its earliest phases it is often diffi-
cult of recognition. The points to be considered
are, the occurrence of a sore, generally single, ten
days or more after connection, its slow development,
comparatively innocent appearance, and scanty and
serous secretion, together with a painless induration
of the lymphatic glands in one or both groins ; these
features will generally contrast strongly with the
early appearance, rapid increase, and rather abun-
INFLAMMA TOR Y AFFECTIONS. \ \ 9
dant and purulent secretion from the result of
chancroidal inoculation ; this latter often exhibits
multiple sores, angry in appearance, and is early
accompanied by painful, general swelling about the
inguinal glands of one side.
By the end of a week induration can generally be
made out in the chancre, and sometimes the indura-
tion is first observed. The abrasion may often be
very insignificant, and occasionally is hardly noticed
by the patient.
Chancres may affect any part of the body, and
extra-genital chancres have been observed on almost
every portion. While the most common mode of ac-
quiring the disease is by impure contact, it is often
communicated in ways which arc quite innocent.
Among the various methods by which the disease has
been accidentally acquired, may be mentioned the
processes of vaccination and circumcision, also that
of tattooing and skin grafting ; it has also been c(;m-
municated by a bite, and in the act of kissing, like-
wise during nursing ; and physicians, nurses, and
midwives have acquired it in the discharge of their
duty. The means of conveying the poison from
one individual to another are almost as numerous as
the objects of common life. It has been passed
from one to another on the glass-blower's pipe, also
by means of smoking pipes and segars ; surgical in-
struments, lead pencils, tooth brushes, drinking and
eating utensils, toys, etc., have all been reported as
120 MANUAL OF DISEASES OF THE SKIN,
the agents by means of which individuals have been
infected.
The important point to remember in connection
with this is, that however or wherever the poison
enters, the result is a chancre, the system is not af-
fected in any gradual or occult manner, but invari-
ably by the direct introduction of the poison at
some particular place, and that at that place a sore
results, which is the first stage of syphilis, the pri-
mary lesion.
The period at which the secondary lesions mani-
fest themselves is somewhat uncertain. After the
appearance of the chancre, a second interval of incu-
bation occurs, during which the sore heals, and tlie
patient may be in apparent health. But very soon
symptoms of lassitude come on, often with consider-
able headache and pains in the limbs, and shortly
the entire surface is found to be covered with a con-
gestive eruption, which may present one of several
forms, macular, papular, or pustular. In conjunction
with this eruption there is a general enlargement of
the lymphatic glands, and more or less sore throat
of a superficial form, and possibly iritis. The pa-
tient is now ushered very completely into what is
known as secondary syphilis.
Macular syphiloderm. — Synonym : Syphilo-
derma erythematosum. This, the wrongly called
syphilitic roseola, is the most common form, and
occurs earliest after infection, often within the first or
INFLAMMATORY AFFECTIONS. 12 1
second month, and occasionally entirely escapes the
attention of the patient. It consists of a thickly set,
slightly marked eruption of congestive blotches, of
irregular shape and size, mostly small, seeming to
be slightly elevated ; the color is of a pinkish red,
giving to the skin a mottled look. In searching for
it the abdomen and back should be examined, and
the eruption becomes more visible after a little ex-
posure to the air.
Diagnosis. — The diagnosis is quite easy when all
points are considered ; the eruptions with which
it might be confounded are rubeolay rotheltiy the
eruptions produced by copaiba and quinitUy also pos-
sibly some rare cases of erythe'kna multiforme and
urticaria, and the parasitic eruption tinea versicolor.
Papular syphiloderm. — Synonyms: Syphilo-
derma papulosum ; Syphilitic lichen f Various forms
of the papular eruption of syphilis are seen ; some-
times it follows directly upon the preceding, oftener
it is that which is first observed. The entire body,
head, and limbs may be the seat of a fine papular
eruption, thickly set, with a moderate tendency to
scale ^after some days' duration. Or, the papules
may be larger, and even of irregular size, some as
large as a split pea, others the size of large pin
heads. In other instances fine papules will be
grouped around a larger one, or the entire eruption
of smaller or larger papules may be arranged more
or less in circular or crescentic form. Still another
122 MANUAL OF DISEASES OF THE SKIN.
variety is seen in the lar^e, flat papular syphilo-
derm, whose elements may even reach the size of a
large finger nail, and become more or less covered
with a light, moderately adherent scale. The color
of the papular eruption of sy'philis is far more pro-
nounced than that of the macular ; and when it has
lasted any length of time, it assumes a deep red,
coppery tint; on disappearing coppery stains are
left, but no scars. The papular eruption very com-
monly affects the palms and soles at the same time.
Diagnosis. — ^This eruption is more frequently con-
founded with psoriasis, it also resembles somewhat
papular eczema, also liclutty lichen planus, and lichen
scrofulosus.
Vesicular svphiloderm.— This is so rare that
it is hardly worth considering; it seldom exists
alone, and possesses no distinctive features.
Bullous SYPHILODERM. — This is also a very rare
manifestation of syphilis, and in the acquired disease
is only seen in broken down subjects. In hereditary
syphilis it is not so uncommon, and is quite often
met with on the palms and soles of infants, as will
be mentioned later.
Pustular syphiloderm. — Synonyms: Syphilo-
derma pustulosum ; Syphilitic impetigo and ecthyma ?
The pustular eruptions of syphilis are usually later
than those just described ; they may follow them
either after or without treatment, or may seem to
be the first manifestations of constitutional syph-
INFLAMMATORY AFFECTIONS,
123
ills. The pustules may be small and pointed, or
flat, and generally crust over very soon ; they are
apt to remain some time, and when gone frequently
leave small, depressed, brownish scars, which dis-
appear slowly. The larger form of the pustular
syphilide sometimes assumes a formidable appear-
ance ; the crusts may become large and heaped up,
constituting what was formerly known as syphilitic
rupia. This leaves considerable scarring, which is
permanent.
Diagnosis. — ^The pustular eruptions of syphilis may
resemble /«y/«&r eczema^ scabies, the eruption from
liccy and that induced by iodide of potassium.
Tubercular syphiloderm. — Synonyms: Syph-
iloderma tuberculosum ; Tubercular syphilide ; Syphi-
litic lupus ? The tubercular syphilitic eruption be-
longs to the later stages of the disease, and is often
spoken of as a tertiary lesion. It consists of one or
many solid formations in the skin, generally about
the size of a split pea, roundish, and of a brown-
ish red color. They are seldom seen in great num-
bers, and never over the whole surface ; they are
usually grouped together, generally forming circles
or segments of circles. Occasionally the disease
will travel over a large surface (serpiginous tubercu-
lar syphilide). Ulceration takes place in the tuber-
cles very readily, and they are often covered with
crusts, though they may also only scale over and
become absorbed without ulceration ; the tubercu-
124
MANUAL OF DISEASES OF THE SKIN,
lar syphilidc almost invariably leaves a permanent
scar.
Diagnosis. — This eruption of syphilis most resem-
bles InpuSj from which it is, however, to be carefully
differentiated ; the designation syphilitic lupus is
wrong, lupus is a disease entirely distinct from
syphilis. Certain cases may also resemble epithelioma
and carcinoma^ also the eruption of leprosy.
Gummy syphiloderm. — Synonyms : Syphilo-
derma gummatosum ; Syphilitic gumma ; Syphiloma ;
Syphilitic lupus ? This is one of the latest manifes-
tations of the poison, and occurs principally in
broken down subjects. It consists generally of a
single mass of moderately firm substance, of vary-
ing size, originating from the sub-cutaneous tissue,
and sooner or later ulcerating through the skin.
Beginning very small, it may remain for weeks
without attracting much attention, but when it
begins to ulcerate the destruction may be deep
and extensive, attacking bones and joints. Gummy
deposits of syphiloma may also form in internal or-
gans, and may destroy life.
Diagnosis. — Cutaneous gummata may be mistaken
in their early stages for fatty or fibrous tumors^
enlarged lymphatic glands^ and carcinoma ; when
ulcerating, they may resemble simple and varicose
ulcers^ also lupus^ and epithelioma.
Pigmentary syphiloderm. — This is an altera-
tion in the coloring of the skin, which is occasion-
INFLAMMATORY AFFECTIONS.
125
ally seen, mainly upon the neck and almost invari-
ably in women ; the reasons for these peculiarities
in the eruption have never been explained. The
skin appears of a darker color, a yellowish brown,
and upon this are seen numerous white spots, sepa-
rate or touching one another, as though a white
surface had been stained and then finger marks had
been made upon it, showing the white beneath.
This pigmentary lesion occurs during the first or
second year of the disease, and is not the result of
previous lesions ; it is quite different from the cop-
pery brown stains left by many syphilitic eruptions.
Diagnosis. — The pigmentation most resembles leu--
codertna ; it is to be also differentiated from tinea
versicolor y and chloasma.
Mucous PATCHES. — Synonyms : Condylomata ;
Plaques muqueuses. These are moist lesions found
upon mucous membranes or upon parts where two
surfaces of skin come in contact and are softened
and macerated, as about the anus and genital region,
beneath the mammae, in the mouth, etc. ; they may
occur at any period of syphilis, but are more com-
mon during the earlier stages. They differ some-
what according to the situation : within the mouth
they are superficial, of a grayish white color, with a
raw appearance, often as though a coarse network had
been stretched over a denuded surface. About the
genitals they are more exuberant, of a reddish color
and raised even to the height of a line above the sur-
126 MANUAL OF DISEASES OF THE SKIN.
rounding skin. The surface of mucous patches gives
off a glairy secretion which is intensely contagious.
Diagnosis, — In the mouth these lesions are to be
differentiated from simple and aphthous stomatitis^
also from the white patches commonly seen in
smokers, the leucoplakia or wrongly called psoriasis
buccalis, and from eczema of the mucous membranes.
In other locations, as about the anus and genital
region, some care must be given to exclude the ordi-
nary vegetations or venereal wartSy which have no
connection with syphilis.
Syphilis of the palms and soles. — Synonyms :
Palmar and plantar syphiloderm : Syphilitic palmar
psoriasis? Psoriasis syphilitica? During the early
stages of syphilis, the palms and soles may be in-
volved in the general eruption, which will here par-
take of the ordinary characters, and need not be
difficult of recognition. But later in the disease,
even as long as twenty years after infection, these
parts may be affected alone and give trouble in
diagnosis. The lesions seen then are papules or
tubercles, which are arranged in groups or circles, or
parts of circles, and the surface is denuded of epider-
mis over them, often causing painful fissures.
Diagnosis, — The lesions in this situation may be
mistaken for ecze7na and psoriasis : the latter should
be excluded at once if well marked psoriasis is not
found elsewhere, as it is probable that it never occurs
on the hands without appearing on other parts at
INFLAMMATORY AFFECTIONS,
127
the same time. The diagnosis from eczema may at
times be very difficult. It is to be remembered,
however, that the lesion of syphilis is always com-
posed of separate papules or tubercles, while the
eruption of eczema spreads peripherally in an even
surface; as a result, the margin of the syphilitic
eruption will be sharply defined and scalloped or
uneven, and the separate elements can always be
made out ; the eruption also is worse at the margin
and with a tendency to clear in the center, exactly
the reverse of what is seen in eczema.
Hereditary syphilis. — When syphilis is in-
herited, the child escapes the primary lesion, and the
poison is in some way instilled into the system with
life ; a child born healthy may, of course, acquire
syphilis while passing through the mother's parts, or
at any time afterwards, as by nursing an infected
wet nurse,' or otherwise; it then has infantileh\xtno\.
hereditary syphilis, and the disease begins with a
chancre.
The mode in which syphilis is communicated to
the offspring has never been accurately determined ;
it may be given directly from the father, although
many have doubted it ; the woman can readily com-
municate the disease to her offspring, or rather, the
child being part of the mother is necessarily affected.
Syphilis is a very common cause of abortions, and,
operating still further back, can cause sterility.
128 MANUAL OF DISEASES OF THE SKIN,
Inherited syphilis may manifest itself during
intra-uterine life, and the child be bom with an
eruption, erythematous or bullous. Or, as is more
commonly the case, the child comes into the world
apparently healthy but soon fails in strength, and
after about three or four weeks exhibits a weazened
" old man appearance," has snuffles, and shortly the
surface to a greater or less extent is seen to be cov-
ered with a maculo-papular eruption, of a dusky red
color. The mouth becomes sore from mucous
patches, which also appear about the anus; the
palms and feet often present bullae. When the
eruption is plentiful the child often sinks and dies
in spite of all treatment ; if there is but a sparing
amount it may improve rapidly under treatment,
and regain apparent health.
If the child survives and recovers from the erup-
tion, it is still liable to the effects of the poison in
the form of bone and eye disease, and even many
years later Tnay have tubercular and ulcerative
lesions of the skin, and exhibit the peculiar teeth,
the front upper incisors being pegged-shaped,
notched from side to side, and thickened.
As stated in the definition, syphilis may affect
any or all of the organs of the body, and it may
even destroy life : the limits and scope of the pres-
ent work forbid entering more fully into the subject.
Treatment, — While mercury may be rightly con-
INFLAMMATORY AFFECTIONS. 129
sidered an antidote for syphilis it is to be used with
discretion, and often is efficacious only in propor-
tion as all other measures are rightly employed with
it. Hygiene is of the greatest importance in syphilis.
Authorities are divided in regard to the propriety
of giving mercury for the primary sore, but no one
who has seen much syphilis can deny that the in-
duration melts away far more rapidly with than
without mercury. For many reasons, however, it is
advantageous to wait until the diagnosis is estab-
lished with certainty, otherwise a non-syphilitic
sore which healed while under mercury might be
wrongly considered an initial lesion. There is little
if any use of cauterizing the chancre lightly, as often
practiced; if attempted at all it should be done
very early and very thoroughly, as with fuming
nitric acid ; about the best local application is the
black-wash (Formula 48), kept freely applied on lint,
renewed several times daily ; dry calomel is also a
good application, and powdered iodoform is recom-
mended by many, but its nauseous -odor is a very
great objection to its use. A valuable method is
by means of the emplastrum mercuriale (Formula
18), spread on linen and wound around the penis.
In the earlier stages of syphilis iodide of potas-
sium is of very little use, and mercury only need be
given. This may be administered in a number of
ways, by the mouth and through the skin. Blue
mass is largely used and should be given just short
130
MANUAL OF DISEASES OF THE SKIN.
of salivation, the teeth being slightly tender, the
action on the bowels being checked by opium if
necessary. Bi-chloride of mercury, in pill or solu-
tion, so that from one-twentieth to one-eighth of a
grain is taken, three times daily, is preferred by
many, while others use the bi-cyanide in the same
doses. The proto- iodide is one of the most valu-
able preparations (Formula 69), and was a favorite
with Ricord.
Through the skin there are three methods of in-
troducing mercury ; by inunction, by vapor baths,
and by hypodermic injection. Inunction is usually
performed with the unguentum hydrargyri U. S. P.,
rubbed alternately into the insides of the thighs
and the sides of the chest, to the amount of
from half a drachm to a drachm of the ointment
once or twice in the twenty-four hours. The stain-
ing from the " blue ointment " may be obviated by
employing the oleate of mercury, in twenty per cent.
solution with an equal quantity of vaseline; the
oleate is rather apt to irritate the skin.
Mercury may also be introduced satisfactorily by
means of mercurial vapor baths ; these may be given
at public establishments, but are also readily admin-
istered at home. The patient sits naked on a chair,
beneath which is placed a lamp having a dish over
it partly filled with boiling water, with a little cup
on it containing half a drachm of calomel, or a
drachm of the black oxide. A couple of blankets
INFLAMMATORY AFFECTIONS.
131
are thrown over the patient, and tucked in tightly
over the chair, and the lamp lighted ; the duration
of the bath should be about half an hour, during
which the patient should perspire freely ; the effect
of the bath may be heightened by opening the
blankets and inhaling a little of the mercurial fumes.
It is well not to dry off the skin, but to get into bed
either still enveloped with the blankets, or with a
flannel night dress.
Hypodermic injections may be of service when
rapid and sure effects are desired ; the corrosive
sublimate is generally used (Formula 108), and may
be employed daily in doses of about one-eighth of a
grain.
In the later stages of syphilis, even six months
after infection, the addition of iodide of potassium,
forming what is known as the " mixed treatment "
undoubtedly hastens the disappearance of the symp-
toms, and contributes much to the patient's well-
being. To be most serviceable the mercury and
iodide of potassium should be combined with iron
and tonic remedies (Formulae 61, 62), and thus com-
bined can be only of service. Syphilis being a dis-
ease tending greatly to debility, a tonic treatment,
both as to diet and hygiene as well as medicine,
should be ever aimed at.
Very late in the disease when gummy tumors
exist, or when serious brain symptoms threaten,
iodide of potassium may be required in much larger
132
MANUAL OF DISEASES OF THE SKIN.
doses, and should be pushed to almost any amount
necessary to cause the symptoms to yield. When
the iodide of potassium cannot be taken, that of
sodium and ammonium may be used, or iodine given
in the compound tincture of iodine, or as iodoform,
or the iodide of starch (Formula 75) may be em-
ployed. But it is never to be forgotten that a little
mercury may be required even very late in the his-
tory of syphilis.
In regard to internal treatment a few general di-
rections may be of service. Mercury if properly
used does not do harm, but good, and all the popu-
lar fears about the drug remaining in the system
and causing subsequent trouble, are wholly ground-
less ; when used as directed, and for syphilis, it is
surely a tonic. It is never necessary really to sali-
vate, and although this accident sometimes hap-
pens, it should be sedulously guarded against. To
this end the mouth and teeth should be kept clean,
and the state of the gums watched; the slightest
tenderness of the teeth on biting should excite sus-
picion. The mercury should then be lessened or
stopped, and chlorate or permanganate of potassa
be used freely as a gargle, and, if necessary, bella-
donna or atropine given internally.
The treatment of syphilis should be continued
long after the disappearance of all symptoms ; best
authorities place the entire duration at two years,
at the least.
INFLAMMA TOR Y AFFECTIONS.
133
Infantile and hereditary syphilis is best treated
by means of inunctions, with mercurial ointment
diluted once or more, rubbed in and worn on the
binder ; tonic treatment should also be used as re-
quired. Gray powder also answers well, and I have
seen excellent results even in small infants from the
"mixed treatment" (Formula 62). Later lesions
of the bones do very well on the syrup of the
iodide of iron.
Little need be said in regard to the local treat-
ment of the eruptions of syphilis. Generally none
is called for ; if any be required, it is generally such
as would be indicated by a similar lesion not due to
syphilis. For obstinate tubercular eruptions the em-
plastrum hydrargyri (Formulae 18, 19) is of service;
scaly eruptions on the hands are much benefited
by the application of the oleate of mercury in five
or ten per cent, solution. Calomel in ointment, half
a drachm or a drachm to the ounce, is often valua-
ble, or ammoniated mercury (Formula 91) ; and
where there is much pain and unhealthy discharge
from ulcerating gummata, powdered iodoform alone
or in ointment, fifteen to forty grains to the ounce.
Is of service ; its pungent odor is a great objection to
its use in private practice. A compound ointment of
mercury, iodine and lead (Formula 103), is valuable
in old palmar syphilis, and even in syphilitic tumors.
8. Pustula maligna. Malignant pustule is the
134
MANUAL OF DISEASES OF THE SKIN.
result of inoculation of the poison from animals
with charbon : inoculation takes place through
abraded surfaces. After a very brief incubation a
small, dark red induration occurs, which soon vesi-
cates, and rapidly becomes a pustule, followed by a
slough. The sore becomes gangrenous, severe con-
stitutional symptoms appear, and death may result
in a few days.
The treatment consists in the destruction of the
inflamed point with powerful escharotics at the ear-
liest possible moment ; the separation of the slough
is to be encouraged by charcoal poultices, and at-
tention is given to sustaining the life powers of the
patient.
9. Equinia. Glanders is a rare affection which
originates from contagion derived from a similar
disease in the horse. In this animal it is character-
ized by inflammation of the nasal cavity, leading to
swelling and ulceration, with a purulent discharge ;
later the lymphatics become involved, and swellings
may appear in various parts, which ulcerate and dis-
charge fetid matter.
In man there is first inflammation about the
wound or scratch where the poison gained entrance,
and lymphatic inflammation accompanied with pros-
tration and rheumatic pains ; soon the nasal cavity
Is inflamed and a bloody purulent secretion oc-
curs ; very shortly a more or less general pustular
INFLAMMATORY AFFECTIONS.
^s
eruption appears, first on the face, somewhat re-
sembling small pox, but in reality being more tuber-
cular, and with a subsequent vesiculation or pustu-
lation, and with a rapid tendency to ulceration.
The prognosis is almost always bad, the disease
frequently proving fatal in about a week.
There is no treatment established other than such
as is indicated by the conditions present. Farcy ap-
pears to be identical in nature with glanders, but a
somewhat different manifestation.
10. Diphtheritis cutis. Under certain circum-
stances the skin may become the seat of diphtheritic
membrane, wherever there has been any abrasion ;
even eczematous surfaces are said to become thus
covered. In very rare instances it is stated that a
vesicular eruption occurs in the disease, and, the
vesicles taking on the membranous formation, may
coalesce, and large surfaces of disease be thus formed.
1 1. Erysipelas. This is an inflammatory disease of
the skin, more commonly of the head and face, at-
tended with fever of greater or lesser severity, gen-
erally commencing with a chill, and accompanied
with considerable prostration. The skin appears
swollen, red, and shiny, and burns and is tender to
the touch ; the eruption may spread very rapidly
until a large portion is involved. In certain cases
the disease travels over much of the surface of the
136 MANUAL OF DISEASES OF THE SKIN.
body, disappearing in one portion as it moves on ;
thus the process may be repeated several times.
This is called erysipelas migrans^ wandering or mi-
gratory erysipelas.
The real cause of erysipelas, the poison, is as yet
unknown ; the disease appears most certainly to be
transmissible by contagion, also through the air, as
when surgical wards of a hospital become infected,
so that every wound is attacked by the disease.
But there seem also to be other cases where the dis-
ease starts idiopathically, without connection with
any previous case.
There are again a certain number of instances
where an erysipelatous eruption appears again and
again on the face, generally on one side, creeping
over the nose, so as to cover the middle portion of
the face in a few days ; there is some malaise and
fever, but the condition is rarely very severe. These
cases are generally observed to be associated with
nasal catarrh, and the process seems to be excited
by lymphatic absorption from ulceration within the
nasal cavity : these I have looked upon as a pseudo-
erysipelas^ and non-contagious.
Diagnosis. — Erysipelas should not be confounded
with any other eruption, when the constitutional
symptoms and the character of the lesions as de-
scribed are taken into consideration. But many cases
of erythematous eczema^ especially on the face and
legs, are often wrongly called " chronic erysipelas,"
INFLAMMA TOR Y AFFECTIONS. \ 37
as also cases of acne rosacea. Herpes zoster was also
formerly confounded with erysipelas, which accounts
for some of the varieties described in older books, as
vesicular and bullous erysipelas : while the inflam-
mation may occasionally result in an indefinite rais-
ing of the epidermis by fluid, this is really very rare.
Erythema is differentiated by the absence of consti-
tutional symptoms, by its more superficial character
and more rapid course, and by the absence of desqua-
mation later.
Treatment, — A sharp purge with compound ca-
thartic pills, followed by very free and oft repeated
doses of the tincture of iron, together with thorough
powdering of the surface with flour will very com-
monly be all that is required.
CHAPTER XIII.
CLASS IV. EXSUDATIONES. — EXUDATIVE OR IN-
FLAMMATORY AFFECTIONS. — {Continued.)
»
Group B, — Of Internal or Local Origin.
This group contains many of the most common
and troublesome diseases of the skin, indeed two-
thirds of the cases ordinarily presented would be
rightly classed here. No attempt at etiology is made
in their arrangement, which is based upon the gross
lesional aspects belonging to each affection. The
nine sub-groups correspond largely to those of Wil-
Ian. Some of the eruptions here placed are of local
origin ; most of them are from internal causes, many
of which are as yet undetermined.
I. ERYTHEMATOUS ERUPTIONS.
Three diseases are found here, roseola^ erythema^
and urticaria^ all characterized by a very superficial,
congestive or slightly inflammatory redness, disap-
pearing momentarily on pressure.
I. Roseola. This is the most superficial of cuta^
neous inflammations, presenting often only a transi-
tory redness, hardly more than a hyperaemia, al-
138
INFLAMMATORY AFFECTIONS,
139
though in some cases the lesions may last several
days. The term has been variously applied by
writers, both to idiopathic rashes, and to those symp-
tomatic of, or belonging to other affections ; thus
we hear o{ roseola variolosa, roseola vaccinia, roseola
cholerica, roseola syphilitica, etc, referring to fugi-
tive congestive eruptions seen* in small pox, vaccinia,
cholera, syphilis, and other diseases.
The term roseola is here used to represent an
idiopathic eruption of rose-colored papules or small
patches, diffused more or less completely over the
whole surface and not connected with any other
disease state. There is generally slight constitu-
^tional disturbance, restlessness, and fever. The
causes are temporary digestive disorders ; it is most
commonly seen in infants. The older designations
of Willan, roseola cestiva, autumnalis, annulata, in-
fantilisj etc., are quite unnecessary.
Diagnosis. — ^This must be made from scarlatina,
measles, rotheln, the erythematous syphilide, and the
eruptions caused by the internal administration of
copaiba, quinine, belladonna, etc.
Treatment. — Little or nothing is required beyond
slight attention to the digestion and action of the
bowels : the condition is very fugitive.
2. Erythema. Three varieties of erythema are
recognized in the classification, erythema simplex^
e. multiforme, and e. nodosum.
140 MANUAL OF DISEASES OF THE SKIN.
Erythema simplex. — This is characterized by
the presence of a patch or patches of evenly reddened
surface, an inch or more in diameter, of various
shapes, a little raised, slightly hot to the touch, and
disappearing momentarily on pressure. The con-
dition is often a transitory affair, lasting a single
day ; sometimes the patches remain longer or recur
repeatedly.
Erythema multiforme. — Polymorphous ery-
thema is a very curious and often puzzling affection.
It includes several conditions, namely : erythema
palpulatufHy e, tuberculatunty e. annulare or margina^
turn, and e. vesiculosum or e, iris.: that is, while the
real lesion is spoken of as an erythema, the process
may be so severe that papules or raised rings are
formed, and the congestion may even be so great
that fluid exudes and vesicles or bullae form. With
all of these, larger erythematous patches of various
shapes are often observed, quite appreciably raised,
hot to the touch, and attended with burning sensa-
tions. The hands and forearms are almost always
most severely affected, also the backs of the feet and
the thighs, the eruption being commonly symmetri-
cal ; the face is usually involved. There is generally
some malaise and more or less of fever. The dis-
ease may be prolonged several weeks, with repeated
accessions of lesions.
Erythema nodosum. — Synonyms : Dermatitis
contusiformis. This is often described as a separate
INFLAMMATORY AFFECTIOXS. 141
disease, distinct from the preceding fonns of en*the-
ma ; but, while it generally presents quite charac-
teristic features of its own. it is also seen in less
marked d^^rees, and in forms which so resemble the
multiform eruption previously described, that there
can be littie doubt as to their relationship.
When characteristically developed, the eruption
is in the form of rounded, more or less elevated,
node-like blotches, which are reddish at first, but
with a tendency soon to become darker colored and
to fade to a yellowish hue as they disappear, within
a week or so of their development. They are far
more commonly developed on the extensor aspects
of the limbs, but may appe^* elsewhere : they are
accompanied with burning pain and are tender on
pressure ; unless injured they never suppurate, and
the affection is usually a mild one, although it may
be prolonged by successive crops of eruption.
Diagnosis, — Erythema simplex may be mistaken
for erysipelas and erythematous eczema. Erythema
multiforme at times resembles urticaria^ papular ec-
zema^ and lichen planus J while the gyrate forms may
be mistaken for ringworm. Erythema nodosum
may be confounded with bruises and cutaneous ab-
scesseSy and, when occurring only over the tibiae, the
swellings resemble syphilitic nodes.
Treatment, — Very little medication is called for
in any of the forms of erythema, except when the
multiform variety is due to nervous depression,
142
MANUAL OF DISEASES OF THE SKIN.
in which case the most careful treatment will be re-
quired. Ordinarily a little stomach and bowel de-
rangement will be discovered, and rhubarb and soda
(Formula 55) will generally correct this ; when more
severe, such a mixture as that of magnesia and iron
(Formula 52) will be found serviceable. Locally
protective powders (Formulae 76, yj, 78, 79), or as-
tringent lotions (Formulae 25, 26), assist in allaying
the cutaneous hyperaemia.
3. Urticaria. Synonyms: Nettle rash; Hives; Cnu
dosis ; Febris urticata ; Gtrvrnxv, Nesselsuckt ; French,
Urticaire, This is characterized by the sudden ap-
pearance of flat, solid, slightly elevated blotches
called wheals, which are irregular in size and shape,
and are either reddish or paler than the normal
skin. The eruption is always accompanied by irri-
tation of a pricking, stinging, or burning character,
which is often worst just before its appearance.
The individual spots generally last but a short time,
from a few hours to a day, and the eruption may be
acute and consist of one or a few outbursts, or it
may be chronic with the continual or frequent re-
production of the wheals. The spots may vanish
as suddenly as they appear, or may subside slowly.
One variety, to be described, leaves a small, solid,
papule in its center. There is usually stomach or
bowel disturbance, a coated tongue, and, if the at-
tack be sudden, a little headache and even fever.
INFLAMMATORY AFFECTIONS,
143
Several forms of urticaria are spoken of.
Acute urticaria.— This generally arises from
acute gastric disturbance, often from irritating in-
gesta, as stale fish, fruit, etc. There is a general
sense of fullness, the entire skin seems hot and
tense, and shortly a greater or less development of
wheals takes place, accompanied by most distress-
ing burning and itching.
Chronic urticaria. — This form is often devel-
oped insidiously; the patient may seem to enjoy
good health, but is tormented with the continual
formation of wheals and irritation of the skin, which
is generally greatest after meals. In certain cases
the urticarial attack will come on at a regular time
of day, or even on alternate days, and is found to de-
pend upon malaria, and to be broken up by efficient
doses of quinine.
Urticaria papulosa. — This is sometimes
wrongly called lichen urticatus^ because of the
lichenoid papules which are left after the subsi-
dence of the wheals. It is most commonly seen in
children, and often the only visible eruption will
be scratched papules with a faint halo around them.
Urticaria tuberosa. — Occasionally the swell-
ings of urticaria assume some size, even to almost
that of half an ^^^ ; this has been called giant urti"
carta, of which I have seen one striking case. When
the urticarial swelling takes place about the face
considerable deformity may be produced ; some-
144
MANUAL OF DISEASES OF THE SKIN.
times the tongue is affected, and the patient may
be almost choked.
Urticaria pigmentosa. — A very curious con-
dition has been described under this name to which
Tilbury Fox once gave the name of xanthelasmoidea,
because of the resemblance of the patches which
are left by it to the yellow patches of xanthelasma.
It is a rare affection, of which I have seen but two
cases in this country and several in England. The
earlier development is in the form of wheals like
ordinary urticaria, which on subsiding leave yellow-
ish, slightly elevated patches, which remain for a
long time ; the cases have been mostly in very young
children, and have given rise to much suffering.
Diagnosis, — Ordinarily urticaria Is easily recog-
nized by the history, and the presence of the
wheals ; it may be mistaken for erythema multi-
forme, and the papular variety often resembles sea-
biesy and also papular eczema.
Prognosis, — An acute attack, as from mushrooms,
stale fish, etc., occurring for the first time, may pass
off readily, or it may be the beginning of a chronic
condition : the chronic form often proves most re-
bellious.
Treatment, — Where an irritating substance may
reasonably be supposed to be yet in the stomach,
an emetic should be given ; almost always a moder-
ate purgative is of service at the beginning of treat-
ment, as calomel and jalap, or blue mass (Formula
INFLAMMATORY AFFECTIONS,
145
65), and the laxative effect may be kept up by mod-
erate use of rhubarb and soda, or magnesia (Formula
55). In more chronic cases the greatest care must
be paid to the diet and hygiene, and every possible
source of ill health removed. * Especially must the
excretion from the bowels and kidneys be cared
for; aloes and iron (Formula 66) aids the former
excellently, and alkaline remedies (Formulae 53, 54,
55) are generally called for; in chronic cases min-
eral acids are of most service.
The local treatment is of considerable impor-
tance ; first, all irritating elements must be removed,
as flannel next the skin. Alkaline baths (Formulae
I, 2, 3) are of great value, with the subsequent ap-
plication of carbolized ointments (Formula 104);
when there is much liver disturbance acid baths
are of most value (Formula 5) ; salt water baths are
also good. Ammonia spirits relieves the itching,
also lotions with acetic acid, and alcohol, also bella-
donna, aconite, and carbolic acid (Formulae 32, 44).
On exposed parts much relief may be obtained by
calamine and zinc lotions (Formulae 25, 26), and
chloral and camphor in powder or ointment (For-
mulae 81, 105) assist greatly.
II. PAPULAR ERUPTIONS.
There are two distinct eruptions whose charac-
teristic lesion is recognized to be a papule, namely,
lichen and prurigo.
7
146 MANUAL OF DISEASES OF THE SKIN.
4. Lichen. Lichen is characterized by the pres-
ence of inflammatory papules, of various sizes and
shapes, though generally small, which preserve their
character to the end, and are accompanied by
marked itching. The name lichen has been vari-
ously used and abused, but at present is applied
with tolerable unanimity to three or perhaps four
conditions which resemble each other, if indeed they
are not closely related ; these eruptions differ so
much that their separate consideration is necessary.
Lichen simplex. — In this the papules are pointed
and hard, with a redness which disappears momen-
tarily on pressure ; they may be scattered, or gath-
ered together in groups, and generally affect the
extensor surfaces of the limbs, and also the body.
The eruption may very readily be confounded with
papular eczema. When grouped together the term
lichen circumscriptus has been used. Lie/ten tropicus
or prickly heat, consists of numerous, minute, bright
red papules, seen commonly in infants; by some
writers it has been regarded as a congestive affec-
tion of the sweat glands ; it is a transitory affair,
and requires little treatment. Lichen agrius is an
old term for aggravated lichen, and the cases to
which this name was given are now generally recog-
nized as eczema. Lichen urticatus is another name
given to urticaria papulosa.
Lichen ruber planus. — The papules in this are
sharply defined, about a line in diameter, flat on the
INFLAMMATORY AFFECTIONS. 147
top, and often slightly depressed in the centre,
of a purplish pink color, and shiny on the surface.
They appear quickly and increase to the size men-
tioned, and will often remain for a very considera-
ble time, resisting treatment; they may run to-
gether, forming patches of some size. They more
commonly appear first on the wrists and backs of
the hands, and the glans penis may be first affected.
There is sometimes great itching, often it is slight.
The lichen ruber of Hebra is thought to be the
same affection ; the papules here are more acumin-
ate, and tend to crowd together ; it is very rare in
this country.
Lichen SCROFULOSUS. — This is in reality lichen
simplex occurring in strumous subjects. It is char-
acterized by reddish or yellowish papules, more or
less grouped, and usually covered with greasy scales;
the skin is commonly inactive and dry; there is
little itching. The eruption is rare in this country,
but has been observed here.
Lichen pilaris is not a true lichen, but an epi-
dermal hypertrophy, and will be described as kera-
tosis pilaris,.
Diagnosis. — ^All the forms of lichen may be mis-
taken ior papular eczema^ and urticaria papulosa^ dXso
for the scattered papular syphiloderm ; great care
will often be necessary in differentiating the erup-
tion from scabies. Lichen planus sometimes resem-
bles guttata psoriasis and erythe^na papulatum.
148 MANUAL OF DISEASES OF THE SKIN.
Prognosis, — Acute lichen generally yields readily,
as also lichen scrofulosus ; lichen planus often proves
obstinate.
Treatment. — ^The treatment of lichen is essentially
that of eczema, and need not be fully detailed.
Both internal and external measures are required ;
alkaline tonics and baths are especially valuable.
S. Prurigo. The distinction must be clearly
made between /r«r//«j ditid prurigo; the former is a
subjective symptom, namely itching, which accom-
panies many eruptions, such as eczema and scabies,
and which may also occur idiopathically, and thus
constitute a disease, as already described. Prurigo
represents a papular eruption of peculiar character,
accompanied also by itching, which is usually in-
tense. The name prurigo has b^en very vaguely
applied, and many older writers thus designate the
eruption caused by lice, which is now known as
phthiriasis or pediculosis. The terms prurigo po-
dicis and prurigo scroti are also met with, used to
designate an itching eruption of the anus and gen-
ital region; most of these cases are eczema, others
simply pruritus ; prurigo does not affect these por-
tions alone. Again, others have applied the term
prurigo to papular urticaria, known also as lichen
urticatus^ already described; and others speak of
prurigo senilis, to indicate the pruritus which at-
tends the changes in the skin incident to old age.
INFLAMMATORY AFFECTIONS.
149
As understood by dermatologists to-day, prurigo
is characterized by the development of numerous,
small, solid papules- deep in the skin, either of the
color of the integument or of a pale red, and at-
tended with great itching. The papules are the
primary lesions, and until torn in scratching exhibit
little or no inflammatory element ; when recent, they
are felt rather than seen, although they project
slightly above the surface. The original seat of
their appearance is the extensor surfaces of the
limbs ; as later features we have their more or less
general development, with harshness and pigmenta-
tion of the skin, enlarged lymphatic glands in the
groins, and exhaustion from constant irritation.
Diagnosis, — This eruption in a severe form, such
as is seen in Vienna, is a very rare one in this coun-
try, although cases oi papular eczema and urticaria
often simulate it very closely. But in a milder form
it is not unfrequently met with among the poor,
especially in children ; here a large portion of the sur-
face is moderately covered with an eruption, papular
in character, with many scratched points, and a dry,
hard surface; true prurigo is said always to begin
in childhood. It resembles very closely urticaria
papulosa^ but papules occur without the existence
of wheals; it also resembles scabies. This milder
form in children corresponds to what has been de-
scribed by the French as strophulus prurigineux.
Prognosis. — ^Always very doubtful.
1 50 MA J^ UAL OF DISEASES OF THE SKIN.
Treatment. — This relates largely to general mea^
sures, looking towards a perfect restoration to
health, which is always lowered in these patients*
Kidney and bowel secretion should be attended to,
and iron, cod-liver oil, the phosphates, etc., are
given. Arsenic has only a moderate effect, but car-
bolic acid internally has been said to control the
itching in a measure. Local treatment is very im-
portant; alkaline baths (Formulae 1,2, 3,4), followed
by a carbolized ointment (Formula 104), are of value.
Also tarry preparations, as the alkaline tar solu-
tion (Formula 42), diluted to a strength sufficient to
give relief ; likewise oil of cade freely applied, pure
or diluted, with cod-liver or linseed oil (Formula 41).
III. VESICULAR ERUPTION.
But one name appears here, namely herpes^ al-
though vesicles are observed in several other dis-
eases, because in this alone the vesicle is a constant
pathognomonic sign. This herpes is distinct from
herpes zoster or zona, which has already been de-
scribed as a neurosis because of the constant path-
ological nerve change found in it.
Herpes. Herpes is an acute inflammatory affec-
tion, whose characteristic lesion is a group or groups
of flattened vesicles, seated on an inflamed and sen-
sitive base. Four varieties are recognized : herpes
febrilis^ k. iris, h. progenitalis, and h. gestationis.
INFLAMMATORY AFFECTIONS,
151
Herpes febrilis. — Synonyms : Herpes facialis;
Herpes labialis. This relates to what are commonly
known as " cold sores '* or " fever blisters," occurring
most frequently about the mouth and lips ; the erup-
tion is also occasionally seen elsewhere on the face,
and inside the mouth, and even about the anus. The
phenomena of burning and a. little pain are familiar
to all ; very little is known of their significance. In
certain rare cases a general eruption of febrile
herpes has been observed, {Jierph g^n&alisd febrile),
attended with considerable malaise, headache and
fever.
Herpes iris. — Synonyms : Herpes circinatus; Hy-
droa ? This is a comparatively rare eruption, and is
closely allied to erythema multiforme, if indeed it is
not to be looked upon as a phase of it. The erup-
tion is characterized by the occurrence of vesicles
in circles around a central one ; sometimes several
develop in succession and a series of concentric
rings of vesicles may be observed. These cases have
sometimes been described as herpes circinatus^ a, term
more commonly applied to ringworm, or tinea tri-
chophytina.
Herpes progenitalis. — Synonym : Herpes pre-
putialis. In this the small groups of flat vesicles
form and rupture very quickly, so that there is
usually presented only a raw surface, which may
readily be mistaken for venereal lesions. The erup-
tion is most apt to appear on the prepuce, but niay
152 MANUAL OF DISEASES OF THE SKIN.
also come on the glans and body of the penis, also
on the female labia. The superficial and grouped
character of the vesicles, abrasions, or ulcerations,
and their sudden appearance after a little burning
pain, should distinguish them. Their course is
short, and in a few days, if uninjured, they crust
over and disappear.
Herpes gestationis. — This curious eruption, as
the name implies, belongs to the pregnant state.
During the later months of gestation, generally after
the seventh, sometimes beginning with the fifth
month, excessive itching begins upon the extremi-
ties, and is soon followed by the development of
grouped papules which soon vesicate and may de-
velop into bullae of some size. The eruption is pro-
longed by successive crops, and lasts until delivery,
when it disappears suddenly, or may be followed by
an outburst three days or so after parturition.
Diagnosis, — ^This should not be difficult. Febrile
herpes may resemble mucous patches ; herpes iris
could only be mistaken for multiform erythema; the
herpetic eruption on the genital regions resembles
venereal sores and also balanitis ; and herpes gesta-
tionis appears WVlq papulo-vesicular eczema.
Prognosis, — ^AU forms of -herpes tend to spontan-
eous recovery; but herpes progeni talis is very apt to
relapse, and is important as affording a point of
entry for syphilitic or chancroidal virus ; " cold sores*'
on th« lips may also receive infection from mucous
INFLAMMATORY AFFECTIONS. 153
patches. Herpes gestationis is very apt to recur
with each succeeding pregnancy.
Treatment, — In most cases little internal treatment
is required, other than a cooling laxative, as citrate
of magnesia or the mineral waters ; in herpes iris a
nervous breakdown may be the cause of the erup-
tion, and in this, as in herpes gestationis, strong nerve
tonics and arsenic are of much service (Formulae 58,
60, 64). Soothing and protective lotions and oint-
ments (Formulae 25, 26, 27, 28, 30, 83, 84, 85,95) are
of value ; tannin in ointment (Formula 87) or lotion
(Formula 22), assists in warding off herpes prepu-
tialis. These raw points should never be cauterized.
In herpes gestationis, in addition to cooling lotions
and ointments, great relief to the itching may be ob-
tained from the liquor picis alkalinus (Formula 42)
diluted ten to twenty times, more or less, followed
by a protective ointment (Formulae 83, 84, 85).
IV. BULLOUS ERUPTIONS.
Three affections are thus classed, namely, hydroUy
pemphigus y zxiA pompholix,
7. Hydroa. The term hydroa is 0/ recent intro-
duction, and its exact use is by no means yet set-
tled. It is employed mainly to represent a class of
cases characterized by the occurrence of bullae of
various sizes, generally small, which can hardly be
grouped with herpes, nor yet with pemphigus ; the
1 54
MANUAL OF DISEASES OF THE SKIN.
eruption is very apt to recur, and is often associated
with the gouty habit. There is room for doubt as
to the propriety of making a separate affection by
this name, as many of the cases thus reported appear
to be related to bullous urticaria^ erythema multi-
forme y herpes iriSy or pemphigus.
The treatment is to be guided by the conditions
present, and is the same as is of value in similar
eruptions.
8. Pemphigus. Pemphigus is essentially an
eruption of bullae, but under certain conditions these
become so altered as to be hardly recognizable,
while in many cases they form a striking and almost
startling feature. Two forms of the disease are re-
cogmz^d, pemphigtis vulgaris znd pemphigus foliaceus.
Pemphigus vulgaris may attack any or all por-
tions of ^he body ; different cases differ very greatly
in their severity and extent. The bullae generally de-
velop rapidly, and often blisters of great size form
in a day ; the contents soon become purulent ; there
is but little inflammation at the base or around
them. In certain cases there is a strong tendency
to ulcerate, and each bleb may become the seat of a
diphtheritic appearing membrane, refusing to heal.
Pemphigus foliaceus. — The appearance exhib-
ited by this eruption, when of any duration, would
hardly suggest the bullous character of the disease.
The surface presents a raw condition, with nu-
INFLAMMATORY AFFECTIONS.
I5S
merous, partially attached, thin sheets of epider-
mis; these have resulted from ruptured bullae, or
from such as have but imperfectly formed. The
course of this eruption is most chronic and rebel-
lious to treatment ; the patient suffers greatly and
finally succumbs.
The term pemphigus pruriginosus has been applied
to the eruption of herpes gestationis ; pemphigus
ntalignuSy cachecticuSy and gangrcenosus relate to
severe cases and lowered vitality.
Diagnosis, — Bullae are observed in a number of
affections, dermatitis, hydroa, erythema multiforme,
urticaria bullosa, erysipelas, pompholixy syphilis, and
sometimes in scabies and lepra ; moreover they arise
in some persons upon very slight local irritation.
But it is to be remembered that the characteristic
lesion of pemphigus is a bulla, whereas in other erup-
tions this is a secondary matter, and other lesions
are present. Pemphigus foliaceus resembles chronic
general eczema and dermatitis exfoliativa.
Prognosis. — This is always grave except in very
mild cases.
Treatment. — There is one remedy which has a
very great power over pemphigus, and that is arsenic ;
given rightly, it is almost a specific. To be effective
it must be administered v/ith a free hand, given
every two or three hours, even in doses suf^cient to
act on the bowels, or to cause its physiological ef-
fects on the eyes and stomach, if the eruption does
156 MANUAL OF DISEASES OF THE SKIN.
not yield sooner ; it is well administered in Vichy
water, and the liquor sodae arseniatis is preferable to
Fowler's solution. Tonics are also called for, and
most nutritious diet. Locally it is to be remem-
bered that the epidermis forms the best covering
for the abraded surface, and therefore if the bullae
are evacuated, as is often necessary to relieve the
tense distress, they should be disturbed as little as
possible. Evaporating lotions, containing powdery
sediments (Formulae 25, 26, 28, 30), give considera-
ble relief ; raw places are to be dressed with sooth-
ing ointments (Formulae 83, 84, 85). When there is
itching the liquor picis alkalinus (Formula 42), diluted
ten or more times, gives great relief, either alone or
added to other lotions.
9. Pompholix. Synonym : Cheiro-pompholix, This
is another eruption of recent definition about
which opinion is still unsettled. It consists of an
eruption upon the hands or feet of deep seated ves-
icles which may develop into bullae ; these often are
seated along the sides and backs of the fingers, and
also occur on the palms and about the ankles. The
appearance of the vesicles and blebs is preceded by-
burning and tingling, and there is little inflamma-
tion attending the process ; there is also very little
tendency for the later development of anything like
eczematous surfaces, but the lesions incline to dry
up shortly. This condition is believed to be differ-
INFLAMMATORY AFFECTIONS. 157
ent from the dysidrosis of Tilbury Fox, which is de-
scribed among diseases of the perspiratory glands.
Diagnosis, — The eruption resembles eczema^ also
dysidrosisy and could be mistaken for scabies.
Prognosis, — There is a strong tendency to recur in
pompholix ; separate attacks yield readily.
Treatment. — ^Arsenic has a very considerable con-
trol over the eruption, and arrests its development ;
strychnia, quinia, and nerve tonics, together with
cod-liver oil and good diet, form the treatment of
most service. In acute attacks a purge and an alka-
line tonic (Formulae 52, 53, 55, 65), give the most
immediate relief. Locally, cooling lotions and mildly
astringent ointments (Formulae 25, 26, 28, 85, Zj^ 94)
serve to relieve the condition.
y. PUSTULAR* ERUPTIONS.
Four distinct diseases are placed here, whose
characteristic lesion is a pustule ; these are sycosis^
impetigo y impetigo contagiosa^ and ecthyma.
10. Sycosis. Synonyms: Sycosis non-parasitica ;
Folliculitis pilorum ; Mentagra; Acne mentagra.
Sycosis is an inflammation around and in the hair fol-
licles , principally of the hairy face, exhibiting pustules,
penetrated each by a hair, accompanied by pain and
burning sensations. This disease must be carefully
differentiated from parasitic sycosis, a form of ring-
worm often known as barber's itch, described under
158 MANUAL OF DISEASES OF THE SKIN.
parasitic diseases as tinea trichophytina barbae. Syco-
sis begins with a deep seated stinging or burning pain,
which is shortly followed by the appearance of red
points which quickly show signs of pus ; later the
inflammation becomes more general, the inter-fol-
licular tissue is involved, and a more evenly red-
dened surface may occur, or even a succulent, tuber-
cular, or fungoid condition. This latter, however,
belongs rather to tinea barbae or the parasitic erup-
tion of hairy parts.
Sycosis being a peri-foUiculitis at first, when pus
appears at the surface it has traversed the follicle ; the
hair is, therefore, found to be detached and easily ex-
tracted from its seat, together with a mass of suc-
culent epithelial cells composing its root-sheaths,
which are infiltrated with pus and serum. Another
sign relating to the deep-seated inflammation is ex-
hibited in a tenderness when the hairs are seized
and pushed in, or lightly drawn on, there being a sore-
ness felt which is quite different from the sensations
belonging to other affections. As a result of the
thorough involvement of the follicle from beneath,
there is not infrequently permanent baldness from
sycosis. The most common region to be attacked
is the sides of the face, also the chin, and upper lip,
but it may also affect any part of the body where
there are large hairs.
Etiology. — This is little understood ; the eruption
often appears quite unconnected with apparent
INFLAMMATORY AFFECTIONS. 159
local cause ; while it is more common in those who
have recently ceased shaving, it is also observed in
those who have never shaved, or not for many
years, and in those who shave daily ; it is not con-
tagious. It is often observed in those exhibiting an
eczematous habit, and commonly seems to be con-
nected with digestive derangements.
Diagnosis. — Sycosis often resembles eczema of
hairy parts very strongly; it may also be con-
founded with tinea barbce, acne, and an eruption of
syphilis.
Prognosis. — This should always be guarded, for
the eruption is apt to be most rebellious.
Treatment. — ^The internal measures are largely
those applicable in eczema, with which the disease
has close affinity; arsenic often seems to have a
controlling influence ; when there is much old thick-
ening, small doses of mercury are of service. The
local treatment is all important. First is the re-
moval of the hair; when pustules are formed the
hairs in them should be extracted, but if much pain
IS caused the hairs should not be taken out, the
object being only to remove loosened hairs and to
permit the escape of pus. Next, the part must, in
most cases, be shaved, and that even every day.
The operation is painful at first, but is soon pre-
ferred by the patient ; when only clipped short the
stiff hairs irritate the deep portions as they are
pressed on in making dressings. The most service-
l6o MANUAL OF DISEASES OF THE SKIN,
able application is the diachylon ointment (For-
mulae 94, 95) spread on the woolly side of lint, and
bound firmly on the part. If this cannot be worn
during the day, it may be wiped off, and an oint-
ment of calamine (Formula 84), spread lightly on,
may be substituted. In the more acute stages it
should be treated like pustular eczema, and when
more chronic, stimulant and absorbent applications
(Formulae 19, 92, 102) may be employed.
II. Impetigo. In former times many cases of
pustular eczema were thus named, but at the pres-
ent time a limited but definite application is made
of the term impetigo, while some observers discard
it entirely. Practically, however, cases are met with
which exhibit pustules which are peculiar, and do
not belong to eczema or to any other recognized con-
dition. The pustules of impetigo are separate, superfi-
cial, and small, with a comparatively insignificant
amount of surrounding inflammatory action ; they
tend to dry into yellow crusts, and, if undisturbed,
heal kindly. This eruption is more frequently seen
among the, poor, and especially among children; it
is most common on the face and hands, but may
affect any portion of the body.
Diagnosis. — The eruption resembles pustular or
impetiginous eczema^ impetigo contagiosa^ scabies, the
lesions accompanying phthiriasis, and pustular jy/-
philis.
INFLAMMATORY AFFECTIONS. i6l
Prognosis, — This is invariably good, if properly
treated, but if neglected the pustules may continue
to be produced for a long time. Unless greatly
irritated and caused to ulcerate, they do not leave
cicatrices.
Treatment, — ^This is essentially that of eczema;
as far as known, the causes are the same. The pro-
cess is inflammatory, and the mildest and the most
soothing local measures must be employed.
12. Impetigo contagiosa. All pus is more or
less inoculable, but in this affection there appears
to be a contagious principle which propagates the
disease, both on the affected person and others ; it
is supposed to be local in its action, the system not
being affected.
The eruption resembles ordinary impetigo, but is
characterized by the superficial nature of the lesions,
which consists of flat vesico-pustules, which rapidly
dry into yellow, friable, brown-paper-like crusts.
They may be isolated or grouped together, and vary
in size from that of a small split pea to that of a
finger nail. Beneath the scabs the surface is moist,
and secretes a little pus, and heals without a scar.
The most common locations are the face and hands,
but any portion may be attacked, it usually spread-
ing from above downwards ; children are most fre-
quently attacked, and sometimes it appears in a
number of cases in a community.
1 62 MANUAL OF DISEASES OF THE SKIN.
Some recent writers have revived the old term
porrigo as a synonym for a pustular eruption of
the scalp; the descriptions of porrigo in older
books are so uncertain, that it is hardly possible to
recognize what was meant. Many diseases, eczema,
phthiriasis, favus, etc., were formerly thus con-
founded.
Etiology. — The cause is supposed by some to be
a vegetable parasite, but the reports in regard to it
differ so much that it is probable that the elements
found in the crusts were accidental.
Diagnosis, — The eruption may be mistaken for
impetigo^ pustular eczema^ hydroa^ varicella^ and a
pustular syphiloderm.
Prognosis. — The eruption is almost self-limited,
running its course in a week or two, if not subjected
to irritation.
Treatment, — Mild laxatives and correctives are of
service, followed by tonics, as it is seen most com-
monly in those in a lowered state of health. Lo-
cally only the mildest ointments are required (For-
mulae 85, 86, 90, 91) ; a very weak white precipitate
ointment answers best, with a little carbolic lotion
(i : 20) if it does not yield.
13. Ecthyma. This is characterized by larger
and deeper pustules than those of the preceding
eruptions, seated upon a more inflamed base, leav-
ing excoriations and temporary scars ; ecthyma dif-
INFLAMMATORY AFFECTIONS. 163
fers from a boil in not having a central core of necrosed
tissue. The pustules may appfear singly or scattered
over much of the body ; they are highly inflamma-
tory, and often cause considerable pain. Lesions
resembling ecthyma appear in syphilis, scabies, and
phthiriasis, but are excluded in the present under-
standing of the eruption. It occurs most commonly
among the poor, and is often the result of neglect
and filth ; scratching often plays a prominent part
in its causation and continuance.
Diagnosis, — Ecthyma resembles the large flat pus-
tular syphilodernty also the lesions seen in scabies and
phthiriasis^ also impetigo^ impetigo contagiosa, and
pustular eczema.
Prognosis, — The state is entirely curable, and there
is no particular tendency to relapse.
Treatment, — Powerful tonic remedies are called
for (Formulae 52, 58, 59), care being also taken of
the emunctories, and that the diet is most nutri-
tious, with the avoidance of stimulants and tobacco.
Locally, soothing and slightly stimulant applications
(Formulae 84, 85, 88) are called for, together with
perfect cleanliness.
CHAPTER XIV.
CLASS IV. EXSUDATIONES. — EXUDATIVE OR INFLAM-
MATORY AFFECTIONS. — {Contintied.)
VI. MULTIFORM ERUPTIONS.
While syphilis, scabies, erythema multiforme, and
perhaps some other eruptions may be polymor-
phous, there are but two whose essential character
is recognized as such in the classification employed ;
these are eczema and dermatitis. These two often
resemble each other very closely, but, as will appear
later, it is very important that they should be dif-
ferentiated ; dermatitis is a local inflammation, en-
tirely due to local irritants, while eczema is a con-
stitutional affection, in which it is often impossible
to trace any local cause for the eruption.
14. Hczema. Synonyms : Salt rheum ; Moist tet-
ter ; Scall; Milk crust. Foremost among all dis-
eases of the skin in importance, both from the num-
bers affected and the distress occasioned, must
always come this ever-varying eruption eczema. It
attacks all classes and conditions, from the cradle
to the grave, appears about equally in both sexes,
164
INFLAMMATORY AFFECTIONS, 165
and comprises nearly one third of all cases that
make up statistics; among the 8,000 cases here
analyzed, eczema occurred 2,679 times, forming
33.99 per cent, in private and 33.24 per cent, in
public practice; probably the real proportion is
nearer one-half of all skin cases, inasmuch as many
have it without seeking relief.
Eczema may be defined as a non-contagious in-
flammatory disease of the skin, of constitutional
origin, acute or chronic in character, manifesting
any or all of the results of inflammation at once or in
succession, and accompanied with burning and itch-
ing. As further details niay be mentioned, the ten-
dency to exude a serous discharge, which stiffens
linen and dries into scales and crusts, and in later
stages an infiltration or thickening of the skin, which
then cracks, producing painful fissures.
It will be seen that eczema is no longer regarded
as a vesicular eruption, as formerly, but that its
manifestations may be most varied. Among one
hundred miscellaneous cases of acute and chronic
eczema, not ten instances, if indeed five, would pre-
sent a single well-marked vesicle when first pre-
sented for treatment. The eruption may remain
erythematous from firstr to last, or it may be papu-
lar ; or vesicles may be repeatedly formed, of the
epidermis may be stripped off very quickly, leaving
a raw, red surface ; or, pustules may be freely de-
veloped, isolated and distinct, or a purulent and dis-
1 66 MANUAL OF DISEASES OF THE SKIN.
charging surface may become covered with a crust ;
or, there may be a thickened and reddened tissue,
more or less covered with thick scales. These phases
and others will be more particularly described later.
It will, however, be impossible to enter into all de-
tails in the present compass ; the manifestations of
the disease are so varied and its elements of causa-
tion so numerous, that even a brief statement of the
subject must occupy many pages.*
The earliest local phenomena in eczema are nerve
and capillary disturbances, and the skin lesions are
to be looked upon as secondary to these ; eczema
has been well spoken of as a catarrh of the skin, the
exudative feature is rarely absent at some period in
its course.
There arc six general symptoms of eczema, which
it is well first to fix firmly in the mind : these are,
I. Itching, pricking, or burning pain; 2. Redness
from congestion ; 3. Papules, vesicles, pustules, or
exudation; 4. Crusting and scaling; 5. Infiltration,
or thickening; 6. Fissures, or cracks.
I. Itching. — The most prominent and constant
symptom in eczema is the itching, which may be
preceded by or give place to a burning pain. In
some locations, and in milder degrees of the com-
« ^^
* For a complete study of the disease, the reader is referred to the
recent work by the writer on ** Eczema and its Management, A prac-
tical treatise based on the study of 2,500 cases of the disease." — 8va
pp. 344. G. P. Putnam's Sons, 1881.
INFLAMMATORY AFFECTIONS. 167
plaint, the itching amounts only to a disagreeable
tickling or pricking, as though a minute insect were
beneath the skin, while in other cases the sensation
is insupportable, and nothing will allay it but the
most severe, deep, and thorough scratching. This
symptom of cutaneous irritation is placed first, be-
cause of its very great importance in causing and
perpetuating the eruption of eczema. Often the
itching will appear to be the only symptom, and the
lesions will develop after scratching; often, again,
some itching will remain after external appearances
have subsided. The itching is always worse when
the parts are exposed to the air.
2. Redness from congestion. — This is an essential
element of the eruption, dependent upon the nature
of the process ; there is almost invariably an eleva-
tion of temperature in the part affected. This red-
ness disappears momentarily on pressure ; after it
has continued some time a yellowish staining re-
mains.
3. Papules^ vesicles^ pustules^ or exudation. — Eczema
being an inflammatory eruption of the catarrhal
type, the exudation takes place in the upper por-
tion of the corium and deeper layers of the rete. If
the process goes no further, there is only erythema-
tous redness, with infiltration or thickening of tissue,
and consequent scaling. When the congestion and
exudation are localized, small solid papules of plas-
tic matter are formed ; if the fluid is more abundant
l68 MANUAL OF DISEASES OF THE SKIN.
and less plastic, it raises the epidermis, and vesicles
result, or pustules when the inflammation is intense
or the vitality lowered ; after the diseased patch has
been bereft of its normal epidermis, the fluid exudes
directly from the surface, and forms the " watering,"
" leeting," or discharging feature belonging to cer-
tain phases of the eruption {eczema madidans). In
some cases this moist stage occurs almost immedi-
ately, the epidermis being shed in a mass.
4. Crusting and scaling. — The exudate of eczema,
which stiffens and stains linen, has a very strong
tendency to dry into crusts and scales. If a dis-
charging surface is left exposed to the air it soon
becomes glazed over and slippery, but dry, in place
of being sticky ; this coating increases from beneath,
and forms scales or crusts of varying thickness. Es-
pecially in infants, as in " milk crust," and upon the
scalp, the masses may be very great ; on removing
them the surface is still moist beneath. Another
condition of scaliness is seen where, without any
previous moist stage, the epidermis is continually
shed from a more or less reddened base, as upon
the- scalp, forming " dandruff," in erythematous
eczema.
5. Infiltration^ or thickening, — This belongs princi-
pally to chronic eczema, but is seen more or less in
every case ; the skin then acquires a hard, leathery
condition, and the increased thickness is recognized
by comparing a fold of diseased integument with
INFLAMMATORY AFFECTIONS, 169
a correspondfng portion of unaffected skin. This
thickening may extend even through the entire co-
rium, and on the legs simulates elephantiasis Ara-
bum.
6. Fissures^ or cracks, — Closely connected with and
dependent upon the last symptom, are the fissures
or cracks, which occur in localities where eczematous
skin is called on to stretch and bend, as on the
knuckles and palms, behind the ears, and elsewhere.
The infiltration of the corium with the products of
inflammation renders the fibres, which should be
very elastic, dense and hard ; and the inflammatory
cells, without cohesive power, scattered among the
fibres, weakens what strength is left. Sometimes
cracks on the ends of the fingers appear to be the
only sign of eczematous disease.
In regard to the names given to the varieties and
forms of eczema, there has been too much confu-
sion, and too great stress is laid upon them ; the
disease is one and the same, although the external
manifestations may vary greatly in different pa-
tients, or even in the same case at different times,
and also according to the locality. The various
names which are found in literature connected with
eczema amount to about one hundred and eighty,
given mostly to express various features in the erup-
tion. They relate to five elements of importance in
the consideration of the disease, namely, i. The
8
170
MANUAL OF DISEASES OF THE SKIN.
stage of the eruption ; 2. The lesion present ; 3.
The location of the eruption ; 4. The condition of
the diseased part ; 5. The cause. A sixth group
may be made of miscellaneous popular and other
names. The actual name employed is of little im-
portance, provided the condition represented be
understood, which is very important both for diag-
nosis and treatment.
The first element is the stage or state of the ex-
isting eruption. Three general divisions may be
here made, namely, into acute, sub-acute, and chronic
eczema; the same case may present each phase,
either at the same time in different loccdities, or at
different times.
Acute eczema is characterized by heat, burning,
and tingling, with redness and oedema, which latter
may be considerable whefe the skin is lax. Shortly
papules and vesicles may appear, or the epidenhis
may be stripped off, leaving a raw, exuding surface ;
or, the process may remain erythematous to the end.
Acute eczema resembles dermatitis very greatly, and
it is often impossible to determine the true charac-
ter at once. If the eruption of acute eczema is
protected, or not further irritated, it tends to sub-
side in a few days, but not completely, for the erup-
tion lingers in a less acute condition, and is apt to
pass into the state next described.
Sub-acute eczema refers to a less inflammatory
condition, with a reddened, itchy surface, and mod-
INFLAMMATORY AFFECTIONS. 171
erate thickening ; the diseased portions may be
moist, tending to become scaly of crusted, or they
are hard and papular, exuding a glairy fluid when
scratched.
Chronic eczema. — This term is applied both to
an eruption of long duration, and to the condition
which usually obtains in old cases ; it is character-
ized by reddened and thickened skin, which itches
furiously, and may desquamate freely, or exude if
scratched, ^yhere there is motion there is a tend-
ency to fissures, which may be very painful. Itching
may be absent in particular cases of chronic eczema.
The lines of demarcation between these three
conditions are not well defined, but the distinction
between the acute inflammatory state and the
chronic, indolent condition must be remembered,
as it is of great importance therapeutically ; in the
former the mildest soothing and astringent applica-
tions are called for, in the latter very severe stimu-
lation may be required.
The second point to be considered is of especial im-
portance diagnostically ; this relates to the anatom-
ical lesion constituting the eruption ; and here we
may have four varieties or conditions of eruption;
eczema erytkematosunty e. papulosuniy e. vesiculosuniy
and e, pustulosum. There are also certain other forms
of eczema which are commonly recognized, as eczema
madidanSy e. squamosum, e, sclerosum, and e. fissum.
172
MANUAL OF DISEASES OF THE SKIN.
Eczema erythematosum is marked from first to
last by the erythema-like character of its lesion:
there is always some infiltration, and the surface has
a harsh, leathery feel, and may be more or less scaly.
Eczema papulosum. — The lesion is here com-
posed of papules, perhaps existing alone, or com-
bined with the former condition, or with occasional
vesicles: many cases which were formerly called
lichen are now recognized to be papular eczema.
Eczema vesiculosum. — Typical vesicular eczema
is comparatively rare, and is generally acute ; more
commonly the vesicles have already broken down
into moist surfaces, or hard patches, when presented
for treatment. Where the epidermis is thick, as on
the palmar surface of the hand and fingers, the vesi-
cles appear as pearly, or boiled-sago-like points ; the
burning and stinging is generally relieved when
vesicles are formed, and often ceases when they dis-
charge.
Eczema pustulosum. — Here pustules take the
place of vesicles, either from the intensity of the in-
flammation, or from the lowered or strumous condi-
tion of the patient. As in vesicular eczema, the separ-
ate elements are often not visible, and what is called
pustular eczema, as seen in " milk crust " in infants,
presents a mass of yellow crusts only ; many cases
which were formerly called impetigo are now recog-
nized as pustular or impetiginous eczema. Pustular
eczema of hairy parts seldom itches much.
INFLAMMATORY AFFECTIONS.
173
These four conditions may be spoken of as pri-
mary lesions of eczema. The following terms are
used to express the pathological states presented
clinically as secondary to the- preceding :
Eczema MADIDANS, or eczema rubrum, results
from a shedding of the epidermis, which may be
either the result of a chronic eczematous process, or
may occur acutely. The denuded and diseased rete
malpighii if irritated may give exit to vast quanti-
ties of serum, or the exudate dries into crusty scales,
upon a moist base : it is often observed typically on
the lower legs.
Eczema squamosum. — This represents a secon-
dary stage following many conditions : there is a
continuous exfoliation of epidermis, generally from
a reddened surface.
■ • Eczema sclerosum. — This relates to the thick-
ening of skin, which sometimes forms almost the sole
feature of the case, as upon the palms and soles, and
finger tips. This form leads to the next :
Eczema fissum, or rimosum presents cracks of
varying size and depth, often very painful : upon the
«nds of the fingers the hardening and fissuring are
<iuite peculiar {eczema fendilU),
The next consideration relates to the location of
The eruption, which maybe of importance diagnosti-
^rally and therapeutically ; in both of these aspects
■^he eruption will now be considered in the various
Xocalities.
174
MANUAL OF DISEASES OF THE SKIN^.
Eczema of the face and scalp. — The face and
scalp are very common seats of the eruption in in-
fants ; at first it appears as an itchy, reddened patch,
with a few papules which are quickly torn, and a
raw, exuding surface results, which soon becomes
covered with crusts, to be again torn off by scratch-
ing ; the surface rapidly increases in size until a large
portion of the face and scalp may be affected. In
adults the eruption commonly assumes the erythe-
matous or papular forms on the face, or a pustular
one upon hairy parts. Erythematous eczema of
the face is very frequently mistaken for erysipelaSy
or erythema. Papular eczema may resemble cu:ne
rosacea^ or a small, grouped papular syphiloderm.
Eczema of the eyelids is sometimes a very trouble-
some affection ; its real nature often passes unrecog-
nized, and it is often regarded as a simple blepharitis,
and proves rebellious until proper constitutional
treatment is instituted. The edges of the lids are
thickened and red, and the lashes glued together.
Eczema of the lips may exist alone, affecting the
skin or the vermillion border; about the mouth
erythematons eczema is very rebellious, owing to the
constant movements of the part. Eczema of the
upper lip is often closely connected with, if not de-
pendent upon, an irritating discharge from the nose.
Eczema of the ears is not uncommon in children,
and behind the ears it is also common in adults ;
chronic eczema of the external auditory canal is
INFLAMMATORY AFFECTIONS.
175
not infrequent, but often unrecognized. When
acutely affected the ears are greatly swollen, hot and
painful ; in a chronic state of eczema they are moist,
thickened, and itchy. Behind the ear the eruption
is very apt to linger for a long time, causing annoy-
ing cracks.
Upon the scalp eczema may be seen in three
phases : pustular^ moist exuding^ and dry scaly. Pus-
tular or impetiginous eczema is common in young
persons, presenting separate pustules, or more often
only crusts, which mat the hair together, with a moist
surface beneath. In moist or exuding eczema of
the scalp the hairs are often stiffened as though from
mucilage ; the condition may remain some period
of time or may pass quickly into the next form.
Squamous or scaly eczema exhibits many phases and
degrees ; often it is but a later stage of other forms,
but it may also appear to be a primary affair, slowly
increasing from a moderate scaling, until what at first
appeared as a mild dandruff becomes annoying in
the extreme, by the itching and the constant shed-
ding of scales.
Diagnosis. — Eczema of the face may be confound-
ed with erythema^ acne rosacea, and erysipelas ; in the
beard, with sycosis and tinea barbce (or parasitis syco-
sis). Upon the lips it may be mistaken for syphilitic
mucous patches, especially at the corners of the
mouth, and for herpes labialis. Pustular eczema
of the scalp may resemble phthiriasis, a pustular
176 MANUAL OF DISEASES OF THE SKIN.
syphiloderniy and crusted favus; scaly eczema of
the scalp resembles seborrhceUy pityriasis y psoriasis^
tinea tonsuransy and old cases of favus.
Treatment, — The treatment of eczema of the face
and scalp should be essentially soothing and astrin-
gent. Tannin ointment (Formula 87), is especially
suited to the scalp ; it should be applied freely and
left on, the part being washed very seldom, with tar
soap, and the ointment reapplied within a" few
minutes after the washing. In using stimulant
lotions subsequently (Formulae 49, 50, 51), to pro-
mote the growth of the hair, care must be taken not
to overstimulate.
The face is a difficult portion to treat, and bears
stimulation poorly. During more acute stages sooth-
ing lotions and ointments (Formulae 25, 26, 28, 83,
84, 85) are required ; later those containing tar are
of service to relieve the itching (Formulae 88, 90).
In eczema of the beard daily shaving with Pear's
transparent soap, and the continuous application of
a calamine or diachylon ointment (Formulae 84, 94,
95) give the best results.
Eczema of the hands and arms. — The erup-
tion is very rebellious on the hands, owing to their
exposure to air and water, the great motion of the
parts, and the difficulty in keeping dressings applied.
Acute eczema may exhibit much inflammation and
considerable oedema : more commonly the eruption is
sub-acute or chronic, with the repeated production of
papules, aad izw. xsrz jsn — rr^^ -vTzni usir^s. _rr
the pahns 1 23d s^iks ixnm: *:rT:^?mfc ^r-fs^trrir l snE-
hard soTiace. r^dSsDsf ir nisi^ tt-jil i. nt^^^i ^-f — .£,
and cracks, ^fcaZjrxsrr cszrfxl. iriciZiurrt:! "vizi: — ^-
ing which iczfr ^»; c5sc:»s5cr;r- Tre ^V.ari.'i'Sif r»t-
as a rule the crrpcSoc cc r7pi£ii= 2= n.iri s'.-.-rly i:±-
fined than that of «7;frT,f.,. -riii: i ft^i^ftrf tf=:ii:crr
The margin erf tie fjpcfliiii tr::^^:- if ritnj-issed
of separate cJcsnests. p20^es :t r-btrile^- ir^i the
cracks are osoalhr tirc^i^ these : --her =12^ th:se hr
eczema mav occur ai^^Trherr iz^f h: zrv directirri
through the thickened sldn.
Eczema of the arms exhibits the fear-res of ec-
zema elsewhere: at the bends of the elr^r-ws it is
apt to present cvenlj' reddened surfaces, verj- itchy,
exuding freely when scratched. Elsewhere the
eruption is usually papular or in patches of red-
dened and moderatelv thickened tissue- A ver\-
scattered papular eruption on the forearms should
always suggest scabies.
Diagnosis. — Eczema of the backs of the hand^
may be mistaken for scabieSy dysidrosisy lichen planus^
and erytlietna papulatum ; on the palms (and soles)
the condition suggests scleroderma^ syphilis^ and ps^y-
riasis.
Treatment. — This varies greatly with the condi-
tion present ; in the more acute form of the crup-
8*
178 MANUAL OF DISEASES OF THE SKII^.
tion, envelopment of the hand and arm in a bag
containing buckwheat flour is most serviceable, also
cooling and astringent lotions and ointments (For-
mulae 25, 26, 28, 30, 83, 84, 85). In sub-acute states
an ointment with tar is of most service (Formulae
88, 89). The chronic forms resist severe stimula-
tion, and blistering will often be required. The
compound tincture of green soap (Formula 39), well
rubbed on with flannel or with a brush, and followed
by a soothing ointment (Formulae 83, 84, 85), will
sometimes accomplish much ; often this aggravates
the trouble, and solutions of caustic potash (For-
mula 16) used similarly, are best borne. Eczema of
the palms is greatly benefited by soaking the part
on the surface of very hot water, for a few min-
utes, and the subsequent application of diachylon
ointment (Formulae 94, 95) spread on lint and bound
firmly on ; in some cases a mercurial application is
of the most service (Formulae 90, 102).
Eczema of the feet and legs. — The eruption
in this locality is obstinate because of the relations
of the parts to the circulatory system : the depend-
ent position taken for so much of the time tends
to produce and keep up congestion, and to hinder
absorption. Upon the lower legs the eruption is
usually seen in the form of what is known as eczema
rubrum or madidans^ exhibiting a red, raw, and
tender surface, exuding greatly if irritated, but also
tending to cover itself with imperfectly formed epi-
JNFLAMHIATORY AFFECTIONS.
179
dermal scales and crusts. The itching is often most
distressing, and there is frequently great soreness
and pain from the accompanying varicose veins.
Ulcers of the leg are frequently associated with
eczema, and are due to the same causes. Eczema
may also appear upon the legs in all the ordinary
forms, and is often seen in scattered or grouped
papular eruptions ; in the popliteal spaces it may be
so severe as to impede walking.
Upon the feet eczema often exhibits vesicles, es-
pecially on the toes ; chronic hard patches also often
occur about the ankles, which are very rebellious.
On the soles the eruption resembles that on the
palms.
Diagnosis. — Eczematous and varicose ulcers may
frequently be confounded with the lesions of syphilis^
as also may the eruption on the soles ; eruptions
about the toes and ankles of children should always
suggest scabies.
Treatment. — The treatment of eczema and ulcers
of the leg has been much simplified since the intro-
duction of the rubber bandage ; it is of almost uni-
versal application. It is applied directly upon the
diseased surface, not too tightly, and worn during
the day ; at night the surface is gently wiped with
a damp cloth and, if necessary, a soothing lotion or
an ointment (Formulae 25, 26, 28, 83, 84, 8$) applied.
The bandage, having been washed on removal and
aired all night, is re-applied while in bed, after the
l80 MANUAL OF DISEASES OF THE SKIH.
dressing for the night has been removed, and any
ointment gently wiped oflf ; as grease and glycerine
soon destroy the bandage. In more chronic cases
the application of caustic potash, or green soap,
alone or in solution or with tar, or the liquor picis
alkalinus in varying strength (Formulae 16, 38, 39,
42) are of service, always to be followed by sooth-
ing applications (Formulae 83, 84, 85). Eczema of
the feet yields well to tar and zinc ointment, and
later to tannin and diachylon ointments (Formulse
87, 88, 94, 95).
Eczema of the anus and genital region is
most intractable if wrongly treated, and very man-
ageable if all is done rightly. Internal treatment is
specially important. The eruption manifests vari-
ous degrees of severity, from a moderately itchy,
soddened condition around the anus, to a severely
raw eczematous surface, involving many square inches
of this region. Many cases formerly cdM^d prurigo
podicis and prurigo scroti are now recognized as ec-
zema. The thickening is very manifest upon the
scrotum, and the element of cracking is very- com-
mon at the anus ; the itching from eczema in this
region may be excruciating.
Diagnosis, — This is generally not difficult ; the
most important lesion to bear in mind is the ring-
worm of this region, tinea trichophytina cruris^ the
so-called eczema marginatumy already described un-
der parasitic diseases. Phthiriasis pubis should be
INFLAMMATORY AFFECTIONS, igj
excluded, also syphilitic lesions , mucous patches and
others ; likewise scabies^ which may give rise to in-
flamed points on the penis.
Treatment. — The internal and dietary treatment
are of the greatest weight, but proper local measures
are also very important, both in regard to the act-
ual measures employed and the method of their use.
The most universally serviceable application in
chronic eczema of this region is the ointment of tar
and zinc (Formula 88) ; this is to be spread thickly
on the woolly side of lint and bound on the parts,
after they have been soaked for a few minutes with
a cloth dipped in very hot water. The dressing is
to be changed twice daily, but the hot water applied
only at bed-time. Other local measures are also of
service, as the calamine lotion (Formula 25), fol-
lowed by the free application of Fuller s earth or
other powders (Formulae 78, 80) ; later, stimulation
with the compound tincture of green soap (Formula
39), followed by a soothing ointment (Formulae 83,
S4, 85). Especial attention must be paid to the con-
dition of the liver, bowels, and kidneys, and sulphur
with cream of tartar taken freely at bedtime is a very
important aid.
Eczema of the trunk and general eczema. —
On the body the eruption may take many phases ;
papular and erythematous eczema are most com-
mon. Beneath the breasts raw, moist surfaces are
apt to form very rapidly, and disappear quite as
1 82 MANUAL OF DISEASES OF THE SJCII/.
quickly under proper measures. The region of the
nipple is sometimes the seat of a condition resem-
bling eczema, to which the name of " Pagefs disease*^
has been recently given, which is in reality an epith-
elial degeneration, frequently ending in cancer. The
umbilicus is occasionally the seat of an obstinate
eczema, and the axillae are sometimes aflfected to a
very troublesome degree ; boils and abscesses are
not uncommon in the latter region, in connection
with eczema.
General eczema of the entire body, head and limbs
is always a serious aflfair, especially in adults, and
indicates profound depression.
Diagnosis. — Eczema of the trunk may be mistaken
ior psoriasis, tinea^ syphilis, zona, ^nA pityriasis rubra.
Eczema of the breast for " Paget*s disease " or
epithelioma^ and scabies ; eczema of the axillae for
ringworm of this region.
Treatment, — The local measures do not diflfer from
those detailed in regard to other portions of the
body; baths (Formulae i, 2, 3) are particularly val-
uable, together with the subsequent free use of an
ointment, or cod-liver or linseed oil, with or without
oil of cade (Formula 41). Laxatives and cooling
alkaline mixtures (Formulae $2, 53), followed by
powerful tonics, are required.
Infantile eczema. — In children under five years
of age the eruption of eczema is exhibited in its
typical form, as far as the acute, raw, and exuding
JNFlAMMATORY AFFECTIONS. 183
aspects are concerned. Beginning with a compara-
tively small amount of papular or erythematous
eruption, the condition may rapidly extend until the
entire scalp and face, also the arms, legs, and much
of the body, is the seat of a diseased cutaneous action.
The surface of exposed parts is generally covered
with crusts, which are frequently torn off, leaving a
bleeding and exuding corium ; covered parts become
more dry, generally adhere to dressings, and when
these are forcibly removed exhibit a reddened, papu-
lar surface, with numerous excoriated points, which
sometimes bleed. The itching of infantile eczema
is generally frightful, and the little sufferers become
frantic in endeavors to get relief.
Treatment. — In the local treatment of infantile
eczema the utmost care must be exercised to avoid
over-stimulation of the affected part ; the measures
must be soothing and astringent, and relief to the
itching is to be looked for rather in carefully di-
rected internal and dietary treatment and proper
protection of the part than in applications which
have any very great anti-pruritic effect. The tar and
zinc ointment (Formula 88) is a safe and valuable
remedy if efficiently applied, spread on lint and
bound on. This should be removed twice daily, and
on exposed surfaces the ointment is reapplied
as often as rubbed off, even many times daily, to
the entire exclusion of the air. Zinc and bismuth
ointments, to which a little camphor or oil of cade
1 84 MANUAL OF DISEASES OF THE SKIN.
may be added (Formulae 8$, 86, 89), are also effi-
cient remedies. Air and water are highly injurious
to cczematous skin ; the first is kept away by means
of the ointment, the other by force of will. Ecze-
matous skin should not be washed ; when this is ab-
solutely necessary the part should be again instantly
and thoroughly protected by ointment, after being
very carefully and rapidly dried, without friction.
Etiology, — Eczema appears to be hereditary in a
comparatively small proportion of cases ; it is not
caused by infection or contagion ; it is not directly
due to malaria, but this element may be of impor-
tance in certain cases ; it is never wholly produced
by external irritative agents without additional in-
ternal conditions ; as far as is known, it is not
caused by any single article of diet ; there is no
one efficient, recognizable cause to which it can be
always attributed.
The causation has to do with two classes of ele-
ments, constitutional and local, though the direct
effect of the latter is often very difficult to trace.
Eczema is eminently a disease of debility ; this may
be of three kinds, assimilative, nutritive, and ner-
vous, or, as more commonly spoken of, gouty, stru-
mous, and neurotic. By far the larger share of pa-
tients with eczema exhibit what has been known as
the gouty state ; that is, a condition of system tend-
ing to gouty development, manifested by the most
INFLAMMATORY AFFECTIONS. 185
varied signs of imperfect assimilation and disinte-
gration. The strumous and nervous states act also
efficiently as predisposing causes of eczema.
Local causes are found in any agencies which irri-
tate and inflame the skin. Many cases seem to de-
pend upon occupation, but it must ever be remem-
bered that these local agents only suffice to cause an
eczema in a very few of the persons exposed to them.
Treatment, — The treatment of eczema is a very
broad subject, reaching deeply into general medi-
cine. Wilson has well said that ** the highest and
best qualities of medical art and science must be put
in practice with foresight and discretion for the
treatment of an eczema." There is no specific for
the disease ; arsenic will not cure it ; the general
state should be most rigidly studied, and remedies
and measures suited thereto. Most eczema patients
are benefited by alkalies, combined with bitter
tonics (Formulae 52, 53, 54, 55), together with judi-
cious regulation of the action of the liver and the
bowels (Formulae 65, 66), although much purgation
often does harm. Tonics are required later (For-
mulae 58, 59, 60, 64), and of these iron, strychnine,
arsenic, and cod-liver oil hold the first place. But
harm can often be done by tonics if the emunctories
do not act properly ; the action of the skin as an
organ must never be forgotten, and alkaline baths
(Formulae i, 2, 3, 104) are of value in most cases of
eczema.
1 86 MANUAL OF DISEASES OF THE SKIN
Diet and hygiene are of the utmost importance ;
the benefits of most careful regulation of the diet
are especially noticeable in infantile eczema, but the
ill results from late errors in diet may be observed
in almost all eczema cases. Sweets and starches
in excess must be avoided, and fats encouraged.
Exercise is all necessary in eczema.
The local treatment has already been detailed in
regard to the eruption in different localities ; a few
words may be added in reference to the principles
governing its use. The main point to be remem-
bered is the irritable nature of eczematous skin, and
the danger of using too severe measures ; it is far
easier to increase the stimulation as required than
to soothe a skin which has been unduly excited. In
ohronic eczema, however, very severe measures, even
scrubbing with a brush and green soap, may be re-
quired, but the subsequent treatment must be
soothing.
Air and water are irritating to skin affected with
eczema ; the effort must be made, therefore, to ex-
clude the former by proper dressing, while the latter
is avoided ; if washing is employed the part is to
be at once protected by a proper dressing. Too fre-
quent washing of an eczematous part will often keep
up the eruption in spite of proper local measures.
The mode of making local applications is often of
great 'importance ; as a rule ointments which are in-
tended to be protective should not be rubbed on the
INFLAMMA TOR ¥ AFFECTIONS. 1 87
diseased part, but spread on the wooly side of lint,
and kept in close apposition to the diseased surface.
But in keeping them applied care must be exercised
that the part be not overheated by warm wrappings.
For more acute eczema, powders are applicable,
and buckwheat flour forms one of the best dressings
possible. Lotions which leave a powder on the skin
(Formulje 25, 26, 27) are also very grateful ; some
skins are irritated by the glycerine often used in
them, which may then be replaced by almond emul-
sion. In sub-acute and chronic conditions powders
and mild lotions are almost useless, and ointments
are called for, soothing, astringent, or stimulating;
these are often combined with stimulating lotions,
especially those containing tar (Formulse 16, 39, 40,
42), the lotion being wiped gently off with a damp
cloth, if it burns.
Many mistakes are often made in endeavoring to
relieve itching, stronger and stronger applications
being employed only to the' aggravation of the erup-
tion, often, indeed, when the mildest remedies will
give relief. Tar and carbolic acid (Formula; 84, 88)
are valuable antipruritics; the liquor picis alkalinus
(Formula 42), diluted ten times or more, is very ser-
viceable, also chloral and camphor, in powder or
ointment (Formulae 81, 105). The tincture of gel-
semium, taken internally in doses of ten drops, re-
peated and increased, is often of great service, but
is not well borne by every one.
1 88 MANUAL OF DISEASES OF THE SKIN.
In the treatment of eczema, more is to be accom-
plished by a careful study of the pa^tient in every
aspect, and the adaptation of remedies suitable to
the condition found, than by the employment of
any special prescription which is supposed to be of
value in the disease, or which is recommended by
ever so high an authority. Attention to details is
of the first importance in eczema, and the good ef-
fect of even the best remedies may be frustrated by
failure in some particular in the management of the
case, while the best local application will often fail
of its end, or even do harm, if wrongly employed.
Dermatitis. This term is employed to designate
inflammation of the skin from causes which are out-
side of the economy ; these may be either local irri-
tants, or articles taken into the system, as food,
drugs, or poisons. The lesions may be most varied,
from the erythematous condition caused by heat or
by mustard, to the large bullae sometimes following
the internal administration of iodide of potassium.
Five varieties of dermatitis are recognized : dermati-
tis caloricUy d, traumatica^ d, gangrcenosay d, venenatay
and d. medicamentosa.
Dermatitis calorica. — The effects of heat and
cold upon the skin vary with the individual and the
degree of caloric ; they exhibit various degrees of
severity, from the milder sunburn and frosting, to a
bullous eruption, or even death of the part.
Dermatitis traumatica. — Mechanical injury
INFLAMMATORY AFFECTIONS, 189
to the skin produces various lesions, from the mild
congestive state caused by friction of the clothing,
to pustular lesions, due to scratching, or abrasions
due to violence. The eruptions produced by lice
and the itch mite are in reality dermatitis, but are
described as phthiriasis and scabies. What is com-
monly known as intertrigo is a local affair due to ir-
ritation of the parts by confined and acrid secre-
tions, with friction.
Dermatitis GANGRiENOSA. — Under certain cir-
cumstances gangrene affects the skin in circum-
scribed patches ; this may appear to occur sponta-
neously, or as the result of injury, or it may follow
lesions of nerves, even those which are far distant.
Dermatitis venenata. — Various external irri-
tants are capable of exciting inflammation of the
skin, often to a very severe degree ; such are mus-
tard, cantharides, mezereon, arnica, thapsia, tartar
emetic, croton oil, and other substances used in med-
icine; also certain dye stuffs, notably those from
aniline and arsenic ; likewise certain plants, es-
pecially the rhus toxicodendron ox poison ivy or oak^
and the rhus venenata, ox poison sumac. These ar-
tificial eruptions at times resemble acute eczema or
erysipelas so closely that an immediate diagnosis is
almost impossible. The eruption from the poison
ivy and sumac is papular or finely vesicular, accom-
panied with much redness and burning, and the dis-
tress from it may be very great. It is usually sym-
190
MANUAL OF DISEASES OF THE SKIN.
metrical, on both hands and arms, and the face is
generally affected, also the male genitals ; it is far
more common in children, and especially in those of
light complexion and hair ; often of a group of chil-
dren of the same or different families the dark ones
will escape, while those of fair skin will be affected.
All these artificial eruptions tend to spontaneous
recovery, if the cause is removed and the parts pro-
tected, but in a certain number, thus disposed,
eczema will result ; in some cases the eruption from
poison ivy and sumac will return very readily on
each exposure, and instances occur where even rid-
ing by the plant when in flower will suffice to excite
a fresh attack.
Dermatitis medicamentosa. — This term relates
to the eruptions produced upon the skin by the in-
gestion of certain drugs : facts in regard to seven-
teen drugs have been collected by Van Harlingen,*
to which full study, with a complete bibliography,
reference may be made, as also to a careful pres-
entation of the subject in Duhring's Treatise on
Diseases of the Skin. The drugs reported as having
occasionally given rise to eruptions are as follows :
arsenic, belladonna, bromine, cannabis indica, chloral,
copaiba, cubebs, digitalis, iodine, mercury, opium,
phosphoric acid, quinine, salicylic acid, santonine,
strychnia, tar, carbolic acid and turpentine.
* Archives of Dermatology, Vol. vi., No. 4, October, 1880.
r
^■■a si
INFLAAfMATOKY AFFECTIONS.
191
The eruptions caused by drugs vary greatly, from
a slight erythema to papules, vesicles, pustules,
bulls, and even fungoid masses, as occasionally seen
from bromide and iodide of potassium. At times
they resemble very many diseases of the skin ; the
mottled eruption from quinine and copaiba may be
mistaken for measles or the macular syphiloderm ;
the pustular eruption from iodides and bromides re-
sembles syphilitic and other eruptions, and the pur-
pura from iodide of potassium can hardly be distin-
guished from ordinary purpura. The lesions thus
produced are liable to such variations that they can-
not be detailed here ; but, although they are rare
effects, their possibility should always be borne in
mind, especially if .an eruption presents anomalous
features. Under this head must also be classed the
transient eruptions sometimes caused by the inges-
tion of certain articles of diet ; thus strawberries, or
bananas, etc., will in some persons invariably cause
an urticarial eruption, in others only under certain
conditions. Stale fish, mushrooms, and various arti-
cles of food at times excite erythematous and urti-
carial conditions of the skin.
In connection with the forms of dermatitis men-
tioned, feigned eruptions should ever be borne in
mind, that is, lesions artificially produced by the
patient for the purpose of deception. These gener-
ally occur in hysterical women, and a number of au-
thentic cases arc on record; the eruption may take
192
MANUAL OF DISEASES OF THE SKIN.
the form of bullae, produced by acids, or abrasions
of various degrees. Their true nature can usually
be detected, suspicion first arising from their failure
to correspond with recognized types of disease.
Treatment, — The indications for treatment of all
the forms of dermatitis are simple, namely, removal
of the cause and protection of the affected parts ;
there is more danger of doing too much than too
little. The eruptions from poison ivy and sumac
are sometimes troublesome, as the poison seems to
penetrate the skin and the eruption continues some
time after what was perhaps a brief contact with the
plant. Cooling lotions (Formulae 25, 26, 27, 28,48)
are most acceptable, followed later by slightly astrin-
gent ointments (Formulae 84, 87). Duhring speaks
of the fluid extract of grindelia robusta diluted thirty
or forty times, as the best remedy. The eruptions
caused by dyes in gloves, socks, etc., will often
prove very troublesome; they are to be treated
locally as an acute eczema.
CHAPTER XV.
CLASS IV. EXSUDATIONES. — EXUDATIVE OR INFLAM-
MATORY AFFECTIONS. — {Continued.)
VII. — SQUAMOUS ERUPTIONS.
Three separate conditions are thus grouped, ^r-
matitis exfoliativa {or ^\tyr\^.sisrnhr^)y psoriasis , and
pityriasis capitis: in these the scale, if it is not a
primary lesion, is an inseparable element in the
eruption.
1 6. Dermatitis exfoliativa, or pityriasis rubra. By
this is understood an inflammatory, non-contagious
affection, involving a greater or less extent of sur-
face, either continuously or in patches, characterized
by a red, congestive color, and the production of a
greater or less amount of branny scales. The process
appears to be simply a congestive and slightly in-
flammatory condition, which goes only to a desquam-
ative stage, without thickening or exudation, as in
eczema, and with comparatively little burning or
itching.
Various degrees and grades of this affection have
been observed by different writers; Hebra is in-
9 193
194
MANUAL OF DISEASES OF THE SKIN.
clined to regard as pityriasis rubra only cases where
a large share of the body is affected, and where the
process thus becomes a severe one, generally fatal.
Other observers have recorded milder degrees of the
same condition, and with favorable prognosis; in
certain cases the disease is limited to patches, to
which the name pityriasis maculata et circinata has
been given by Bazin, Duhring and others, while in
other instances the eruption which has occupied
larger tracts, has been characterized by a tendency to
recur again and again.
Diagnosis, — Many eruptions are characterized by
redness and scaling, but the disease under consider-
ation, when considered in its whole course will be
found to differ materially from all other affections.
It is most likely to be confounded with more or less
general squamous eczema^ also with psoriasis^ pem-
phigus foliaceuSy and lichen ruber ; also possibly with
tinea circinata and tinea versicolor.
Treatment. — The eruption is rebellious to all the-
rapeutic measures, and no single line of treatment
can be recommended with prospect of great suc-
cess. Milder cases yield to alkaline and tonic reme-
dies (Formulae 52, 53, 58, 59), together with baths
and emollients (Formulae i, 2, 3, 41, 104) ; in the
more severe cases constant envelopment in oil, as
the linseed or cod-liver oil, affords the most promise.
17. Psoriasis. Synonyms: Lepra vulgaris; Lepra
I.
/■■
Willani ; Alphas; Dry or Scaly Utter. Psoriasis is
a non-contagious affection of the skin, exhibiting
slightly elevated, reddened patches, of varying size
and shape, generally circular, covered with a greater
or less quantity of dry white scales, heaped together,
and having a peculiar, shiny, bran-like appearance
when removed. Beneath the scales there is found,
on scraping, a little pellicle which comes off in a
sheet, and is soft and pliable ; the reddened sur-
face beneath this may be made to bleed very
readily.
The amount and degree of eruption in psoriasis
may vary greatly with the case, from a very few
small patches, perhaps not covering in all one square
inch, to an eruption affecting the larger share of the
entire integument. The eruption selects by prefer-
ence the extensor aspects of the limbs, and will gen-
erally be found upon the elbows or the front of the
lower limbs ; the scalp and top of the forehead, also
- the loins, are favorite seats of psoriasis. Certain
other portions arc rarely affected, as the genital
region, backs of the hands and feet, and face ; while
the palms and soles are almost nev.er attacked, it
may be said, never, without a development of the
eruption elsewhere.
Various designations have been given to the dif-
ferent appearances which the eruption of psoriasis
presents, all based upon the mode of development
of the lesions. The first appearance is always in the
1^6 MANUAL OF DISEASES OF THE SKIN.
form of a minute red spot {^psoriasis punctata^ which
speedily becomes covered with a white scale, looking
as if mortar had been spattered on (^psoriasis guttata).
The tendency is always to increase in size peri-
pherally, and when a little larger (^psoriasis nummu-
laris) there is a fancied resemblance of the round
spots to coins ; as the patches also tend to clear in
the center, a ring-like appearance results {^psoriasis
orbicularis or circinata). In certain cases these
rings may coalesce, and so clear up in portions as to
produce gyrate forms {psoriasis gy rata) \ when large
surfaces are involved the name psoriasis diffusa or
aggregata has been used, and psoriasis inveterata is
applied to express obstinacy. All these represent
the same eruption in various forms.
The term lepra was formerly applied to the erup-
tion when forming the larger patches seen mpsoriasis
nummularis and orbicularis^ the most typical forms of
the eruption ; at present the term lepra is used to
designate leprosy, elephantiasis Graecorum, an en-
tirely different affection, with which this has noth-
ing in common. Willan applied the term psoriasis
also to many C9nditions now recognized to be forms
of eczema ; these two diseases are to be entirely
separated, eczema does not become psoriasis when
a scaly stage is reached, although occasionally the
two may be combined, and sometimes the one may
develop into the other.
Psoriasis presents quite different aspects as it oc-
INFLAMMATORY AFFECTIONS,
197
curs in strumous or gouty persons ; in the former
the scales are thick and apt to become heaped up,
and the base is less congested, while in gouty sub-
jects the scales are thin, often scanty, and the base
is very red ; the former itch but little, the latter may
prove very troublesome from this symptom. The
strumous cases are generally seen in children and
young persons, and yield more readily to cod-liver
oil ; in the gouty cases, which are rebellious, alka-
lies, colchicum, and arsenic are most useful.
Diagnosis. — Psoriasis may be mistaken for eczema^
favuSj lichen planus Jupus erythematosus, pityriasis cap-
itis, seborrhoea, syphilis, tinea trichophytina, and xero-
derma ; generally, sufficient care will suffice to de-
monstrate features which are quite typical in every
case of psoriasis. Upon the scalp the diagnosis
from squamous eczema may be difficult, and certain
cases of scaly syphilis resemble it very closely.
Etiology, — Little or nothing is known of the actual
causes of psoriasis : it has no connection with syph-
ilis, or leprosy, it is not contagious, and no single
article of diet, nor any local cause will produce it.
It is met with about equally in males and females,
seldom appears before puberty, although children
may be affected, and very rarely develops for the
first time after forty years of age. Very many
psoriasis patients appear to be in perfect health, but
in most of them faulty assimilation and disintegra-
tion can be made out.
198
MANUAL OF DISEASES OF THE SKIN.
Treatment. — This is often very unsatisfactory, the
eruption proving most rebellious, and recurring
again and again, even in the face of energetic meas-
ures. Internal treatment is necessary, as well as
local, for the eruption will pretty certainly return if
removed by local means alone.
The strumous cases, as stated, do best under tonics
and cod-liver oil given freely. Gouty cases require
alkalies, which need to be administered with a free
hand, while at the same tjme or later, arsenic,
strychnia, and other tonics are required. The best
alkalies are the acetate and bi-carbonate of potas-
sium, and liquor potassae, combined with bitter
tonics (Formulae 53, 54, 57, 59) ; the mineral waters
do not seem to act as well as these. Later, arsenic
is of service ; but in the more acute and itchy condi-
tions it will often aggravate the eruption.
Local treatment will sometimes be followed by
fnost excellent results, and at other times will pro-
duce almost no impression upon the eruption ; it is
very questionable if local measures alone have ever
been followed by permanent cure. The agent hav-
ing the most decided effect upon psoriasis is chryso-
phanic acid, used in the form of ointment (Formula
98). Under its use the spots will speedily become
smooth and white, while the surrounding skin is
stained of a purplish hue, deepening into mahogany
color ; if its use is discontinued too soon the spots
will reappear; to be effectual it should be per-
INFLAMMATORY AFFECTIONS. Jgg"
sisted in until the skin is evenly colored. But there
are serious objections to it, from the staining of the
skin and clothing, and the irritation often produced ;
on delicate skins it will sometimes cause very con-
siderable inflammation, and should always be em-
ployed with caution at first ; pyrogallic acid (For-
mula 99) has been substituted for it with fair results,
and docs not stain so badly ; it must be used with
some caution, as serious systemic effects have been
reported from its very free employment. Mer-
curial ointments (Formulae gi, 92, 93) rank veiy
high, white precipitate being one of the best ; sul-
phur preparations also have considerable power
over the eruption, and of these Vlemingkx solution
(Formula 37) is most powerful, bu. often proves ir-
ritating. Tar will often control the eruption, and
may be employed in va'rious ways, pure or in com-
bination with other agents ; the liquor picis alkali-
nus, and the compound tincture of green soap (For-
mula 39, 40, 43) are very serviceable.
To be effective local applications should be made
directly to the diseased surface deprived of scales ;
for this purpose the patches are scrubbed or washed
to free them, or alkaline baths are given (Formuls
I, 2, 3), after which the appropriate remedy is well
rubbed into the affected parts. Mechanical removal
of the scales, and even the scraping of the surfaces
until they bleed, before the application, is sometimes
followed by the best results. In more acute stages
200 MANUAL OF DISEASES OF THE SKJN.
and phases the eruption must be first treated by
soothing measures, as described under- eczema.
1 8. Pityriasis capitis. Synonym : Alopecia fur-
furacea. Several diseased states give rise to a scaly
condition of the scalp, causing the so-called dandruff
or dandriff ; these are seborrhasa, eczema^ psoriasis^
tinea tonsurans^ and pityriasis capitis ; the scales
which fall in these may be very much alike, but
careful examination of the diseased surface will dif-
ferentiate the conditions.
Pityriasis capitis is an affection of the epithelial
portions of the skin, exhibiting excessive growth
and rapid exfoliation. The surface is seen to be
white, and the scales are pearly ; not only are they
thrown off from the surface between the hairs, but
the epithelial covering of the hair follicle takes part
in the process, and the hair is seen to be surrounded
by a small sheath of scaly formation, which will
often be observed encircling the hair at any point,
as it has slid on it after being detached. There is
no moisture at any time, nor crusts ; there is no red-
ness of the base, nor thickening, nor itching, as in
scaly eczema; nor are the scales greasy as in se-
borrhoea. The nutrition of the hair remains fair,
and the latter may be quite thick, although in time
it falls ; the annoyance is caused mainly by the
mass of branny scales which dusts upon the cloth-
ing at every movement.
IN FLAM MA TOR Y AFFECTIONS, 20 1
Treatment, — To be successful a thoroughly tonic
internal treatment must be given, including careful
attention to all the functions of the body ; iron, ar-
senic (Formulae 52, 58, 59), cod-liver oil, and every
means of improving the nutrition must be resorted
to. Locally, occasional shampooing with soapy
solutions (Formula 38) or washing with tar soap,
followed by tannin ointment (Formula 87), and later
by stimulating hair washes (Formulae 49, 50, 5 1) can,
with proper internal measures, entirely remove this
annoying affection.
VIII. PHLEGMONOUS ERUPTIONS.
This group is characterized by localized inflam-
matory action, resulting often in destruction of tis-
sue and in the discharge of a slough of necrosed
substance, the process being deeper than in the
eruptions classed as pustular. Four affections are
placed h^r e, furunculus, anthrax, abscessus, and hor^
deolunt.
19. Furunculus. Boils or furunculi consist of
circumscribed points of inflammation of the corium
and connective tissue, terminating in suppuration
and the formation of a central slough or core ; when
this escapes the little abscess tends to heal. Boils
seldom come alone, but often in considerable num-
bers, and frequently one will succeed another for a
considerable period; the condition or state exhib-
iting furunculi is known diS fur unculosis.
202 MANUAL OF DISEASES OF THE SKIN.
Etiology, — The causes of boils are unknown, as far
as any single element is concerned ; they are always
indications of lowered vitality, although the impres-
sion is very common that boils are salutary, and
either indicate excess of health, or are in themselves
healthful. The local cause can sometimes be found
in local irritation, but often no adequate reason for
their appearance can be discovered.
Diagnosis, — There are few conditions which can
be mistaken for boils ; ecthyma^ and the large pustti-^
lar syphiloderm sometimes resemble them, but the
hard, painful inflammation of a boil is charac-
teristic ; from carbuncle it is differentiated by its
size.
Treatment, — This should always be directed to-
wards rectifying general errors in nutrition ; tonics
are always called for (Formulae 52, 55, 58, 59, 60),
together with improved diet and hygiene. The
preparations of sulphur have the most direct con-
trol, and of these the most powerful is the sulphide
of calcium, one-tenth to one quarter grain, from
three to six times daily ; the hyposulphite of sodium
is also efficacious. Locally, irritation should be care-
fully avoided ; such common remedies as soap and
sugar to " draw '' the boil, do harm and cause pain.
Very much relief can be obtained from an ergot
ointment, a drachm to the ounce, with a little oxide
of zinc, applied both when forming and after rup-
ture ; when tense and hard, flaxseed meal poultices
INFLAMMATORY AFFECTIONS. 203
are best, but if too long used they rather encourage
the formation of new boils.
20. Anthrax. A carbuncle is an inflammation of
the skin and subcutaneous tissue, exhibiting dusky
redness and brawny hardness, with deep, boring
pain, and the subsequent formation of a large slough,
with numerous sieve-like openings through the skin,
discharging a small amount of pus ; later the entire
center sloughs out to a varying extent, leaving a
granulating surface which heals with a scar.
The most common location for a carbuncle is the
back of the neck, but they may also be observed
upon any portion of the body ; it is always a serious
affair, if of any size, and may prove fatal in those
who are debilitated. The cause is unknown, other
than such as produce furuncles.
Diagnosis, — The red surface might be mistaken
for erysipelas, but the hardness soon determines the
diagnosis.
Treatment. — Tonic treatment should be given
from the outset, and the strength husbanded by the
best of dietary and hygienic conditions, care being
taken that the bowels and kidneys act rightly,
especially in gouty subjects; stimulants, quinine,
tincture of iron, etc., are all called for, and sufficient
opium to secure rest at night. Sulphide of calcium
given as for boils, has been effective in my hands in
diminishing the suppuration. Locally most author-
ities agree that benefit results from pressure, as with
204 MANUAL OF DISEASES OF THE SKIN.
lead plaster, early in the disease, while poultices are
required later ; the matter of poulticing can be over-
done, and it should not be continued too long.
21. Abscessus. Cutaneous abscesses are often
seen on the face in connection with indurated acne,
where large fluctualting collections of grumous pus
are formed ; they are also seen on the scalp of in-
fants, especially in hot weather, and in connection
with eczema. In the axillae the abscesses often
appear to be wholly cutaneous, and such are prob-
ably connected with the sweat-glands {hydra-adenitis).
The treatment is to be conducted on surgical
principles, and often that suitable for eczema gfives
the best results.
22. Hordeolum. Styes are closely related to
boils, and consist of an inflammation in and around
the meibomian glands, characterized by a painful
swelling which rapidly suppurates, and disappears
very quickly after the discharge of its contents;
there generally is no central slough. Styes are very
frequently associated with eczema and boils, and
less commonly so with acne. They seldom come
alone, but often in a succession, even of a dozen or
more. They ar^ always an indication of lowered
vitality and disordered system ; the principles of
treatment applicable to eczema and boib are of
most service.
INFLAMMATORY AFFECTIONS. 20$
IX. ULCERATIVE AFFECTIONS.
Ulcers are very generally secondary lesions, the
result of some previous pathological process, as in
the case of epithelioma, those connected with syph-
ilis, etc., and are properly considered and classified
in connection with the diseases to which they be-
longc There are, however, several ulcerative lesions
which are primary, such as ulcerative onychia, and
simple ulcer of the leg, and the chancroidal ulcer ;
the chancre, the primary lesion of syphilis, belongs
to and is considered in connection with that dis-
ease.
23. Onychia. Many conditions affect the growth
of the nail, such as eczema, psoriasis, and pityriasis
rubra, and in syphilis there may be inflammatory or
other disease from new deposit around or near the
nail; ring-worm and favus also attack the nails,
rendering them brittle (onycho-mycosis).
True onychia is most commonly of traumatic or-
igin, as in ingrowing toe-nail, or sometimes results
from occupation ; it is characterized by a suppura-
ative inflammation of the tissues at the root of and
around the nail, which may proceed to considerable
ulceration, especially in strumous subjects, if not
properly treated. When fully developed the tissues
around are infiltrated and the nail seems sunk in a
mass of fungoid granulations.
Diagnosis. — It is very important to distinguish
206 MANUAL OF DISEASES OF THE SKIN.
syphilitic onychia from the non-specific form ; other
than this there is no difficulty in diagnosis.
Treatmefit, — External irritation must be removed ;
when a badly fitting shoe is the cause, cure is impos-
sible without a change. Soothing and astringent
treatment generally suffices to remove the difficulty ;
an ointment of the liquor ferri subsulphatis, a
drachm to the ounce, acts well, applied thickly
after soaking the part in very hot water. Stru-
mous onychia yields fairly to the application of
powdered iodoform.
24. Ulcus. Two* kinds of ulcers are here recog-
nized, ulcus simplex, or simple ulcer, and ulcus vene-
rum, the venereal ulcer or chancroid.
Simple ulcer. — This is best typified in varicose
ulceration of the lower leg. When fully formed this
exhibits a painful, red, ulcerating surface, with hard,,
brawny and everted edges ; it tends to bleed easily
and gives rise to only a moderate, sanious exuda-
tion, quite different from the purulent, fetid dis-
charge from syphilitic ulcerations. Varicose ulcers
are very commonly associated with more or less ec-
zema, both being due to the same causes ; they are
more apt to be single than those of syphilis, are
more commonly found on the lower portion and
anterior surface of the leg, whereas in syphilis they
generally exist on the sides and back of the calf,
also on the upper third, and often about the knee.
INFLAMMATORY AFFECTIONS. 20/
Ulcers may form on any portion of the body, from
injury, and as bed sores may give much trouble.
Venereal ulcer, or chancroid.— This is en-
tirely distinct from the initial lesion of syphilis, or
the chancre, and is a local sore produced by inocu-
lation with a contagion whose nature is unknown :
inflammation is commonly * excited in neighboring
glands producing bubo, but the system is never in-
fected by the chancroid. The forms which the ulcer
takes are various, but its main features are the fol-
lowing : I. Its brief incubation, it appearing almost
immediately after inoculation ; 2. Its copious, puru-
lent secretion, which is anto-inoculable ; 3. Its soft,
ulcerated red base, with sharply cut and often un-
dermined edges ; 4. Its generally multiple character
and tendency to spread ; and, 5. The inflammatory
engorgement of neighboring glands, with the tend-
ency of the swelling to become red, painful, and to
suppurate.
Diagnosis. — It is often very difficult to differen-
tiate chancroid from the true chancre, and often herpes
progenitalis and balanitis will simulate it closely ;
eczema, psoriasis, lichen planus, and scabies may also
affect the penis.
Treatment. — Ulcers of the leg are best treated by
the rubber bandage, as directed for eczema ; very
commonly constipation and defective urinary excre-
tion exists, which must also be remedied. Varicose
ulcers are most frequently found in those who stand
208 MANUAL OF DISEASES OF THE SKIN.
a great deal, as in cooks, laundresses, bakers, bar-
tenders, and car-drivers, and are rarely seen in those
who walk, even though they remain long on their
feet, as postmen. The therapeutic hint from this is
that the more that walking can be encouraged, if at
all well borne, the more quickly and permanently
will the ulcers be healed ; this is especially true
while wearing the rubber bandage, by means of
which patients, who before were almost helpless
from painful ulcers, can often walk long distances.
Strapping with . adhesive plaster also answers fairly,
and mildly stimulating and astringent ointments
(Formulae 94, 95, 97) are of service in some cases. The
treatment of the venereal ulcer relates to destroying
the poison and modifying the diseased action ; nitrate
of silver is almost useless for this purpose, and the
stronger acids, sulphuric or nitric, or the actual cau-
tery are effective, with subsequent dressings of
finely powdered iodoform or solutions of carbolic
acid or zinc.
CHAPTER XVI.
CLASS V. HEMORRHAGIC. — HEMORRHAGIC AFFEC-
TIONS.
Three diseases are here %xo\x^^A^ purpura^ hcemaU
idrosis, and scorbutus, all characterized by the escape
of blood from the capillaries of the skin.
I. Purpura. Synonyms: Land scurvy; Purples.
Three varieties of this disease are recognized, pur-
pura simplex, p. rheumatica, and p. hemorrhagica, all
exhibit hemorrhagic patches of various sizes and
shapes, slightly raised or level with the skin, which
do not disappear upon pressure ; appearing first of
an almost arterial red, they quickly deepen in color,
until, before they have entirely disappeared, they
have passed through various changes, from purple
to greenish brown, and yellow.
Purpura simplex. — This is commonly seen first
upon the lower limbs, and also upon the forearms ;
the eruption usually develops symmetrically, and is
prolonged by successive crops. There are few con-
stitutional symptoms, though the patient generally
feels languid. Purpura sometimes occursduring the
administration of iodide of potassium.
209
210 MANUAL OF DISEASES OF THE SKIN.
Purpura rheumatica, or peliosis rheumatica
resembles erythema multiforme almost more
than purpura. It is characterized by rheumatic
pains, affecting principally the large joints, and the
subsequent appearance of small, sharply defined
macules, often first about the knees, which are found
to be hemorrhagic, and not to disappear on pressure.
Purpura hemorrhagica. — This is a severe affec-
tion exhibiting hemorrhages from various mucous
surfaces as well as in the skin. There is prostration
and the sudden appearance of hemorrhagic spots of
varying size, often quite large and purplish, not dis-
appearing on pressure.
Diagnosis, — Purpura may resemble eczetna^ eryth-
ema vmltiforme and nodosuniy and syphilis; the
hemorrhagic variety may be mistaken for scorbutus^
and hemorrhagic sf nail pox, often wrongly called ^r-
pura variolosa and black measles.
Prognosis, — Purpura simplex is generally a mild
affair, and yields well to treatmentj purpura rheu-
matica is much more obstinate; purpura hemor-
rhagica is not unfrequently fatal.
Treatment, — Ergot is the chief remedy of service
in purpura, although quinine in free doses is most
effective in the rheumatic form ; ergot should be
given boldly, and if necessary by hj'podermic injec-
tion. Tonic treatment is also indicated.
2. Hsematidrosis. Synonyms : Ephidrosis cruen-
HEMORRHA GIC AFFECTIONS. 2 1 1
ta; Bloody sweat. This is a very rare condition,
characterized by the escape of blood through the
swqat glands ; the fluid which exudes may be very
watery. It is most frequently seen in hysterical
girls with faulty menstruation.
Treatment. — This must be directed against the
conditions present ; in addition, ergot should be
given in doses sufficient to arrest the hemorrhage.
3. Scorbutus. Synonym : Scurvy, This is a
constitutional state of exhaustion, during which
hemorrhagic, bruise-like ecchymoses occur upon the
skin, generally of some size, together with a spongy
state of the gums and subsequent loosening of the
teeth ; it is due to a deficiency of fresh vegetable food
in the dietary, and if unchecked tends to death.
There is a leaden color to the skin, malaise and
rheumatic pains, and oedema.
Treatment, — The treatment is almost wholly diet-
ary; an abundant supply of fresh vegetables and
lime-juice is generally all that is required ; tonics are
of service later.
CHAPTER XVII.
CLASS VI. HYPERTROPHIiE.— HYPERTROPHIC AF-
FECTIONS.
These are characterized by an augmentation of
some of the normal elements of the skin, and are
grouped under five heads : Hypertrophy, A, of pig-
ment ; B, of epidermis and papillae ; C, of connective
tissue ; D, of hair ; E, of nail.
A. HYPERTROPHIES OF PIGMENT.
In this group are found five distinct states : len-
tigo^ chloasma^ melanoderma^ morbus Addisoniiy and
ncevus pigmentosus ; all exhibit hypertrophy of pig-
ment, deposited in varying degree and manner in
the deeper cells of the rete malpighii. Their treat-
ment will be considered together.
I. Lentigo. Synonym : Freckles. This well
known deformity consists of deposits of pigment of
small size, of a yellowish or brownish color, scat-
tered mainly over the exposed portions of the skin.
They are most common in those having light com-
plexions, especially persons with red hair; they
212
HYPERTROPHIC AFFECTIONS. 2 1 3
may affect other regions besides those exposed to
sunlight.
2. Chloasma. Synonym : Liver spots ; Moth, This
consists of yellowish brown, pigmentary discolora-
tions of various sizes, situated chiefly about the face
and neck ; it is most commonly seen in females, but
occurs also rarely in males. The surface is smooth
and not scaly, unless irritated, and the margins of the
patches are quite sharply defined ; the forehead and
temples are common localities, also about the mouth.
The cause in females is frequently uterine or ovarian
disease (chloasma uterinum)^ though it is quite prob-
able that liver disordeji; is also an important ele-
ment.
Diagnosis. — It may be mistaken for tinea versicolor y
also for th^ pigmentary syphilide and leucoderma,
3. Melanoderma. This relates to various brown
discolorations, which may occur from different
causes, some local, others constitutional. The ef-
fects of the sun are to produce a general darkening
of the skin termed epkelis, sunburn, or tan ; irritat-
ing agents as blisters often leave behind them a
considerable discoloration of the integument. Long
continued cutaneous congestion and inflammation
results in pigmentary deposits, as is observec after
eczema of the lower extremities, in old cases of
phthiriasis, and after many syphilitic lesions.
214
MANUAL OF DISEASES OF THE SKINl
Again, pregnancy induces a discoloration about
the nipples ; cancer causes a general pigmentation,
as also melanotic sarcoma, leprosy, scleroderma, etc.
A mechanical discoloration of a peculiar leaden or
bluish color, is brought about by the long continued
internal administration of nitrate of silver, which
has received the name of argyria. The most re-
markable general discoloration of the skin is that
connected with disease of the supra-renal capsules,
which is such a constant feature in this complaint as
to receive a separate name, well recognized, as next
described. ^
4. Morbus Addisonii. Synonyms: Bronzed-skin
disease ; Supra-renal melasma. The curious anae-
mic and cachectic state described by Addison as
connected *with disease of the supra-renal capsules,
has often, as its first symptom to excite serious at-
tention, a peculiar bronzing of the skin ; this pre-
sents ** a dingy or smoky appearance, or various
tints or shades of deep amber or chestnut brown,
most strongly manifested on the face, neck, superior
extremities, penis and scrotum, and in the flexures
of the axillae and around the navel/*
Diagnosis, — The only conditions which could be
mistaken for this are a general ephelis or tanning,
chloasma^ leucoderma^ pigmentary syphilis^ and tinea
versicolor,
5. Nsevus pigmentosus. Synonym : Pigment^
HYPER TROPHIC AFFECTIONS, . 2 1 5
ary mole. This consists of a pigmentary deposit of
varying size, color, and shape, often of congenital
origin, but occasionally developing at any period ;
generally there are several of these deformities.
This form of naevus may exist alone, or be combined
with hypertrophy of other elements ; the epidermis
and papillary layer are often involved, and a rough,
warty condition results {ncevus verrucosus). When
hair grows as well, it takes the name of ncevus pi-
losuSf to be described later.
Treatment of hypertrophies of pigment. — The loca-
tion of the coloring matter deposited in all the
lesions described is beneath the epidermis, either in
the rete malpighii, where pigment is found normally,
or still deeper. It is difficult, therefore, to remove
it by superficial applications, which destroy the life
of the cuticle only ; if attempted by agents which at-
tack deeper tissues, a scar may result. If effected at
all it must be by measures which modify the nutri-
tion and cause the absorption of the pigment, or by
repeated removal of the epidermis by such means
will induce the newly formed cells to have less
coloring matter.
These deformities are, therefore, unsatisfactory to
treat ; the best means are lotions containing bi-chlo-
ride of mercury (Formula 45), and if their action is
too strong it can be modified by an ointment (For-
mula 91). Freckles sometimes yield to these appli-
2l6 MANUAL OF DISEASES OF THE SKIN.
cations, but are often rebellious ; chloasma can usu-
ally be thus removed, but is apt to return with a
continuance of liver or sexual derangement. But
little can be done for the forms of melanoderma ; the
discoloration accompanying Addison's disease is
irremediable ; pigmentary moles may be excised or
destroyed with strong potassa solutions.
B. HYPERTROPHIES OF EPIDERMIS AND PAPILLA.
Six conditions of disease are recognized as be-
longing to this group, ichthyosis^ keratosis pilaris^
cornu cutaneumj clavuSy tylosis j and verruca.
I. Ichthyosis. Synonym: Fish-skin disease.
This, as the name signifies, is characterized by a
dry, hard, scaly condition of the skin to agreatei: or
less extent, which in marked cases may assume an
appearance suggestive of the scales of a fish ; in
severe degrees the papillary layer takes part in the
process and may be very considerably hypertrophied.
Most commonly ichthyosis is a congenital disease,
several cases often occurring in a family, which, while
manifesting but a slight degree of alteration during
the first years, may increase greatly during child-
hood. The eruption is always most developed on
the extensor surfaces of the body, especially on the
elbows and knees, the flexor surfaces of these joints
being spared, however greatly the disease is de-
veloped. In milder degrees it has the name xero^
HYPERTROPHIC AFFECTIONS,
217
derma^ dry or parched skin ; ichthyosis patients sel-
dom perspire much, and the integument may be so
dry and harsh as to crack and cause great pain. Two
degrees or forms of the affection are recognized,
ichthyosis simplex and ichthyosis Jtystrix.
Ichthyosis simplex represents the milder de-
grees, where the hypertrophy appears confined to
the epidermis ; the scales are not thick, and may be
laid out in a strikingly regular form, showing the
deepest fissures in lines of motion.
Ichthyosis hystrix. — Under this name have
been described cases presenting a great hyper-
trophy of papillae with heaped up masses of epi-
dermal tissue ; this may occur over a considerable
extent, or appear in localized patches, sometimes
following nerve tracts. Different cases present very
different grades of the disease, from a few groups
of brownish yellow, wart-like excrescences, to large
areas of almost horny productions, sometimes of
deep color (^porcupine men).
Diagnosis. — Milder cases resemble squamous ecze-
ma, pityriasis rubra , and possibly psoriasis ; but all
these have redness of skin, while ichthyosis is char-
acterized by the leaden paleness of the integument.
Prognosis, — The condition is well-nigh incurable,
but very great relief and benefit can be obtained by
proper treatment. Young subjects should be per-
sistently and actively treated when the disease is
developing, as affording the best hope of escapin^"
10
2i8 MANUAL OF DISEASES OF THE SKIN.
further trouble. In very severe cases, the pain and
even deformity may be very great.
Treatment, — The very free internal and external
use of oily preparations, as linseed and cod-liver oils,
yields the best results, together with frequent alka-
line baths (Formulae i, 2, 3).
2. Keratosis pilaris. Synonyms : Lichen pilaris;
Pityriasis pilaris. This is characterized by the ap-
pearance of minute, pointed, epidermal elevations
about the orifices of hair follicles. The localities
most commonly affected are the thighs and backs of
the upper arms, but any portion may present the
eruption. In three cases I have seen it affecting
the hair follicles of the scalp, in one of these the
eruption was also very general.
Treatment. — The epidermic mis-growth is best
treated by alkaline baths (Formulae i, 2, 3), or the
free use of ordinary baths and soap, with the subse-
quent inunction of oily matter, such as cod-liver and
linseed oil, and mild mercurial ointment (Formulae
94, 96).
3. Cornu cutaneum. Synonyms : Cutaneous
horn; Cornuhumanum; Horny excrescence. Cutaneous
horns in structure resemble very closely the ordi-
nary horns observed on the lower animals ; they are
usually of small size, but have been observed six
inches in length. They are also of varying thick-
HYPERTROPHIC AFFECTIONS. 219
iiess, and rather abruptly conical. Human horns
commonly develop on the head, from any portion
of the face, but have also been noted in various por-
tions of the body, and in a number of instances on
the penis.
Treatment. — If a horn is torn ofiT it regrows, unless
the base is destroyed ; it is necessary, therefore,
either to excise the entire structure with its base,
or to destroy the latter very thoroughly with a deep
acting caustic, as the chloride of zinc or Marsden's
arsenical paste (Formulae 10, 14).
4. Clavus. A corn is a localized hypertrophy of
the epiderniis, in the form of a small, rounded mass,
horny to the feel, projecting slightly from the skin ;
its base is conical, reaching down even upon and
into the true skin, which may atrophy by the pres-
sure occasioned. Two varieties of corns are spoken
of ; the hard corn when seated on an outer surface,
and the soft corn, located between the toes, where the
parts are kept moist. Both are essentially the same,
and both are due almost invariably to wrongly fit-
ting coverings for the feet ; both may give rise to
serious inconvenience from the darting pains which
occur when pressed upon, or even spontaneously.
Treatment. — The first step is to secure a properly
fitting shoe, for without this the condition will re-
cur in the same or another situation ; often it is
necessary to have special lasts made, but it also
220 MANUAL OF DISEASES OF THE SKIN.
may suffice to wear difiFerent pairs of shoes on alter-
nate days, that the pressure may come in other
places. The ringed protective plasters in common
use answer to keep off the pressure in a measure.
To remove the corn, soaking with hot water, or a
poultice over night will soften the part and admit of
its being dug or picked out with little pain. The
corn plasters contain various softening agents, such
as carbonate of potash and acetic acid ; most of
them are probably harmless, and often ineffectual.
Cutting or rasping frequently suffices, if attention be
paid to the foot covering. Soft corns yield to care-
ful separation of the toes with picked cotton and
oxide of zinc or tannin ointment, with occasional
touching with nitrate of silver, and the relief of
pressure by properly fitting shoes.
5. Tylosis. Synonyms: Tylonta ; Callositas ; Cal-
lus ; Callosity. This consists of an abnormal de-
posit of epidermal cells, forming yellowish or gray-
ish horny masses of varying size and thickness, oc-
curring especially on parts exposed to pressure or
friction ; this condition is an augmentation of that
normally found on the soles and palms, and may at
times give much annoyance. It differs from clavus
or corn in its diffuse character, the absence of pain
except when cracked, and its involving only the
outer portions of the epidermis. In rare cases the
entire palms and soles may become the seat of this
HYPER TROPHIC AFFECTIONS, 22 1
alteration, and they become thickened and stiff,
without any known cause, certainly not from press-
ure or friction.
Treatment. — No means of cure are known other
than mechanically removing the superfluous matter
by a knife or rasping. When the soles become
greatly hardened from standing, and are fissured and
painful, great benefit can be obtained by wearing
oiled silk cut a little larger than the sole, within the
stockings, day and night.
6. Verruca. A wart consists of a circumscribed
papillary hypertrophy, with more or less epidermal
accumulation : it may vary greatly in size and shape,
quite different conditions presenting themselves in
different situations. ^ Four varieties may be made
out, verruca vulgaris^ v. senilis, v. necrogenica, and v.
acuminata.
Verruca vulgaris. — Common warts are hard, at
times almost homy excresences, usually flat on the
surface, which is marked by fissures representing the
spaces between the hypertrophied papillae. The up-
per portion may be pared down, but at a certain
point the bleeding papillae are reached, with the
epidermal prolongations between them : the seeds of
warts are the hypertrophied epidermis masses pro-
jecting down between the enlarged papillae.
Verruca senilis. — This refers to the multiple,
flat, dark yellow or brown, slightly homy elevations,
222 MANUAL OF DISEASES OF THE SKIN,
seen especially about the face, shoulders, and arms
of elderly persons.
Verruca necrogenica. — Peculiar, indolent,
warty growths, red at their base, and moderately
elevated, sometimes occur upon th6 hands as the
result of dissection wounds ; they are very obstinate,
and occasionally almost disappear in one place, and
regrow near by, or again on the former site.
Verruca acuminata. — This constitutes the so-
called z/^;^^r^<^/ wart, or vegetations ; it is also known
as the pointed condylomay spitze condylom of the Ger-
mans, to distinguish it from the broad or flat condy-
loma of syphilis, with which it has no relation, the
latter being a mucous patchy mucous tubercle, or syphi-
litic papule in a situation where it is kept continuously
moist. Venereal warts occur commonly about the
genital and anal regions, and exhibit clusters of
papillary growths, generally pointed on the extrem-
ity, red and succulent, and often bathed in a puru-
lent secretion ; they sometimes attain 'great size.
They are not, strictly speaking venereal, for although
the acrid secretions of gonorrhoea and chancroid favor
their growth, they are often found entirely dis-
tinct from any possible venereal cause, and are ob-
served on other portions of the body than the geni-
tal region.
Treatment, — Common warts often disappear spon-
taneously ; they may also be removed very conveni-
ently and satisfactorily by means of the curette or
HYPERTROPHIC AFFECTIONS.
223
sharp spoon. Caustics of various kinds may be used,
after paring down the wart, care being taken not to
cause too much destruction. They disappear slowly
under the application of diluted acetic acid, applied
morning and night ; equal parts of tincture of iron
and diluted muriatic acid are also effective. Arsenic
internally also, is sometimes followed by their dis-
appearance. Venereal warts, when small, may be
snipped off and the base cauterized with glacial acetic
or strong nitric acid ; when large they will shrivel
under the persulphate of iron, also under the tinc-
ture of thuja occidentalis, and may then be removed
by the knife, sharp spoon, or ligature.
C. HYPERTROPHIES OF CONNECTIVE TISSUE.
Six names appear in this division, scleroderma,
tnorphoea^ sclerema neonatorum, elephantiasis (Ara-
bum), dermatolysisy and framboesia.
I. Scleroderma. Synonyms: Scleriasis ; Scler-
ema; Dermatosclerosis; Hide-bound skin. As the name
signifies, this is characterized by a hard, sole-leather
like condition of the skin of a greater or less extent,
which may occasion much discomfort by its rigid,
tense, and immovable state, and even pain by its
tendency to contract. In some instances the altera-
tion is limited in extent, as in a band along or around
a limb or on the body ; or again the disease may be
224 MANUAL OF DISEASES OF THE SKIN,
more general, and involve the entire trunk, and
cause great distress by interfering with respiration.
Generally the disease commences insidiously, and
the hardening is the first feature noticed; in rare
cases, and when more general, it may be preceded
by chilly feelings and pains, or a numb sensation in
the part. When well developed, the skin is of a
brownish yellow, waxy look, generally on a level
with the surrounding integument, with or without
slight scaling, and so stiff, hard, and board-like, that
it cannot be pinched up or slid upon the tissues be-
neath.
Etiology. — This is entirely unknown ; the disease,
which is very rare, occurs far more frequently in fe-
males than males.
Diagnosis, — The only condition which much re-
sembles this is morphcea, which by some is consid-
ered to be the same affection, more localized ; dif-
fused cancer, especially of the trunk, cancer en cuir"
assc, may also be mistaken for scleroderma in this
region. Some cases of eczema of the palm present a
hard condition, which has been wrongly called scler-
oderma at times, with which it has no connection
whatever.
Treatment, — Very little can be accomplished by
internal medication ; tonics and oily substances are
most indicated. Locally, electricity has been found
of service, and this, with stimulating inunctions, of-
fers the best prospect of improvement. The disease
HYPERTROPHIC AFFECTIONS, 225
sometimes disappears spontaneously; often it re-
mains for a long period stationary, and sometimes
it progresses rapidly until even great areas are in-
volved.
2. Morphcea. The features of the diseased skin in
morphcea resemble those of scleroderma, in the hard,
lardaceous character of the affected portion, and the
impossibility of pinching it up, and in its dirty, yel-
lowish color. * But it differs from that disease in the
limited extent and commonly roundish shape of the
patches, which are surrounded by a pinkish, conges-
tive border or halo ; their outline is often very sharply
defined, so that their edge can be detected by pal-
pation with the eyes shut ; this contrasts strongly
with the indefinite outline of scleroderma, which
merges insensibly into the healthy skin.
Writers are by no means agreed upon all the
characteristics of morphcea, as sometimes cases pre-
sent very peculiar phenomena; the process which in
its earlier and more characteristic phases exhibits
the elements of hypertrophy, and the infiltrated,
leather-like skin, may at a later stage show atrophy,
although at times resolution takes place, leaving
healthy skin. The disease is pretty certainly of
neurotic origin, and it is probable that the condition
known as hemiatrophia facialis is closely related to
that under consideration, if not identical with it.
Diagnosis, — The only lesion liable to be con-
10*
226 MANUAL OF DISEASES OF THE SKIN.
founded with morphoea is scleroderma^ from which it
is differentiated by the features given in the accom-
panying table. The so-called morphoea patches of
leprosy have nothing to do with this disease, but are
only one phase of its skin lesion.
MORPHCEA.
SCLERODERMA.
Beginning, — Generally from a Begins insensibly over considera-
purplish congestive spot ; new ble areas, the hardening being
ones being often obsefved in the first change observable,
the neighborhood.
Margin, — Sharply defined and Illy defined edge merging insensi-
generally bordered by a con- bly into healthy skin ; no con-
gestive halo. gestivehalo.
Extent, — Generally small and cir- Generally greater expanse af-
cular ; and extended patch is fected and the neighboring
generally composed of several parts involved by extension,
others.
Condition, — Tolerably movable ; Firm and immovable : harden-
hardness rather waxy. ing more di£Fuse.
Color. — Pretty uniformly of a Apt to be irregularly pigmented,
tawny yellow, old ivory color.
Tendency, — Often disappears Exceedingly persistent, with a
spontaneously, or if remaining, tendency to increase and to
generally causes little inconven- cause distress by contraction,
ience; seldom, if ever, contracts.
Duration. — Increases rather rap- Generally increases slowly, and
idly and sometimes disappears may remain for years, or until
in a few months. death from intercurrent disease.
HYPERTROPHIC AFFECTIONS,
227
Treatment. — Very little can be said in regard to
this ; tonics, and especially arsenic long persisted in,
are of most value, with electricity locally, and mer-
curial inunctions.
3. Sclerema neonatorum. This very rare affec-
tion occurs soon after birth, and is generally fatal.
It commences with an oedematous infiltration, the
skin being hard, tense, and of yellowish, brownish, or
even a livid purple hue ; it is generally observed
first upon the feet or calves, and extends rapidly
upwards. There are with the stiffened skin, pain,
convulsive movements, scanty urine and failing
strength, and the child generally dies with some af-
fection of the lungs.
Treatment. — This has generally proved unsuccess-
ful. External warmth, by baths and other means,
with inunctions, together with stimulants, offer the
best prospects.
4. Elephantiasis (Arabum). Synonyms : Pachy-
dermia ; Bucnemia tropica; Elephant leg; Barba-
does leg. This disease is to be entirely disasso-
ciated from elephantiasis Graecorum, which is now
known as lepra or leprosy. It is characterized
by an hypertrophic thickening of the skin and subcu-
taneous tissue, with oedema and subsequent papil-
lary hypertrophy ; the most common seat of the
disease is one lower extremity, rarely both ; next
228 MANUAL OF DISEASES OF THE SKIN.
the genital parts, and rarely the upper extremities
and breasts. The disease begins with repeated at-
tacks of cutaneous inflammation like erysipelas, of
greater or less severity, leaving some thickening
after each accession, until, after a varying period, the
part is found to be greatly increased in size, quite
hard and more or less pigmented, and in older cases
presenting papillary prominences and fissures ; the
swelling is found to be somewhat oedematous,
but the amount of pitting on pressure may be very
slight.
Etiology. — The nature of the disease appears to
be essentially connected with the lymphatics, which
are greatly increased in size, and the mass of the
disease consists of hypertrophied connective tissue.
The affection is common in warm countries, but oc-
casional cases are met with in every land : its true
cause is unknown, but has been attributed by
many to the presence of the filaria sanguinis, which
has been found in the lymph exuded from the vesi-
cles occurring in lymph scrotum^ a condition which is
believed by observers in the East to be identical with
elephantiasis. The disease is most frequent between
the ages of twenty- five and sixty, and is far more
often seen in males than females, and especially
among the poor.
Diagnosis. — Certain cases of chronic eczema of the
feet and legs, may exhibit such a thickening and
papillary hypertrophy as to resemble elephantiasis ;
HYPERTROPHIC AFFECTIONS.
229
the swelling attendant upon phlegmasia dolcns may
also suggest this disease.
Treatment. — When well developed, the rubber
bandage affords the best results upon the legs ; when
the disease affects the genital parts, excision gives
almost universally good results. In earlier stages,
quinine in full doses is recommended, with diuret-
ics and rest, together with cooling antiphlogistic
measures.
5. Dermatolysis. Synonym : Cutis pendula. This
consists of an hypertrophy of the connective tissue
elements of the skin of any portion, to such an extent
that it hangs in folds ; this may be so slight as to
cause little annoyance, or may increase to an exces-
sive degree. Any region may be affected, and
cases are reported where the condition had assumed
monstrous proportions and very curious aspects.
The causes of this freak of nature, are unknown.
Treatment. — Operation with the knife affords a
satisfactory means of relief.
6. Frambcesia. Synonyms: Yaws; Pian ; En-
demic verrugas. This is a disease almost wholly
confined to tropical climates and principally seen
among the colored races. It is characterized by the
presence upon the skin of a papulo-pustular erup-
tion, which ulcerates and is followed by exuberant
granulations. "The skin remains unbroken until
230
MANUAL OF DISEASES OF THE SKIN.
the yaws attain, perhaps, the size of a small pea,
but the cuticle may give way at any time. Then a
yellowish, spongy surface presents itself, from which
a thin fetid fluid oozes, and this spongy body con-
tinues to enlarge, and. projects considerably from
the surface. Yaws are usually circular in form, and
may be seen in the same patient of all sizes, from
that of scarcely more than a pin's head to a patch
of one or two inches in diameter, and in every stage
of their progress. Generally they are separate, but
sometimes in groups close together, small and great.
Again they may be met with in oval form, but more
rarely, in other cases they are irregular in shape,
and so close together as to make one mass. It fre-
quently happens that one of these tubercles as-
sumes very large proportions, one or two inches in
diameter, or even more, projecting from the skin,
like the other yaws, covered with yellow scabs, or
having a moist yellow surface, streaked with red."
Etiology. — The disease is one of filth, and is prop-
agated by contagion. Its real nature is unknown,
and recent observers agree that it has no connection
with syphilis.
Diagnosis. — It is most liable to be confounded
with syphilis. Under certain circumstances exu-
berant granulations appear in many diseased con-
ditions, and to these the name framboesia is some-
times wrongly given ; its use should be restricted to
the tropical disease here described. Mycosis is a
HYPERTROPHIC AFFECTIONS. 23 1
term which has been employed as a synonym for
yaws ; this name is also used by the French, to rep-
resent lymphadenoma, with the title mycosis fun--
goide.
Treatment, — Cleanliness, good food and hygiene,
with tonics, usually arrest the disease ; locally, car-
bolic acid lotion and weak nitrate of mercury oint-
ment comprise the measures required.
D. HYPERTROPHIES OF HAIR.
Two hypertrophic conditions of hair are found
here, hirsuties and ncevus pilosus ; the former repre-
sents excessive hairy growth, either of the entire
body, or of parts nominally supplied with long hair,
or in situations provided only \^\\}[i lanugo ; the lat-
ter refers to localized hypertrophy of hair, in patches,
which generally exhibit, also, hypertrophy of pig-
ment.
I. Hirsuties. Synonyms: Polytrichia; Hyper-
trichosis; Trichauxis ; Augmented hairy growth.
Individuals vary greatly in the amount of hairy de-
velopment, and various instances are on exhibition,
from time to time, where the normal hair of the
head or beard is augmented very greatly, or even
where the entire body and limbs present an exces-
sive growth. Medically, hypertrophy of hair is of
special interest when it develops in unusual situa-
tions, as on the face and arms of females, which it
232
MANUAL OF DISEASES OF THE SKIN,
may do to a varying degree, from a few straggling,
stiff hairs on the chin or upper lip, to a completely
bearded condition.
Etiology, — No satisfactory cause is established for
the excessive growth of hair on the face of women,
but frequently it occurs in those of masculine quali-»
ties, although in some of the most marked instances
of those having a full beard quite the contrary is ob-
served ; they have even been mothers of families. In
a certain number of those thus affected, uterine or
ovarian disease is present, and insanity has also been
noticed in this connection.
Treatment, — To be effectual the life of the follicle
and the hair papilla must be destroyed ; consequent-
ly, in the case of hairs of any length, the " depilato-
ries *' so largely advertised to permanently remove
this condition, are not to be relied on. For the re-
moval of finer hairy growths they may occasionally
prove sufficient, but again they may stimulate them
to greater hypertrophy. Depilatories are agents
which soften and dissolve the hair in the same man-
ner as, but to a greater degree than soap, when used
for shaving ; they are put on as a paste, and left five
to ten minutes on the skin and then scraped off.
For hairs of larger growth and fewer in number,
destruction of individual follicles is necessary. This
can be accomplished by introducing a straight glov-
er's needle into each follicle, after the extraction of
the hair, and rotating it several times, as first prcH
HYPERTROPHIC AFFECTIONS,
233
posed by the writer several years ago ; the effect is
heightened by dipping the needle in carbolic acid
before insertion. More recently electricity has been
employed with advantage for this purpose ; the
negative pole is attached to the needle, and the
positive is held in the patient's hand, a current from
between six and twelve cells being employed ; the
current is to be completed by the patient touching
the electrode in the hand after the needle is in situ.
The needle is introduced while the hair is yet in its
follicle, and the electrolytic action loosens the hair
with the formation of a foam around it, when it can
be readily extracted. With either of these processes
a certain proportion of hairs regrow.
2. Nsvus pilosus. Synonym : Hairy mole. With
hypertrophy of hair in small localized patches there
is generally a pigment deposit, and some little pa-
pillary hypertrophy, whereby the surface is slightly
raised. Hairy moles may be of various sizes and
shapes, even to covering a portion of the face or body.
Treatment, — Caustic potassa, in very strong solu-
tion, carefully applied, will destroy the whole growth
and leave a moderate scar ; unless too large, excis-
ion or thorough removal with a sharp spoon is to be
preferred.
E. HYPERTROPHIES OF NAILS.
The nails become affected in many diseases, as
236 MANUAL OF DISEASES OF THE SKIN.
unknown ; it is most common in the negro race, and
in the same family some children may be very black
and others perfect albinos. It also occurs partially
in the negro as a congenital condition ; when devel-
oping subsequently its condition belongs to that
next described,
2. Leucoderma. Synonyms: Vitiligo; Leuko^
pathia acquisita ; Cutis variegata; Acquired leucas-
mus ; Piebald skin. This consists of an irregular dis-
tribution of the pigment matter of the skin, whereby
smooth, rounded, white patches of varying size and
extent are produced, surrounded by an area in which
the pigment is augmented. The surface is devoid
of scales and on a level with the surrounding integu-
ment, and there is no abnormal sensation experi-
enced in the parts. Their most common location is
upon the backs of the hands and fingers, and on the
neck, though any region of the body, or a consider-
able portion of it, may ultimately be affected ; these
cases are often exhibited in museums as " spotted
men.*'
Diagnosis. — It is to be distinguished from chlo-
asma^ tinea versicolor y and morphcea. It has no con-
nection with leprosy, although it has sometimes
been described as white leprosy ; nor has it any re-
lations to syphilis, although the pigmentary syphil-
oderm may resemble it very closely.
Treatment, — The condition is a very rebellious
ATROPHIC AFFECTIONS, 237
one ; nerve tonics are mostly recommended, and I
have seen a very marked benefit from the use of
phosphide of zinc and nux vomica (Formula 71)
taken internally ; as the eruption sometimes varies
spontaneously, the real value of this cannot be yet
determined. Local applications of bi-chloride of
mercury and ammonia (Formula 45) certainly bene-
fit it greatly in many cases.
3. Canities. Synonym : Grayness of the hair.
The causes of the turning gray of the hair are en-
tirely unknown ; while it is a common sign of age,
the period at which the hair changes varies very
greatly in different individuals, and often appears to
be a family peculiarity. In many instances prolonged
grief and trouble cause it to whiten early, and un-
doubted cases are on record where sudden fright or
sorrow have caused the change to take place within
a single day. It is not very uncommon to have
tufts of gray hair over the track of nerves which
have been the subject of neuralgia ; the hair on
patches of leucoderma is usually white.
Although all signs point toward a nervous influ-
ence m producing the change, but little can be ac-
complished by treatment in the way of restoring the
normal condition.
B. ATROPHIES OF THE CORIUM.
Two affections are recognized here, atrophia otitis^
238 MANUAL OF DISEASES OF THE SKIN.
from idiopathic causes, occurring in various forms
and conditions ; and atrophia senilis.
I Atrophia cutis. Atrophy of the skin may
occur in three forms: first, as a more or less general
condition such as occurs in connection with certain
other disease states, and also following injury of
nerves, the glossy skin of writers. Atrophy may ap-
pear as a symptomatic condition in parts which have
been greatly distended, as in the linice albicantes,
seen on the abdomen after pregnancy and tumors,
also on the breasts, and on anasarcous legs. It also
occurs as an idiopathic condition without known
cause, constituting the strict atrophicce^ and maculce
atrophiccB ; these appear as separate, white, slightly
depressed spots, long or rounded, exhibiting evident
atrophy of the deeper structures, and may be found
in any situation.
2. Atrophia senilis. Senile atrophy of the skin
is mainly important as being a factor in the causa-
tion of the pruritus which is common in old age.
The senile alterations which take place in the integ-
ument are characterized by thinning of the whole
skin and atrophy of the papillary layer, alteration in
the sebaceous glands, and a diminution in the elas-
ticity and extensibility of the skin.
C. ATROPHIES OF HAIR.
Four states are located in this group, ordinary
ATROPHIC AFFZCT:::rz ---
alopecia^ alopecia areata^ iht curi:>i:r ilit:rc,ii'jz. iiiii^v::
as trichorexis nodosa^ andyVjz^'^Tiz: mnivm.
I. Alopecia. Synonymsi AUferia ziil^jri: ; Zri-
cJwrrhcea; Defiuvium capUlorum. BELldr.t:i= my re-
sult from many different causes, Kzt t3:h;b:t= difTtr-
ent characteristics accordingly : it ullv be spcktr
.A
of as s3rmptomatic and idiopathic.
Symptomatic baljjness. — The hafr iravf^:: as a
result of severe sickness, and also after pre^.anc>%
and as a consequence of a number of diseas-es ~Ahich
affect the scalp ; these are syphilis^ erysipelas, £cz£via^
psoriasis^ seborrhxa^ favus^ and ringzvorm^ also any
ulcerating disease, as lupus. In addition to the loss
of hair caused by ulcerating lesions, there are tvvo
periods at which syphilitic alopecia is met with ;
first, during the earlier stages, in conjunction with
general eruptions, iritis, etc., and second, during a
later period, from the cachexia sometimes observed,
accompanied with seborrhoea. The hair lost early in
syphilis, and in consequence of erysipelas and acute
eczema of the scalp, also from psoriasis, tends to re-
turn as these are removed. The most fertile cause
of baldness is seborrhoea, and also a low grade of
chronic eczema ; both manifest abundant scales or
dandruff, those of seborrhoea are more greasy, while
in eczema there is commonly considerable itching.
Long continued favus is very prone to leave per-
manent baldness by destroying the follicles, causiiHj
240
MANUAL OF DISEASES OF THE SKIN.
scarring ; ringworm seldom does more than to tem-
porarily destroy the hair.
Idiopathic baldness. — This results from failure
in the hair producing powers of the follicles, and
that which is a natural event in advancing age, may
occur as disease during early years. Premature loss
of hair is common in some families, as also early
fuming gray, and where this strong hereditary tend-
ency exists it is very difficult to arrest the falling or
to restote that which is lost. The history in the
family of early falling of the hair, however, need not
always indicate an unfavorable prognosis, because
each case may have been due to causes which were
remediable.
Etiology, — Debility and dyspepsia, either directly
or through the agency of squamous eczema or
seborrhoea, are the most frequent causes of early
loss of hair, together with the absence in the food of
the phosphates found in whole wheat. Continuous
and severe mental application, likewise severe nerv-
ous strain can also cause the hair to fall.
TreaUnent. — Symptomatic baldness is treated by
measures suited to the condition present, and by
the subsequent use of stimulating hair lotions (For-
mulae 49, 50, 51). Where cicatricial tissue has
formed, ail efforts are of course useless. It is very
important to determine whether slight, chronic ec-
zema is present, or seborrhoea, for unless these con-
ditions are recognized and treated properly but little
permanent gain will result.
TROPHIC AFFECTIONS. 24I
L 2. Alopecia areata. ^yuGnyva^: AreaCdsi; Por-
iHgo decalvans ; Tinea decalvans ; Pelade. This is
characterized by the appearance upon an otherwise
apparently healthy scalp of one or more sharply de-
fined, perfectly bald, smooth, white, and shiny spots,
which may remain and increase in size, or slowly re-
gain their normal condition by a growth of fine
downy hair. The disease usually appears very sud-
denly, and often on awaking in the morning the
patient or friends will discover a spot, generally
roundish, completely devoid of hair, of a size vary-
ing from half an inch upward in diameter. The
most common seat for the first appearance of the
disease is either parietal region, or the top of the
head. The beard may also be affected either pri-
marily or later in the disease. The condition may re-
main stationary for a considerable period, or may
advance rapidly or slowly, even until every hair is
removed from the entire body. In certain rare cases
all the hair of the scalp will be loosened at once and
come out with the slightest touch at any point.
Etiology. — The cause of the falling of the hair
must be looked upon as neurotic, although opinion
is still divided as to its true nature. Many have con-
sidered it to be caused by a vegetable parasite, to
which the name microsporon Audouini has been
given; repeated and careful studies by competent
observers have failed to find the fungus, and the
parasitic theory is abandoned by most recent writers.
242 MANUAL OF DISEASES OF THE SKIN.
After repeated and thorough search I have never
been able to find the parasite ; the youngest patient
I have seen affected is a girl of six, the oldest a man
of fifty-four.
Diagnosis. — The only eruption liable to be mis-
taken for alopecia areata is tinea tonsurans .* as a
rule this presents the symptoms described, but oc-
casionally will exhibit quite bald and smooth
patches, much resembling the disease under consid-
eration, and the question arises whether the tricho-
phytic disease may not by nerve irritation induce
true alopecia areata.
Treatment. — Internal treatment has very little
immediate effect, but should never be neglected ;
it should always be tonic, with especial reference to
the nervous system (Formulae 55, 60, 64). Phos-
phates should be supplied in the diet, as in bread
from the whole wheat ; also fats. The local treat-
ment is embraced in the single;word stimulation :
small patches may be blistered with advantage;
where a large surface is involved stimulating
lotions (Formulae 49, 50, 51), are applicable, in-
creased in strength, with acetum cantharidis until
their action is severe. Sulphur ointment, well rub-
bed in, is also a good application. Injections
under the skin of the nitrate of pilocarpin, one-
tenth grain every few days, will sometimes act won-
derfully well.
Prognosis. — This should always be guarded, as
ATROPHIC AFFECTIONS.
243
occasionally the disease will prove most rebellious
even for years.
3, Trichorexis nodosa. This consists of a pe-
culiar alteration in the shaft of the hairs, whereby
nodosities, of a whitish appearance, occur singly or
at intervals along the hair; the hair is liable to
break at these swellings, and the ends have a brush-
like appearance. It is most common on the mous-
tache, and beard, but has also been observed on the
scalp. It is not parasitic.
Treatment. — Repeated shaving and inunction with
the oleate of mercury, five per cent, solution, affords
the best prospects, but often the disease proves
very rebellious, the nodules reappearing as soon as
the hairs attain sufficient length. Constitutional
treatment has little if any effect.
4. Fragilitas crinium. Synonym: Atrophia pU
larum propria. In this the hairs fracture easily, gen-
erally breaking only in part, then stripping down
the shaft. In other instances they break at their
exit from the skin, and the illy-growing hair irritates
the follicle.
A number of other curious mis-growths of the hair
have been reported, which cannot be noticed here :
not very infrequently it will be seen to curl itself up
just beneath the epidermis, and sometimes cause
considerable irritation.
244 MANUAL OF DISEASES OF THE SKIN.
m
D. ATROPHY OF THE NAIL.
Atrophy of the nail is generally due to diseases
affecting the skin extensively, or the region of the
nails alone; it may also appear independently of
other disorder than an imperfect formation of nail
substance.
Onychatrophia. Synonyms: Degeneratio un--
guium ; Mollifies unguium. In psoriasis the nails are
apt to be covered with little pits or apparent
erosions ; in eczema they may be mal-formed, and
either thin or thickened. In phthisis the nails are
thin and apt to be curved. As an idiopathic con-
dition we occasionally find the nails thin, fragile,
and easily split when buttoning the clothes; in
other cases the nail is furrowed lengthwise. After
severe sickness an atrophic furrow appears as the
nail is growing out, corresponding to the date and
duration of the illness.
CHAPTER XIX.
CLASS VIII. NEOPLASMATA. — NEW FORMATIONS.
Two subdivisions occur in this class, relating to,
I. Benign new formations, and, II. Malignant new
formations ; these differ more in their clinical fea-
tures and tendencies than in any pathological char-
acters. They are all characterized by a deposit of
elements which may correspond with the normal
tissues of the skin, as connective tissue, blood vessels,
lymphatic tissue, etc., or of cellular elements which
destroy the life of the part and produce scars.
/. Benign New Formations.
The diseases in this division give trouble by
their presence and unsightly character rather than
by any tendency to cause great pain or to destroy
life ; eleven diseases are thus classed in six sub-
groups : New formations, A, of connective tissue ;
B, of fatty tissue ; C, of granulation tissue ; D, of
blood vessels ; E, of lymphatics ; F, of nerves.
A. NEW FORMATIONS OF CONNECTIVE TISSUE.
Three diseases are grouped here, keloid^ fibroma^
and xanthoma.
245
246 MANUAL OF DISEASES OF THE SKIN
1. Keloid. Synonyms: Kelts; Cheloid ; Chelo^
idea. This is a flat or rounded new growth of
connective tissue, smooth and firm, generally of a
reddish color, and of various shapes, usually pre-
senting claw-like projectipns, and bearing much re-
semblance to the cicatrix from a burn. Writers
have often spoken of a spontaneous or true, and of a
cicatrical or false keloid ; it is questionable if in
every instance the disease does not arise from trau-
matism, although individuals vary greatly in their
tendency to the production of this new growth. It
is observed to follow all sorts of injuries, also se-
verely ulcerative affections, syphilitic and other,
although generally the traumatic cause is unrecog-
nized ; the front of the chest is a favorite location.
It is more common, and apt to be larger in negroes
than in the white races. The cause is unknown.
Diagnosis. — This is usually simple, owing to the
peculiar features belonging to the disease ; it is dis-
tinguished from ordinary scars by its tendency to
spread slowly, and by pricking pains which generally
occur.
Treatment. — No treatment is of much, if any, avail ;
destruction or removal in any way is generally fol-
lowed by reproduction of the disease.
2. Fibroma. Synonyms : Molluscum fibrosutn ;
Molluscunt simplex ; Molluscum pendulum. This con-
sists of soft, roundish tumors, of various sizes, either
NE W FORMA TIONS.
247
.pedunculated or imbedded in the skin, and of the
color of the normal integument, unless when irritated
or inflamed. There may be a single one, or multi-
tudes ; over three thousand have been observed on a
single person. In some instances they have long
pedicles and occasionally may attain great size ; they
consist of connective tissue with more or less serous
and mucoid elements.
Diagnosis. — The tumors differ from acne mollus-
cunt in being solid, and having no central opening;
fatty tumors or lipomata are apt to be lobulated and
more flat ; sarcomata are more round and solid.
Treatment, — Removal by excision or ligature.
3. Xanthoma. Synonyms : Xanthelasma : Vitili-
goidea : Fibroma lipomatodes. This is characterised
by the presence of one or several spots or patches of
yellow or buff-colored tissue, either on a level with
the skin or slightly raised, smooth and velvety on
the surface. It is most commonly seen upon the
eyelids, in patches of varying size and shape, but
may also affect many portions of the body ; it is
fnuch more frequent in females than males, and is
rare in children.
Two forms of the eruption are spoken of, xan^
thoma planum, and xanthoma tuberosum ; in the for-
mer, the new deposit is evenly disposed, and in the
latter, gathered more into small nodules or points ;
in a very striking case still under my care the
248 MANUAL OF DISEASES OF THE SKIN.
nodules exist in considerable numbers on the el-
bows, and moderately below one knee, while on all
the lines of flexure of the hands the yellowish de-
posit is in streaks quite on a level with the skin.
Etiology, — Liver disorder is thought to be a cause,
as jaundice has been observed to precede the erup-
tion in a certain number of cases ; the connection
and true causation is still doubtful.
Diagnosis, — The lesion can hardly be mistaken,
there is no other which resembles it.
Treatment. — Excision, where practicable, offers
about the only means of cure ; where the disease is
recent and progressing with evident liver disorder,
as in the case of xanthoma multiplex y the latter should
receive careful and thorough attention.
B, NEW FORMATION OF FATTY TISSUE.
Lipoma. — Fatty tumors belong rather to the sub-
cutaneous tissue than to the skin proper, but they
are introduced here because of their frequent im-
portance diagnostically. They are characterized by
their indefinite outlines, their soft and flabby feel,
and their mobility with the skin, which is normal
over them ; they may be of any size, and are seldom
abruptly elevated.
Diagnosis. — Lipomata may be mistaken for car-
cinoma, lym^phangioma, sarcoma, and a syphilitic
gumma.
NE W FORMA TIONS.
249
C. NEW FORMATIONS OF GRANULATION TISSUE.
This group embraces three diseases, lupus, scrofu-
lodermUy and rhinoscleroma ; these approach closely
to the second division, namely, malignant new for-
mations, in their pathological features, as well as in
their occasional destructive tendency.
I. Lupus. The two conditions, lupus erythema-
tosus znd lupus vulgaris, which are classed under this
name, differ from each other in so many respects
that it is desirable to treat of them quite separately.
Lupus erythematosus. — Synonyms : Lupus ery-
thematodes ; Lupus sebaceus ; Seborrhcea congestiva;
Scrofulide erythemateuse. This is characterized -by
the presence upon the skin of one or more patches
of infiltrated tissue, presenting congestive redness,
and of a smoked-ham color, tending to become cov-
ered with grayish brown, adherent scales ; upon the
forcible removal of the scales from patches occur-
ring upon the face, they are found to have prolonga-
tions from their under surfaces, which extend into
the ducts of the sebaceous glands, which are thus
left gaping, giving much the appearance as though
a needle had been thrust into reddened wax.
The beginning of the disease is often so slight
that a correct diagnosis cannot be made ; there is
only a rather dusky, generally circular, erythema-
tous point or patch, which persists in spite of medi-
II*
250 MANUAL OF DISEASES OF THE SKIN.
cation, gradually thickens, and becomes scaly, ac-
companied with occasional pricking sensations; it
is always dry from beginning to end. The most
common location is the face, and especially the nose
and cheeks, although the disease may attack any
portion of the body ; the eruption may involve a
considerable region by extension, or by the appear-
ance of new spots; in certain rare cases the
disease may develop rapidly over a considerable
extent, and even be accompanied with constitu-
tional and febrile conditions.
Pathology, — While in the fully developed disease
there is found cell infiltration which leads to destruc-
tion of tissue and scarring, the earliest phases ex-
hibit mainly the phenomena of inflammation ; it was
once thought that the disease originated in the se-
baceous glands, hence the name first proposed by
Hebra, sebarrhcea congest iva, but recent investiga-
tions have shown that it may begin in other struc-
tures as well.
Diagnosis. — The eruption is liable at times to be
mistaken for lupus vulgaris ySeborrhoea, chronic eczema ^
psoriasis y erythema multiforme {circinatum), ringworniy
syphilis, and non-eroding epithelioma. In rare cases
erythematous lupus develops into lupus vulgaris, but
commonly is distinguished from it by the absence
of the pulpy tubercles belonging to the latter.
Treatment. — Lupus erythematosus is always a re-
bellious disease, and is very little affected by inter-
NE W FORMA TIONS.
251
nal medication ; phosphorus will sometimes act very
favorably, iodide of starch (Formula 75) has also
been recommended. Local treatment is of most
service, but also often proves insufficient to remove
the disease, and cannot prevent the development of
new patches. The treatment is stimulating, sooth-
ing measures having but little effect. Soapy solu-
tions or those of caustic potash (Formulae 16, 38, 39)
well rubbed in are most highly recommended ; they
often cause considerable inflammation, but are fol-
lowed by absorption. The emplastrum mercuriale
(Formulae 18, 19) is also of value. Erasion, or
scraping with the sharp spoon, is an effective plan
of treatment, as also multiple scarification, repeat-
edly employed ; the actual cautery produced by
Paquelin's apparatus, or by galvanic action, is also
of service.
Lupus vulgaris. — Synonyms : Lupus exedens ;
Lupus tuberculosus; Lupus hypertrophicus; Noli me
tangere; Scrofulide tuberculeuse. True lupus is rare in
this country, but twenty-five cases occurring in the
8,000 analysed, orabout three per thousand ; tubercu-
lar syphilis which may simulate lupus, and to which
the term syphilitic lupus is sometimes given, is ex-
cluded ; true lupus has no connection with syphilis.
Lupus vulgaris consists of a new deposit of cellu-
lar elements, forming reddish or brownish masses,
which are soft and pulpy, more or less translucent,
and are followed by cicatrices. The cellular deposit
252
MANUAL OF DISEASES OF THE SKIN,
may be in distinct papules or tubercles, or, as is fre-
quently the case, may infiltrate larger portions ; in
older cases an evenly affected surface is often seen,
interspersed with cicatricial bands, and covered with
epidermal scales of some size, firmly attached on
one edge, or more rarely with crusts over some por-
tions. Many of the cases presenting great ulcera-
tion and destruction of tissue, formerly called lupus
exedens, and noli me tangere, touch me not, are now
recognized to be epithelioma or rodent ulcer, and
syphilis. True lupus is very rebellious and may
cause disfigurement and distress, but very rarely
makes the inroads described in older books as be-
longing to the disease, whence the Latin name lupus,
a wolf, was derived. It is most commonly seen upon
the face and extremities ; it generally commences
in young life, before twenty, and rarely, if ever, be-
gins after fifty years of age.
Diagnosis, — Lupus vulgaris is most frequently con-
founded with tubercular and gummy syphilis, also
with lupus erythematosus and epithelioma; it should
never be mistaken for other eruptions. The history
and the rapid development of the lesions of syph-
ilis, together with their characteristic grouping, their
tendency to heal and reappear, and the crusts gen-
erally seen, should suffice to distinguish the syphi-
litic eruption.
Treatment, — This is frequently very unsatisfac-
tory ; internal measures have comparatively little
NEW FORMATIONS, 253
efiFect, but every element should be attended to look-
ing toward improved health and nutrition. Cod-
liver oil is often of some service, also phosphorus
and iodide of potassium. Local measures, to be
effectual, must be energetic ; the disease itself pro-
duces scarring, and the object of treatment is to de-
stroy diseased tissue and to substitute healthy inflam-
matory action for disease. Nitrate of silver in stick,
thoroughly bored into the nodules until healthy tissue
is reached, is one of the best measures ; the surface
is to be covered with picked lint, which dries into a
crust and falls off in some days ; any remaining disease
should be immediately attacked anew. Caustics in
paste or ointment, as arsenic and red iodide of mer-
cury (Formulae 12, 15) answer if efficiently applied,
but are slow and painful ; also acetate of zinc in
crystal, and chloride of zinc. The actual cautery,
erasion with the sharp spoon or curette, and mul-
tiple scarification are also of great service in the
treatment of lupus.
3. Scrofuloderma. While lupus is often seen in
strumous patients, and by many is regarded as a
scrofulous affection, this is not always the case ;
the present term is employed to represent other
changes in the skin and subcutaneous tissues than
lupus, which are observed in those exhibiting more
clearly the marks belonging to that illy defined but
still practically acknowledged condition or state
called scrofula or struma.
254 MANUAL OF DISEASES OF THE SKIN.
The most common form of disease is that ob-
served to take its origin from lymphatic glands, as
when they become enlarged and suppurate beneath
the jaw, or in the region of the clavicle ; here the
resulting cutaneous ulceration is of a purplish red
color, with undermined edges and indolent, granu-
lating base, bleeding easily, with a sero-purulent dis-
charge, often coming from a sinus communicating
with the ulcer. A rare form of scrofulous disease is
seen in the form of rather hard, dark red elevations,
sometimes verrucous in character, tending to ulcerate
and to become covered with crusts ; at times they
are fungoid and give exit to sero-purulent discharge.
Diagnosis, — The exact conditions of disease of
the skin which are to be grouped under the name
scrofuloderma are by no means well defined as yet,
and differentiation is to be made rather by exclusion
than by peculiar features which are entirely charac-
teristic. These lesions mostly resemble syphilis^
lupus ^ and epithelioma.
Treatment. — The most careful and complete treat-
ment for the scrofulosis is that most appropriate for
the diseased skin, with such remedies as cod-liver
oil, iron, lime, etc. Locally the preparations of
iodine, as the compound iodine ointment, aid absorp-
tion ; mercurial ointments (Formulae 92, 93, 102, 103)
are also of service. The process tends to produce
scarring, and if left to itself is very tedious ; the
earlier that radical measures are undertaken the
NE W FORMA TIONS,
255
better ; erasion with the curette is often the best
method of treating the strumous deposit.
3. Rhinoscleroma. This curious affection, which
is almost unknown in this country, was first de-
scribed by Hebra and Kaposi in 1870. It consists
of a very hard, dense formation about the nose and
its immediate neighborhood ; the surface is either of
normal color, or of a light or dark, brownish-red
shade, and may be either flat or raised into promi-
nences ; it has little or no tendency to ulcerate, and
heals kindly, but is reproduced, after destruction or
excision. The mass gives little trouble except by
its increased growth, but is somewhat painful when
pinched. It has no connection vjith syphilis, and is
quite distinct from epithelioma and lupus.
Treatment. — This is extremely unsatisfactory ; Ka-
posi states that no successful method of treatment
has been found. He had observed twenty-five
cases.
D. NEW FORMATIONS OF BLOOD VESSELS.
Two diseases are placed in this group, ncevus vas-
culosus and telangiectasis.
I. Nsevus vasculosus. Synonyms: Ncevus san-
guineus; Claret stain; Port-wine mark; Mother's
mark. This coiftists of a new growth of blood-ves-
sels, congenital or appearing shortly after birth, pre-
256 MANUAL OF DISEASES OF THE SKIN.
senting various appearances. It may be a mass of
larger vessels, and form a tumor of a round or oval
shape and of varying size and height ; or it may be
composed only of smaller capillaries and be level
with the surface. The latter constitutes what is or-
dinarily known as port-wine mark or claret staitiy
called also mother's mark and birth mark^ and may
vary from a trifling disfigurement to a hideous de-
formity, covering much of the face or even of the
body. The color varies from an arterial red to a
bluish purple. In larger naevi pulsation is often very
distinct.
Treatment. — Larger cavernous naevi requires sur-
gical operation, or they may be treated by electroly-
sis, with the introduction of needles connected w;ith
the negative pole into them, the positive pole being
placed above. . Superficial naevi may be destroyed
with caustics or with the actual or galvanic cautery.
Multiple scarification, electrolysis, and multiple punc-
ture, with the introduction of carbolic or chromic
acid, have also been used with success.
2. Telangiectasis. In distinction from congeni-
tal vascular new growths or naevi, this term is ap-
plied to those which appear later, generally in early
adult life. Various forms and degrees are observed ;
the slightest is that appearing generally about the
face as a minute red dot from which several small
vascular lines radiate, the ncevus araneuSy or spider
NE W FORMA T ION'S.
2S7
ncBvus, After lesions which produce cicatrices there
is frequently a telangiectasic condition of the capil-
laries, which are tortuous and dilated. This state is
often seen upon the nose and cheeks in connection
with acne rosacea, and to this the term rosacea alone
has been applied. Varicose veins also belong in
this class.
Treatment. — Naevus araneus may be easily re-
moved by boring into the central vascular point
with a caustic: a convenient method is to use a
sharpened match dipped in mono-chloro-acetic acid.
The enlarged veins on the face may be obliterated
by slitting them with a knife, and cauterizing their
course with a stick of nitrate of silver ; electrolysis
is also valuable.
E. NEW FORMATIONS OF LYMPHATICS.
Lymphangioma. Synonym : Lymphangioma tu~
berosum multiplex. This very rare affection consists
of the production of many, small, rounded or oval,
brownish-red nodules, slightly painful on pressure,
and firmly embedded in the corium. These are
found microscopically to present circular or oval
spaces, identical in structure with dilated lym-
phatics.
The cases described by French writers as " lym-^
phacUnie cutan^e " are now thought to be forms of
sarcoma.
17
258 MANUAL OF DISEASES OF THE SKIN.
F. NEW FORMATIONS OF NERVES.
Neuroma cutis. This term lias been applied to
a very rare affection characterized by small, firm,
flattened tubercles, packed together or irregularly
disseminated, which may be of the color of the skin,
or a little reddened, and presenting a roughened
surface. Beginning with itching, the later develop-
ment is attended with pain, which is paroxysmal
and very severe, radiating from the part ; movement
or pressure, also exposure to cold air and change of
season, excite the attacks of pain. In other in-
stances a single " subcutaneous painful tubercle " ap-
pears. *
Treatment, — Excision of the nerves leading to the
part has given much relief ; all other measures are
only palliative.
//. Malignant New Formations,
Four diseases are grouped here, each presenting
several clinical phases, all marked by their malig-
nant character, tending in the end to destroy life ;
these are, lepra, carcinoma, epithelioma, and sarcoma.
I. Lepra. Synonyms: Leprosy; Elephantiasis
Grcecorum ; Leontiasis. Leprosy is a constitutional,
malignant disease, characterized by the occurrence
of cellular deposits in the skin and other tissues,
producing changes which tend to destruction and
death. Leprosy is endemic in certain countries,
NE W FORMA TIONS, 259
especially in Asia and the islands of the sea, also in
some sections of Europe, as Norway, and also in
portions of South America ; it is very rarely seen in
this country, and generally in persons who have fre-
quented affected countries, although well marked
fatal cases have occurred in the United States with-
out any connection with other regions. The disease
is frequently known as elephantiasis Grcecoruniy but
it should be clearly distinguished from the elephan-
tiasis ArabufKy previously described, with which it
has no connection whatever.
Three forms or varieties of leprosy are spoken of,
lepra maculosa, lepra tuberculosa, and lepra ancesthet-
tea, but the disease is identical in every instance,
and all forms may appear in the same individual ;
the tubercular form often commences with macules,
and all cases exhibit more or less anaesthesia.
Lepra maculosa makes its first appearance in
the form of macules, or with occasional bullae ; the
macules are at first red, slightly elevated, and with
illy-defined margins; later they become brownish-
red, and as they enlarge tend to clear in the centre;
still later they may present an atrophied condition^
and the eruption then exhibits pale patches, an inch
or so in diameter, round or oval, with a slightly ele-
vated, dark, brownish-red, or ham-colored margin
of considerable breath, shading insensibly into the
normal skin. During their entire course the ma-
cules have an infiltrated appearance ; there is apt to
260 MANUAL OF DISEASES OF THE SKIN.
be hyperaesthesia first, and anaesthesia later: the
first sensation may be as though a hair lay on the
surface, tickling it. Still later, marked anaesthetic
symptoms and tuberculous deposits appear, as next
described.
Lepra tuberculosa. — Tubercular leprosy is the
form most commonly encountered ; here irregular
masses form within the tissues, which may be from
the size of a pea to that of a large nut or larger, of
a yellow, and later of a brown color. These are apt to
develop first in the lobes of the ear and the nose, next
on the forehead and lips ; the term leontiasis has
been applied to the appearance thus presented, from
a supposed likeness to a lion's face. In later stages
the tissues of other parts become the seat of similar
deposits, which may also affect the mucous mem-
branes, and the eye.
Lepra an^sthetica. — This form is seen most
commonly in countries where the disease is en-
demic; the nervous tissue appears to be first af-
fected, and tickling and burning sensations are felt,
with pain; thickening of the nerves also occurs,
which can be especially felt along the ulnar nerve.
Macular patches and perhaps bullae appear, and
shortly the tissues of the fingers and toes become
thickened and the parts feel numb ; ulceration now
readily occurs and the phalanges separate and are
lost one by one, without pain, the stumps healing
perfectly {lepra mutilans). The process may go or
p
i
i
NEW FORMATIONS. 261
to the removal of all the fingers and toes, and even
of the feet and hands ; or the parts may become
shrunken and distorted.
Diagnosis. — Leprosy may most frequently be mis-
taken for ^y/A/Zw, also ioT lupas ; the occasional biilliE
might suggest pet»/iAigus, and the whitened patches
with dark borders resemble leucoderma or morpkaa;
a distorted hand might resemble scleroderma. When
fully developed it can hardly be mistaken.
Patlwlogy. — -The lesions consist of new deposits of
cellular elements resembling those in lupus and
syphilis ; the nerves are found to be swollen and
darkened, mainly by new deposit in their sheaths, the
pressure of which accounts for the nerve symptoms,
Prognosis. — This is always bad ; treatment has ef-
fected but little in staying the progress of the dis-
ease, even in other lands than where it is endemic;
it may last three, five, ten, or even more years be-
fore the patient succumbs. While in foreign coun-
tries it is found mainly among the lowest classes,
the cases met with in this country are often in good
circumstances; but the best of care accomplishes
but little. While leprosymaynot be communicated
by ordinary contagion, the experience in other lands
shows that it is desirable to segregate lepers ; there is
no doubt in regard to its transmission by heredity.
Reported cases and statistics show that the disease
is certainly on the increase in the United States,
Treatment.— \n addition to the best dietetic and
262 MANUAL OF DISEASES OF THE SKIN.
hygienic management, and the treatment of symp-
toms as they arise, powerful tonics, especially qui-
nine, have some control over the disease. Special
drugs have also been found of service by different
observers, but have as often failed ; these are chaul-
moogra oil, internally and externally, gurgun balsam,
the oil of the cashew nut, and hokng nkn.
2. Carcinoma cutis. Cancer of the skin com-
monly arises as a secondary deposit in connection
with cancer of other organs, chiefly of the breast. It
is characterized by the appearance in the skin,
especially on the chest, of small, very hard masses,
of a pinkish or brownish red, with some hardening
of the tissues between ; the little kernels are pain-
ful when pressed on.
Another form is presented as a diffuse induration
of the integument, more commonly first seen on the
chest, exhibiting when fully developed a hardened
and somewhat contracted, and shiny skin, with or
without separate nodules, the so-called cancer en
cuirasse. This may extend and so press upon the
blood vessels as to cause oedema of the arms and
much pain.
Carcinoma melanodes, or melanotic cancer, is a
malignant form of disease often starting from a
pigmentary mole, which forms fungating, bleeding
masses ; other organs, often almost the entire sys-
tem, may be later infiltrated with the disease.
NE W FORMA TIONS. 263
Diagnosis. — The diffuse forms of cancer are liable
to be mistaken for scleroderma.
Treatment, — This is at the best but palliative.
3. Epithelioma. Synonyms; Epithelial cancer ;
Cancroide; Rodent ulcer. The forms and appear-
ances of epithelioma in different degrees and stages
vary so greatly that those unacquainted with the
disease may fail to appreciate the lesion ; cases also
differ very greatly in their malignity. The begin-
ning is always very small, and commonly its real
nature is not recognized until it has lasted some
time ; the disease may start from a mole or wart, or
from a hardened sebaceous concretion, or begins .un-
recognized as a scaly patch, which exhibits a raw
and frequently slightly bleeding surface, whenever
the crust is picked or rubbed off. Soon greater in-
filtration is manifested and more ulceration ; in the
progress of the disease small pearly tubercles, hard
and cartilaginous are often formed, which break
down on their summits and form ulcers. The edge
of an epithelioma generally becomes hard and ele-
vated, the ulcer extends and deepens, and great de-
struction of tissues, even of the bones may result
{rodent ulcer). Upon the lip the disease, beginning
in a very insignificant raw spot, may increase to such
an extent as to present a fungous mass of granula-
tions; in occasional instances large areas of skin
may be occupied by the disease.
264 MANUAL OF DISEASES OF THE SKIN.
The face is the most common seat of epithelioma,
but no portion of the body is exempt ; the lower
lip is most frequently attacked, also the region of
the eyes and the nose. The male and female geni-
tals are also common locations, and the tongue and
mucous membrane of the mouth are not rarely af-
fected ; the process may attack old ulcers of the
leg.
Pathology. — The disease is to be looked upon as a
perverted growth of epithelial elements of the skin ;
the " epithelial nests ** are compacted masses of cells,'
arranged like the layers of an onion.
Diagnosis. — In its beginning, when there is only a
slight scaly patch, with a little viscid secretion or
slight bleeding beneath, epithelioma may be con-
founded with eczema and horny seborrhoea. Later, it
may be mistaken for lupuSy the lesions of syphilis^
and venereal zvarts ; many cases, formerly called
lupus, under the title noli me tangere, are now recog-
nized to be epithelioma. Upon the lip and mu-
cous membranes the disease may resemble a chancre^
or a mucous patch.
Prognosis. — This must vary greatly with the case ;
if taken early and treated radically, the disease
may generally be cured ; old, extensive, and neg-
lected or badly treated cases are always very unfavor-
able. In some instances it runs a rapid and very
destructive course ; the glands are seldom affected as
in cancer, even in severe cases.
NE W FORMA TIONS. 265
Treatment. — This must be as early and radical as
possible, and consists of complete and thorough re-
moval of the diseased tissue by surgical operation, or
deep and perfect destruction by means of caustics ;
scraping with the curette has been advised, but often
fails to reach deeply enough to remove all the dis-
ease. Various caustics may be used, chloride of
zinc, caustic potassa, or Vienna paste (Formulae 13,
14, 16), or other which destroys deeply; the one I
prefer is the arsenical paste as used by Marsden
(Formula 10) in the London Cancer Hospital. This
consists of equal parts of powdered arsenious acid
and gum acacia, which are mixed into a thick paste
at the time of using, with a few drops of water. It
is to be laid upon the part, freed from crusts, and al-
lowed to dry on, covered with a little cotton batting ;
after from six to twelve hours the part is poulticed
with flaxseed meal, with renewals every two hours
until the slough separates and the wound is healed,
the bit of cotton, saturated with the caustic,
being left adherent as long as possible. A second
application may be required, although seldom,
except in large or deep seated lesions ; not more
than one square inch of surface can be safely at-
tacked at once with the paste.
4. Sarcoma cutis. Sarcoma of the skin is a very
rare affection, but three cases occurring in the eight
thousand analyzed, all in males. It consists of few,
266 MANUAL OF DISEASES OF THE SKIN.
or many, well defined, elastic tubercles or tumors,
forming deep, rounded masses, with a tendency to
reach the surface and ulcerate. The skin over them
is, at first, of the normal color, and somewhat mov-
able, but as they approach the surface it becomes
adherent and reddened ; or, if the sarcoma is of a pig-
mented variety it acquires a bluish black hue (sar-
coma pigmentosum, or melanosis). The so-called
lymphadenomay ** lymphaddnie cutande " and " my^
costs fungoide " of the French, appears to be a
form of sarcoma, as, also, the disease described by
Geber and by Duhring under the name " inflamfna-
tory fungoid neoplasm'' ] the tumors in these latter
cases developed with great rapidity.
Diagnosis, — Sarcomatous tumors may be con-
founded with tubercular and gummy syphilitic de-
posits, cancer y lupus , leprosy y ^LnA fatty tumors.
Prognosis, — ^This is always most unfavorable ;
death usually results within two or three years.
Treatment, — Nothing can be done to check the
development of the tumors ; surgical interference
may be of service in particular situations.
CHAPTER XX.
DIET AND HYGIENE OF DISEASES OF THE SKIN.
The subject of the effect of diet upon the skin in
health and disease, is one which has been greatly
neglected in the study of Dermatology, and yet is
one which is of the utmost practical importance, and
which should receive the careful thought and obser-
vation of every physician. Hygiene is also of very
great consequence, both as regards the individual
and others. First, of diet.
All are more or less familiar with the acute ery-
thema, or urticaria, occasionally resulting from the
ingestion of certain varieties of fish, particularly
shell-fish, also, at times, from mushrooms, bananas,
strawberries, raspberries, etc. ; in some the eruption
will appear whenever these are eaten, in others, only
when the articles are stale, or when they themselves
are in a peculiarly susceptible condition. Gross in-
discretions in eating, as of mince pies, fruit-cake,
rich cheese, etc., often cause acne ; and many drugs
taken internally, such as iodine and bromine com-
pounds, copaiba, quinine, and others, frequently
produce cutaneous lesions.
In like manner, chronic errors in diet can induce
267
268 MANUAL OF DISEASES OF THE SKIN.
alterations in the skin nutrition, although the extent
to which this happens, and the manner in which it
occurs are by no means clearly defined as yet. As a
most striking illustration may be mentioned the ef-
fect of a deficiency in fresh vegetables in producing
scorbutus; alcohol and tobacco also undoubtedly
exercise a strong influence upon the skin.
The commonly accepted signification of dieting is
that of a famishing process, which is to be continued
for a longer or shorter period of time, with a view, as
it were, of starving out a disease. In the present
connection it has a much broader meaning, and sig-
nifies such a regulation of the quantity and quality of
food and drink taken, its mode of preparation and time
and method of its consumption as shall conduce to the
restoration and maintenance of health. Diet is un-
doubtedly of varying importance in different affec-
ions, and in different individuals, but to a certain
degree it is of importance in relation to every case.
Defective assimilation and disintegration are import-
ant factors in disease, and these defects are to be
remedied, not by medicine alone but by the regula-
tion of every element entering into nutrition.
Undoubtedly a healthy appetite and sound judg-
ment are good guides in the matter of diet ; but un-
fortunately every one does not possess one or both
of these, and the surroundings of modern society
often act very prejudicially. Not every one dis-
criminates between taste and appetite ; the taste is
DIET AND HYGIENE.
26g
gratified long after the appetite is satisfied, and sweets
and indigestible articles are often partaken of in ex-
cess.
Eczema has often been called the " keystone of
dermatology/' and a brief consideration of dietary
matters as related to this disease will throw light on
those of other inflammatory affections of the skin, as
it will be impossible, in the present compass, to con-
sider the diet of every disease separately ; we will
first notice errors in diet constantly observed in those
suffering from the disease in infant life.
In infants at the breast too frequent feeding is a
common cause of the aggravation of eczema if not
of its production ; the breast is given every time the
child cries, or is restless with itching, and this ex-
cites or aggravates the digestive disorder. The
time of feeding should be regulated, and the breast
not given oftener than every two hours, at the
least.
But, again, while the times of feeding may be cor-
rect, the nourishment may be erroneous from the
quality of the milk furnished, which again depends
upon diet. Those nursing eczematous children are
often found to be taking ale, beer, porter, wine, or
tea freely, to increase the breast milk ; these should
be prohibited and milk or gruel substituted.
Dyspepsia, constipation, or debility in the mother
are elements to be considered and rectified when
nursing children with eczema are being treated ; and
2/0
MANUAL OF DISEASES OF THE SKIN.
alkalies and tonics to the mother are often of great-
est service to the child.
Many infants with eczema are fed erroneously,
either conjointly with nursing or in place of it. Milk
is the best food, and yet the majority of infants take
starchy and saccharine substances, often in great ex-
cess ; frequently animal matter, in the form of eggs,
beef extract, etc., is given far too freely, while oc-
casionally it will be found that even very young in-
fants are fed from the table with the food of adults,
tea, coffee, cheese, pies, etc. Space forbids more
than brief allusion to this vast and very important
subject, but sufficient emphasis can hardly be laid
on the advantage of attending to the matter of diet
most stringently, as a necessary item in success-
ful treatment. The diet must also be carefully
watched in older children. Indeed, eczema at any
period of life requires care in this regard.
Eczema patients are generally found to dislike
fatty matter, whereas its use should be encouraged,
while other hydrocarbons, sugar and starch, are to be
diminished in the dietary. The fatty matter taken,
however, should not be in combination with other
substances, as in gravies, pastry, and fried articles,
but in the form of fat of beef and mutton, also but-
ter, cream, and cod liver or other oils. Where the
latter are not well tolerated by the stomach, they
maybe freely employed externally.
In regard to the diet of adults with eczema, dur-
DIET AND HYGIENE,
271
ing acute attacks it should be light and unstimulat-
ing, with but little meat ; while in chronic cases it
should be the most nutritious possible, and yet sim-
ple, all elements calculated to produce indigestion
or mal-assimilation being sedulously avoided.
In regard to the many substances which may enter
the dietary it is difficult to make exact statements ;
the matter must be guided on general principles,
but some of the more common articles may be com-
mented on.
Alcohol acts very prejudicially in very many skin
diseases, and should, as a rule, be avoided, unless in
the greatest moderati6n, and with the meals. Fer-
mented liquors are even more injurious, and fre-
quently it is impossible to cure the eruption while
they are indulged in ; the relative harmfulness of
some of the more common ones is about as follows :
ale, porter, champagne, lager beer, cider, port wine,
madeira wine, sherry, claret, white wine. Tobacco
is certainly hurtful in acne, and in eczema of the face
and anus, and is probably noxious in many other
affections.
Tea and coffee are seldom injurious if taken in
great moderation ; but tea is often used excessively,
and certainly does much harm in eczema, if not in
other eruptions.
Milk is often taken as a beverage with meals ; as
a rule, this is not well for adults, but if taken en-
tirely alone, and on a perfectly empty stomach, it
272 MANUAL OF DISEASES OF THE SKIN.
forms a most valuable means of improving nutrition,
and rarely disagrees. The preparations of malt are
well administered in milk.
Water may be quite as harmful as other drinks, if
taken in excess and too cold ; many cases of acne
are greatly aggravated by the inordinate use of iced
water with the meals, or at other times. Much
benefit can constantly be had by giving a cup of hot
water half an hour before eating ; the thirst is thus
quenched, and water with the meals can easily be
avoided.
Soup will frequently be found to cause the face of
acne patients to flush, and to Excite heat and itch-
ing in eczema ; rich, greasy soup is more apt to have
this effect, but with some patients all varieties will
produce the same results.
Fish is commonly supposed to be injurious and to
be interdicted in skin affections, because urticaria is
sometimes caused by shell-fish. On the contrary, fish
may very often be used with advantage in place of
meat in many skin diseases, especially those exhib-
iting nervous phenomena.
Salted meats and salted fish are rightly thought to
act prejudicially in skin diseases; they should be
avoided, as also pickles, olives, rich salads, stimulat-
ing sauces, pepper, etc. Hot breads are also injuri-
ous, likewise gravies, the skin and filling of poultry,
and richly made dishes.
Acids are generally not harmful, although when
DIET AND HYGIENE.
273
they come from unripe fruit they prove injurious ;
vinegar and lemons are rather beneficial in most
skin affections.
The use of certain articles of food requires to be
encouraged in certain diseases, of which mention
has been made of fresh vegetable products in scor-
butus, fatty matter in eczema and strumous erup-
tions, and also the whole wheat products in many
affections. Oatmeal, on the other hand, appears
often to be " heating," and patients with skin dis-
eases often do better without it. Mention was also
made of the avoidance of excess of sweets and
starches in eczema ; these are to be guarded against
sedulously by acne patients, and also by all those
exhibiting gouty tendencies. Sweet potatoes, cab-
bage, bananas, and apples often do harm to those
with inflammatory skin diseases.
Space forbids the developing of other practical
matters in reference to diet, such as the quantityy
preparation of food, and the time and mode of con-
sumption, but they must be looked after or errors
will occur. Very many eat excessively, others very
rapidly without sufficient mastication, others very
irregularly.
HYGIENE.
This relates to the individual and to others ; first,
as to personal hygiene. Exercise, rest, sleep, bath-
ing, occupation, and recreation are all items which
274
MANUAL OF DISEASES OF THE SKIN.
are often of importance in dealing with obstinate
skin affections. Sedentary habits, if not a direct
cause of, are often an obstacle to the cure of many
eruptions ; good brisk walking, several miles daily,
suffices, and is within the reach of nearly every one ;
while horseback riding, rowing, boxing, and fencing,
are all excellent adjuvants.
Proper care of the skin is also necessary, but over-
stimulation by the frequent use of the Turkish bath
frequently proves harmful. Occupation may be in-
jurious in many ways ; by the sedentary habits in-
volved, by bad air breathed, by poisonous or irrita-
ting agents employed, by irregular hours entailed, and
by circulatory derangements caused, as when long
standing produces varicose eczema, or stooping devel-
ops an acne rosacea. All these and other elements are
to be considered in connection with particular cases.
In regard to hygiene as related to others, this per-
tains to the contagious diseases. The "hygiene of
syphilis is all important ; the patient should be con-
tinually warned against the danger of communicating
the disease to others, as in connection, and by mu-
cous patches. Scabies, ringworm, and favus cases
should always be guarded against transferring the
eruption to others ; and in schools and public institu-
tions the most stringent precautions are often neces-
sary to check the spread of the disease. The protect-
ive measures relating to acute infectious diseases are
familiar to all.
CHAPTER XXI.
THERAPEUTICS OF DISEASES OF THE SKIN.
The only basis of rational and successful thera-
peutics is a thorough knowledge of disease and of
the action of remedies, separate and combined, and
accuracy of diagnosis is indispensable for the sue-,
cessful management of skin affections. The pre-
scriptions presented in this chapter are, therefore,
given with a view of suggesting lines of thought in
regard to the employment of remedies, rather than
as fixed formulae to be employed in every instance ;
individual cases vary so greatly that no absolutely
definite prescriptions can be given which are suited
for all, and the combinations here recorded must be
used with discretion and knowledge, and not simply
because the disease for which they are recom-
mended is present. In some instances varying
strength is indicated : in the main they are all in-
tended for adults.
BALNEA.
Baths are employed for the purpose of, i. Allay-
ing local irritation and inflammation ; 2. Softening
the skin and removing diseased products ; 3. Stimu-
275
276 MANUAL OF DISEASES OF THE SKIN,
lating the skin and promoting absorption ; 4. As a
means of acting on the general economy in quicken-
ing the processes of assimilation. Vapor, Turkish,
sulphur, and mercurial baths should not be used in
inflammatory states ; in the main more harm than
good is done by them ; in sluggish conditions they
may be of service in quickening the circulation. It
is needless to say that it is useless to attempt to
sweat out " impurities in the blood " by this means.
Medicated liquid baths should vary in tempera-
ture somewhat with the patient, the season, and the
effect desired; a tepid bath ranges from 85° to 92**
Fahr.; a warm bath, from 92° to 98° Fahr. ; and a
hot bath from 98° to 112° Fahr.; to be of much ser-
vice the patient should remain in the water from
fifteen to twenty-five minutes or longer, children a
less time, hot water being added if necessary, to pre-
vent chilling. The following formulae are calculated
for a bath of thirty gallons :
I. Balneum potassii et sodii,
Q Potassii carbonatis, J iv 124 41
Sodii carbonatis, ^ iij 93 30
Pulveris boracis, § ij 62 20
M. Use in a thirty (30) gallon bath, with half a pound of starch. Gelatin,
one pound, may be substituted for the starch, or bran, a pound or
two being soaked in a muslin bag.
UsB : Soothing and cleansing, in sub acute eczema, and psoriasis.
2. Balneum potassii et glycerincB.
"Bf Potassii acetatis, § vj — | xij 186161 — 373-22
Glycerinae, 5 viij 320I )
M. For a 30 gallon bath.
Usb: Soothing and antipruritic.
THERAPEUTICS OF DISEASES OF THE SKIN.
277
3. Balneum ammonia: et glycerina.
"Bf Spiritus ammonise aromatici,
Glycerinae, aa | viij 320
M. For a 30 gallon bath.
Use : Slightly stimulating and antipruritic.
4. Balneum acidi carbolici,
1^ Acidi carbolici, \ ss — J i j 15 — 30
Gelatinae, lb. j 373
Aquae, Oj j 960
M. For a 30 gallon bath.
Use : Stimulating and antipruritic.
5. Balneum acidi nitrici,
^ Acidi nitrici,
Acidi muriatici, aa | j 30
M. For a 30 gallon bath.
Use: Stimulating and antipruritic.
6. Balneum sulp hurts compositum,
"Bf Sulphuris precipitati, J i j 62
Sodii hyposulpnitis, §j 31
Acidi sulphurici diluti, § ss 15
Aquae, Oj 480
M. For a 30 gallon bath. (London Skin Hospital)
Use: Stimulating and anti-parasitic.
20
10
B,
M.
7. Balneum mercufiale,
Hydrargyri chloridi corrosivi, 3 iij 11 '66
Acidi hydrochlorici, 3 j 3 75
Aquae, Oj 48o|
For a 30 gallon bath. (London Skin Hospital).
UsB : Stimulating and anti-syphilitic.
8. Balneum iodinii.
^ Iodinii. 3 j- 3 ij 3'88— 7'77
Potassii iodidi, ? j- 3 ij 31 10 — 62 20
Aquae, Oj 48o|
M. For a 30 gallon bath.
UsB : Stimulating and absorbent.
278 MANUAL OF DISEASES OF THE SKIN.
9. Balneum brominii.
Vf Brominii, tlixx 1 12
Potassii iodidi, § ij 62 20
Aquae, Oj 480
M. For a 30 gallon bath.
Use : Stimulating and absorbent.
CAUSTICA.
Various caustics are of service in certain dis-
eases of the skin, but in the main they are compara-
tively seldom required : in employing a caustic to
destroy a new growth, care should be taken that it
is used sufficiently strong to accomplish the desired
result, otherwise further development is stimulated.
Nitrate of silver, the mineral acids, and mono-chloro-
acetic acid are all of lighter destructive power ; the
following may destroy deeply.
10. Causticum acidi arseniosi, (Marsden's paste. )
!^ Pulveris acidi arseniosi, •
Pulveris gummi acaciae, aa 3 j 3188
M. Mix a little with water at the time of using, and apply-
as a thick paste to a surface of not over one square
inch at once.
Use : Of especial value in epithelioma.
II. Causticum acidi arseniosi comp, (Cosme's paste.)
1^ Pulveris acidi arseniosi, gr. xx I 29
Pulveris hydrargyri sulphureti rubri, 3 j 9 88
Unguenti aquae rosae, 3 j 31 lO
M.
Use : Moderately destructive in lupus.
12.' Causticum arseniosi et hydrargyri,
"Sf Hydrargyri chloridi mitis, 3 iv I5 55
Hydrargyri bi-sulphureti, gr. viij 51
Acidi arseniosi, gr. xij 77
M.
Use : A moderate arsenical caustic of value in lupus.
THERAPEUTICS OF DISEASES OF THE SKIN,
13. Caustlcum acidi nitratis hydrargyri.
^ Hydrargyri, § j 31 lO
Acidi nitrici (Sp. gr. I. 4), § j 30
M.
Use : A medium strong caustic, especially useful for syphilitic lesions.
14. Causticum zincl et antimonii chloridl, (Canquoin's paste).
I^ Zinci chloridi,
Antimonii chloridi, aa 3 j 388
Pulveris amyli, 3 iss 582
Aquae, q.s
M. Make into a paste at the time of using.
Use : A deep acting caustic, for malig^nant growths.
15. Causticum hydrargyri iodidi,
'Sf Hydrargyri iodidi nibri, •
Unguenti aquae rosae, aa 3 i j 7177
M. et ft. unguent.
Use : A superficial destructive, of value in lupus.
16. Causticum potasses causticcs,
"Sf Potassae causticae, gr. v, — 3 ij 132 — 7 77
Aquae, 3 ij — S j 7150—30
M . et ft. solutio.
Use : In weakest solutions a mild stimulant in acne, eczema, and psoriasis ;
in strongest solutions, a medium caustic, in diffuse lupus.
17. Causticum sodii ethylatis,
'Sf Sodii ethylatis, § ss 1555
279
Alcohol absoluti, 3 v j 23
M.
Use : Superficial caustic in vascular and pigmentary nsevus.
EMPLASTRA.
18. EmplcLstrum mercuriale.
^ Hydrargyri, 1 j 31
Olei terebinthinae, § ss 13
Emplastri plumbi, | iv 124
M. Spread on linen and apply closely to the part.
Use : In chancre, syphilitic lesions, lupus erythematosus, and sycosis.
32
10
50
41
280 MANUAL OF DISEASES OF THE SKIN.
19. Emplastrum hydrargyri compositum, (Emplastnim de Vigo).
^ Hydrargyri, 3 ij 7 77
Olei terebinthinae, Tll,xx i 12
Cerae flavae, gr. xx i 29
Resinae, gr. xl 2 59
Styracis, 5 j 3 ^8
Emplastri plumbi, § j 31 10
M. Spread on linen and apply closely to the part.
UsB : In sjrphilitic eruptions, acne rosacea, and sycosis.
20. Emplastrum depilatorium, (Epilating stick).
'Sf Cerae flavae, 3 iij ii 66
Laccae in tabulis, 3 iv I5 55
Picis burgundicae, 3 x 38 87
Gummi damar, ^ iss 46 65
M. Make into sticks half an inch to an inch in diameter and two inches
in length.
Use : Applied with heat to extract the hairs in favus ; also in hirsuties and
some cases of tinea tonsurans.
GLYCERITA.
21. Glycefitum plumhi, (Squire's glycerole of subacetate of lead.)
I^ Plumbi acetatis, gr. cxx 777
Plumbi oxidi, gr. Ixxxiv 544
Glycerinae, J j 40I
Digest the acetate of lead and the litharcre in the glycerine (heated to 3oo<*) in an
oil bath, for half an hour, constantly stirring. Then filter in a chamber
heated to 300°.
Use : Diluted from three to seven times with water and glycerine as an as-
tringent and sedative in chronic eczema.
22. Glyceritum acidi tannid,
^ Acidi tannici, | j 3i|iO
Glycerinae, J iv 160I
M. Rub well together and heat slowly till dissolved.
Use : Diluted with water as an astringent in seborrhcea and chronic eczema,
also in herpes preputialis.
23. Glycefitum picis liquidce,
"E^ Picis liquidae, 3 ij >. 7 77
Magnesii carbonatis, 3 iv 15 55
Glycerinae, J j 40
Alcohol, I ss 13 50
Aquae, 1 iiss 75
M. Apply diluted with water, if irritating.
Use : An antipruritic in chronic eczema, and diluted in acute conditions.
THERAPEUTICS OF DISEASES OF THE SKIN. 28 1
24. Glyceritum amyRl
I^ Pulveris amyli, 5j 3i|lo
Glycerinae, § viij 320I
M. Rub together till mixed, and heat slowly, with stirring.
UsB : Emollient, as a substitute for fatty substances in ointments. '
LOTIONES.
In preparing lotions containing mineral ingredi-
ents, great care should be exercised to avoid coarse
and gritty particles, which can readily irritate a
delicate skin ; the ingredients should be very care-
fully pulverized and intimately mixed. When a lo-
tion containing a powder is applied, the resulting
deposit should form a smooth, even, non-irritating
coating ; as a rule, parts to which lotions are ap-
plied should be kept continually moist with them,
but not covered with oiled silk or too heavy dress-
ing, as the application is then converted into a poul-
tice. Glycerine is not well borne by every skin, and
its place can be supplied by other demulcents.
25. LoHo calamines et glycerituB,
'Of Pulveris calaminae preparatse, 3 ss — 3 j i
Zinci oxidi, 3 j — 3 ij 3
Glycerinae, 3 j — 3 iij 5
Aquae rosse, | iv 120
M. etft. lotio.
UsB : Cooling and slightly astringent in erythematous conditions.
26. Lotio calamine et cretcs (Startin).
"Sf Pulveris calaminse preparatSB, 3 j 3
Cretae preparatae, 3 j — 3 ij 3
Acidi hydrocyanici diluti, 3 ss i
Glycerinae, 3 i j — 3 iv 10
Liquoris calcis, § iij 90
Aquae sambuci, ad^ viij 240
M. et ft. lotio.
UsB : Cooling and antipruritic in subacute inflammation.
94— 3
88— 7
-- 15
88
77
S8
88—
90
— 20
77
282 MANUAL OF DISEASES OF THE SKIN.
27. Lotio bismuthi et amygdala,
Vf Bismuthi sub-nitratis, 3 iss 5
Acidi hydrocyanici diluti, 3 ss — 3 j • • • i
Emulsionis amygdalae, § iv 120
M. et ft. lotio.
Use : Antipruritic in eczema, with unbroken surface.
83
90— 3
80
28. Lotio zinci et plumbi,
^ Zinci oxidi, 3 j— 3 ij 3188— 7
Liquoris plumbi subacetatis dil., ^ vj.. . . 22 50
77
Glycerinae, 3 ij — 3 iv 10 — 20
Infusi picis liquidae, ad %iy 120
M. et ft. lotio.
Use : In erythematous conditions.
29. Lotio boracis et camphorcB,
Vf Pulveris boracis, 3 j 3 88
Tincturae camphorae, 3 j — 3 i j 3 40 — 6 80
Glycerinae, 3 j — 3 iij 5 — 15
Aquae aurantii florum, ad \\s 120
M. et ft. lotio.
Use : Soothing and softening in chronic erythematous eczema, and pruri-
tus.
30. Lotio plumbi et opii.
"Bf Liquoris plumbi subacetatis diluti, . . . .
Tincturae opii, aa §j
Aquae, ad O]
M. et ft lotio.
Use : Antiphlogistic in acute infla^Drnatory conditions.
30|
480
31. Lotio plumbi glyceriii,
"Sf Glyceriti plumbi subacetatis, 3 j — 3 iv.
(Squire's glycerole of the subacetate of
lead. Formula 21) 5
Glycerinae, 3 ij.. 10
Aquae rosse, ad § iv 120
M. et ft lotio.
Use : Astringent and sedative in chronic eczema.
— 20
THERAPEUTICS OF DISEASES OF THE SKIN. 283
32. Lotio antipruritlca,
^ Folionim belladonnae,
Foliorum hyoscyami, aa 3 iv 15 55
Folionim aconitii, 3 j 3 88
Acidi acetici, § ij . . . 60
M. Macerate well in the acid for several days.
OsB : To be diluted, a drachm or so to the ounce of water and glycerine ;
a ix>werful antipruritic.
33., Lotio alba,
"Bf Potassii sulphureti, ...
Zinci sulphatis, aa 3 j 3 188
Aquae rosae, § iv 120J
M. Dissolve the ix>tash and zinc, each in one-half the water, and mix.
UsB : As an astringent in acne ; glycerine (31 — 3 ij ) may be added if too
drying.
34. Lotio sulphuris.
"Sf Sulphuris precipitati, 3 ss i 94
Glycerinse, 3 iv 20
Aquae rosae, | iiiss 105
M. et ft. lotio.
Use : As a stimulant in acne.
35. Lotio sulphuris camphorata,
Vf Sulphuris precipitati, 3 ij — 3 iv 7J77 — 1555
Tincturae camphorae, 3 i j 7|5^
Liquoris calcis, § iv 120)
M. et ft lotio.
Use : As a stimulant in acne.
36. Lotio sulphuris composita,
1^ Sulphuris precipitati, 3 ss — 3 j i|94 — 3 88
Etheris sulphurici, 3 iv 13 50
Spiritus vini rectificati, § iiiss 94 5^
M. et ft. lotio.
UsB : As an astringent in acne.
37. Lotio calcii sulphureti, (Vlemingkx' solution).
1^ Calcis vivae, 3 iv I5|55
Sulphuris sublimati, 3 v j 23 32
Aquse destillatae, § viss I95i
M. Boil together with constant stirring until the mixture measures four
fluid ounces, then filter.
UsB : A powerful stimulant in scabies, psoriasis, and acne.
284
MANUAL OF DISEASES OF THE SKIN.
38. Lotto saponis vifidis, (Spiritus saponis kalinus of Hebra).
'Sf Saponis viridis, § iv , 124 41
Spiritus vini rectificati, § i j 54
M. Filtra et ft. lotio.
Use : On the scalp for a shampoo, with friction, adding a little water until
a lather is formed.
39. Tinctura saponis cum pice,
(Compound tincture of green soap of Hebra).
"Sf Olei cadini, .
Saponis viridis,
Spiritus vini rectificati, aa § j 30
M., filtra, et adde,
Spiritus lavandulae, 3 ij 7 50
M. et ft. lotio.
(JsB : As a stimulant in chronic eczema.
40. Tinctura picis,
'Sf Picis liquidse,
{vel olei rusci, vel olei cadini),
Alcohol, aa J j 31 lO
M., solve, et filtra.
Use : A stimulant in chronic eczema and psoriasis ; to be used with caution.
V
41. Lotio olei cadini.
^ Oleicadini, 3iv— §j 1350—27
Olei morrhuse,
(veloXei lini, vel olei amygd. express.)
ad I'vf 108
M. et ft. lotio.
Use: Applied freely as a lubricant and antipruritic in general chronic ec-
zema.
42. Liquor picis alkalinus,
"Sf Picis liquidae, § ij 62|20
Potassae causticse, § j 31 lO
Aquae, §v 150I
M. Dissolve the potash in the water and add slowly to the tar, in a mor-
tar, with friction.
Use : Antipruritic and stimulant in chronic eczema ; when diluted from
ten, to twenty times, sedative in more acute conditions.
THERAPEUTICS OF DISEASES OF THE SKIN. 285
43. Lotio glycerina et potassa,
5 Glycerinse, | j 40
Liquoris potassae, J ij 60
M. etft.lotio.
UsB : A strong antipruritic application, to be diluted if too irritating.
44. Lotio acidi carbolici composita,
'Bf Acidi carbolici, 3 i j 7 75
Potass causticae, 3 j 388
Aquae, § iv 120
M. et ft. lotio.
UsB : Antiparasitic and antipruritic ; to be diluted if too irritating.
32 — I '29
94
45. LoHo amygdala,
5 Hydrargyri chlor. corrosivi, gr. v — xx
Ammonii chloridi purificati, 3 ss I
Misturse amygdalae amar., | iv 120
M. etft.lotio.
UsB : A stimulant and absorbent in pigmentary conditions ; also a para-
siticide in vegetable parasitic eruptions.
46. Lotio hydrargyri composita,
"Sf Hydrargyri chloridi corrosivi, gr viij 52
Zinci sulphatis, 3 ss i 94
Plumbi acetatis, 3 ss i 94
Aquae rosae, ^ iv 120
M. et ft. lotio.
UsB : Stimulant and absorbent in pigmentary conditions.
47. LoHo flava,
"Bf Hydrargyri chloridi corrosivi, 3 ss i 94
Aquae calcis, Oj 480
M. et ft. lotio.
Use : A stimulant in phagaedenic ulcers.
48. Lotio nigra.
"Of Hydrargyri chloridi mitis, 3 j 388
Liquoris calcis, Oj 480
M. et ft. lotio.
UsB : Astringent in acute erythematous conditions, and in syphilitic ulcera^
tion.
286 MANUAL OF DISEASES OF THE SKIN.
49. LoHo plumbi ei ricini,
9 Plumbi acetatis, gr viij 51
Olei bergamii, 3 ss I 94
Olei ricini, 3 iv I5 55
Spiritus vini rectificati, ad § iv 108
M. etft.lotio.
UsB : Cooling and cleansing lotion for the scalp, in erythematous eczema
and seborrhoa.
50. Lotio quinia et zind,
^ Quiniae sulphatis, 3 j I
Zinci sulphatis, gr x
Tincturae cantharidis, 3 iij 11
Alcohol absoluti,
Glycerinse, aa 3 iv 15
Spiritus myrciae, ad § v j 162
M. etft.lotio.
UsB : Mildly stimulating lotion for the scalp.
29
64
66
55
51. Lotio cantharidis et capdci,
"Bf Tincturae cantharidis, 3 ij — 3 iv 7
Tincturae capsici, 3 ij — 3 iv 7
Tincturae nucis vomicae, 3 iv 15
Olei ricini, 3 ij — 3 iv 7
Spiritus vini rectificati,
{;vel aquae cologniensis,) ad %iy 124
M. et ft. lotio.
UsB : Stimulating lotion for the scalp in alopecia.
77— 15 55
77— 15 55
55 I
77— 15 55
41
MISTUR^E.
The following formulae for mixtures represent
average doses for adults. Occasionally the efficient
dose is even larger than here given : some of the
prescriptions are quite inapplicable for children, and
their dosage must be governed by general rules.
THERAPEUTICS OF DISEASES OF THE SKIN. 287
52. Mistura ferri et magnesii,
"Sf Magnesii sulphatis, 3 vj — § jss 23 '32 — ^46^65
Ferri sulphatis, 3 j . ^ 3 88
Acidi sulphuric! diluti, 3 ij 10
Syrupi pnini virginianse, | j 40
Aquae, ad'^xv 120
M. S. Teaspoonful in water, through a tube, after meals.
Usb: An aperient and cooling tonic in acute erythematous conditions:
qumine and strychnine may often be added to this with advantage.
53. Mistura potassii acetatis,
"Sf Potassii acetatis, 3 iv — § jss 15 55 — 46 65
Tincturae nucis vomicae, 3 ij 7 77
Inf usi quassiae
{;vel tincturae cinchonae comp.), ad^vj, , 120
M . S. Teaspoonful in water, after meals.
Usb: An antacid tonic in acute erythematous affections, and in chronic
eczema in gouty subjects.
54. Mistura ammonii acetatis,
5 Potassii acetatis, 3 j — 3 iij 3 88— 11
Spiritus etheris nitrosi, 3 ij — 3 iv 6 75 — 13
Tincturae aconiti radicis, nixv — 3 ss. . . , 80 — i
Liquoris ammonii acetatis, ad^iv 120
M. S. Teaspoonful in water, on an empty stomach.
Use : In febrile conditions in children, in eczema and other disorders.
66
50
70
55. Mistura rhei et sodii.
3
120
88— 7
88—11
"Sf Pulveris rhei, 3 j — 3 i j
Sodii bi-carbonatis
{;vel magnesiae), 3 j — 3 iij • •
Aquae menthae piperitae, § iv
M. S. Teaspoonful in water, after meals.
Use : Antacid and corrective in eczema, and inflammatory affections.
77
66
56. Mistura rumicis composita,
^ Potassii acetatis, 1 ss— 1 j I5|55— 31 lo
Tincturae nucis vomicae, 3 ij 7j50
Extracti rumicis radicis fluidi, § iv i2o|
M. S. Teaspoonful half an hour before meals, largely diluted.
Usb : In indurated and rosaceous acne.
288 MANUAL OF DISEASES OF THE SKIN.
50
57. Mistura taraxici composita,
'Bf Potassii acetatis, ^ j 31 10
Spiritus aetheris nitrosi, § jss 40 50
Acidi acetici diluti, 3 j 3 75
Extract! taraxici fluidi, § i j 60
M. S. Teaspoonful on an empty stomach, well diluted.
UsB : In indurated and rosaceous acne.
58. Mistura ferri et cinchona^
Q Ferri'et ammonii citratis, 3 j 388
Potassii citratis, 3 ij 7 77
Liquoris potassii arsenitis, 3 j — 3 ij . . • • 3 75 — 7
Tincturae nucis vomicis, 3 ij 7 50
Tincturse cinch onae compositse, ad^iv. , 120
M. S. Teaspoonful in water, after meals.
UsB : Tonic and alterative in eczema and chronic aftections.
59. Mistura ferro-arsenicalis,
^ Ferri et ammonii citratis, 3 j .\ . . 3 88
Liquoris potassii arsenitis, 3 ss — 3 ij • • • • i 90— 7 50
Liquoris potassae, 3 j — 3 i j 3 75 — 7 50
Syrupi pruni virginianae, 3 j 40
Villi ferri dulcis (Malaga), ad 5 iv 120
M. S. Teaspoonful after meals.
UsB : Especially valuable for children, as a tonic and alterative.
60. Mistura arsenici chloridi,
"Sf Liquoris arsenici chloridi, 3 j — 3 iv. . 3 75 — 15
Acidi muriatici diluti, 3 iv 15
Tincturae ferri chloridi, 3 ij — 3 iv. . . 7 50— 15
Aquae, a^ § iv 120
M. S. Teaspoonful in water, throug^h a tube, during^ or after meals.
.UsB : Powerftd tonic in chronic inflammatory affections.
If
61. Mistura hydrargyri et potassii iodidi,
06
M.
Hydrargyri chlor. corros., gr.j — gr. ij,
Potassii iodidi, 3 ij — 3 iv 7
Ferri et ammonii citratis, 3 j 3
Tincturae nucis vomicae, 3 ij 7
Tincturae cinchonae compositae, ad^iv 120
S. Teaspoonful, in water, after meals.
75—
88
50
23
12
32
UsB : In syphilitic eruptions, and as an alterative.
THERAPEUTICS OF DISEASES OF THE SKIN. 289
62, Misiura hydrargyri et ferri,
"Bf Hydrargyri chlor. corros, gr. j — gr. ij, 06 13
Potassii iodidi, 3 iij — 3 iv 11 66— 23 32
Ferri et ammoniii citratis, 3 j 3 88
Vinii ferri dulcis (Malaga), | iv. . . , . . 120
M. S. Teaspoonful after meals.
UsB : In syphilitic eruptions, and as an alterative.
63. Mistura acidi nitfici,
^ Acidi nitrici fortioris, 3 ss — 3j 250 — 5
Syrupi zinziberis, § ss 20
Tincturae gentianae compositae, 5 j. ... 30
Aqu83, ad | iv 120
M. S. Teaspoonful in water, through a tube, after meals.
UsB : A bitter tonic, in cases exhibiting oxaluria and liver derang^ement.
64. Mistura ferri et phosphoti,
"Bf Tincturae ferri chloridi,
Acidi phosphoric! diluti, aa. J j 30
Syrupi limonis, § i j 80
M. S. One half to one teaspoonful in water, through a tube, after meals.
Use : An iron tonic in nervous cases.
PILULiE.
65. Pilulce hydrargyfij colocynthidis^ et ipecac,
Bf Pilulae hydrargyri,
Extracti colocynthidis comp. aa gr. x 64
Pulveris ipecacuanhas, gr. ij 13
M, et divide in pilulas No. iv.
S. Take two at night and two on the second night after ; to be followed
each morning by a Seidlitz powder or Kissingen water.
Uss : A moderate cathartic in cases exhibiting liver derangement.
66. Pi lula ferri et aloes,
I^ Ferri sulphatis exsiccati, 3 ss i 94
Pulveris aloes purificatae, 3j i 29
Pulveris aromatici, 3 j 388
Confectionis rosoe, 3j I 29
M. et divide in pilulas No. xl.
S. Take one or more after each meal, and diminish the dose and its fre-
quency as rapidly as possible.
Uss : A tonic laxative in habitual constipation.
290 MANUAL OF DISEASES OF THE SKIN',
94—
64
88
67. Filula rhei, sodiiy et ipecac.
Tf Pulveris rhei,
Sodii bicarbonatis, aa 3 ss — 3 j i
Pulveris ipecacuanhae, gc, x
M. et divide in pilulas No. xxz. S. Take one after meals.
UsB : A mild laxative and corrective in digestive derangement.
68. Filida ferri et arsenici,
^ Liquoris potassii arsenitis, 3 j — 3 ij • 3
Ferri sulphatis exsiccat, 3j 3
Sodii bicarbonatis, 3 j — 3 i j 3
Extract! gentianae, 3 ss — 3j i
M. Evaporate and divide into 30 pills. S. Take one after meals.
UsB : Alterative and tonic.
75—
88
88—
94—
50
77
88
29
59
55
69. Pilulce hydrargyri protO'iodidi,
"Sf, Hydargyri iodidi viridis, 3 j i
Extracti conii alcoholici, 3 i j 2
M. et divide in pilulas No. xl. S. Take one after meals.
Usb: In syphilitic eruptions.
70. Filula ferfi et potcusii,
^. Ferri sulphatis exsiccati,
Potassii carbonatis,
Potassii tartratis, aa § ss • . » « « 1 , # 15
M. et divide in pilulas No. xcvi.
S. Take, at first, one after meals and increase up to three or more after
each meal.
UsB : Powerfully tonic in chlorotic cases.
71. PilulcB zinci phosphidi,
"Bf, Zinci phosphidi,
Extracti nucis vomicae, aa gr x 64
M. et divide m pilulas No. xxx. S. Take one every 2 to 4 hours.
UsB : Nerve tonic, in zoster, leucoderma, etc.
/
PULVERES.
72. Pulvis hydrargyri chloridi,
I^, Hydrargyri chloridi mitis, gr. v — gr xv..
Sodii bicarbonatis, gr. x — ^gr. xxx
M. et divide in pulveres No. vi.
S. Take one every other morning; for children.
UsB : Laxative and alterative in infantile eczema.
32—
64-
97
94
THERAPEUTICS OF DISEASES OF THE SKIN.
73. Pulvis bismuthi U sodii,
^. Bismuthi subnitratis, 3 j — 3 i j 3' 88 — 7 77
291
Sodii bicarbonatis, 3 i j 7 77
Pulveris zinziberis, 3ij ^ 2 59
M. et divide in pulveres No. xii. S. Take one after meals.
UsB : Corrective in dyspepsia, in acne and eczema.
74. Pulvis manganesii etpepsini,
"Sf, Manganesii oxidi nigri,
Pepsini porci, aa 3 j 3I88
M. et divide in pulveres No. xii. S. Take one or more after meals.
Use : Digestive and tonic in dyspepsia \ in acne and eczema.
75. Pulvis amyli iodidi.
Add tincture of iodine to boiled starch until it ceases to give a
blue color and all is black. Evaporate to dryness and powder.
Each 20 grains represents one grain of iodine, or about 15
minims of the tincture of iodine U. S. P.
Use: A safe method of administering iodine in late syphilis and lupus
erythematous.
In preparing dusting powders for external use the
greatest caution must be exercised that they are in
the finest possible state, and entirely free from
gritty particles: those which contain mineral sub-
stances should be shaken or stirred before being
applied, as otherwise, a separation of the ingredients
may interfere with their beneficial action. Care
must be taken that powders be not allowed to cake
upon the skin or to become worked into a paste, as
in the flexures of the joints and elsewhere.
76. Pulvis antipyreticus,
I^ Buckwheat flour —
Use : This forms a most agreeable and cooling application if kept contin*
ually applied in acute erythematous conditions.
292
MANUAL OF DISEASES OF THE SKIN.
77. Pulvis calamituB compositus.
'Bf Pulveris calaminae prepar
Pulveris oryzae sativae, aa § j 31 10
M. et ft pulvis. ^
UsB : As a dusting powder in acute erythematous and vesicular eruptions.
78. Pulvis terrce cimolia,
I^ Fuller's earth, in fine powder,
Use : An absorbent application in eczema and intertrigo.
79. Pulvis magnesii et acidi salicylici,
9 Magnesii usti, 3v 19 43
Pulveris talci venetii, J ijss 77 76
Acidi salicylici, gr. xij 77
Balsamii peruviani, gtt. x. , 80
M. et ft. pulvis.
Use : An absorbent and astringent application in acute erythematous con-
ditions and hyperidrosis.
80. Pulvis magnesii carbonatis,
55
I^ Magnesii carbonatis levis,
Pulveris lycopodii, aa § ss 15
M. etft pulvis.
Use : As a dusting powder in erythematous eczema.
81. Pulvis antiprufiticus,
I^ Chloralis hydratis,
Camphorae, aa 3 j 3 88
Rub together until liquid, and incorporate with
Pulveris amyli, J j — § ij 31 10
M. Keep tightly corked in a wide-mouthed bottle.
Use : A powerful antipruritic, to be well rubbed in with the hand.
82. Pulvis camphorce et zinci,
^ Pulveris camphorae, 3 ss— 3 j i 94 — 3 88
Zinci oxidi, 3 iv 15 55
Pulveris amyli, § j 31,10
M et ft. pulvis.
Use : As a dusting powder to relieve pruritus.
THERAPEUTICS OF DISEASES OF THE SKIN
293
UNGUENTA.
In the preparation of ointments too much care
cannot be exercised in reducing to the finest possible
state the substances to be incorporated, for more
harm than good is often done by having coarse par-
ticles in an ointment which is to be applied to an
abraded surface. The physician should, therefore,
take especial supervision over the preparation of
ointments, and should frequently inspect those in
use by the patient. It is well to first grind down
any mineral ingredient in a mortar, adding a little
sweet almond oil, making it into a paste, which is
then to be added to the excipient. The greatest
care must also be exercised that the material be per-
fectly fresh, for the least rancidity of the ointment
renders it irritating. The preparations of petroleum,
cosmoline and vaseline meet this requirement, but
where protection of the part is desired a more solid
substance is needed, and most of the following pre-
scriptions are made with the unguentum aquae
rosae, U. S. P., a most invaluable aid in the treat-
ment of skin diseases. Ointments should always be
spread on cloth, as on the wooly side of lint, when
the surface is raw ; in chronic conditions gain is had
hy rubbing them in. When protection is desired, it
is well to have new dressings ready spread with the
ointment before the old ones are removed.
294
MANUAL OF DISEASES OP- THE SKIN.
83. Unguentum zinci oxidi,
^ Zinci oxidi, 3 ss— 3 j.... i;94— 3!88
Unguenti aquae rosae, §j 3ijJO J
M. et ft. unguentum.
Use : Soothing and protective ; a drachm of .tincture of camphor or chlo-
roform may be added, or from five to fifteen drops of carbolic acid, as an
antipruritic.
84. Unguentum calamina.
"Bf Acidi carbolici, gtt. v — xvj. . . .
Pulveris calaminae prep., 3 ss-
Zinci oxidi, 3 ss — 3 J,
Unguenti aquae rosae, j j
M. et ft. unguentum.
Use : Soothing and protective.
3 j
I
I
31
32-
94-
94-
10
03
88
88
85. Unguentum bismuthi sub-nitratis,
I^ Bismuthi sub-nitratis, 3 ss — 3 ij i|94"
Unguenti aquae laurocerasi, J j 3i|io
M. et. ft. unguentum.
Use : Soothing and mildly astringent.
77
86. Unguentum bismuthi (vel zinci) oUatis (Anderson).
iQ Bismuthi oxidi,
{ruel zinci oxidi), 3 ij 7
Acidi oleici, J ij 62
Unguenti petrolei, § ij+ 3 i j 70
Cerae albae, 3 v j 23
Olei rosae, gtt vj
77
20
32
32
M. Rub up the bismuth (or zinc) oxide with the oleic acid, and let it
stand for two hours ; place in a water bath, add the vaseline and
wax, and when dissolved stir until cold and add the oil of roses.
Use : Soothing and astringent in acute inflammatory conditions.
87. Unguentum acidi tannici,
I^ Acidi tannici, 3 j 3
Unguenti aquae rosae, | j 31
M. et ft. unguentum.
Use: Astringent; of especial service in eczema of the scalp and ears.
88
10
THERAPEUTICS OF DISEASES OF THE SKIN.
29s
88. Unguentum picis et zinci.
88— ri
94— 3
10
9 Unguenti picis liquidae, 3 j — 3 iij 3
Zinci oxidi, 3 ss — 3 j i
Unguenti aquae rosae, ad '^] 31
M. et ft. unguentum.
UsB : Antipruritic and protective ; of especial value in infantile eczema.
89. Unguentum cadini et zinci,
5 Olei cadini {ruel nisei), 3 ss — 3 j i
Zinci oxidi, 3 ss — 3 j i
Unguenti aquae rosae, § j 31
M. et ft. unguentum.
UsB : Antipruritic and mildly astringent.
66
88
94— 3[88
94— 3.88
10
90. Unguentum picis et hydrargyf i,
5 Liquoris picis alkalini, 3 j — 3 iij 3
(See Formula 42.)
Unguenti hydrarg. ammon., 3 ij — 3 iv 7
Unguenti aquae rosae, ad %} 31
M. et ft. unguentum.
88— II
77— 15
10
66
55
UsB : Antipruritic and mildly stimulating ; of especial value in psoriasis
of the scalp.
91. Unguentum hydrargyri et bismuthi,
"Bf Bismuthi sub-nitratis, 3 j 3! 88
Unguenti hydrarg. ammon., 3 j — 3 iv 3 88 — 15 55
Unguenti aquae rosae, ad %] 3l|io
M. et ft. unguentum.
Use : Astringent and slightly stimulating.
92. Unguentum hydrargyri nitratis.
5 Unguenti hydrargyri nitratis, 3 j — 3 iij 3 88 — ii 66
Unguenti aquae rosae, ad 1] 31 ,10
Olei geranii, gtt. v .... 28
M. et ft. unguentum.
UsB : Mildly stimulating in chronic eczema.
93. Unguentum hydrargyf i oxidi rubri.
"Bf Unguenti hydrarg. oxidi rub., 3 j — 3 iij 31 88 — ii|66
Unguenti aquae rosae, ad ^j 31110
M. et ft. unguentum.
UsB : Mildly stimulating in chronic eczema.
296
MANUAL OF DISEASES OF THE SKIN,
94« Unguentum diachyli, (Hebra's Diachylon ointment).
Q Olei olivanim optimi, \ xv 466 54
Plumbi oxidi, 1 iij4- 3 vj I16 62
Olei lavandulae, 3 i j 675
M. Add the oil to two pouuds of water and heat it with constant stir-
ring ; the lithai^ is to be slowly sifted in while it is well stirred,
fre^ water being added as required. The ointment is to be stirred
until cold and the lavender then added. In winter a slightly larger
quantity of oil is required to make a soft ointment.
UsB : Astringent and soothing, but irritating to some skins in acute cond&ions.
95. Unguentum diachyli modijicatum,
"Bf Emplastri diachyli,
Vaseline, aa, § j 31 10
M. Dissolve with heat, and stir until cold.
C7sB : Astringent and soothing in subacute eczema.
• 96. Unguentum hydrargyn cumplumbo (Startin).
"Bf Plumbi acetatis,
Hydrargyri chloridi mitis, aa gr. x 64
Zinci oxidi,
Unguenti hydrargyri nitratis, aa 3 j . . . , i 29
Adipis recentis,
Olei palmae rectificati, aa ^ ss ^5 55
M. et ft. unguentum.
UsB : Moderately stimulating ; much used in England in eczema capitis.
97. Unguentum plumbi et stramonii.
Idf Liquoris plumbi subacetatis diluti, 3 j
Acidi tannici, 3j
Unguenti stramonii, | j
M. et ft. unguentum.
UsB : Astringent and soothing ; of especial value in external hemorrhoids,
3
I
31
75
29
10
98. Unguentum acidi chrysophanici,
Q Acidi chrysophanici, 3 ss — 3 i j • • • ^ 94 — 7 77
Unguenti aquae rosse, J j 3^ ^o
M. Dissolve with heat and stir until cold.
UsB : Powerfully stimulating and irritant to many skins ; of especial value
in psoriasis and ringworm.
THERAPEUTICS OF DISEASES OF THE SKIN.
297
99. Unguentum acidi pyrogallici,
'Bf Acidi pyrogallici, 3j — 3 i j i
Unguenti aquae rosse, § j 3^
M. Dissolve with heat and stir until cold.
29— 7
10
75
UsB : Moderately stimulating in weakest, caustic in greatest strength ; of
especial value in psoriasis and ringworm.
icx>. Unguentum styracis et sulphuris,
^ Styracis liquidis, 3 i j 10
Unguenti sulphuris, 3 ij — 3 iv 7 77 — 15
Unguenti petrolei, ad W 31 10
M. et ft. unguentum.
UsB : Anti-parasitic and moderately stimulating, for scabies.
loi. Unguentum sulphuris compositum,
(Modified Wilkinson's ointment.)
;^ Sulphuris sublimati,
55
77
71
10
Olei cadini, aa 3 ij 7
Cretae preparatse, 3 ijss : 9
Saponis viridis,
Adipis, aa § j 31
M. et ft. unguent.
UsB : A rather stimulating remedy for scabies.
102. Unguentum hydrargyri et olei rusci,
^ Olei rusci, 3 ss — 3 j 2 50— 5
Unguenti hydrai^. oxidi rub., 3 j — 3 iij 3 88 — 11 66
Unguenti aquae rosae, ad %] 31 10
M. et ft. unguentum.
Use : Mildly stimulating and anti-parasitic, in chronic eczema and ring-
worm.
103. Unguentum hydrargyri et iodinii.
Q Unguenti hydrargyri,
Unguenti iodinii comp
Unguenti diachyli (Formula 94) aa | ss 15
Misce intime.
55
Usb: Powerfully stimulant ; ta be rubbed well into the skin over syphilitic
indurations and bone lesions.
298
MANUAL OF DISEASES OF THE SKIN.
104. Unguentum acidi carbolici,
'Bf Acidi carbolici, 3 j — 3 ij i 29 — 7 77
Glvceriti amyli (Formula 24)
(w/ unguenti petrolei), § iv 124 41
M. et ft, unguentum.
UsB : Antipruritic, to be used freely to the body, especially after alkaline
baths.
105. Unguentum anti-prufiiicum,
Q Gummi camphorae,
Chloralis hydratis, aa 3 j — 3 i j 3 88 — 7 77
Rub together until a liquid results, then add
slowly with friction,
Unguenti aquae rosae, § j , 31 10
M. et ft. unguentum.
Use : Powerfully antipruritic ; if applied where the surface is abraded it causes
burning and irritation.
106. Unguentum picis et belladonna,
'Bf Unguenti picis liquidx, 3 v j \ 23
Unguenti belladonna;, 3 iv 15
Tincturae aconiti, 3j 3
Zinci oxidi, 3 ij 7
Unguenti aquae rosae, 3 v j 23
M. et ft. unguentum.
32
55
75
77
32
Use : Powerfully antipruritic ; of especial service in pruritus and eczema of the
vulva.
107. Unguentum sulphuris hypochloridi.
Idf Sulphuris hypochloridi, 3 j — 3 ij 3 88 — 7 77
Extracti nimicis rad. 3 ij — 3 iv 7 77 — 15 55
Unguenti aquae rosae, J j .' 31 '10
M. et ft. unguentum.
Use : Stimulating and absorbent, in acne indurata.
108. Solutio hydrargyru
"Sf Hydrargyri chloridi corrosivi, gr. iv 125
Glycerinae, 3 j ^ 3 88
Aquae destillatae, 3 vij. 27 21
M.
Use : For hypodermic injection in S3rphilis ; twelve drops contain one tenth
of a grain of mercury.
INDEX.
Abortion, syphilis a cause of, 127.
Abscesses of the skin, 204 (141).
Absorption by the skin, 16.
Acarus or steatozoon foUiculo-
nim, 76.
Acarus scabiei, 68.
Accuracy of diagnosis in skin
disease, 2, 34, 35.
Achorion Schonleinii, 46, 56.
Achroma, or leucoderma, 236.
Acne albida, 76.
disseminata, 78,
indurata, 73, 78, 79.
juvenilis, 78.
mentagra, 157.
molluscum, 73, 76 (247).
nigra, 75.
papulosa, or simplex, 73, 78.
punctata, 73, 75, 76.
rosacea, 73, 78, 79 (137,
I74» 175).
sebacea cerea, 74.
sebacea cornea, 74.
sebacea oleosa, 73, 74.
simplex, 73, 78.
vulgaris, 78.
causes of, 13, 80, 81.
diagnosis of,, 80 (51, 109,
137, 159. 247).
frequency of, 29, 31.
treatment of, 75, 81, 82, 83.
Acquired achroma or leucoderma,
236.
Adenopathy, 9, 120.
Addison's disease, 212, 214.
Age, influence of, on the produc-
tion of skin diseases, 45.
Air, effect of, in eczema, 186.
Albinismus, 235.
Alopecia, 239-242.
areata, 239, 241.
furfuracea, 200.
idiopathic, 240.
symptomatic, 239.
syphilitica, 239.
vulgaris, 239.
Alphos, 195.
Anaesthesia cutis, 90, 99.
Anaesthetic leprosy, 260.
Analgesia, 99.
Analysis of 8000 cases of skin
disease, 25.
Anatomy of the skin, 4,
Angioma, or telangiectasis, 256.
Anidrosis, 85.
Aniline, dermatitis from, 189.
Animal parasitic affections, 63.
Anthrax, 201, 203. '
Anus, eczema of the, 180.
Aphthous stomatitis, diagnosis
from mucous patches, 126.
Applications, method of making,
in eczema, 186.
Area Celsi, 241.
Ai^;yria, 214.
Arms, eczema of the, 176, 177.
Arnica, dermatitis from, 1891
Arrectores pilorum, 12, 13.
299
300
INDEX.
Arrectores pilorum, connection
with acne, 13.
Arsenic, dermatitis from, 189.
Artificial eruptions, 72, i8g, 191.
Atrophia cutis, 237, 238.
pilonim propria, 243. .
senilis, 238.
Atrophy of corium, 237.
of hair, 238.
of nail, 244.
of pigment, 235.
of skin, 237, 238.
Atropine in mercurial salivation,
132-
Auditory canal, eczema of the, 174.
Avoidance of certain kinds of food
in skin disease, 271, 272, 273.
Baker's itch, or eczema of ■ the
hands, 176.
Balanitis, diagnosis from chan-
croid, 207 ; from herpes, 152,
Baldness, idiopathic, 240.
symptomatic, 239.
syphilitic, 239.
Balnea, 275.
Bandage, rubber, in eczema of the
legs, 179.
Barbadoes leg, 227.
Barber's itch, 50.
Baths in skin diseases, 276.
Baths, mercurial, in syphilis, 130.
Baths, Turkish, harm from, 97,
274, 276.
Beard, ringworm of the, 50.
Belladonna eruption, diagnosis
from roseola, 139.
Belladonna in mercurial saliva-
tion, 132.
Birth-mark, 256.
Black-heads, 75.
Black measles, 102 (108, 210).
Black small pox,. 108, 210.
Blanching of the hair, 237.
Bleb, 36, 37.
Blood-vessels of the skin, 7.
Bloody sweat, 210.
Body louse, 61.
Boils, 201.
Breasts, eczema of the, 181.
Bricklayer's itch, or eczema of the
hands, 176.
Broad condyloma, or mucpus
patches, 125, 222.
Bromides, eruption from, 195, 267.
Bromidrosis, 86.
Bronzed-skin disease, 214.
Bruises, diagnosis from erythema
nodosum, 141.
Brushes, tooth, syphilis transmit-
ted by, 119.
Buboes, 9.
Bucnenia tropica, 227.
Bullae, 20, 37, 153.
Bullous eruptions, 122, 153, 154.
Burmese ringworm, 52.
Callositas, callus or callosity,
220.
Cancer of the skin, 262 (124, 248).
Canities, 235, 237.
Carbuncle, 203.
Carcinoma cutis, 262 (124, 248).
Causes of skin diseases, 42.
Caustics, 278.
Cauterization of chancres, 129.
Chafing or intertrigo, 189.
Chancre, 118, 120, 129(207).
extra-genital, 119,
Chancroid, 118, 207.
Chaps or fissures in eczema, 169.
Charbon, 133.
Cheiro-pompholix, 88, 156, 157.
Cheloid, 240.
Chicken-pox, iii, 112, 113,
Chinese ringworm, 52.
Chloasma, 212, 213 (31, 6i, 125,
213, 216, 236).
Choleric roseola, 139.
Chromidrosis, 86, 87.
INDEX.
301
ChromophytosiSy 60.
Chylopoietic viscera, importance
of attention to in skin diseases,
81.
Cicatrical keloid, 246.
Cicatrix, 36, 40.
Cingulum, 90.
Circumcision, syphilis transmitted
during, Tig.
Claret stain, 255.
Classification of skin diseases, 18.
Clavus, 2 1 6, 219.
Clothes louse or body louse, 63.
Cnidosis, 142.
Cofifee, effect in skin diseases,
271.
Cold sores, 151.
Color of skin, 7.
Comedo, 75, 76.
Condylomata, 125, 222.
Confluent small-pox, 108.
Congestive seborrhoea, 249.
Congestion in eczema, 167.
Connective tissue, hypertrophies
of, 223.
Constipation, 56, 80, 81, 185, 207,
269.
Constitutional causes, 43, 44.
Contagious impetigo, 161.
Copaiba eruption, 121, 139, 191.
Corium, 6.
atrophy of, 237,
Corns, 219.
Comu cutaneum, 216, 218.
humanum, 218.
Corpuscles, tactile, 8.
Cosme's paste, 278.
Couperose, 79.
Crab louse, 65.
Crabs, 65.
Cracks, or fissures, 36, 39, 169.
Croton oil, dermatitis from, 189.
Crusta lactea, or milk crust, 164,
168, 182.
Crusts, occurrence of, 35, 38, 168.
Crusted ringworm, 56.
Cuniculus, the, in scabies, 68, 69.
Cutaneous horns, 216, 218.
Cuticle, structure of, 7.
Cutis ansenna, 13.
pendula, 229.
variegata, 236.
vera, 6.
Cysts, sebaceous, 77.
Dandruff, or dandriff, 74, 200.
Dartos of the scrotum, 9.
Death from varnishing skin, 14.
Debility a cause of baldness, 240.
in eczema, 184.
Definition of terms, 36.
Degeneratio unguium, 244.
Demodex foUiculorum, 76.
Depilation, 50, 55, 59, 60.
Depilatories, 232.
Derma, 6.
Dermatalgia, 90, 98.
Dermatitis, 188.
calorica, 188.
contusiformis, 140.
exfoliativa, 193.
gangraenosa, 189.
medicamentosa, 190.
traumatica, ' 188.
venenata, 188, 189.
Dermatology, on the study of, i.
relations to medi-
cine, 3.
Dermatolysis, 223, 229 .
Dermatosclerosis, 223.
Dermatosyphilis, 120.
Desquamative dermatitis, 193.
Diagnosis, 32.
Diet, definition of the term, 268.
errors of, causing skin dis-
ease, 81, 97, 267.
in eczema, 186, 269.
Diphtheritis cutis, 135.
Discoloration of die skin, 38, 212.
Distribution of eruptions, 33.
302
INDEX,
Drinking utensils, sjrphilis trans-
mitted by means of, 119.
Dry tetter, 195.
Dyes causing eruptions, 189.
Dysidrosis, 87, 157, 177.
Dyspepsia in skin ^disease, 82,
184, 240, 269.
Dystrophia cutis, 90, 99.
Ears, eczema of the, 174.
Eating tetter, or lupus, 249.
Eating utensils, syphilis trans-
mitted by means of, 1 19.
Ecthyma, 157, 162.
Ecthyma, syphilitic, 122.
Eczema, 164-188,
acute, 17c.
chronic, 171.
dry, 175-
erythematosum, 172.
fendille, 173.
fissum, 171, 173.
impetiginosum, 171, 172.
infantile, 182, 183.
madidans, 168, 171, 173,
178.
marginatum, 52, 180.
moist, 175.
papulosum, 171, 172.
pustulosum, 171, 172.
rimosum, 171, 173.
rubrum, 171, 173.
sclerosum, 171, 173.
squamosum, 171, 173 (74»
168).
vesiculosum, 171, 172.
causes of, 184, 185.
congestion in, 167.
cracks of, 169.
crusting in, 168.
definition of 42, 165.
diagnosis of, 174, 175,
176,177, 178, i79»i8o
(48, 50, 51, 53, 58,61,
65, 66,80, 88,122,123,
Eczema, diagnosis of, 126, 136,
141, 144, 147, 149, 152,
155, ^59» 194, I97»207.
210, 217, 228, 250,264).
diet in, 269.
exudation in, 168, 175.
frequency of, 28, 165.
infiltration in, 168.
itching of, 166, 167.
location of, 174, et seq,
of the anus and genital
region. 180.
of the auditory canal, 174.
of the breasts, 181.
of the eyelids, 174.
of the ekrs, 174.
of the face, 174.
of the feet and legs, 178.
of the hands and arms,
176. 177.
of the lips, 174.
of the scalp, 174,
of the trunk, 181.
papules in, 167.
pruritus in, 96.
stages of, 170.
statistics of, 28, 165.
thickening in, 168.
varieties of, 169, 170.
vesicles in, 167.
Eggs or nits of pediculi» 64.
Elasticity of the hair, ii.
Electrolysis, 233, 257.
Elephantiasis Arabum, 223, 227.
Grgecorum,258 (196,
227, 236).
Elephant leg, 227.
Emplastra, 279.
Emplastrum mercuriale, I2g, 279.
Emunctory function of the skin, 5.
Endemic verrugas, 229.
Ephelis, 213,
Ephidrosis, 84.
cruenta, 210.
Epidemic roseola, 103.
INDEX.
303
Epidermal hypertrophies, 216.
Epidermis, 6.
Epilation, 50, 55, 59, 60.
Epithelial cancer, 258, 263.
Epithelial nests, 264.
Epithelioma, 258, 263 (182, 250,
252, 254. 255).
Equinia, 134.
Errors of diet in eczema, 269.
Eruption, definition of, 42.
Eruptions, artificial, 72, 189, 191.
caused by dyes, 189.
feigned, 87, 191.
Eruptive fevers, loi.
Erysipelas, 135.
migrans, 135.
vaccinal, 115.
bullae in, 155.
diagnosis of, 136 (141,
174, 175, 203).
Erythema, 138, 139.
annulare, 140.
iris, 140.
marginatum, 140.
multiforme, 140, 154.
nodosum, 1 39-141.
papulatum, 140.
simplex, 139, 140.
tuberculatum, 140.
vesiculosum, 140.
diagnosis of, 141 (105,
121, 137, 147, 152, 174,
175, 177, 210, 250).
varieties of, 139, 140.
Erythematous eczema, 171, 172.
eruptions, 138.
lupus, 249.
scrofulide, 249.
syphilis, 120.
Etiology of skin diseases, 42.
Exanthemata, 20, loi.
Exanthematous nature of syph-
ilis, 117.
Excessive sweating, 84.
Excoriatio, 36, 39.
Excoriations 36, 39, 63.
Excretory function of the skin,
5, 15- .
Exfoliative dermatitis, 193.
dermatitis, diagnosis of;
194.
External causes of skin diseases,
44.
Extra-genital chancres, 119.
Exudation in eczema, 167.
Exudative affections, 10 1.
Eyelids, eczema of the, 174.
Face, eczema of the, 174.
Facial herpes, 1 5 1.
False measles, or r5theln, 103 .
Family tendencies a cause of skin
disease, 44, 45.
Farcy, 135.
Fatty tissue, new formation of,
248.
Favus, 56,
diagnosis of, 58, 59 (176,
197).
Febrile herpes, 150, 151.
Febris urticata, 142.
Feet, eczema of the, 178.
Feigned eruptions, 87, 191.
Females, skin diseases in, 30.
Fermented liquors, 271,
Fever sores, 151.
Fibroma, 245, 246.
lipomatodes, 247.
Filaria sanguinis, 228.
Fish-skin disease, 216.
Fissura, 36, 39, 169.
Fluxus sebaceus, 73.
Folliculitis pilorum, 157.
Food in eczema, 269.
Fragilitas crinium, 239, 243.
Frambcesia, 223, 229.
Freckles, 212.
Frequency of skin diseases, 25-31,
Furf uraceous alopecia, 200.
Furrow or cuniculus, 68.
304
INDEX,
Furancular inflammation due to
vaccijiation, 115.
Furuncles, 201.
Gangrene of the skin, 188, 189.
Genital region, eczema of the, 180.
German measles, 103.
Giant urticaria, 143.
Glanders, 134.
Glands of the skin, 12, 13, 14.
sebaceous, diseases of, 73.
sweat, diseases of, 83.
Glandular affections, 73.
enlargement in syphi-
lis, 120.
Glassblower's pipe, syphilis trans-
mitted on, 119.
Glossy skin, 99.
Glycerita, 280.
Goose skin, 13.
Gouty state in skin diseases, 184.
Grayness of hair, 237.
Grocer's itch, or eczema of the
hands, 176.
Growth of nails, 15.
Grubs, 75.
Grutum, 76.
Gummy syphilis, 124.
Gutta rosea, 79.
HiEMATIDROSIS, 87, 209, 210.
209.
purpura, 209, 210.
small pox, 108.
Hair, atrophy of, 238.
elasticity of, 11.
follicles, structure of, 10, 1 1.
gray, 237.
loss of, 239.
muscles of, 12.
papilla, structure of, 10.
structure of, 10, 11.
Hairs, number of, 11.
Hairy mole, 214, 231, 233.
Hands, eczema of, 176, 177.
Head louse, 63.
Heat eruption, or prickly heat,
146.
Hebra's classification of skin disr
eases, 20.
Hemiatrophia facialis, 226.
Hemorrhagic purpura, 210,
small pox, 108.
Hereditary syphilis, 117, 127.
Herpes, 150.
circinatus, 47, 15 1.
facialis, 151.
febrilis, 150, 151.
generalise febrile, 1 5 1,
gestationis, 150, 152.
iris, 150, 151, 154.
labialis, 151.
preputialis or progenita-
lis, 150, 151, 152.
tonsurans, 49.
zoster, 90, 150.
diagnosis of, 152 (137,
175. 207).
Hirsuties, 231.
Hives, 142.
Honey-combed ringworm, 56,
Hordeolum, 201, 204.
Homy excrescence, 218.
Hydroa, 153 (151, 162).
Hydro-adenitis, 204.
Hygiene, 273.
Hypenemia, 167.
Hyperaesthesia cutis, 90, 98.
Hyperidrosis, 84.
Hypertrichosis, 231.
Hypertrophiae, 212.
Hypertrophies of connective tis-
sue, 223.
of epidermis and
papillae, 216.
of hair, 231.
of nails, 233.
of pigment, 212.
Hypodermic injections of mercury
in syphilis, 131.
INDEX.
305
Ichthyosis, 2t6.
hystrix, 217.
Idiopathic baldness, 240.
Idrosis or hyperidrosis, 84.
Ignis sacer or zoster, 90.
Impetiginous eczema, 171, 172.
Impetigo, 157, 160.
contagiosa, 157, 161.
syphilitic, 122.
diagnosis of, 160 (162,
163).
Incubative period of chancre,
118.
Individual tendencies, 44, 45 .
Induration of chancre, 119.
Infantile eczema, 182, 183.
sjrphilis, 127.
Infiltratio, 39, 168.
Inflammatory affections of the
skin, loi.
Inherited syphilis, 117, 127, 128.
Initial lesion of syphilis, 118.
Injections, hypodermic, of mer*
cury in syphilis, 131.
Insensible perspiration, 14.
Internal causes of skin diseases,
43-
Intertrigo, 189 (53).
Inunction, mercurial, in syphilis,
130-
Iodide eruption, 191, 267.
Iritis, syphilitic, 120.
Itch, the, 68.
baker's, or eczema of the
hands, 176.
barber's, 50.
bricklayer's, or eczema of
the hands, 176.
grocer's, or eczema of the
hands, 176.
washerwoman's, or eczema
of the hands, 176.
Itching, or pruritus, 94 (70, 96,
166).
Ivy, poison, 189.
Kelis, 246.
Keloid, 245, 246.
Keratosis pilaris, 2l6, 2l8 (147).
Kerion, 50, 51, 55.
Kidneys, relation to skin, 15.
King's evil, or scrofuloderma, 253.
Kiss, syphilis given by, 119.
Labial herpes, 151.
Land scurvy, or purpura, 209.
Lead pencils, syphilis transmittep
by, 119.
"Leeting " surface, 168.
Legs, eczema of, 178,
Lentigo, 2ii.
Leontiasis, 258.
Lepra, 196, 258.
anaesthetica, 260.
maculosa, 259.
mutilans, 260.
tuberculosa, 260.
vulgaris, 194.
Willani, 194.
Leprosy, 258 (226, 236, 261).
Leucasmus, acquired, 236.
universalis, 235.
Leucoderma, 235, 236.
diagnosis of, 236 (62,
125, 214, 261).
Leukoplakia, 126.
acquisita, 236.
congenital, 235.
Lice, body, 63.
Lichen, 145, 146.
agrius, 146.
circumscriptus, 146.
pilaris, 147, 2x8.
ruber planus, 146.
scrofulosus, 147.
simplex, 146.
syphilitic, 121.
tropicus, 146.
urticatus, 143, 146, 148.
diagnosis of, 147, 148 (71,
122,141,177,194,1971207).
3o6
INDEX.
Linise albicantes, 238.
atrophicse, 238.
Lipoma* 248.
diagnosis of, 248 (247).
Lips, eczema of, 174.
Liquor picis alkalinus, 284.
Liver spots, 60, 213.
Local causes of skin disease, 43.
Loss of hair, 239.
Lotions, 281.
Lousiness, 63.
Lues, 117.
Lupus, 249.
erythematosus, ^ 249.
exedens, 251.
hypertrophicus, 251.
sebaceus, 249.
syphiliticus, 123, 124, 251.
tuberculosus, 251.
vulgaris, 251.
diagnosis of, 250 (48, 80,
197, 254, 255, 261, 264).
frequency of, 30.
Lymphad^nie cutanee, 257.
Lymphangioma, 257.
diagnosis of, 248,
257.
tuberosum mul-
tiplex, 257.
Ljrmphatic new formations, 257.
Lymphatics of the skin, 8.
Lymph scrotum, 228.
MACULiE, 20, 36.
atrophicse, 238.
Macular leprosy, 259.
syphilis, 120.
Malaria, 97, 143, 184.
Males, skin diseases in, 30.
Mali^ant pustule, 133, 134.
Matrix of the nail, 15.
Measles, 3, loi, 102, 103.
black, 108, 2ia
diagnosis of, 102, 103
(105, 109, 113).
Measles, German, 103.
Medicinal eruptions, 188, T90.
Melanoderma, 212, 213, 2l6.
Melanotic cancer, 262.
Mentagra, 157.
Mercurial salivation, treatment of,
132.
Mercurial vapor baths in syphilis,
130-
Mercury, hypodermically, in syph-
ilis, 131.
in syphilis, 128, 130, 131.
Method of applying ointments,
186, 187, 293.
Microsporon Audouini, 241.
furfur, 60.
Miliaria, 89.
Milium, 75, 76.
Milk crust, 164, 171, 172.
in skin disease, 271.
Mixtures, 286.
Mixed treatment in S3rphilis, 131.
Moist eczema, 175.
papules or mucous patches,
125, 264.
tetter, 164.
Mole, hairy, 214, 231, 233.
pigmentary, 214, 215.
MoUities unguium, 244.
MoUuscum contagiosum, 76, 77.
fibrosum, 246.
pendulum, 246.
sebaceum, 76, 77.
simplex, 246.
Morbilli, loi.
Morbus Addisonii, 212, 214.
pedicularis, 63.
Morphoea, diagnosis of, 225, 226
(236, 261).
223, 225.
frequency of, 30.
Moth patches, or chloasma, 213.
Mother's mark, 255, 256.
marks, or naevi, 214, 255.
Mucous patches, 125.
INDEX.
307
Mucous patches, diagnosis of, 126
(152, 175, 181, 22<2, 264).
Multiform eruptions, 164.
Muscles of the hair follicles, 12.
Muscular fibres of the skin, struc-
ture of, 9.
Mycosis, 230.
fungoide, 231.
NiEVUS araneus, 256, 257.
flammeus or naevus vascu-
losus, 255, 256.
pigmentosus, 212, 214.
pilosus, 214, 231, 233.
sanguineus, 255.
spilus or naevus pigmen-
tosus, 214.
vasculosus, 255, 256.
verrucosus, 215.
Nails, atrophy of, 244.
hypertrophy of, 233 .
structure of, 14, 15.
Neoplasmata, 245.
Nerves, new formations of, 258 . .
of the skin, 8.
Nesselsucht, 142.
Nettle rash, 142.
Neuroma cutis, 258.
Neuroses, 90.
New formations, 245 .
Nitrate of silver discoloration, 214.
Nits of pediculi, 64, 65 .
Nodes, sjrphilitic, diagnosis from
erythema, 141.
Noli me tangere, 251, 264.
Nomenclature of skin diseases, 18.
Non-parasitic sycosis, 157 (175).
Number of hairs, ii.
Nursing, syphilis communicated
by, T19.
Oak, poison, 189.
Occupation, influence of, in the
production of skin diseases, 45,
274.
Oily seborrhoea, 73.
Ointments, 293.
mode of applying in
eczema, 186, 187.
Onychatrophia, 244.
Onychauxis, 234.
Onychia, 205, 206.
Onycho-gryphosis, 234.
Onycho-mycosis, 205.
Osmidrosis, 86.
Pachydermia, 227.
Pacinian corpuscles, or tactile cor-
puscles, 8.
"Paget's disease," 182.
Painful subcutaneous tubercle,
258
Palmar sypljiilis, 126.
Panniculus adiposus, 6.
Papilla, hair, structure of, 10.
Papillary layer of the skin, 6.
hypertrophies, 216.
Papular eruptions, 145 .
Papule, 20, 37.
moist, or mucous patch,
125.
Parasitic diseases, 46-72.
sycosis, 50 (51, 157)-
sycosis, diagnosis of, 175.
Parchment skin, xeroderma, or
ichthyosis, 216.
Pars papillaris, 6.
Patches, mucous, 125 (264).
Pediculosis, 63.
Pelade, 241.
Peliods rheumatica, 210.
Pencils, syphilis transmitted by,
119.
Pemphigus, 153, 154.
cacheticus, 155.
foliaceus, 154.
gangraenosus, 155.
malignus, 155.
pruriginosus, 155.
syphuiticus, 122, 128.
308
INDEX.
Pemphigus vulgaris, 154.
diagnosis of, I55(i94»
261).
frequency of, 30.
Perspiration, insensible, 14.
Phlegmonous eruptions, 201.
Phthiriasis, 63.
capitis, 64.
corporis, 63.
pubis, 65.
diagnosis of, 65, 66,
67, 68(70, 160, 175,
180).
frequency of, 29.
Phyma, 36, 38.
Physiology of the skin, 15.
Pian, 229.
Piebald skin, 236 .
Pigmentary atrophies, 235.
hypertrophies, 212.
mole, 214, 215.
naevus, 212, 214.
syphiloderm, 124, 125.
Pigment of the skin, 7.
Pills, 289.
Pimples of acne, 78.
"Pitting" of small-pox, treat-
ment of, no.
Pityriasis, 74.
capitis, 193, 200.
maculata et circinata,
194.
pilaris, 218.
rubra, 182, 193, 217.
versicolor, 60.
diagnosis of, 197 (51,
74, 176, 182, 217).
Plantar syphilis, 126.
Plaques muqueuses, 125.
Plasters, 279.
Pointed condyloma, 222.
Poison ivy, 189.
oak, 189.
sumac, 189.
Polytrichia, 231.
Pompholix, 156 (88, 153).
Pomphus, 36, 37.
Porcupine men, 217.
Porrigo, 162.
decalvans, 241.
favosa, 56.
Port wine marks, 255.
Powders, 290.
Pox, 117.
Predisposition to skin affections,
45.
Pregnancy, influence on the skin,
44. 239-
Preputial, or progenital herpes,
151.
Prickly heat, 146.
Primary lesion of syphilis, 120.
lesions of the skin, 35.
Prurigo, 145, 148.
podicis, 148, 180.
scroti, 148, 180.
diagnosis of, 66, 149.
pruritus in, 96.
Pruritus, 90, 94 (66, 148).
ani, 95.
hiemalis, 95.
scroti, 95.
senilis, 95.
vulvae, 95.
diagnosis of, 96 (66, 71).
Psoriasis, 74, 193, 194.
aggregata, 196.
buccalis, 126.
circinata, 196.
diffusa, 196.
pyrata, 196.
mveterata, 196,
nummularis, 196.
orbicularis, 196.
punctata, 196.
syphilitica, 126.
diagnosis of, 197 (48,
50, 51, 59, 65, 66, 74,
122, 126, 147, 176, 177,
182, 194, 197, 207,250).
INDEX.
309
Psoriasis, frequency of, 30.
pruritus in, 96.
Purples, 209.
Purpura, 209.
hemorraghica, 209, 210.
rheumatica, 209, 210.
simplex, 209.
variolosa, 210.
frequency of, 30.
Pustulae, 20, 36, 37.
Pustula maligna, 133.
Pustular eczema, 175.
Quantity of fluid daily excreted
by the skin, 14.
Quinine eruption, 190, 267.
Recurrent exfoliative dermatitis,
194.
Red gum, or lichen simplex, 146.
Removal of superfluous hairs, 232.
Rete malpighii, 7.
mucosum, 7.
Rhagades or fissures, 36, 39.
Rheumatic purpura, 209, 210.
Rhinoscleroma, 249, 255.
Rhus toxicodendron, 189.
venenata, 189.
Ringworm, 47.
Burmese, 52.
crusted, 56.
honeycombed, 56.
Tokelau, 52.
diagnosis of, 48, 50,
51, 53.
frequency of, 29.
Rodent ulcer, 263,
Rosacea, 257.
Roseola, 138.
sestiva, 139.
annulata, 139.
autumnalis, 139.
cholerica, 139.
epidemic, 103.
infantilis, 139.
Roseola, syphilitic, 120, 139.
vaccinia, 139.
variolosa, 139.
diagnosis of, 139.
Rose rash, or roseola, 139.
Rotheln, 103 (121).
Rougeole, loi.
Rubber bandage in eczema of the
legs, 179.
Rubeola, loi.
diagnosis of, 102, 103,
(121).
Running tetter, or eczema, 164.
Rupia, syphilitic, 123.
Salicylic acid, eruption from, 190.
Salivation, treatment of mercurial,
132.
Salt rheum, 164.
Sapo viridis, 284.
Sarcoma cutis, 258, 265.
Sarcoptes scabiei, 68.
Scabies, 68.
diagnosis of, 70 (66, 88,
144, 147, 149. 160, 163,
177, 179, i8i, 182,
207).
frequency of, 30.
over-treated, 72.
Scale, 36, 38.
Scall, 164.
Scalled head, or milk crust, 164.
Scalp, eczema of, 174.
Scaly tetter, 195.
Scarf skin, structure of, 7.
Scar, 36, 39.
Scarlatina, 3, 104.
Scleroma, 223.
neonatorum, 223, 227.
Scleriasis, 223.
Scleroderma, 223.
diagnosis of, 224
(177, 225, 226,
261, 263).
frequency of, 30.
3IO
INDEX.
Scorbutus, 209, 211.
diagnosis from pur-
pura, 210.
Scratching, causing skin lesions,
63, 69, 167.
Scrofulide erythemateuse, 249.
tuberculeuse, 251.
Scrofuloderma, 249, 253.
Scurvy, 211.
land, 209.
Sebaceous cysts, 77.
glands, anatomy of, 11.
glands, diseases of, 73.
glands, secretion from,
12.
Sebiparous glands, 1 1, 12.
Seborrhagia, 73.
Seborrhoea, 73, 200.
congestiva, 249.
diagnosis of, 73, 74
(50, 51, 62. 176, 197,
250, 264).
Sebum, 12.
Secondary lesions, 35.
Segars, syphilis transmitted by,
IT9.
Senile atrophy of the skin, 238.
Sex in skin diseases, 30, 45.
Shingles, 90.
frequency of, 30.
Skin, anatomy of, 5.
atrophy of, 237, 238.
grafting and syphilis, 1 19.
diseases, analysis of 8,000
cases of, 125.
Small-pox, 107.
Spargosis or elephantiasis Arabum,
227, 260.
Spiritus saponis kalinus, 284.
Spitze condylom, 222.
Spots or macules, 36.
Squamae, 20, 35, 38.
Squamous eruptions, 193.
Stains, 36, 38.
St. Anthony's fire : term applied
to erysipelas, 135, and herpes,
150.
Starch, iodide of, in S3rphilis, 132.
Statistics of 8000 cases of skin dis-
ease, 25.
Steatorrhcea, 73.
Steatozoon folliculorum, 76.
Stimulants in skin disease, 271.
Sterility caused by sjrphilis, 127.
Striae atrophicae, 238.
Strophulus albidus, 76.
« prurigineux, 149.
Struma, 253.
Structure of the skin, 5, 6.
Styes, 204.
Subcutaneous connective tissue, 6.
painful tubercle, 258.
Sudamina, 89.
Sudoriparous glands, 13.
Sumac, poison, 189.
Sunburn, 213.
Superfluous hairs, 231.
Supra-renal melasma, 214.
Sweat, bloody, 87, 211.
glands, action of, 14.
glands, anatomy of, 13.
glands, diseases of, 83.
glands, number of, 13, 14.
Sweating excessive, 84.
colored, 86, 87
offensive, 86.
Sycosis, 157.
parasitica, 50.
diagnosis of, 159 (51,
175).
Sjrmptoms in diagnosis, 32.
Syphilis, 117.
vaccinal, 114.
diagnosis of, 121, 126
(48, 50, 5ii 58, 65, 66,
80, 139. 147, 159, t6o,
163, 174, 176, I77» I79»
181, 182, 202,210, 214,
230,236,250,254,255,
261, 264).
INDEX.
3"
Syphilis, exanthematous nature of
117.
Syphilis, frequency of, 29.
initial lesion of, 118.
length of treatment of,
132.
modes of transmission of,
T17, 119.
Syphilitic alopecia, 239.
gumma, diagnosis from
lipomata, 248.
lupus, 123, 124, 251.
mucous patches, diag-
nosis from eczema,
175.
onychia, 206.
roseola, 120, 139.
Syphiloma, 124.
Tactile corpuscles, 8.
Tar wash, alkaline, 284.
Tattooing, syphilis conveyed by,
119.
Tea in skin disease, 271.
Telangiectasis, 256.
Tetter, dry or scaly, 195.
Tetter, moist, 164.
Therapeutics of skin diseases,
275.
Thickening, or infiltration, 36, 39,
168.
Tinctura, or stain, 36, 38.
Tinea barbae, 50.
capitis, 49.
circinata, 47.
corporis, 47.
cruris, 51.
decalvans, 241.
favosa, 56.
furfuracea, 60.
kerion, 50, 51.
sycosis, 50.
tondens, 49.
tonsurans, 49.
trichophytina,47f 50«
Tinea unguium, or onycho-myco-
sis, 205.
versicolor, 60.
diagnosis of, 48, 50, 51, 53,
58, 59, 61 (175, 176, 180,
182, 194, 197, 242).
Tissue, adipose, 6.
Tokelau ringworm, 52.
Tooth brushes, syphilis transmit-
ted by, 119.
Toys, syphilis transmitted by,
119.
Transmission of syphilis, modes
of. 117, 119.
Trichauxis, 231.
Trichophyton tonsurans, 29, 46,
Trichophytosis, 49.
Trichorexis nodosa, 239, 243.
Trichorrhoea, 239.
Trophic nerves of the skin, 8.
Tubercle, subcutaneous painful,
258.
Tubercula, 36, 38.
Tubercular leprosy, 260.
Tumor, 36, 38.
Tyloma, 220.
Tylosis, 216, 219, 220.
Ulcer, 36, 40, 205, 206.
rodent, 263.
Ulcus, simplex; 206.
venereum, 207.
Unilateral atrophy of the face.
226.
Urticaria, 138, 146.
acute, 143.
chronic, 143.
bullosa, 154.
papulosa, 143.
pigmentosa, 144.
tuberosa, 143.
diagnosis of, 144 (71,
121, 141, 147, 149).
frequency of, 30.
312
INDEX,
VAcaNAL erysipelas, 115.
roseola, 139.
syphilis, 114.
Vaccination, 113.
safety of, 1 1 3-1 16.
syphilis communi-
cated by, 119.
f uruncular inflamma-
tion due to, 115.
Vaccinia, 113.
Vapor baths, mercurial, in syphi-
lis, 130.
baths, when harmful, 276.
Varicella, in.
Variola, 107.
maligna, 108.
modihcata, 108.
Variolous purpura, 210.
roseola, 139. .
Vaso-motor nerves of the skin, 8.
Vegetable parasites, 2.
Vegetations, 222 (126).
Venereal ulcer, 207.
warts, 222 (126).
Verruca, 216, 221.
acuminata, 221, 222.
necrogenica, 221, 222.
senilis, 221.
vulgaris, 221.
Verrugas, endemic, 229.
Versicolor, pityriasis or tinea,
60.
Vesicula, 20, 36, 37.
Vitiligo, 236.
Vitiligoidea, 247.
Vlemingkx' solution, 283.
Warts, 221, 222.
Washerwoman's itch, or eczema
of the hands, 176.
Water, effect of, in eczema, 186.
in skin disease, 275.
Watering or " leeting " surface in
eczema, 168.
Wens, 77.
Wheal, 36, 37.
Wilkinson's ointment, 297.
Xanthelasmoidea, 144.
Xanthoma, 245, 247.
multiplex, 248.
planum, 247.
tuberosum, 247.
Xeroderma, 85, 86, 217.
Yaws, 229.
Zona, 90, .150.
Zoster, 90.
frequency of, 30.
BULKLEY. Archives of Dermatology. A
Quarterly Journal of Skin and Venereal Dis-
eases. Edited by L. Duncan Bulkley, A.M., M.D.,
Attending Physician for Skin and Venereal Diseases at the
New York Hospital, Out-Patient Department ; late Physi-
cian to the Skin Department, Demilt Dispensary, New
York, etc. Price, per year, $4.00 ; specimen copies, $1.00
The aim of the Archives of Dermatology has been
and shall still be to meet the wants of the general prac-
titioner^ and to serve as a communication between the
specialist, whose entire attention is devoted to skin and
venereal diseases, and those in general practice, that the
daily-gained experience of the latter may reach the
former.
The Archives of Dermatology is now the only Sci-
entific y^ournal published in the English language devoted
exclusively to skin and venereal disea^es^ and is of service
to every practitioner.
With a view of furnishing simple matter in each issue
of immediate practical advantage to the general prac-
titioner, the editor will endeavor, as space permits, to
give, as in the past, plain comments on common diseases
of the skin in the form of serial articles.
The digest department will continue, as before, to
epitomize the current literature of the day by means of
the able staff of collaborators, who have already so faith-
fully and earnestly aided the Journal.
OPINIONS OF THE "ARCHIVES."
^^ This journal, under Dr. Bulkley's management, continues to be conducted
with much spirit. It contains not only original papers which represent most of
the dermatological work done in the States, but excellent abstracts of all Eu-
ropean work in this department."— Z-£;»<fo» Practitioner,
" In every sense a credit to American literature." — Medical Record,
" * The Archives of Dermatology * is not only the only journal in the English
language devoted to the specialty of skin diseases, but, it may be safely said,
is unequalled by any similar journal, French, Italian, or German. The num-
bers before us present an excellent example of a journal which, while contain-
ing scientific matter for the specialist, also furnishes practical information for
the general practitioner. Here the practitioner may find what it is impossible
to get in any text-book, — from the circumstances of the case, — a varied armory,
from which he can draw weapons for every emergency. We can cordially
recommend this journal to the general reader as a special journal which is not
for specialists o\Ay^'^— Philadelphia Medical Times,
G. P. PUTNAM'S SONS, Publishers, New York.
BULKLEY. Eczema and its Management.
A Practical Treatise Based on the Analysis of Two
Thousand Five Hundred Cases of the Disease. By L.
Duncan Bulkley, A.M., M.D., Physician for Skin
and Venereal Diseases at the New York Hospital, Out-
Patient Department, etc. Price, . . . $3 06
" The whole work is fascinatingly interesting, and we recommend it
to the general practitioner, for whom it is chiefly written, as a most
valuable guide to the intelligent treatment of one of the most fre-
quent as weU as troublesome of skin affections. * * * in regard
to treatment, he enters most minutely into details. * * * The
chapter on diet and hygiene is equaUy comprehensive. A formulary
is also appended." — Philadelphia Medical and Surgical Reporter,
" Every general practitioner should read this book, that he may
know how to cure eczema." — American Specialist,
** The book is a clear guide. It is practical, simple, direct in
style, logical in arrangements, and exhaustive in the treatment of the
subjects. It cannot fail to extend the reputation of its distinguished
author." — Philadelphia Medical Times,
" In every sense it is a good book, worthy of the most careful study
by every member of the profession, general practitioner or specialist."
— Detroit Lancet,
** This book is one of the most valuable contributions to medical
science which has been made within a decade." — Medical Herald^
LouisviUe.
** A work which, in good faith, teaches the physician of average
intelligence how to bring such cases to a successful issue. * * *
Any physician who sees one case of eczema per annum can afford
to buy and study this valuable book. It is a model of what a medical
monograph should be, uniting the thoroughness of the German in-
vestigator with the practical acumen of the American practitioner."
— St, Louis Clinical Record,
G. P. PUTNAM'S SONS, PubUshers,
New Yorki
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