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Full text of "A practical treatise on diseases of the skin"

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lANE MEDICAL LIBRARY 
STANFORD UNIVERSITY 
MEDICAL CENTER 
STANFORD, CALIF. 94305 



lui^ 





rsuriasL'i (fn>m Nature). 



A PKACTIOAL TREATISE ON 



DISEASES OF THE SKIN 



BY 

JOHN V. SHOEMAKER, A. M., M. D. 

ProftMWtqfSHn and Venertal DiteoMi in ttu Medico- CMrurgical CMUgt and 

Jl08pUal of PMUuMphia 

Phpridan to the PhUadelphia HotpHalfor IHgeas€9 qf the Skin 

Mander of the American Medical Aeeodation 

qfthe Penneylvania and Minnesota State Medical Societies 

nf the American Aeademy of Medicine., and qf the British Medical Ai/sociation 

Fdlow of the Medical Society of London 



SECOND EDITION, REVISED AND ENLARGED 
WITH CHROMOGRAVURE PLATES AND OTHER ILLUSTRATIONS 



NEW YORK 

D. APPLETON AND COMPANY 

1893 



»r 1 ±27r:.ryi^ a53 o>x?iJT- 



PREFACE TO THE SECOND EDITIOX. 



&. nsooND edition of this work being demanded, the author has 
taken tlie opportunity of incorponitiug In it varioui? new points 
relative to etiology, pathology, and treatiiient wliieh have been 
brought forward since the tir^t edition was issued. Many niemoira 
and valuable text-books have api)eared witldn tliat time, and their 
jiages have been carefully consulted ivith the view of making this 
volnrae useful to the reader and a faitlifid representation of the 
present knowledge of dermatology. lutercisting faets pertaining to 
tlie clinical history of different affections have been added, and the 
object has ever been kept in view to deisoribe the maladies of the 
skin in tlieir relation to the general state of the eeonorny. The 
results of the eultivation of Imcteriology have, in Beveral instances, 
given precision to our views conceniing etiology. Brief descriji- 
tions have been given of those micro-organisms which have heen 
demonstrated to be exciting causes of certain cutaneous maladies. 
Tlie effect of local antisepsij^ is hrifiiy dl.scussed in the introductory 
chapter upon treatment in Part I. The most efficient baetericides 
and tlieir influence in various morbid conditions are described in 
tlie eame portion of the l>ook, while the details of their application 
are given in the consideration of the various disea^^s in wliich they 
are applicable. A &|>ecial section liaa been added upon electricity. 
Id wliicli tlie value of this agent is discussed in the treatment of 
many diseases of the skin. The effect of diet in the production 
and treatment of cutaneous affectiiiii.s is ako alluded to at some 
length. Attention is given to improved methods in the treatment 
of the eruptive fevers. Many additions have been made to the 
chapter on sypldlis. A euffieioTvtIy full account lia,^ l>een given 
of the various methods of hypodennie medication that have been 




IV 



PREFACE TO THE SECOND EDITION. 



advocated ia i}u» disea^^e, together with an estimate of their adva 
trtges and defects. A jscotton Las lK?eti added deseriptive of the 
various ciiariges which the naik undergo in consequence of local 
or general disease. The recent literature upon the subject of lep- 
rosy lias heen Burveyed, and the opposing doctrines concerning its 
contagious and hereditary character have l>een jjatiently consideretl. 
Upon these tiuhjects, httwcver, the writer has »vun no i-eason for 
changing the opinions advanced in the tinst edition. The consti- 
tutional effects of carcinoma are hrielly deFeril)ed. An account 
has been given of the recent literature upon the etiology of cancer 
in connection witli the views advanced h>' Darier and iithers upon 
the guhject of cutaneous psoro8]KTniOf^i8. The {jathogenesis of 
lupus vulgaris and its relation to otlier forms of cutaneous tuber- 
culosis receive due attention. The results of the treatment of 
hipua by tuherculine are described in accordance with the experi- 
ence of the author in the use of this renicdv. 

A number of additional valuable formula} have l>een end)odied 
in the work, Illustrative of the therapeutic methods of various 
authorities at home and abroad. 

The recent treatise of Leloir and Vidal (unfortunately incom- 
j)lete at this date) npou patiiology, arnl tliat by Brocq on treatment j 
the excellent works of Fox, Piffard, Morrow, and Taylor; together 
wjtii innmnerable memoirs a|>i>eariMg in the journals of onr own 
and foreign countries^ with the per^ional exjKTience of the author 
during the last four years, form the ha?>is uf the additions made 
to the original text. 

The author wishes to tliaiik Ids colleagues. Prof. Frank Wood- 
bury, D]\ George Jlcwitt, and Dr. E. 8. Gans, for kind assistance 
during the preparation of this edition for the press. 

John V. Suoi^makek. 



No. 1510 Walnut Strut, PKiLADLLrnu, Jw/j/, ]$0S. 



FKEFACE TO THE FIRST EDITION. 



AfiSOCiAnoN during the past few yearn witli many students and 
plijBi<^ns^ at the Medico Chinirgieal College and at the Philadelphia 
no^ital for Skin Diseases, Laving tanglit me as a teacher the de- 
eirability of conciseness in the treatment of aiij subject, in this work 
will be found but little reference to the extensive literature of tho 
affections of which it tx-eat*. The limits in size to which a work of 
iU intention should lie circnnisenl>ed having been rigorouelj imposed 
tipon it and adhered to, it has been my constant aim within those 
limits to present brief, although cknir, dcscri[>tions of nuiuerons 
affections of the skin. I have also in the preparation of the work 
purposely omitted many cnmbroua technical words and phrases 
which often confuse and mislead the student, and in their stead 
have substituted words and phrases well understood and fully con- 
veying their meaning. All tliat I claim in it as especially originsd 
is a statement of the relative effects and values of numerous agents 
tested in my own many years of clinical ex]>erience in the treatment 
of skin-diseases. 

The pictures representing the normal skin and the pictures pro- 
daced !»y photo-mieiM>graph liave been contributed by Dr. Morm 
LoTigstreth, assisted by Dn Martin Rively* To Dr, Richard J. 
DnngliBon my thanks are due for the execution of t!re complete 
index that accompanies the work. The drawings for the woodcuts 
were executed by Mr. William Eaii Smith, and are for the most 
port from caseB of roy own in the Philadclpliia Hospital for Skin 
Diaeases. 

In conclusion, I would merely add that the whole work has been 
written from the standpoint of an active general practitioner, and, 





vi PREFACE TO THE FIRST EDITION. 

as I think it reasonable to believe, can hardly fail to bear that im- 
press ; and if I am right in so thinking, knowing as I do that that 
standpoint has been inclusive of special opportunities and study 
within the department of skin-diseases, I cannot but hope that the 
work will fulfil in some measure its intention of supplying the 
needs of the medical student and of the busy physician. 

John V. Shoemaker. 

No. 1619 Walnut Street, Philadelphu, Janua%'y, 1888. 



COITTEI^TS. 



PART I. 
GENERAL CONSIDERATIONS. 

PAOS 

AXATOXT OF THE SkIN 1 

EnDEBMIS 3 

CORIUM 

Subcutaneous Connective Tissue 8 

Sweat-Glands 9 

Sebaceous Glands 12 

Hairs 14 

11 air-Follicles 17 

Muscles of the Skin 20 

Blood- Vessels of the Skin 21 

Lymphatics ok the Skin 22 

Nertes of the Skin 23 

Pacinian Corpuscles 23 

Tactile Corpuscles 24 

Non-medullated Nerves 24 

Physiology op the Skin 25 

Regulation op the Temperature of the Bodx 25 

Respiratory Function of the Skin 27 

Sensation 28 

Absorption 80 

Secretion and Excretion 33 

Sebum 33 

Perspiration 33 

Electric Currents of the Skin 30 

Odor of the Skin 37 

Symptomatology 38 

Diagnosis 48 

Pathology 52 

Etiology 58 

Treatment 05 



PART 11. 

CLASSIFICATION. 

Class I. Disorders of Secretion and Excretion (Anoinaliro Socretionis et 

Excretionis) 121 

Class II. HypenBHiias (Hypenemijp) 121 



viii CONTENTS. 

PAGB 

Class III. Hffimorrhages (Hsemorrhagiff) 121 

Class IV. Exudations (Exudationes) 121 

Class V. Hypertrophies (HTpertrophia*) 121 

Class VI. Atrophies (Atrophiie) 121 

Class VII. Tumors (Neoplasmata) 121 

Class VIII. Neuroses (Neuroses) 123 

CUtss IX. Parasites (Parasitic) 122 



Class I. 

DISORDERS OP SECRETION AND EXCRETION. 

Seborrhoea 122 

Comedo 131 

Milium 134 

Sebaceous Cyst 135 

Hyperidrosis 130 

Anidrosis 140 

Bromidrosis 141 

Chromidrosis 143 

Sudamina 145 

Hydradenitis destruens suppurativa 145 



Class II. 

UYPER.EMIAS. 

Erythema simplex 148 

Erythema Intertrigo 150 

Class III. 

HJEMORRHAGE.S. 

Purpura 152 

Hemophilia 159 

HflBmatidrosis 159 



Class IV. 

EXUDATIONS. 

Rubeola 160 

ROtheln 165 

ScarUtina 160 

Variola 1"8 

Varicella 189 

Vaccinia 190 

Erysipelas 195 

Chancroid 204 

Syphilis 211 

Erythema Multiforme 263 

Erythema Nodosum 205 



CONTENTS. ix 

PAOB 

Urticaria 268 

Lichen Planus 279 

Lichen Scrofulosiis 282 

Prurigo 284 

Herpes 287 

Miliaria 2»7 

Pemphigus 800 

Uydroa 308 

Pompholyx 310 

Acne 311 

Rosacea 827 

Sycosis 836 

Impetigo 341 

Impetigo Contagiosa 344 

Ecthyma 845 

Pityriasis Rubra 348 

Furunculus 352 

Carbunculus 356 

Anthrax aW 

Equinia 861 

Delhi Boil 362 



Wounds and Contusions 364 

Dissecting Wounds 364 

Poisoned Wounds 365 

Ulcere 366 

Eczema 369 

Dermatitis 446 

Combustio 464 

Congelatio 469 

Class V. 

HYPERTROPHIES. 

Lentigo 478 

Chloasma 474 

Naevus Pigmentosus 479 

Callositas 480 

Clarus 481 

Coma Cutaneum 483 

Keratosis Pilaris 485 

Psoriasis 486 

Lijchen Rub^r 505 

Verruca 508 

Ichthyosis 512 

Scleroderma 517 

Sclerema Neonatorum 522 

MorphcBa 524 

Elepbantuisift 527 

Dermatolysis 533 

Hypertrophy of the Hair 534 

Hypertrophy of the Nails 538 



CONTEXTS. 



Class YL 

ATROPHIES. 

Albinismns 542 

Vitiligo 543 

Csnitieg 545 

Atrophia Cutis 550 

Xeroderma Pigmentosum 551 

Senile Atrophy 553 

Stris ct Maculae Atrophicie 554 

Alopecia 555 

Alopecia Circumscripta 565 

Atrophy of the Hair 570 

Atrophy of the Nails 5?3 

Class YII. 

TUMORS. 

Rhinosclcroma 578 

Lupus Erythematosus 581 

Lupus Vulgaris 586 

Scrofukxlerma 605 

MoUuscum Epitheliale 613 

Ijepra 615 

Epithelioma 644 

Sarcoma Cutis 655 

Carcinoma Cutis 650 

Keloid 661 

Molluscum Fibrosum 668 

Xanthoma 670 

Lipoma 673 

Angioma 074 

Lymphangioma 682 

Neuroma 683 

Myoma 684 

Class VIII. 

NEUROSES. 

Ilypcnpsthcsia 686 

Anossthesia 686 

Dermatalgia 686 

Parajsthesia 688 

Class IX. 

PARASITES. 

Scabies 607 

Pediculosis 706 

Cimex Lectularius 713 



CONTENTS. xi 



pAoa 



Pulex IrriUns 714 

Pulex Penetrans 714 

Demodex Folliculorum 714 

Leptus 715 

Gysticercus CellulosaD 716 

Filftria Medinensis 716 

(Bstrus 717 

Culex 718 

Ixodes '. . 718 

Tinea Versicolor 719 

Tinea Favosa 726 

Tinea Tonsurans 733 

Tinea Sjcosis 744 

Tinea Circinata 747 

Trichomycosis Nodosa 753 



LIST OF ILLUSTRATIONS. 



PUATB PAOB 

1. Psoriasis (from Nature) FrwUispiece 

II. Gummatous syphilide, with ulceration and necrosis of the frontal bone 

(from Nature) facing 280 

III. Acne indurata (from Nature) "813 

IV. Dermatitis venenatA (from Nature) *' 446 

V. Ichthyosis (from Nature) " 512 

VI. Alopecia circumscripta (from Nature) •* 565 

VII. Lupus vulf^ris (from Nature) '• 586 

VIII. Tubercular leprosy (from Nature) " 017 



FtO. 

1. Anatomy of the skin 2 

2. Section of skin magnified seventy-five diameters 3 

8. Sweat-gland 10 

4. Magnified hair 15 

5. Human hair magnified 16 

6. Transverse section through hairs magnified seventy-five diameters . . 17 

7. Section through end of finger of a child 20 

8. The author's woven gum bandage Ill 

9. Dermatological case 112 

10. Dermatome, or needle-knife 112 

11. Rupia 280 

12. Cutaneous horns 484 

13. Atrophy of hair-root 571 

14. Atrophy of hair-substance 571 

15. Epithelioma magnified seventy-five diameters 647 

16. Keloid tumor 662 

17. Keloid in negro 668 

18. Section of keloid magnified seventy-five diameters 663 

19. Acarus scabiei and QQg 700 

20. Pedicul us capitis 707 

21. Pediculus corporis 708 

22. Pediculus pubis 709 

28. Demodex foUiculorum 715 

24. Spores in epidermis of the chest 722 

25. Achorion SchOnleinii 729 



DISEASES OF THE SKIN. 



PART I. 

GEXEHAL CONSIDERATIONS. 



ANATOMY OF THE SKIN. 

The skin is a firm, fibro-elastic membrane which covers the e.Tter- 
nal surface of the body, and is continuous at the natural oriticea with 
the macouB membrane lining the interior ; is Taried in function and 
complex in organization ; adapts itself by it^? ehxjsticity to the move- 
ments of the underlying structures, and protects them from external 
irritation or injury ; binds the muscles and fascia together, gives 
shape and color to the body, and ])re vents the too rapid escape of tluid 
from the tissues. It is also of tlie utmost importance as un organ of 
sensation, absorption, secretion, and excretion. 

The fikin is grooved by a network of minute furrows which corre- 
spond to the depressions between its papillsB and cross each other in 
all directioni*. These furrows are especially noticeable on the back of 
the hand, where they divide the surface into a multitude of irregular 
triangnlar and tiuadrilatcral !?i»aces. Larger ones, in conformity with 
the folds of the skin, are found on the face and neck, and near the 
joints* The surface of the skin is pierced by millions of minuto 
openings — the orifices of the hair-follicles, and of the jsebaeeous and 
gndori parous dnct^. Hairs, coarse or line, are found on every region 
of the body except tlie clitoris, the glans penig, the inner surface of 
the prepuce and labia majora, the palms of the hands, the soles of the 
feet, unci the tlorsal surfaces of the last plmlanges. The color of the 
gkin dej)enda upon the amount of fngnientary matter it contains. The 
chAracterisiic racial dilTerenccs, as wt'll us tlie variations of complexion 
of individuals of the same nice, are Jue to a more or less abuiidaut sup- 
ply of this material- In the Caucasian race it is usually deposited in 
the greatest rpiantity in the scrotum and labia, and in the aureolae of 
the nipples. 

The skin varies in thickness in difTercnt parts of the body. It is 

thinnest on the eyelids and prepuce, and thickest on tlie back, but- 

tockji^ palms, and soles. Its attachment to the structures beneath ifc 

varies with the density of the areolar tissue and the amount of adi- 

1 





jl DISEASES OF THE PKIN. 

pose matter present. In those portions of the body where tbo areolar 
tissue is compact, or where there is an abuDckuce of fat, as on the 
pubes, parineuiii, and back, the connection is tirm and close. Where 
great mobility is desirable, as around the joiuts and on the eyelids, 
the areolar tissue is loose, and contains little or no fat lu these 
regions the attaciiment is comparatively slight, and the soft and pliant 
skin can easily be rau^ed into folds between tlie fingers. Turner and 
other writers of the eighteenth century record the case of a Spaniard 
wh6se skin was go loose and elastic on the right side, that it could 
be drawn out from his body for twelve inches in any direction. An 
analogous caise is that of Ilerr Ilaag, a native of Nuremberg, wlio has 
recently been on exhibition in the cities of Europe and the United 
States as '* the India-rubber-sk^n man." This abntiniialiiy is only 
explicable on the supposition that there is a large increju^e of elastic 
tissue in the corium, and an absence of any connecting fibres between 
it and the deeper structures. 




Fio. 1.— A. Epidermis. B. Coriuro. C. Subcutaneotwi (^^>mlecti v*j tisauc, I. Coracom layer. 
2. Stmrum lucidiim, 8. Gmuular layer. 4. Muixiua layer. 6. Pfti>illB* 6. Tuctlla 
C'rjiitficJt?. 7. rwiiiUiuy in the papilla. S. lLiir-*.hoft. 0. Excretory duct of sudoripOr 
roiiB gliuid. 10. SudoriparouB or awcflt gland firming Iho coil. 11. PaelmiitJ cor[>u»cIe, 
12. i*u|>tliii of the hair. 1ft. Sebooeoua or Bebiparou» gland. 14. Kri}otor>pili muacie. 
15, Aiiipoee tissue, 

A knowledge of the minute anatomy, as well as of the general 
structure of the skin, le necessary for a proper appreciation of the 




ANATOMY OF THE SKIN. 



objuiges produced by disease. It is al.so of importance as a basis for 
the raticjDat application of tberapeuticj measured. Sooie morbid cou- 
ditioQs involve tbe ekin in its entirety ; others manifest no tendency 
U> spread beyond the part in which they iirsfc appear. 

The fikiu is composed of three layers : the epidermis, the cnrinm» 
and the eubcutaueous connective tissue, each of which is formed by 
the aggregation of a number of [jrimary layers. The line of demarca- 
tion between the epidermis and tlie corium is sharply defined. They 
can be detached from each other by Diaceratiou, and are B<?parated by 
Tariou8 morbid processes. The eorium and subcutaneous conoeetiYC 
tigsne^ however, merge imperceptibly into each other, the boundary- 
line between them being merely an imaginary one. The skin is abun- 
dantly supplieti with blood-vessels, !ymidiat»cs, nerves, and muscles, and 
is al50 provided with certain siKKjial appenda^^es necessary for the i>er- 
formance of its functions, viz.^ sudoriparous and sebaceous glands^ 
hair-follicleg, hairs, and nails. (See Fig. L) 

The Epidermis. — The epidermis, cuticle, or scarf-skin, is the most 
superficial iK>rtion of the skin. It is a laminated, slightly elastic 
membrane, composed en- 
tirely of epithelial cells 
aod scales. It contains 
no blood-vessels, and is 
btit scaotily supplied 
with nerresi, only a few 
(ilameiiU having been 
tnced to its dfei>er lay- 
ers. It covers the cori- 
um clo^ly everywhere » 
and ^rves to protect that 
Btrocture from external 
irritation or injury. It 
is pierced by the hair- 
follicles and the ducts of 
the sudoriparous and se- 
baceous glands, and is 
marked by a network of 
minute furrows which 
represent the depressions 
between the papillaa of 
the cj»riam. The larger 
furrows found on the face and the neck, and in the vicinity of the 
jomts, corresj>ond to the folds of the skin when not in motion. The 
epidermis oousista of four separate layers : 1. Stratum corneum. 2. 
Stratum lucid am. 3. Stratum granulosum. 4. Stratum mucosum. 
The first two layers are frequently considered as one, denominated the 




Fio. 2. — Photn-mlfTOirpaph. Section of skin^ mo^Eiilied 
siiventv-fivo diamottn*. n. Cfirnt-rHis byer of L^|^>idcvr- 
mt«. h, MucouH hiyor of epidermis, c. Hair in ite 
Mheoth. d. Swent-glond, fr»>m which the lar^'er druw- 
in^* of ftwojit'^land in thiH book wa.s taken, t. Iluir in 
8hc«th out irrt'guliirly. /, /. Subcutaueouji fat. 



4 DISEASES OF THE SEEC. 

hv^TTiT lajer; and The latter two likewise, as one, and styled the mncoas 
lijer. This olissinoation is, however, erroneous, and shonld be dis- 
oarvled. There ar? four lavers, whether viewed from a pathological or 
a hisiv;ogioa] jvin: of view. 

The epidermis varies in thickness in accordance with the develop- 
ment of it^ various laversw It is thinnest about the lips and on the 
fci«>e. and thickest uj«on iho j*alms and soles. The coloring-matter of 
the rpidt-nnis is almost eiL-!usive]v found in the stratum mncosum. 

Stejltim Coexevm iCunxrors Lateeu — This is the external or 
snperfoial layer of the e; idtncis^ It is comjK^sed of several strata of 
fli:'<Et>d. iranspajvni Otl]s of various shapes and sizes. The ceils of 
the dt-eper arv piOvircna] or spina ]r-sha}>ed in form, and are larger 
aisd mere disiir-c: :Lai; :b:i?<e al*. ve them. S«>ce present rrac*» of a 
n-cI-eiiSw ar.d can l«r sTi-.ned faimlv w::h cam.iiie. The superficial 
s:ri:d o-.'usis: of fi:. T*.:_vrn:^."-^%.j« sca'-es. wb:oh l^eix-me more and 
more si:r>r!>i ir. i: >.-sri::i:^ ar.i curved upon ihrni«i:!vr< as the snr- 
frKHr is iv:r^:tt..hei. Tl^rj i> n.: e:':::a:n a::y nr.i:-".ii. The srrarum 
a'»r=:-T:i2: -^ir-r-s :r. i.frreL: p:r::>-sof :he Nxiy. I: :s :h:r:;est on the 
lips s~ i fi^*:. i-i :h:.-kr>: ■:- :he r^'ms iri s^Iv 
no: iej^tni .- '.h-e i^'»-.I>riut::: of :hc v:hrr lay^ 

SrsArvK Lv.irvK. — Th-: s::ta:-ni luoii-n;. ctLU^i al?*:- the stra- 
nd: -f •>fi'. ifr-er ::s rr>: ii><vvertr. is the nsrr. w. :r:i-srAivn: layer 
■-f xnrrr-siir-i jf'/.s i:iz,i :::i!:::-'iii:.r'y lvr.ci:h :hv f:rs:um o:-T::e:izn. 
Acu-iri^j: :. IT-ri* :: c-;:i:a:"s fr.ci f.:ur :o six rows ci ct'Is rbai 
:=. ±r»e-:jh. -LZA'SLZ-t-i 5*ft::-..ns. i::Tsc: a::^r:::T. bj r-i.>.r. ci :hc:r ex- 
TTirZL'f tmsrirfL:". Thry irv i:-r>-:d fr.m :hi s-v'/.s of :he gTAnu'.ar 
liy-rr ty zl-i I-.is? :f :hi: :::±>:zi£. ir.i :he iLcrvA?*:- ::: :ra::srairhr.oy .:f 
'h'z 7^.rr. :i 'hi :^..\ i-zz6'.^z:^. Ki,.h :t:'l cor:^ rs a s:df~shs:<Ai or 
ii:-c L'T'i z 1 : - - s. U :: z i :•-/.:-: "s^^s : h *: : h i ? Uy • r : s :v. ; rv ly a r»: r, i- ■ :: . f 
z'ck r:*iT-izL I'it^-tz^. ini ?-jj:^<:s :hi: zb-: ::v-: :i s::ii:uTL. "u.iiiin 

^7r..iz.r^ -xz.^.--i f rv: r ^rr:*- r:ws :i ri:::v:-.:. ru::^i:cC ot'ls, 
Thj:h iTf T.:~.i:-fi .T-z:-:'! I'r'.j >:~^d:h :>■; s:T\i.:M:" ':::■.:;::::. Th-fv 

i-d-^ni Li :.:•:. r r. . z L -.--: iz*-.*! ir -v ^rir >; w*'.;v. i v^r: .j-^.; ^-cv.:: of 
:h.s ji7«7 :.? r^ir. Z'z-. r ..zz L izl-i-.'-it s Viiril'.-:'. :-: z:.-: s-rfict* of 
::•: ''..L-:r:L.A, Z'zr:j Ln ; -j-LTi'. ::-■"• :i:'.: *ry :":*: yTvsfOt* ir".---.-.: zc-.-r^ 
zi'i'.K. -f 1 izzi'.^r .1 T. z :Zz z'n.r.z'.'z^ .: i ?.i:!i:a:v.>:- Vv:**- i* :*■■.:,;:::. 
▼ !: •:'.!. lo."'. ri zz z: F-uit^cT. > i r::i:cr i". iv-Tcm:-'. .-.Tc v. :*i:~-v rt^ 
•■v^i T. : . 'i-Lr-T. ir-i i-.'^iz z. 1: :? r: ;:^": a*? .:"■ ;.i" : v-:ir :?: "."oI-fL 
of zr.*i >.'.ii. i-'i I :T-'.z\<.:'i^ :t i.^arrejirs x.^ :":'•: •>:•-;. ""or" :.s ip* 
rr:iic>.»r'L Vz^i n-zxrli :!:■: y^S:"..': i" 1 f .■rr:^'/ ": ;: :"*. ^~'1-'.u.'a*< 

4KV9 •!£ *ih! Siin. 



ANATOMY OF THE SKIN. 

of this layer as a necesssiry step in the process of tbe development of 
the stratum luciduni aud the stratum corneum» He believes that 
the color of tbe skin in the whit^* race is also dependent upon the 
preeeme of these granules. They refract the light very strongly, and 
therefore appear white in a reflected light. Prior to their formation 
ibe epidermis of tlie foetus is so transparent that the blood-vessels of 
the corium can be seen distinctly beneath it. 

Stratcm Mucostm ; Stratum Malpighii ; Rete MrcosfM ; 
Eetb Malpiohii. — The stratum ujucoi^um, or mucous layer, called 
alec the layer of Malpighi, is that portion of the epidermis which 
lies immediately above the corium ; it is separated from it by a thin 
bttsement membrane. It adapts itself closely to the upper surface of 
Ihd eorinm by mcjins of its interpapillary processes, which tit into the 
depressions between the papillae. It is composed of several layers of 
encleated cells, which vary in size and sha|>e. Those of the deepest 
layer are small and columnar, with oval nuclei, and are an-anged with 
their long axes perpendicular to the surface of the corium. They are 
compo^d of granular protoplasm surrounding the nuclei, and have 
DO distinct cell-wall. According to Biesiadecki and Henle, the ont- 
Hnes of the individual cells of this layer are obliterated occasionally, 
00 that the surface of the corium appears to be covered with a mass of 
piotoplasiiL containing a number of nuclei. The cells of the next 
two or three rows are larger and cubifurm, or more or less polygonal, 
and the nuclei are spherical, well dellncd, and homogeneous in struct- 
ure, are inclosed in a cell-wall or membrane, and contain granular 
and pigTncnta-ry matter. The cells of the euperticial strata are still 
larger and more gran alar in apt>earance, but become flattened as they 
approach the surface, so tliat their loug axes finally become parallel 
to ihe general surface of the skin. 

All the cells of the stratum mucosnm, except the columnar of 
the internal row, are connected with each other by means of a series 
of minute fibrils of prntoplasni. Schultz, who wa^ the first to discover 
these connecting filaments, believed they were formed by the union 
of projecting processes from adjacent ce\U, In accordance witli his 
view, tbiti layer is s|»oken of as the prickle layer, and the filaments 
are refem?d to as the prickles of ^lax Sehiiltz, These prickles or fila- 
ments vary in size in different part:^ of the body. Robinson eays 
they ure most distinct where the development of the raucous layer 
i^ " . and rhey are thicker arid longer in the upper than in the 
J" iia. They are also found in the stratum granulosum, but are 

^t present in the stratum lucidum. They are true connecting fila- 
lents, and, as asserted by Unna* are to bo regarded as a system of 
protoplasmic fibrils which permit the free circulation of nutritive ma- 
terial through their interspaces, and effect a firm, but not unalterable, 
ouanectioQ between adjacent cells. 



ita^ll 



DISEASES OF TOE SKIN. 



Wandering cells, or lymphoid corpuscles, are occasionally found in 
this layer, especially in the lower and middle strait*. Their number is 
siiiall, however, in the normal healthy state, but they are considerably 
increased in various j)athological conditions. 

The stratum mucosum in color ranges from yellowish white to 
brown or black, dependent on race and the re.^ion of the skin. Thia 
is due to diticrences in the amount of pigmentary material present 
in the cells of thia layer. Kollikcr remarks that when the skin is 
only alightly colored, the pigraeut matter is absent from all but the 
most internal strata of cells. Darker shades are produced by its depo- 
sition and d illusion among two, tliree, or more strata. 

The Corinm. — The corium. derma, cutis, or cutis vera, is the most 
importaut and moat highly organized portion of the skin. It is com- 
posed of a dense network of hnudles of white fibrous tissue with which 
muscular elements and yellow elastic fibrillar are closely interwoven. 
The interstitial spaces, which are much smaller than those of the sut)- 
cutaneoua connective tissue, diminish in size as the surface la ap- 
proaclied. They contain lymjilioid corjiuscles as well as true con- 
nective-tis.«ue cells. Fat-globules are also present. 

This layer varies in thickness in different individuals and tn dif- 
ferent parts uf the body. It is thinnest on the eyelids, the glans penis, 
clitoris, prepnce, and inner surface of the labia majora, wliere, acconl- 
ing to Krause, it ranges from 0^27 to 0"5<l mm. On the face, the scro- 
tum, and the aureola of the nipples, it varies from iH\S to 1'13 mm, 
On the forehead it is 1*50 mm* Its average depth on the general sur- 
face of the body is between l'G9 and 2 '26 mm. It attains its greatest 
thickness on the sole of the foot, the back, and the njites, where its 
continuity is broken by the projection of a number of columns of fat, 
which extend from the subcutaneous connective tissue to the base of 
the follicles of the lanugo. In these regions it is frequently 5*5 mm, 
deep. Warren* observes that the projecting cohimns of fat are of 
material importance in supplying Tiutritiou to the tine hairs. They 
also increase the flexibility of the dense integument, furnish a chan- 
nel for the passage of the vessels of the skin, and serve as an outlet 
for various morbid products in disease. The corium is richly sujjplied 
with arteries, veins, lymphatics* nerves, and muscular tissue. It is 
traversed by the follicles of the deep-seated hoirs and the ducts of the 
sudoriparous glands. The sebaceous glands and the follicles of the 
finer hairs arc^ embedded in its middle third. 

The corium is divided for facility of description into the upper or 
papillary layer, and the lower or reticular layer. This division is, 
however, mainly an arbitrary one, and is based principally upon the 
greater size of the connective-tissue bundles in the lower strata and 

* ♦* Die Thick Cutis Tem," by J, Collins Warren, M. D » in Sattcrthwfiitc'a Manual 
of Histology. 



1 



^^^ ^^^" ANATOMY OF THB SKIN. 7 

^PWonsequent looseness of tlie network formed by them. The siip<5r- 
ficial portion is separated from ttie epidermis by a thin bitsement 
znembrane, but the deej>er one merges imperceptibly into the aubcu- 
taoeoQs connective tissue beneath. 

Pabs Reticitlaris. — The reticular layer is the lower portion of the 
corium. It is compiosed mainly of bundles of white fibrous tissue, 
which decu&sate at first without division, forming a distiuct network. 
The largest meshes are tilled with fatty tissue, and contain blood*ves- 
»ela, Ivmpbatics, and nerves. They also give passage to the deep- 
8eated hair-foUiclea aud tlie sudoriparous ducts. The smaller inter- 
ejiacos contain connective- tissue coiimscles and wandering ccllfi. The 
bundles of connective tissue cross each other ohli<jiiely, and divide and 
subdivide aa they proceed upwaixi until they reach tho pupillary layer, 
which i& formed by the interhieoment of numbers of single tibrillffi. 

Pars Papillakis. — The papilhiry layer is the superfieitd or external 
portion of the corium. It is separated from the epidermis by a distinct 
boeement membrane, but is distinguishable from (he reticular Iftycr 
only by the greater density of its structure. Its tibres are intricately 
bound together, and its interfast^-icular spaces are, consequently, so 
Tery minute, that in many places it presents a perfectly homogeneous 
apj^earancc^ Its upper surface is roughened by the projection of mill- 
ions of small but distinct prominences or elevations, which are termed 
the papillae of the corium, and from which this layer derives its name. 
They conbiin the terminal expansions of the cutaneous vessels and 
nerves, and are the most important constituents of the corium. They 
are ordinarily cylindrical or conical in form, but vary in Pize and shape, 
and also in numljer, in the various regions of the body* Occasionally 
thoy are club-shaped, or square and flattened. Those tliat arise from a 
separate base are termed simple papilla?, in contradistinction to the 
tufts of five or six which spring from a common trunk, and sre there- 
fore called compound papilla?, Thpy may (jo again divided, according 
to their functions, into vascular and nervous papillae. The former are 
provided with an afferent arteriole or cttpillary plexus and an efferent 
vein. The latter contain meduliated nerve-fibres and one or more 
tactile corpuscles. In some rare cases a |)apilia has been observed to 
contain both nerves and blood-vessels. This anomaly is supposed to 
be due to the fusion of two distinct papilla. 

The papillje are mo^t numerous and most perfectly dcvelojicd on the 
palms of the hands, the tips of the fingers, and the soles of the feet, 
where they are arranged in a series of circular or elliptical ridges, 
Meissner observed four hundred upon a square line of the end of the 
finger, and Weber found one hundred and lifty to two hundred single, 
and eighty-one compound papilloe upon a s<puire line of tho palm of 
the hand. They are also present in great numbers upon the nipple, 
the clitoris, the glans penis, the labia minora, and also on the jjro- 



g DISEASES OF THE SKIN. 

labium. The Emillest papillae are foncd on the face, especially upon 
die evdids, brows, nose, cheeks, and chin. Those on the general ear- 
£aoe of the body are also small in size. The total number of the jmi- 
inllie is Terr great. Sappej says that there are orer sixty thousand 
to the square inch in many regions of the body. An estimate, based 
OD this statement, would make the number on the whole sarfaoe of 
the bodv TaiT between one hundred and fiftv and two hundred mill- 



He Sobentaaaoas GoBneetive Tissne.— This portion of the skin is 
oompased principally of bundles of fibrous connectiye tissue, which rise 
obliquely from the periosteum or from the superficial fascia, and mei^ 
imjieroeptibly into the substance of the oorium. These bundles rary in 
aie, but are cylindrical in form, and interweave with each other, form- 
ing a series of networks with well-defined interfascicular spaces. Adi- 
pose tissne is found in more or less quantity in these spaces, consti- 
tuting the pffjiiMV«7iwf (idipofius, upon which the plumpness of the body 
depends. According to Biesiadecki,* the individual fat-globules are 
composed of minute drops of oil, each of which is inclosed in a deli- 
cate membrane. They are sometimes round or oval in form, but more 
frequently polyhedral from pressure. The membrane or cell-wall is 
so distended by its contents that it is not discernible until they have 
been ertracted by alcohol or ether. The fat-globules are aggr^ated 
into masses or lobules of varying sire. Each lobule is provided with 
an afferent artery, a capillary plexus, and one or more efferent veins. 
Sevt-ral Ic^bules at times unite to form an acinous-like structure which 
is surn:»unded by a sheath of connective tissue. Large quantities of 
fat are found beneath the skin of the palms and si^les, the back, the 
buttccks. and the mammary glands. Warren t has shown that in the 
tiiickest portions of the skin, columns or pillars of fat extend from 
this lavfr in an oblique direction through the lower two-thirds of 
the oorium. and terminate at the baf»e of the follicles of the lanugo. 
Tl>ese ccOumns are almost continuous in dire»ction with the erector^ 
pili muscles, to which they are also attached. They convey blood- 
Teasel? and lymphatics to the corium, and otVAsionally contain sudo- 
nparous glands. Their function has not been definit^ely ascertained. 
Warren believes that they furnish flexibility to the otherwise dense 
and unyielding int.egument. and that they as?i<t in the action of the 
ereictor-pili mufcles, and are essential to the nutrition of the lanngou 
In health they furnish a channel for the Mood>vessel> and lymphatics, 
and in disease they provide an outlet for various morbid products. 

The quantity of fat in the subcutancv^us connective tissue varies 

* ** T^ Secsian of tbe Skso," bv Profesftor JLIfrci Bicsiadcc^ ia Scridrer^ 
ALtcoL 



ANATOMY Of THE BKm. 



9 



greatly. It is usually found in larger proportion in women and chil- 
dren than in men, and lessens with advancing age. In cases of 8tar- 
Tatian* and in all diseases attended with waste of tissue, tht.^ contents 
of the fat-globules disap[>ear ; but the eell-walls remain, and are rap- 
idly refilled when health retunis. Obesity coDsitsts in an uver-produc- 
tioQ and abnormal deposition of fat. 

Some portions of the body, as the eyelids, ])eni8, scrotum, and 
labi^ minora, are destitute of fat. The interfa.'^cicular spaces of the 
anbcntaneoud connective tissue in these regions are traversed by fine 
connective-tissue bands or single fibrilloe. The interstices between 
the fibrilhe and the primary bands vary in size under different circuni- 
fitaneea, and in proportion to the amount of fluid in t!ie tissues. In 
some psthological conditions they are almost obliterated, while in 
c^tbeiB they are greatly increased in size. 

The cells of this layer consist of fixed or true eunnective-tissue 
ecU*, and lymphoid corpuscles or wandering cells which have migi-ated 
fr*jiii the blood-vessels, 'fhe former are more or less spindle-shaped, 
uid aend processes between the primitive bundles of white fibrous 
tiifiie. These processes gradually develop into yellow elastic fibrilhe. 
The lymphoid corpuscles are most abundant in the vicinity of the 
blood-vessels and glands, where they are similar in size and appear- 
once to the white corpuscles of tlie blood. As they wander further 
ii5f s they lose their circular form, and become somewhat 

fi]' i i also. 

The sudoriparous glands and the bases of the deep-seated hair-fol- 
idea are imbedded in the subcutaneous connective tissue. It also 
contains lymphatics, nerves, and blood-vessels. 8ome of the nerves 
terminate in Pacinian corpuscles. The larger lymphatic vessels have 
a markedly transverse muscular structure, and are surrounded by a 
minute vascular network. The blood-vessels are of large size, and 
after supplying the hair-follicles, sudoriparous glands, and fat-lobules. 
Bend a number of branches to the coriiim. 

The Sweat Glands. — The sudoriparous or sweat glands are small, 
round or ovnl-shaped bodies, which are imbedded in the sul>cutane- 
ons ctinnective tissue, and open on the surface of the epidermis by 
meajifl of the sudoriparous ducts. They are yellowish or yellowish- 
Ted in color, and vary in size in different parts of the body. Tliey are 
smallest on the eyelids, the nose, and the pinna of the ear, where 
til • from y^ to ^^Tf of an inch in diameter ; and largest on 

til- L of ihe nipple, the base of tlie scrotum, and in the axilla, 

where they sometimea attain a diameter of one- tenth of an inch. A 
•n ' Jand consists essentially of a number of convolutions of 

a i which commences with a blind extremity, and is coiled 

npon rtivtf ,*evenil times to form a more or less globular mass which is 
the body of the gland. The tube then ascends in a perpendicular or 



DISEASES OF THE SKIN. 



oblifjuc direction to tbc free surface of tbe epidorrais, and becomes the 
duct or excretory canal of tbe gland* It passes through the lowex 
portion of the corium in a direct or slightly flexuons manner, and| 
emerging between two papilla?, pursues a more or less tortuous course 
through the layers of the epidermis, and fiually terniiuiites in afunnel- 

shaped ojieuing or pore. 
Where the epidermis ia 
thick, as on the palm 
of the hand and the 
sole of the foot, the tor- 
tuosity of the ducts is 
marked, and the por0 
are large in size, 

KoUiker's investigii 
tions lead him to belicvi 
that the sudoriparottj 
glands tirst appeal* ii 
the fifth month of em-^ 
bryonic life as perfectly 
eolid processes of the 
Btratum Malpighii which 
gradually elongate, and, 
{wnefcratiDg the deeper 
structures, begin to coil 
upon themselves. They 
are therefore to be re- 
garded as simple invo- 
lutions of this layer, which* by a continual process of eell-multipliea- 
tion, grow dee]>er and deeper into the corinra and subeutaneoua con- 
nective tissue, become convoluted, and divide into the glands proper 
and their ducts, while at the same time, either by a process of licjue- 
f act ion of tfieir central cells or by the excretion of a fluid between the 
cells, a lumen or cavity ia formed, Klein has observed that both the 
gland and itd duct are lined with a delicate cuticle which is especially 
marked in the duct and in the commencement of the coiled tube. In 
the epidermis the lumen bordered by this eutiele is all that is present 
of the sudoriparous duct. Unna lusists that the duct ends in reality 
at the surface of the corium, and that the tortuous canal which ap- 
pears to be it^ continuation through the epidermis does not Mong to 
it alone, bat is also the receptacle for the exudations from the inter- 
stices of the epidermis. I 
Tlie duct projwr has two other coats — the external one, or limit-' 
ing membrana propria, which is continuous with the basement mem- 
brane of the surface of the corium» and the middle or cpitheUnl 
coat, which is continuous with the deeper layers of the stratnm ilal- 




JFia, 9,— Swwt-i^Uiid. Dfxiwn from a specimen beneath 
the micivwcof c maffiiified 45<> dijiiiictcrs. The seetiou 
b cut riiflit tlm>ugli thu jflnnd. a, i'oniiMtivu tipaue 
iap(>orting (rlund. h. Glaud. c. Gland uut tnuiaveree- 
ly. d. Duct going off. 



J 



ANATOMY OF TffE SKIS. 



u 



I 



pighii, imd is composed of two or three rows of nucleated polyhedral 
cella. 

The proximal portion of the coiled tube which forms the body of 
the gland is identical in si^o and structure with the sudorijmrous duct, 
with which it is directly continuous. The remaining or distal portion 
IS much larger in diameter, and differs, according to Klein and KuOi- 
ker, in the«e essential respects, that its middle or epitliclial lining con- 
sists of but one layer of transparent columnar cell?, and that there 
exists between it and the limiting membrana propria a layer of non- 
striped mUBcle-eella which are arranged parallel with the long axia of 
the ttibe. This distal portion of the tube is of great length in the 
glands of the palms and soles» the Bcrotum, the nipple, tlic scalp, the 
axilla, and other regions of the body, and its epithelial cells contain a 
considerable number of granules. 

Each sudoriparous gland is surrciunded by an investing sheath of 
eonnective tissue, interspersed with fat-cells, which supports the vessels 
that supply the gland, and binds the conyolutions of the tubes closely 
to each other, Connective-tisstie fibres with numerous etills accom- 
pany the duct, running parallel to it through the eoriuai, and as a rule 
then? are also two accompanying small blood-vessels (Biesiadecki). 
The nervous supply of the sudoriiiarous system has not yet been dem- 
oiiitrated, L*angerhaus, however, claimed, years ago, to have found 
tmoes of a nervous structure in the inter-epithelial spaces of the outer 
ooat of the duct. 

Sudoriparous glands are found in great numbers in every portion 
of the body except the glans penis, the clitoris, and the red border of 
the lips. Their distribution varies widely, however, in different re- 
gions of the body. In the axilla they form a continuous layer beneath 
the csorium^ Krause states that there are 2,736 in a square line on 
the palm of the hand, 2,085 in the same spuee on the sole of the foot, 
1»400 on the back of the hand, 1,2.^8 on the forehead, 1,13*1 on the 
chest and abdomen, 1,123 on the inside of the arm, 5G6 on the inside 
of the thigh, 548 on the cheeks, and 417 on the neek, back, and but- 
tocks in every square inch. The same observer estimated the total 
number of tliese glands on the body of an adult of average size to be 
2>3dl,24d. As the length of an untwisted tube is about one-fourth of 
an inch, the total length of the tubing through which the perspiratory 
function is carried on is almost fifty thousand feet* or over nine miles. 

The secretion of the sudoriparous glands varies in quality und quan- 
tity according to their size and situation, and a number of other nor* 
mal and abnormal circumstances. The small glands secrete a clear, 
watery fluid without any granular matter. The hirger glands, especially 
those of the axilla, secrete a thicker fluid coutainiug numerous fat- 
cells, and granules with free nuclei, which are derived from the epi- 
thelial cells Lining the interior of the gland* This fact led Meissner 




12 



DISEASES OP THE SKIK. 



thirty years ago to believe timt the real function of the eweat-glauds 
was to furnish a material for the oiling of the skin. This view was 
not accepted then. Unna ha^ again revived it, and insists upon its 
correctness, lie claims Ihiit the secretion of the sebaceous glands is 
only sufficient to lubricate the interior of the hair-follicica with which 
they are connected, and that the sweat-glands eiist solely for the pur- 
pose of providing an oily material for the surface of the skin. lie also 
believes that the jx^rspiratory tluid which is generally supposed to be 
Beoreted by the sweat-ghinds is in reality an exudation from the in- 
terstices of the epidermis, therefore they should be entitled ** coil- 
glands '* in future. Further research will* however, probably show 
that they are necessary for the proper jierformance of both functions. 

The ceruminous glands of the ear are similar in appearance and 
structure, and allied in function to the glands of the sudoriparous sysr- 
tem. They do not exist in the whole external auditory meatus, but 
only in the cartihiginous iiortion (Kolliker), between the lining mem- 
brane of the ear and the cartilage. They form a continuons yellowish- 
brown layer, which is occasionally visible to the naked eye. Their 
secretion is mendy a modific^ition of that of the sudoriparous glands. 
The cerumen or wax of the ear is fi combination of the secretions of 
the true ceruminous glands with that of the sebaceous glands of the 
auditory meatus. 

The circumanal glands of Gay, which form a zone around the verge 
of the anus, aro t<3 be reganled as a part of the sudoriparous system 
also. They are identical in structure with the coil-glands of the other 
portions of the body, and differ from them in size only. 

The Sebaoeous Glands. — The sebjiceous or sebijuu-ous glands, called 
also the glands of the hair-follicles, are simple or compound racemose 
glands, which are found in every portion of the skin except on the cli- 
toris, the glans jx^nis, the palms of the hands, the soles of the feet, and 
the dorsjU surfaces of the last phalanges of the fingers and toes. They 
are inrariably situated in the upper or middle part of the corium, and 
do not extend to the subcutaneous connective tissue. They are most 
•boodant upon the hairy {tortious of the body, and arc connected as a 
mle with the hair-follicles into which their secretion is discharged* 
Aceonling to Sappey, they may b© divided into three distinct groups. 
The first group comprises the glands of the scalp, the beard, theaxilla» 
the pubes, the labia majom. and the scrotum. The hairs in these 
n:Lions arc coarse and fully develojied, and each follicle is provided 
witii twoi, three, or more sebac«K>us gland-^. which may proix^rly be 
regarded as ap|ieitdages of the hair-foUicles. 

The glands of tho second group are Uirgtr in sixe and more com- 
plex in stmctBit^ and are connect^ with the lanugo. The duct of 
the gland ist, howevor. so much wider than the lanugo-follicle that 
the relation may be revereed> and the hair oonsidared to be an ^pend- 



ASATOUT OF THE SKIN. 



13 



age of the glaod. The glands of this group are foniid mainly upon 
the forehead, nose, cheeks and aureohi of tlie nipples. A few are also 
present npou the genitiilia, and various portions of tlio chest, the ab- 
domen, and the upper and lower .extremities. Pi ffard says that acne 
gM]most exclusively an affection of this class of f^lands. 
^f The third group is small in numtKT, and comprises those which 
open directly upon the surface of the skin, and are not cotiiiected in 
any way with the hair-foOicles. They are found only on the internal 
6tir£sce of the prepuce and behind the corona glandis in the male, and 
upon the surface of the nipple, the vestibule, and the labia minora in 
the female. 

The sebacoona glands are whitish in color, and vary in size in dif- 
ferent portions of the skin. The largest arc found on the eyelids 
(Meibomian glands), the mous veneris, the scrotum, the labia majora, 
in the axillary and anal regions and <m the aureola of the female nip- 
ple (glands of Montgomery), where they frequently attain an enormous 
iize. Those of the scalp are smaller in gize, but greater in number, 
W. Krause has estimated that there are over eighty thousand hair-fol- 
licles on the average adult head, each of which k provided with two 
or more of these glands. Some of the coarse hairs on the genitalia 
arc surrounded by a labyrinth of glands ; seven or eight being fre- 
quently connected with each hair- follicle. Each gland is composed 
of from two to twenty acini or lobules, and maybe divided into a 
body or gland proper, and an excretory duct. In structure it con- 
oats of an external membruna propria and an internal epithelial lin- 
ing of eeveral layers of nucleated cells, which is practically a con- 
tinuation of the outer root-sheath of the hair-follick\ The external 
membrana propria is identical and continuous with the basement 
membrane of the surface of the corium, and is .surrounded by an in- 
Testment of connective tissue containing blood-vessels, lymphatics, and 
nenrea. The cells of the epithelial lining of the ghind proper are 
almost identical in size and arrangement with those of the stratum 
Malpighii. Those of the first layer are imbedded in the basement 
membrane, and are small, granular, and columnar, with spherical or 
oral nuclei. Next to this, and tilling the entire space of the acini, 
are large polyhedral cells with spherical nuclei, containing a variable 
amount of fat and fat-globules. The cells nearest the centre of 
the alveoli are the largest in size, but l>ecome shrivelled as they ap- 
proach tho beginning of the duct. The cavity, or centre of the gland^ 
contains a grumons pulp formed of free fat, fat-globules, and epi- 
thelial fUbris floating in a watery fluid. This is termed sebum. The 
duct is similar in structure to the body or gland proper. It is com- 
posed of an external basement membrane, an internal epithelial lining, 
and a central cavity or lumen through which the sebum is discharged. 
It openfi into the hair-follicle at an acute angle at its up{>er third ; the 



1 



14 



DISEASES OF TDE SKIN. 



gland proper lies in the corinm nearly on a leyel with the middle third 
of the follicle. The ducts of the glands that open directly upon the 
surface of the skin receive an udditioual layer of cells from the stratum 
corncum of the epidermis. 

The sebaceous glands begin to be developed at the end of the fourth 
month of foetal life as small solid projections from the outer root-sheath 
of t!ie hair-follicles. Tlicy gradually attain their definite size and 
shape by a process of cell-multiplication ; and an internal cavity or 
lumen is finally formed by the fatty metamorphosis of the central layer 
of cells. 

The Hairs.^ — Hairs are slender cylindrical structures comjiosed of 
modified epithelial tissue. They ar^ imbedded in depressions of the 
skin known as the hair-foOicles or sheaths, and are developed from a 
minute ])apillu whicli projects from the ba.se of each follicle. They 
are found upon every portion of the skin except the upjver eyelids, the 
lips, the palms and soles, the clitoris, the glaos penis, and the dorsal 
surfaces of the hist phalanges of the fingers and toes. They vary in 
length and thickness in dilTei*ent regions of the body, and may be 
divided into four groups. Those of the first group are long and fioft» 
and are found only on the scalp. Those of the second group are long 
and coarse, and ai*e found in the beard and whiskers, and in the axil- 
hiry and pubic regions. The third grouji comprises the sluirt coarse 
hairs of the eyebrows, eyelashes, the nostrils, and the externa! audi- 
tory meatus. The fnurth gi-oup consists of the delicate lanugo, which 
are present on the face, trunk, and other pttrtiona of the hody. The 
size of the hairs is further influenced by age and sex. The*y are 
thicker in general in adult age than in childhood, and in the female 
than in the male. 

Their number varies considerably, depemlent upon the region of 
the skin and the individual. According to Whitotf, there are 293 in 
a cpiarter of a square inch on the scalp, 39 in the same space on the 
chin, 34 on the pubes, 23 on the foi*earm, and 11> in the same space on 
the front of the thigh, Wilson estimated the total number on the 
scalp to be 120,000, but Kranse and other observers say there are only 
80,000. This discrepancy may be due in part to the color of the hair 
which was the subject of calcnlation. Light hairs are placed more 
closely together, and are more abnndimt, as a rule, than dark ones. 
They vary in color both in race and individual. The different shades 
depcud upon the amount of pigment material whicli is lu-esent in the 
cells of the hair, and in the interstitial cement substance which binds 
them together. In the dark there is an abundance of the interstitial 
pigment-grannies. In the red the pigment material is confined to 
the substance of the hatr-cells. Whito hairs are destitute of all pig- 
ment. Gray coutjiin bubbles of air in their superficial layers. The color 
of the hair gradually becomes darker from childhood to adult life. It 



AyATOilY OF THE SKIK. 



15 



bis been estimated tliat the hair of light-complexioned male children 
darkens from 55 per cent, during the first five years of life to 33 per 
cent, at forty-five years. This cliange is much less marked in females. 

The hairs are so clastic that they can be stretched to nearly a third 
more than their natural length, and if the tension be not too long con- 
tinued they will contract to very near their normal size. Owing to their 
fibrouis structure thoy are very strong, and will bear a weight of from 
one to three pounds without breaking. They a!>sorb moisture readily, 
&nd part with it freely. They are therefore either di7 and brittle, or 
moist and soft, in accordance with the amount of fluid secreted by the 
skin and the amount of moisture present in the atmosphere. They are 
identical in structure with the horny layer of the epidermis, and like it 
thrty contain neither blood-vessels nor nerves. Their nourishment is 
derived from the cells of the papilla? at the base of the hair- follicles, 
'heir rate of growth varies from five to seven inches or more in a 
Each hair has a certain limit, after attaining which it remains 
stationary for a while, and then becomes detached from its papilla and 
«*T[peIIe<l from the follicle. Those of the scalp when left iiucut fre- 
quently reach a length of six feet 
before this process of degeneration 
ind e^xtmsion occnrs. 

A complete living hair consiste 
of a free portion or shaft, which 
extends beyond the surface of the 
*]dni aa inclosed portion or root^ 
which is contained within the fol- 
Hdr; and an expanded portion or 
bulb, which rtssta upon the hair-pa- 
pilk at the baso of the follicle. 

The hair-papilla is a small, pear- 
shaped or oval body, which arises 
from the b<ise and projects into the 
cavity of the hair-follicle. It is 
aboDt twice as long as it is broad, 
and is oomposed of connective-tis- 

fibres, boiween which ore found 

in' ' ronntl nuclei and spher- 

od colls. It ia identical 

structure with the other papill© 
of the corium, and is continuous at 

origin with the fibres of the 

fcjer f»f the hair-follicle. Its upper surface is coTcrGd by a thin 

It membrane, which is reflected from the inner layer of the fol- 

and which separates it from the hair-bulb* It contains two arfer* 

[Bieaiaiiecki), two or more veine^ and some medullated nerve-fibres. 




d 

FlQ. 4-— Mnjmlft«'<l hair: a. InU'mal rowt- 
(*lH'»th<f consisting ot' twTi Invera. h. Ex- 
Uimal root-«l»eutii. c. I iuir-it>lUc]<?ali(f fat- 
ly torn in places, d. Where blood-vessel 
enters hair- bulb. «. Hair ahowiut; iutcr^ 
ojU and flbrouB structure. 



m 



Tlio huir-bulb \» the terminal earpansion of the root of the hair. It 
nurnHHHlH the impilhi, and completdj tills the Lnver part of the fol- 
Uq\v, It JH com|K)sed of several layers of polyhednil nucleated cellg, 
Whieli referable the eelis of the rete MalpighiL They are united to 
each other by cement substance, and are coutinuouB with the cells of 
the outer root-aheath. The layer which is situated on the basement 
meirihnine immediately above the papilla is composed entirely of short 
columnar cells. According to KleiUj the cells of this layer are in an 
iOtive state of multiplication and proliferation, rejirudiicing them- 
icdvoH continually. A^ this* process goes on ^ the cells of the other 
layers of tlic hair-bulb are gradually forced upward into the cavity of 
the follicle, where they form the cells of the root of the hair. They 
also change in shape, becoming flattened and fuHiform, constituting 
the ceils of the hair'snb.stance, except in the centre, where they remain 
polyhedral na those of the medulla of the hair. The peripheral cells 
which compose the inner root-sheath retain more or lees of their 
original form* 

The hair-root proper consists of t!ie medulla of the hair, the liair- 
substance, arid the cuticle of the hair. The medulla is composed of 
aeveral rows of polyhedral cells which occupy the centre of the hair, 
and extend from the bulb to very nearly the point of the shaft. Kol- 
liker states that they contain neither fat nor pigment granules, but 
derive their color from the presence of a variable number of minute 
vesicles which are filled with air. The lanugo and 

IP|HHH| immature hairs have no medullary cells wdiatever. 
r 1 ^ ^^^^^' hair-stibstance, or cortical substance, is eom- 

I T ^ posed of several layers of flat, elongated fibres, which 
! 1 form the greater part of the hair and give it shape 

I r^ ^ and consistency ; they vary in length and breadth, 

I- fi and are held together by an aU>nmiru-)US cement; 

they are longitudinally striated, and contain a varia- 
ble amount of pigment matter. Each fibre consists 
of two or more flattened epithelial scales, which 
present a remnant of a nucleus, but are so closely 
united one to the other that they can only be sejia rated by strong 
acids or alkalies. Air-bnbbles are present in considerable (piantity 
in the spaces between the hair-fibres. The cuticle of the hair is a 
thin, transparent membrane^ which completely invests the hair, and fa 
intimately united with the hair-substance on the inside and the cuti- 
cle of the inner root-sheath on the ouLslde. It arises from the neck 
of the papilla, and extends from tlie bulb along the entire length of 
the hair. It is composed of a single layer of non-nucleated hyaline 
scales, which are frequently round or columnar in the portion sur- 
rounding the bulb, but become elongated and fusiform in the root 
and shaft. They are arranged transversely, and overlap each other 



Tin. Ct, — Ubiiijun 

Bliowinj^ cortiwiJ 
nulistunoe and 
im'dalla. 



ASATOMY OF TUE SKIN. 



« 




l*Jujtt»-mierogrjipli> ) Tranaven&o secftion thmugh 

huira ma^niticd 75 atainetctv. n. Hair. h. iDk^rnjil 

c. Extemul root-aheath. i/, Hair-follk'ltr. 



bii 
root-sbeaCti 



like the tiles on a bouse or the scales on a fish. The cuticle presenti 
more or leas marked projections or serrations, according to the degree 
in which its scales over- 
lap. 

The shaft of the 
hair, or the part pro- 
jecting beyond the sur- 
face of the skin, is iden- 
tical in fitructure with 
the root of the hair. 

The Hair -Follicles. 
— The hair-follicles, or 
hair - sacs, are flask- 
shaped depressions of 
the epidermis and cori- 
nm which closely envel- 
op the roots of the 
hairs. Each follicle 
commences on the ex- 
ternal surface of the 
ikin by a funnel-shaped 
opening or mouth* and 
paases in an oblique or 

tlightly curved direction through the corium into the subcutaneous 
connective tissue. It terminates in a bulbous expansion which is in* 
vaginated over tlie papilla of the hair. The narrowest portion of 
the follicle is called its neck, and is situated just below the upper 
sarface of the papillary layer of the corium. The duets of one or 
more sebaceous glands empty into the follicle at this point. The 
follicles of the lanugo do not penetrate as deeply into the subcuta- 
neous connective tissue aa do those of the coarser hairs, and fre- 
quently do not extend below the deeper portions of the corium. The 
hair-f'dlicles vary considenibly in diameter, and also in nnmber, in 
the different regions of the body, but agree in their general structure. 

Each follicle consists of an external, tibrous, vascular portion or 
hair-follicle proper, and aa internal epithelial portion, which imme- 
diately surrounds the root, and is therefore usually termed the root- 
sheath. 

The external portion, or hair-follicle pro]ier, is composed of an ex- 
tenialy a middle, and an internal layer. 

The external layer (the external fibrous sheath of Kolliker) is the 
thickcj^t and most important portion of the follicle. It consists of 
compact con nective-ti.>*8ue fibres which run parallel with the long axis 
el tlie follicle, and which are intimately united with the fibres of the 
oorinm above. It merges externally into the surrounding fibrous tis- 




1 



iS 



DISEASES OF THE SKOfr 



sue, and terminates below in an intricate network whieli envelops the 
papilla of the hair. It containsi a mirmte artery uod vein (Biesiadecki), 
and also some nerve-fibres, which divide dichotomoiisly* 

The middle layer (the internal fibrous sheath of Kolliker) is com- 
posed of a single layer of transversely or circularly arranged epiudle- 
fihaped cells with long, narrow nuclei ; they resemble, and are gener- 
ally considered to be, smooth mnscle-eells. They line the whole inte- 
rior of the body of the follicle, but do not extend above its neck. 
Kolliker says that this layer contains neither blood-vessels nor nerves. 
The internal layer is al8J> called the hyaline membrane and glassy or 
vitreous membrane. It consists of a delicate, transparent membrane, 
which lines the whole interior of the follicle, and is reflected over the 
surface of the hair- papilla. It is a direct continuation of the base- 
ment membrane of the eorium, and contains neither vessels nor nerves. 

The root-sheath, or the internal portion of the hair-follicle, is con- 
tinnons with the lower strata of the epidermis, and is made up of an 
out^r and an inner layer. The outer root-sbeath is a prolongation of 
the stratum Malpighii, with ivhieh it is identical in structure and ar- 
rangement. It h composed of an external layer of columnar cells, 
next to whieli are found several rows of polyhedral cells. Its inner 
wall is formed by one or more rows of flattened, nucleated scales. It 
extends along the entire inner surface of the follicle, but is thinner at 
the neck than in the body* and becomes continuous at the base with 
the colls of the hair-bulk There are no blood-vessels in the outer 
root-sheath ; but, according to Langerhaus, it containa a few nerve- 
fibres similar to those w4iieh are found elsewhere in the stratum Mal- 
pighii. 

The inner root-sheath is a delieate membrane which is closely con- 
nected externally with the out«r root-sheath and internally with the 
cuticle of the hair. It arises from the ncek of the papilla at the base 
of the hair* follicle, and is composed of an outer, or IIenle*s layer, 
which is a single layer of elongated cells without nuclei ; an inner, or 
Huxley's layer, consisting of one or two strata of polygonal nucleated 
cells ; and an internal, delieale cuticle. Biesiadeeki remarks that the 
internal root-sheatli is developed from the cells of the root of the hair. 
It terminates at the neck of the follicle, and contains neither blood- 
vessels nor nerves. 

Each hair-follicle ia supplied w^ith one or more muscles, the ftr- 
reetores piH, which are composed of several bundles of non-striated 
fibres. They arise by a series of digitations from the upper portion 
of the eorium just beneath the basement membrane, and, passing ob- 
liquely downward, encircle the sebaceous gland, and become inserted 
in the lower portion of the hair-follicle. They are invariably found 
on the inner side of the folhcle, with which they form an acute angle. 
Their attachment to the hair-follicles is to be regarded as a relatively 



■ 



ANATOMY OF THK SKIN. 



19 



I 



fixed point, and that to the corium aa a relatively movahle one. 
(Tomaer.) 

When these muscles con tract they depress the papillary layer at 
Tarionfi points along the periphery, draw the hair-folHcle from an ob- 
lique into a vertical position, and^ by elevating the hair-follicle and 
hair above the surrouudiug surface, produce the condition known m 
cutis anserina. The hair is at the Siimo time compelled to assume a 
more upright position, or, a^ is commonly said, '*to stand on end.'* 

They also, by contracting, compress the sehaceous gland, and as- 
eist in the discharge of its eecretioii. 

The hairs begin to develop in the third month of ftjetaJ life, as 
small, Bolid, cylindrical projections from the under surface of the 
Btratum Malpighii, which fit into the depressions in the corium. As 
multiplication and cell-proliferation continue, they penetrate deeper 
and deeper into the substance of the corium, which becomes con- 
densed around them, and formi^ the hair-follicle proper, and at ita 
fundus formB the papilla upon which the Malpighian cells are invagi- 
nated. The cells around the papilla proliferate rapidly and create? the 
halr-bnlb from which the huir proper and the inner root-sheath are 
gtmdiially developed. The new hair doe^ not penetrate the stratum 
coraeam of the epidermis at once, but burrows its way into that layer 
in an oblique direction for some time before reaching the sorface. The 
first hairs are always of the lanugo type. 

When a hair has reached its limit of existence it undergoes de- 
generation, becomes separated from its papilla, which atrophies, and 
a new papilla and a new hair are formed in connection with the old 
folHcle. According to Klein, the lower part of the follicle including 
the hair-bulb degenerates also, and is gradually absorbed. There is 
then left only the upper part of the follicle and the hair- root, the 
6bres of which become fringed at the digital end and lost among the 
cells of the outer root-shea rJi, constituting the hair-knob of Ilenle. 
After a time a cylindrical outgrowth of epithelial cells projects down- 
ward from the outer root-sheath and becomes invaginated over a new 
papilla. Multiplication and cell-proliferation ensue, and a new hair- 
bulb and hair are formed, and the old hiiir is gradually pushed out of 
the follicle as the new one makes ita way to the surface. 

The Nails. — The nails are dense, horny, translucent structures 
which are implanted in the skin of the dorsal surfaces of the terminal 
phahinges of the 6ngers and toes. They are quadrilateral in shape, 
and flattened anteriorly and posteriorly, but curved from side to side. 
Their anterior border is free ; their posterior and lateral borders are 
inserted in a fold of the skin called the nail-groove. The nail-groove 
is shallow at its commencement at the tip of the finger, but deepens 
as it extends jjosteriorly. That portion of the nail which is inclosed 
in the groove is called the root of the nail, the remainder constitutes 



20 



DISEASES OF THE SKIN. 



the body of tbe nail. The nail-bed is that part of the skio upon which 
the body of the nail is imbedded. It is composed of stratum Mal- 
pighii, coriam, and subcuttmeous cellular tissue* Tbe matrix is the 
posterior portion of the nail-bed^ and h situated immediately beneath 
the root of the nail. The white line at the biise of the nail is called 
the lunula, and rejiresents the anterior termination of the matrix. 
The corinm of the nail-bed is firmly united by bauds of fibrous tissue 
to the underlying periosteum. It is richly gupplied with blood-ves^ 
mh and nerves, but contains no fat. The subcutaneous cellular tis- 
sue is also destitute of 
fat. 

The nail is com- 
posed of a number of 
layers of liatt^^ncd ho- 
mogeneous epithelial 
scales, some of which 
contain a remnant of a 
nuclens. We learn 
from Klein that it rep- 
resents the stnituni lu- 
cid um of exaggerated 
thickness situated over 
the stratum Malpighii 
of the nail-bed. The 
nail-cells are developed 
from the matrix, and 
arc gradually pressed 
forward over the nail- 
bed. 

The nails grow 
more rapidly in snmmer than in winter, and in childhood than in old 
age. They grow continually if cnt, hut when left uncut they only 
attain a certain length, after which their development cetises. They 
begin to form in the third month f)f fa^al life, and are fully developed 
by the end of the eighth month. The authority just quoted says they 
are produced by a rapid multiplication of the cells of the stratum 
Malpighii, and the conversion of its superficial cells into the scales of 
the stratum lucid nm. The nail is covered by the stratum corneum at 
this st^ige, l>ut at the end of the fifth month its margins break 
through, and by the end of the seventh the greater part has become 
clear. 

Muscles of the Skin. — The skin contains both striated and non- 
striated muscular fibres. The former are found only in the forehead, 
Qoae. cheeks, and neck, wiiere they arise from the subcutaneous cellu- 
lar tissue, or from the fascia of the superficial layer of muscles, and 




Fia. 7.— (Photo-tDicmjfmph.) Section throuffb end of fin- 
der r>f a child : n. Skin Ut tbe side of the auil^ iiho'win^ 
cpidemmiuidpftpiUtt. A. Bone. (?.JNail. <^. Open apuce. 



ANATOMY OP THE SKIN. 



M 



►ward are inserted into the corium between tbo 
le sebaceous glands. The non-striated muscles are 
more numerous, and are present in every portion of the 2»kin either as 
compound fibres which run hurizontally to the surface and form anas- 
toiuoising networks, or as bundles of fasciculi which run obliquely up- 
ward. According to Unna, they may be divided int*i the mnecular 
membranes, the arrcctorcs pili, and the proper diagonal muscles of the 
ooham. The muscular membranes are found in the skin of the scro- 
tiiixL, the penis, the mammary aureola, and the nipple. They arc com- 
posed of a network of bundles of muscular fibres, which are deposited 
in layers in the corium, and run parallel to its surface. They arc 
especially well developed in the aureola of the fenmle nipple, where they 
m arranged in a delicate circular layer which becomes thicker as it 
ipproaches the base of the nipple. Kolliker states that this layer 
id occasionally visible to the naked eye. The muscular fibres of 
the nipple run in va^iouc^ directions, and form an exceedingly close 
network which surrounds the lacteal ducts, and constitutes their 
sphincter. 

The arroctores pili are the muscles of the hair- follicles. 

The proper diagonal muscles of the corium (Unna) are similar in 
itmcture and size to the arrectores pili, but luive no connection with 
the hair-follicles. They arise from the upper portion of the papillary 
later of the corium, and running obliquely downward are inserted into 
its lower portion, or into the reticular layer. \Vhen they contract 
they produce a general condensation of the tissues of the corium. Aa 
a result of this action, the blood-vessels are subjected to increa^^d 
prMSure, the blood is driven from the periphery toward the centre, 
and the papillary layer Ijccomes pale and bloodless. At the same time 
the sebaceous and sudoriparous glands are compressed, and their con- 
tents foit^d outward along their ducts* The cold sweat of fear is thua 
produced. 

The number of muscular fibres Taries in ditTcrent portions of the 
ikin. They are most abundant in the scrotum, where they form a 

itinnous layer — ^the dartos. They are also present in great numbers 
prepuce and the skin of the penis. Neumann observes that 
less developed on the Bexor than on the extensor snrfacea, 
5iir with diminishing frequency on the perineum, scalp, fore- 
arm, thighs, shoulders, forehead, abdomen, axilla, legs, face, the palmar 
luid pUmbir and ilorsid surfaces of the hands and feet. 

The Blood-Vesseis of the Skin.— Thei-e are no blood-vessels in the 
e]>idermis, bnt the corium and subcntaneoua connective tissue are 
I >lied with arteries, capillaries, and veins The arteries 

t i'ous connective tissue are of large size and anastomose 

freely, forming a plexus from which smtdl branches pass off in all 
tUnctiaiis to the fat-lobules, sweat-glands, hair-follicles, and muscles 



22 



DISEASES OF THE SKIN. 



of the skin. Other and larger branches proceed directly or ohliquely 
upwiird to the superficiul Uyers of the corium, and, after sending small 
branches to the sebaceous glands and the upper part of the hair-fulli- 
cles, form a second plexus, whicli is situated directly beneath the base 
of the papillae. Millions of minuttt capillaries arise from this super- 
ficial plexus aud project into the euhstance of the vascular papillaa. 
Each pajiilla is supplied with a single arterial capillary, which, after 
pursuing a tortuous course toward the apex, bends over and pas&es 
down and out as a venous capillary. These vonoua capillaries unite 
in the ujjper layer of tlie corinm to form a network of minute veins, 
from which larger ones arise, and passing downward empty into those 
of the fiubeutaueouB connective tissue. 

There are no capillaries, ius a rule, in the jiapillfo which contain 
nerve-tihres or tactile corpuscles. 

All the arteries and veins in the upper portion of the corium con- 
aifit only of a single layer of endothelial cells, which is re-enforeed as 
they approach the 8uheutancous connective tissue by a rudimentary 
media aud adveutitia (Unna). Uoyer says that many of the cutane- 
ous arteries in the nail-bed and in the skin of the terminal phalanges 
of tlie lingers and toes empty directly into the veins of those parts 
without the int^^rvention of capillaries* 

The fat-lobules, the sebaceous and sudoriparous glands, the hair- 
follicles, aud tlje cutaneous muscle.s, are Burrouuded by a dense net- 
work of capillary vessels which terminate in one or more efferent veins. 
The larger arteries aro richly supplied with nerve-fibres. 

The Lymphatics of the Skin. — The lymphatic system of the skin 
is composed of lymphatic vessels proper and lymph -spaces. The 
former aro well-defined circular canals inclosed by their own distinct 
walls ; the latter are interstices in the substance of the skin between 
the capillaries and lymphatic vessels, and contain a variable amount 
of fluid. They have no distinct wall, and freely communicate with 
each other. They ai-e the principal seat of the effusion in all exuda- 
tive diseases. 

Lymphatic ves.sels are found in eveiT portion of the skin, but they 
are most abundant in those regions where its attach men t to the sub- 
jacent tissues is comparatively loose, as on the eyelids and scrotum. 
They present a distinct lumen, which is bounded by a single layer of 
elongated, flattened endothelial cells. Thuse of the auljcutiiueoiis cel- 
lular tis.<ne have a rudimentary muscular coat in addition, aiid contain 
one or more valves. They are arranged in a series of plexuses, which 
ramify horizontally in the corium and subcutaneous connective tissue. 
Those of the su|>erfioial layer begin with a blind extremity in the 
upj>er portion of the papillae, and unite to form an exceedingly close 
network <>f minute vessels, which become larger in calibre as they de- 
scend in the substance of the coriura. They finally empty by a few 



AXATOMY OF THE SKLV. 



23 



large trunks along with those of the deeper layers into the lymphatics 
of the subcutaneous cellular tissue. 

The lymph-spaces of the corium and eubcutaneous tissue are iden- 
ticul with the interfascicular spaces, and communicati^ with the lym- 
phatic vessels of those parts by means of a multitude of gmall st-omata. 
There are none of these vessels in the stratum Maljjigliii. The cir- 
culation there is carried on entirely through the lympii-sj>aces, which 
are the interstices between the su-called prickle-cells. The fat tissue, 
the sudoriparous and sebaceous glands, and the hair- follicles are sup- 
phed with separate lymjdiatic vessels, and honeycombed with lym- 
phatic cleftg and sinuses. 

The Nerves of the Skin-^The stratum Malpighii, the corium, and 
the subcutaneous connective tissue are richly sit]>plied with uerves, 
but none have yet been discovered iu tlie stratum corneuni. The 
nerves of the anbcutaneous connective tissue are large in size, and are 
directly continuous with the large nerve -trunks of the subjiicent 
gtructures. They send horizontal branches to the large arteries and 
PaeiDian corpuscles, and then pass obliquely ujiward to the under sur- 
fiioe of the corium, where they divide into a number of minuto 
branches which ramify through the substance of the corium, and are 
composed of both niedullated and non-medullated fibres. 

The medu Hated terminate in the Pacinian and tactile corpus- 
cles, and are consequently most numerous in the regions wliere those 
structures are most abundantly developed. The non-medullated are 
present iu every portiun uf the skin. 

Tile PaeiiLlan Corpuscles.^ — The Pacinian coq^uscles, or corpuscles 
of Vater» are small, firm, compact^ semi-transparent bodies, which are 
found in large numbers in the subcutaneons connective tissue of the 
corpora cavernosa, the palms of the hand, and the soles of the feet. 
They are especially abundant and well developed on the inner surfaee-s 
of the terminal phalanges of the fingers and toes. Their total number 
on each hand and foot varies from 000 to U400. They are more or 
Ie«s elliptical or ovoid in form, and are plainly visible to the naked 
eye. They are composed of from twenty to sixty lamellae, or capsules, 
vhieh are arranged concentrically around a cylindrical or elongated 
central cavity. The capsules consist of an internal layer of nucle- 
ated endothelial cells and an external layer of hyaline ground-sub- 
aUnce, in which fine bundles of connective -tissue fibres are im- 
bedded. Each Pacinian corpuscle is pierced at its base by a single 
medullated nerve-fibre, which gradually loses it^ neurilemma as It 
paaees through the capsular layers, and enters the central cavity as a 
simple axis-cylinder, which finally divides into two or more branches, 
terminating in pear-shaped enlargements in the distal portion of the 

itral carity. 

This cavity is lined by a granular albuminous substance containing 




i] 



24 



DISEASES OF THE SKIN. 



traces of cell-etructure, wliich lias been Biipposed to be identical with 
the niedulkiT substimce of the nerve. The hiuiella^ are dovek>ped 
from, and are directly continuous with, the external layers of the 
neurilemma. According to Biesiadecki, a large artery enters the cor- 
puscle near its bitse, and forms a network of capillaries that ramify 
between its outer lamellie. 

The Tactile Corpuscles.— The tactile corpuscles, called abo tonch- 
corpuaeles, corput^cles of Meissuer, and corpuscles of Wagner, are small 
round or oval bodies, which arc present lu the sensory papilla of the 
corium. They vary in number in different regions of the body. Meiss- 
uer has estimated that there are 108 in a square line on the flexor sur- 
faces of the terminal phalang'cs of the fingers, but only forty in the 
game space on the second, fifteen on the first, and eight in tlie palm 
of tlio haiuL They exist in considerable numbers on the lips and nij> 
ples, and arc more or less gcuttered in otlier }»ortions of the body. 
They occupy the greater portion of the papillfe in which they are 
found, and present a transversely striated aiJpearance on section. 
They are composed of large, flat connective-tissue cells, which are held 
closely together by a network of delicate fibres, and are surrounded by 
an investment of fibrous tij^suc. Each corpuscle ia penetrated by a 
single medullated nerve. Klein states that the nerve first pursues 
a winding course around the corpuscle, during Tvhich its neurilemma 
becomes fused with the librous sheath of the corpuscles, it then loses 
its medullary substance, and ]>enetrate9 into the interior of the cor- 
puscle as a simple axis-cylinder. This axis-cylinder further divides 
into a number of minute branches, which ascend spirally through the 
substance of the corpuscle and terminate in small pear-shaped or 
cylindrical enlargements, known as the touch-cells of Merkeh 

The genital cor[)Uscle8 of Krause, or the end-bulbs of Kniuse, are 
similar in structure and arrangement to the t^ietile corpuscles, and are 
found immediately beneath the epithelium of the penis, clitoris, and 
Tagina. 

The Non-MedtillatBd Nerves.^The non-medullated nerres give off 
branches in the lower portion of the corium to the blood-vessels, the 
hair-follicles, and the sebaceous and sudoriparous glands. They then 
ascend oblif|uely to the superficial layer of the corium, wliere thej 
form a flense plexus aroniid the (nipillary vessels. From this plexus 
numerous elementary fibrils ramify in various directions. Some pass 
downward into the tissues of the corium, but the greater number 
pierce the btisement-membrane, and, passing through the stnitnui Mai- 
pighii, form another plexus there, from which other fibrils jrass upward 
into the stratum granulosnm. It was formerly believed that they 
ended in this layer as minute expansions between the granular cells ; 
ITnna, however, states as a result of the most recent investigations that 
they penetrate the protoplasm of the cells and terminate io a minute 




raioLOOY OF the skin. 

bcdby which is closely applied to tlie nucleus of the cells. They some- 
dmM wind around the nucleus, but do not penetratG it. Their manner 
of termination is, therefore, typically intracellular. 



PHYSIOLOGY OF THE SKIK 

Its functions are more numeroua and varied than those of any 
other organ of the body. It forms a protective covering for the un- 
derlying fitmctures, prevents tfie too rapid eeoapo and evaporation of 
the water of the tissues, and assists in maintaining the temjierature of 
the body at the normal standard. It is of the utmost importance as 
sn organ of sensation, secretion, excretion, and absorption. It also 
ier?e8 as an accessory organ of respiration. 

The cushion-like formation of the subcutaneous connective tissue, 
and the elasticity and tirmness of the corium, modify the effect of 
blow@ and other external injuries, and protect the internal organs to a 
morD or less extent from the shock which would otherwise result, 
The comparative impermeability of the horny layer of the epidermis 
prevents the too rapid transudation and evaporation of the fluids of 
the tiaeues. If it were not for the barrier thus interposed, the escape 
and evaporation of the water of the body would be so continiioua and 
excessive that the tissues would become dried up and death ensue. The 
horny layer of the epidermis is also a protection to a considerable ex- 
tent against the action of caustic or irritant substances, and against 
the effects of high or low temperature. The hair of the head and face 
is an additional protection against blows and injnries, as well as exees- 
five heat and cold. The mustache and heard debar dust and other 
foreign matter from entering the air-passagee, the eyebrows prevent the 
perspiration of the forehead from running over the eyelids, the eye- 
lashes prevent particles of dirt and other irritants from settling on the 
oonjunctiva, and the short, stiff huire at the openings of the cars and 
Qoetrtts obstruct the entrance of insects into those passages, 

BegulatioD of the Temperature of the Body,— One of the most im- 
portant functions of the skin is that of maintaining the temjierature 
of the body at the normal standard. An increase of ten degrees above, 
or a decrease of fifteen degrees below that standard, is incompatible 
with life. Owing, however, to the power which the akin possesses of 
nsei^ting or accommodating itself to changes in the external tem- 
perature, much greater variations are every day endured with im- 
panity. 

The skin and its appendages are imperfect conductors of heal. 




DISEASES OF THE SKIN, 



They protect tlio body against the eflfects of cold by retaining T^ithin 
the tissues n considerable proportion of the heiit which is produced 
there. This action is further assisted by the involuntary contraction 
of the cutaneous muscles, by which the blood is driven from tlio pe- 
riphery toward the centre, the general cutaneous surface lessened in 
extent, and the radiation of heat proportionately diminished- 

Tliey also form a mechanical protection against the action of moder- 
ate external heat. The processes by which the liunum hotly is enabled to 
resist a continuously high temperature are more intricate. The prob- 
lem in this case is to prevent the temperature of the body from rising 
above the normal at a time when it is not only iirodncing a super- 
abundance of heat within itself, but is also surrounded by a still hotter 
atmosphere from which it is constantly receiving accessions. The 
chief means by which this result is attained is by a large increase 
of the cutaneous transpiration. In consequence of the impression 
made by a warm or hot atmosphere on the vaso-motof nerves of 
the skin, the ciilaneoiis muscles become relaxed, the blood-vessels 
dilated, and the general superficies of the skin increased. A much 
greater surface is thus exposed for radiation and transudation, the 
skin becomes batliod with iJcrspirationj by the evaporation of which 
active heat is converted into latent heat, and the tein|»erature of tlie 
evaporating surface correspondingly diminished. This effect in re- 
ducing the temperature of the body or preveDting an abnormal rise is 
greatest when the air is dry as well as warm. The amount of perspi- 
ration secreted under these circumstances is sometimes very great, 
amounting to from one to four pounds in an hour. The degree of 
heat that can be endured as long as perspiration and evaporation are 
not interfered with is astonishing. Drs. lilagden and Banks ascer- 
tained that a tem]ierature of 311^ could be borue without much incon- 
venience for a limited time in dry air. During one of their experi- 
ments the temperature was raised to 2iji.f, and kept at that point for 
eight minutes. At the end of that time the clothes and furniture in 
the room were very hot, but the temperature of the body remained^ 
about normal Tillct mentions the ctise of a girl who remained in an 
oven for several minutes without any ill effect while the temperature 
wiis 324'o°, The workmen of Sir F. Charitrey became habituated 
to entering the oven where their moulds were dried while the ther- 
mometer stood at 350°, and those em|>loyed by M. Magnus were ac- 
customed to entering his oven when the temperature was over 400", 
Chabert, tlie fire-king, is said to have entered ovens which were heated 
to 400° and 600", In all these cases the atmosphere was perfectly 
dry^ and the bodily temperature was kept down by the production 
and evaporation of a profuse amount of pei-Bpi ration. 

When, however, the air is moist, as well as hot, eva]ioration is ef- 
fected with more difficulty ; the temperature of the body rises rapidly, 



rarsioLoor of the skin. 



27 



I 



and the degree of heat that can be endured is much lesa. C. James, 
&D English observer, was overcome by a temperature of 112^ in the 
vapor-bath3 of Nero; but in the caves of Testaccio, in wldch tlie air is 
dry, he suffered very little iuconveuienue, although the temperature 
was 176**, In the former evaporation from tlie skin was an impoBsi- 
bility, while in the latter it was abundant. Being exposed to so many 
ricksitnde^, it is not surprising that the ttnnperature of the skin itself 
dioold be neither as elevated nor as constant as that of the ioterior of 
the body. Differences are observable, also, in different regions of the* 
integnment. It is evident to the touch, for instance, that the habitual 
temperature of the forehead is greater than that of the feet. A geries 
of iDleresling experiments upon the subject of local temperatures has 
been conducted by A. J. Kunkel.* This investigator finds, notwith- 
atanding considerable fluctuations due to various causes, that the skin 
tends to approximate a constant degree, which lie t^rms the optimum, 
and that a marked deviation frum this optinjum is prodoetive of pain. 
In a well-clad individual, sitting in a room of ordinary temperature, 
the optimum varied from 33-8° to 34-8° a (92-8° to d4'if R). The 
normal temperature of the parts of the body habitually covered by 
clothing averages from 34'^" to 34-6° C. (93-5° to l>4-5°* R). Local 
variations, however, result from anatomical and physiological causes. 
The heal of the skin is increased by activity of tissue-change in under- 
lying parts or organs. In regions situated near the axis of the budy, 
over bulky muscular masses, and over the cranium, maximum tcmpcra- 
torea are obtained. High temperatures are observed over great vessels. 
The face is generally half a degree warmer than the covered part^ of 
the body. Wiien prolonged exposure to cold luts depresHcd the tempera- 
ture of a large area to 32"* C, (89'6^ F.) or lower, discomfort is pro- 
daced. Runkel states, however, that under highly unfavorable cir- 
cametances the surface temperature of the person experimented upon 
never amk below 31 0'^ C, (889^ F.). Upon the face the tempera- 
ture seldom fell below ae-S?"* C. (70-4^ R). This temperature, 
Ihoagh unpleasant, was not actually painful. When the temperature 

[of the hands wiis reduced to 25° 0. (77° F,), a sensation of pain 
wag experienced. Aft^^r remainiug in a very hot room, the highest 
temperature (35 '5** C. = 95*9° F.) was always found in the face. A 
eeoBatiou of disagreeable heat was present, but no visible persj>iration. 
The result of these inquiries is to show that in spite of the fre- 
quent and extreme fluctuations to w^iich it is exposed, the temperature 
of the human skin is nearly constant. Local refrigeration is soon 
eoanterbalanced by increased local circulation. 
The Respiratory Function of the Skin.— The respinitory function 
of the skin is anulogyus to that ol the lungs. Oxygen is absorbed, and 
carbonic acid ie exhaled. The quantity of either which passes through 
• ** MoDAUhefte far Praktischc DermAtologle." 



28 



DISEASES OF THE SKDf. 



the skill is only a fn^ctional part, however, of that which h taken up 
or given ol! by the lungs. Gerlach states that the lungs absorb 
one hundred and thirty-seven times as much oxygen as the skin, 
Scharling endeavored to make an estimate of the extent of the cuta- 
neous respiration as compared with the pulmonary by a calculation 
based ou the quantity of carbonic acid given off through each during 
the twenty- four hour8» From hia observations, he estimates tliat the 
skin performs from one fiftieth to one fortieth of the entire respira- 
*tory process. It is probable, however, tliat this result is too high, A 
great deal of the carbonic acid which is given off is eliminated through 
its function as a medium of excretion, and is nat connected with the 
procesJ5 of respiration. 

SensatioiL— The skin is the organ of the sense of touch, by means 
of wJiicli external impressions are recognized and localized. Tactile 
sensibility is an exaltation of the sensory power, by means of which the 
shajie, size, and other properties of various objects are recognized. 
The sense of temperature is a variety of common sensation which ena- 
bles us to difTerentiate between heat and cold. According to Schiff 
and Brown-Sequard, each of these impressions is transmitted to the 
brain by a different set of nerve-fibrea. 

All parts of the skin are endowed with common sensation, but some 
regions are more sensitive than others. In tljose regions of the body 
where the epi<lermts is thin, as on the face, neck, breasts, and inner 
surfaces of tlie arms and thighs, the susceptibility to external impres- 
eiong is marked. Where the epidermis is thick, as on the heel, the 
back, and the outer t^urfaces of the limbs, the sensitiveness is much 
less. If tlie epidermis be removed, and the uorium exposed, the sen- 
sation of contact is transformed into pain. 

The tactile sensibility of the skin varies in accordance with the 
number of the nervous papilla^ in the corium, and the presence or ab- 
sence of the tactile and Paciniim corpuscles. Impressions made upon 
the epidermis are transmitted to the papillae, and through them to the 
peripheral nerve-endings. The tactile and Pacinian corpuscles prob* 
ably act mechanically by furnisliing a su{>port for the terminal expan- 
sions of the tactile nerves, and by presenting a hard surface against 
which the delicate nerve-filaments can be pressed. They are not eaeen- 
tial for the exercise of common sensation, but wherever they exist the 
power of appreciating delicate impressions is much increased. Moissner 
remarks that the tactile corpuscles are most abundant on the tips of 
the fingers^ where he counted one hundred and eight in the space of 
a fiftieth of an inch. Consequently tactile sensibility is most highly 
developed there, the delicacy of touch of the fingers being proverbial. 
It can be further increased by education and practice, and by its acute- 
nesa frequently compensates in a great degree for the loss of other 
powers. Ill this manner the blind become able to read sentences in 



3 



PHYSIOLOGY OF TOE SKIN. 



M 



niaed letters, to recognize individnals by tho contour of tbeir faces, 
and eren to distiuguish various shades of color through some inde- 
scribable difference of surface. 

The relative tactile sensibilitv of different piirts of the skin has 
been ascertained by an ingenious method devised by E. Weber in 18"i9, 
ThLs method is based upon the power of recognizing and isvolatiug two 
distinct impressions matie upon the surface at the same time, and at a 
m^iuimum distance aparL It consists in the application to the skin of 
two fine pointa placed at a known dii^tance apart. If two imjiressions 
are felt, the distance between the points is to Ix^ gradually decreased 
until the limit of their perception as two points \h reached. This is 
termed the limit of confusion. If the points be brought still nearer 
together, their double effect will be felt as only one impression. 

We learn from tho experiments made by Weber, and confirmed sinco 
by other observers, that tactile sensibility is most acute on the end of 
the third linger and the tip of the tongue If the eyes be closed, and 
the paints of an ffisthesiometer be applied to cither the tip of the 
tongue or the end of the third finger, a double impression is distinctly 
peioeiired when the points are only one twenty-fourtli of an inch 
apart ; while, for the recognition of two impressions on the pahruir sur- 
face of the thumb, the points must bo separated one twelfth of an 
inch ; on the red surface of the lip, one sixth of an inch ; tip of the 
noee, one fourth of an inch ; middle of the dorsal surface of the tongue, 
one third of an inch ; tlie eyelids and palm of tht* haml, live twelfths 
of an inch ; back of the fingers, seven twelfths of an inch ; forehead 
and cheeks, five sixths of an inch; back of the hand, one and one 
sixth of an inch; crown of the head, one and one fourth of an inch; 
patella and lower portion of the thigh, one and one third of an inch ; 
leg and dorsum of foot, one and a half inch ; back of neck, two 
inches; saci-al region, one and a half inch; sternal region, one and 
two tliirds of an inch ; lumbar UTid upper dorsid vertebral region, two 
inches; and, finally, over the nn'ddle cervical and middle dorsal ver- 
tebrie^ and middle of the thigh and forearm, the points are not per- 
ceived as two until they are separated two and a half inches. It will 
thns be seen that this faculty is sixty times greater in some regions of 
the skin than it is in others. This difference depends upon the num- 
ber of primitive nerve-fibres present, and therefore indirectly upon the 
number of papillfe in the part. If the primitive Tierve- fibres are few 
in number, it is possible that several contiguous impressions may be 
conveyed to the same nerve-fibre, and consequently produce but one 
impressioD an the sensorinm. Each nerve- fibre ends in a tuft of deli- 
eate filaments which supply an oval or circular area of the skin of 
aboat one four-hundredth of an inch in diameter, but the filaments of 
eontiguouB fibres interlace with each other, so that, the more uumer- 
Ofu and closer the nerve-fibres, the greater the probability that two 



a 



BTSEASES OF THE SKIN. 



Bimiiltaneoos impressiona made upon tlie surface will be transmitted 
to different nerve- filaments, and recognized by tlie seixsorimn as sepa- 
nite impressions. 

The sensibility of tlie ekin to changes in temperature varies in dif- 
ferent individuals and in ditTcreat parts of the body. It is nioat acoto 
in those portions of the Burface where the epidermis is thin. Vari- 
ations of even one half a degree can bo distinguished with the tip of 
the tongue. The face and the fingers und the elbow are al80 caimhle 
of appreciating very slight changes in temperature. Leegaard has de- 
vised an instrument by which he has been able to study the sensibility 
of the skin to variations of temperature. Tie found that in healthy 
persons three fourths of a degree eitlier below or above 82° F, was 
the range of indifferent temix^ratnre — that is, which might be pro- 
nounced either hot or cold by healthy people, the eyes being closed 
during application of the test^ He made many observations on dif- 
ferent portions of the body, and determined that from one to one 
degree and a half is the smallest measure of difference which could be 
detected by tlie skin in health. As a result of his experiments, he be- 
lieves that the temperature sense is very equally distributed over dif- 
ferent parts of the body, the variation in tliis respect being much less 
than had been ttiught by Notbnagel. He found a great difference in 
individuals iis regards their ability to distinguish variations of tem- 
perature. 

Weber's experiments have shown that sensations of heat and cold 
are modified by the extent of the surface exposed to the impression j 
the greater the extent of surface exposed, the more intense will be the 
sensation (iroduced. The whole band dipped iu water of a certain 
temperature may feel it too hot to be borne, while to a single finger it 
may be only comfortjibly warm. 

The sense of temperature is distinct from that of touch, and may 
remain unimpaired when all other sensation is lost It is well known 
that paralyzed limbs, which are insensible to pressure and the contact 
of the aesthesioraeter, are capable of recognizing the difference be- 
tween heat and cold. This may be explained by the existence of a 
special set of nerves for the reception and conveyance of thermal im- 
prfssions, or the occurrence of degenerative changes in the cord or in 
the cerebrum. 

Absorption, — It was formally supposed that the horny layer of the 
epidermis presented an insuperable obstacle to the passage of any sub- 
stance through the skin into the blood. 80 much evidence, however, 
has been accumulated to the contrary, that the importance of the skin 
as an organ of absorption is now universally recognized. Under oi-di- 
nary cirenmstaucea this function is limiteti to the absorption of oxygen 
and watery vapor, but it may be utilized for t!ie administration of 
various medicinal preparations. Experience has shown that their ac* 



"PHYSIOLOGY 



SI 



Uon when introduced into the system in tbia manner is almost aa 
prompt and effcacious as when they are taken into the alimentary 
canal. 

The absorption of oxygen by the skin is undoubted, and constitiitcg 
an eeseotial part of the general respiratory process. Tiie absorption 
of watery vapor is well shown by the rapid recovery of the weight 
which has been lost by excessive perspiration. Persons after taking a 
hot bath, during which they lose one or two pounds in weight, almost 
invariably regain their former weight in a couple of hours, although 
they neither eat nor drink in the mean time. Part of this increase is 
effected by pulmonary absorption, but a coTisiderable part of it is due 
to cntaneons absorption. It hiia also been observed tliat the sensation 
of thirst is diminished in a moist atmosphere, and that it may be fur- 
ther lessened by immersing the clothes or the whole body in water. 
Shipwrecked sailors have relieved their thirst iu this way and pre- 
served their lives, long after their supply of drinking- wuter became 
eihaasted. This happy result is in part due to a diminution of the 
evaporation of the fluids of the tissues^ but is also due in piirt to the 
dire<3t absorption of a large quantity of water. In reference to this 
point, Captain Kennedy says, iu the narrative of his shipwreck, which 
he addressed to the Royal Philosophical Society : " I can not conclude 
withont making mention of the great advantage I derived from soak- 
ing my clothes twice a day in sea-water^ and putting them on with- 
out wringing, . . . There is one very remarkable cin-umstauce, and 
worthy of notice, which was that we daily made the same quantity of 
urine as if we had drunk moderately of any liquid, which must be 
owing to a body of water absorbed through the pores of the skin. . . , 
So very great advantage did we derive from this practice that the vio- 
lent drooght went off, the parched tongue was cured in a few minutes 
after bathing and washing our clothes*; at the same time we fonnd 
oorselTes as much refreshed as if we had received some actual nour- 
nhment*' 

Experimental observations have shown that when the temperature 
of a bath is higher than that of tlie body, more water is lost by perspi- 
ration and pulmonary exhalation than is absorbed, and there is eonse- 
quentiy a loss in weight. In a bath of 90° the processes of exhalation 
and absorption are equal, but in tejiid and cold bathing the gain by 
absorption exceeds the loss by exhalation, and the body-weight is 
slightly increased. Various medicinal substances may bo introduced 
into the system through the medium of the bath, and can be afterward 
detected in the urine. The benefit derived from a residence at the 
different springs of Europe or America is due in a considerable de- 
gree to the absorption through the skin of the sulpluir, the alkaline, 
or tlie chalybeate ingredients of the water in which the daily bath is 



33 



DISEA>*ES OF THE SKIN. 



The rate of cutaneous absorption depends upon the solubility and 
diffnsibility of the subBtance which may be placed in contact with the 
skin. Insohible substances can not be absorbed at all, while oxygen, 
hydrogen, chlorine, and other gases, and chloroform, turpentine, ether, 
and similar volatile substances, diSuse into the blood with great rapid- 
ity. Alcoholic solutions are not well ab&itrbed, but chloroformic solu- 
tions of the various alkaloids, when applied to the surface, produce 
their characteristic systemic elfects in a very short time. Prof. N. 
A. Khrjonshtchevsky, of Kiev, has investigated this subject anew in 
series of experiments upon dogs, cats, and boys, llie subjects were 
immersed in a specially constructed bath. Dogs and cats were killed, 
througli the cutaneous absorption, by aqueous solutions of strychnine 
in two and a half or three hours; by alcoholic ones in one or one and 
a half; by nicotine solutions in two and a half; by conium in one or 
one and a half; by veratrin in nine or ten hours; by cyanide of potas- 
sium at 25^ C. {77® F.) in one or one and a quarter hour; at 42" C- 
(107'(j*^ F.) in thirteen to fifteen minutes. Indigo-carmine could be 
detected in an animars nrine in three hours. When a Bolntiou of 
ferrocyanide of potassium was injected into an animal's veins and the 
animal placed in a bath of lactate of iron (or vice twrm)^ there could be 
-Seen in about two or two and a half hours a blue discoloration of its 
cutaneous blood-vessels from the formation of ferrocyanide of iron* 
Prof. Baelz, of Tokio, Japan, has made many experiments in order to 
determine whetlier watery solutions of salti? are absorl)ed by the skin. 
He found that salicylic acid solution 1:1,000 is readily absorbed in hatha 
of 40° to 45^ C. (104° to 113'' F.), but that salicylate of sodium is not 
absorbed. Baelz concludes that there is no general law governing ab- 
Borption or non-absorption through the skin, but that in this respect 
every substance must be individually tried.* 

The absorption of soluble but non-volatile substancea is effected 
more slowly, but may be facilitated by friction, by which their particles 
are forced into the orifices of the glands, where they are dissolved by 
the secretions and carried into the system through the interstices of the 
stratum lucidum. It is in this manner that mercurial ointments 
produce their specific effect in sypliilis. The pnisonnus effects of lead 
and arsenic are developed in the same way in those whose occupations 
compel them to handle these minerals, or who use them for any length 
of time 08 cosmetics. 

The various oils and fats, and substances dissolved or held in sus- 
pension by them» are readily absorbed by the skin. Batlis or inunc- 
tions of cod-liver oil form an invaluable resource in the treatment of 
phthisis, marasmus, and other wasting diseases. 

Medicinal substances applied to the surface of the corium after tiio 
epidermis has been removed are absorbed with great rapidity. 
♦ " Satellite," September, 1889. 



PHYSIOLOGY OF THE SKIN. 



33 



Seoretion and Excretion. — The importance of the skin as an organ 
of gecretiou and excretion can not be overestimated. Any disturbance 
of its functions in this respect i^ liable to be followed by the most 
Bf rions consequences, and their complete fiuspension is certain to result 
in death. Instances of recovery after the urinary secretion has been 
suppressed for several days are recorded, but if the elimination of 
effete material by the skin be completely prevented, a fatal result will 
ensue in a few hours. Burns involving more than one third of the 
geneml surface are invariably fatal, not because of the pain or the 
shock to the nervous system, but because the excretory surface of the 
skin is lessened one third.. As a consecjiience of this sudden diminu- 
tion of the eliminating process, death frequently occurs from cerebral 
effusion in an hour or two after the injury. In the majority of cases, 
however, the kidneys and hangs endeavor to compensate by increased 
irork for the lessened excretion bv the skin, but the over- excitation of 
the»e organs generally results in inflammation in a few days, and the 
^tlent dies from pneumonia or nephritis. 

The ftkin secretes sebaceous matter and tlie perspiration or sweat, 
: " <^arbonic acid and water, and, probably, certain other vola- 

r ^ ^ -s which have thus far escaped observation. The elimi- 

nation of carbonic acid by the skin is an essential part of the respir. 
atorj prooeaa. If an animal be covered with varnish, impermeable by 
water or ^ama, it will die in from six to twelve hours. The cause of 
this has not been definitely ascertained. All that is known is that 
ooraplete suppression of the functions of the skin in this manner is 
followed hy a rapid fall of tem[)crature and death. The fatal result is 
jH'rhaps due in part to the retention of carbonic arid in the system, 
and in part to ihe reteutiun of some uudiscuvered morbiHc cutaneous 
products. 

The SebnnL. — The sebaceous matter, or scbtim, h u semi-fluid itia- 
terial which is secreted by the sebaceous glands. It is coniposud of 
frre fat, fat-cells* and epithelial lUbris, Chemically, it contains about 
thirty- five per cent, of water, forty per cent, of olein and pal mat in, 
thirteen j>er cent, of casein, eight per cent of gelatin, and traces of 
albfitnen and various odorous principles, and a small quantity of the 
chloride, phosphate, and sulphate of sodium. 

The nses of this secretion are manifold. It preserves the normal 
Boftne;»s and jiliability of the skin, aiul acts as a protection to those 
part^ of the body that arc exposed to atmospheric changes. It pre- 
Tenia the maceratinn of the epidermis that would otherwise follow 
profu*»e perspiration, lessens the friction between contiguous surfaces, 
and protects the skin around the outlets of the body from the coiitact 
of ii -xcretions. It also gives lustre aiul pliability to the hairs, 

•nd , . . y contributes to their growth and nutrition. 

Kw Perspiration. — The perspiratory function of the skin is of the 
8 



tfiiii 



IAN£ umm. STANFORD UNWERSJ 



34 



DISEASES OF TFIE SKIN. 



utmost importance, as a means by wliicli efTete materials arc removed 
from the system, and the temperature of the body prevented from 
rising above the normal staudani It was formerly supposed that 
perspiration was the product of the sudoriparous glands alone; it ig 
now known that it is composed in large part of the waiei* which is dif- 
fused outward from the interstices of the deeper layers of the epidermis, 
and becomes intermingled witli the secretions of the glands. Uiina 
and other observers maintain that it is derived exclusively from tiie 
epidermic interspaces and that the function of tliese glands is re- 
stricted to furnishing a lubricating material for the skin. 

Perspiration in health is a colorless fluid, saltish in taste, and 
slightly acid in reaction. It is composed of nine hundred and ninety 
parts of water and ten parts of organic and inorganic solids. Tiie in- 
organic materials consist mainly of the chlorides of sodium and potas- 
sium, with some h-aces of iron and tlie earthy phosphates. The organic 
constituents consist chiefly of urea, fat, and fatty acids. The quan- 
tity of urea contained in perspiration under ordinary circumstances 
is not large, but it is enormously increased when the functions of the 
kidneys arc suppressed, as in certain forms of Bright's disease. The 
odor of perspiration is partly due to the various fatty acids, and partly 
perhaps to some volatile odorous substances which have not yet been 
isolated. 

The mutual relation existing between the skin and kidneys aa 
organs of elimination is shown by the well-known fact that wiuni the 
perspiration is diminished, as in cold weather, the quantity of urine is 
increased, while during warm weatlier, when the perspiration is more 
abundant, a smaller amount of urine is secreted. 

The production of perspiration is controlled by a special system of 
nerves, analogous to those which regulate the secretion of saliva, and 
is stimulated under normal circumstances by the presence of an in- 
creased quantity of blood in the capillaries of the skin. It may, how- 
ever, be increased or diminished by the action of certain medicinal 
agents without regard to the condition of the cutaneous circulation. 
Atropine, as is well known, will check the most profuse perspiration, 
although it may, and frequently does, produce at the same time an 
intense hyperjtmia of the whole surface. Opium, pilocarpine, ipecac., 
and other diaphoretic agents indui.'e free perspiration, during which 
the skin remains pale and cool. The cold sweats of phthisis, of syn- 
cope, and of fear also occur while the surface is pale. It is not im- 
probable, however, that these abnormal perspirations are due to a 
paresis of the nerves and a relaxation of the vessels, and should conse- 
quently be regarded as an exudation rather than a secretion. 

The amount of perspiration in health varies in different indi- 
viduals and under different circumstances. It is decreased by cold 
and increased by heat. It is increased by exercise and by taking food 



PHYSIOLOGY OF TOE SKIN. 



35 



ma 



or drink, by breathing in a confined space, by putting on additional 
clothing, and by all circumstances that product* un increased flow of 
blood through the capillariea of the skin. Peiper has demonstrated that 
the j>erspiration is more abundant upon the right side of the body, that 
the palm of the hand perspires four times more than that of the skin of 
the chest, and the cheeks one and a half times as much. The secretion 
slowly increases in the afternoon, especially from eight o'clock to mid- 
night, after which there is a diminution. Food has but little influence 
Dp3n the perspiration. The qiiaiitity is generally leaa in infiints than 
in adults, while the weight of the body and sex are without marked 
influence. The effect of woolen underclothing upon the perspiration 
been investigated by Lasarew, who kept a number of healthy sol- 
ers under observation for a period of tliirtydays. While such under- 
clothing was worn the amount of all snbstances excreted by the lunga 
and skin was increased and the quantity of urine ilccreased. The sur- 
face tcmpemtare was raised several tcntlis of a degree. The general 
temperature, pulse, and respiration remained unaltered. When linen 
underclothing was worn the urine was increased, and excretion from 
the lungs and skin diminished.* According to the obaervations of 
Seguin, Lavoisier, and others, the average daily amount of water re- 
moved from the body by perspiration is thirty ounces. More than 
this quantity may, however, be lost in an hour when the body is ex- 
posed to a very high temperature. It is by the evaporation of this 
large amount of water that the surface heat is lowered, und the tem- 
perature of the blood prevented from being raised to a point incompati- 
ble with life. The influence of the perspiration upon the constitution 
of the gastric juice and urine has been studied by Viktorin S. Griiztleff, 
who experimented upon seven persons in F*rof. V. A. Manassein'a clinic. 
The loss of weight after sweating varied in ditlerent observutions from 
120 to 1,020 grammes (3 oz. 412 grains to 32 oz. 391 grains). Free 
rspimtion reduced the acidity, digestive power, and total quantity of 
he gastric juice as well as the proportion of free liydrochloric acid 
Fhieh it should contain. The proportion of pepsin appeared to remain 
unchanged. These alterations were less marked in healthy persons 
than in those suffering from chronic gastric catarrh. The more pro- 
fuse the perspiration the more considerable was the decrease of acidity. 
The longer the interval between the sweating and secretion of the gas- 
tric juice the greater the decrease. The alterations in the juice may 
I ' several hours to two davs. Theaciditv of the urine remained 

A remarkable case of post-mortem sweatifig has been placed upon 
record by Mr. John A. Cones. A man, forty- two years of age, the 
Bubject of albuminuria, was suddenly seized, ten daysliefore death, with 
unemic coma and left hemiplegia. The temperature was normal 
• •* Moaat«heft» f ur praktische Dermatologie," No. 6, 




36 



DISEASES OF THE SKIN. 



Tintil within the )ast few tluys, when it ranged from 103° to 104° six 
lioiirs before death, when it began to sink. It was found dltlicult to 
excite perspiration. Pilocarpine was given hypodermieally in gradn- 
ally increasing doses. The htst injection^ three dfiys before death, jiro- 
duccd a fiiir amount of sweating for about twenty minutes, but, as it 
gave rise to excessive bronchial seci*etion, was not repeated. Forty- 
eight hoiira before death, however, the patient began to perspire pro* 
fuBcIy, and this continued without interruption to the very end, even 
wlien the surface temperature was decidedly subnormaL TJie body was 
washed, and four hours later laid upon a bier, nothing unusual being 
noticed at the time of removal or before j but sixteen hours after death 
the sheets and pillows were found absolutely saturated witli sweat, 
and the skin felt moist and clammy. This state continued for at legist 
eight hours. The strange features of the case are the considerable 
time that must have elapsed after death before the secretion wa^ 
poured out, at all events to any extent, and the great quantity of the 
fluid. The writer suggests, in explanation of the phenomenon, that 
m the patient had been sweating freely to the time of his death, the 
glands and lymph-spaces surrounding them were probably engorged 
with fluid, and that with the beginning of rif;or morfis the contents of 
these glands and lymph-spaces had been mechanically expressed.* 

The perspiration emanating from the axilla, the genital regions, 
and between the toes has a peculiar odor, which at times becomes ex- 
cessively offensive, constituting the affection known as bromidrosis. 
It is always distinctly alkaline. Donne states that the alkalinity, m 
well lus the odor, is due to the intermingling and decomposition of the 
secretions of the follicles other than those of the sudoriparous glands. 

Electric Currents.— M. Tarehanoff has studied the production of 
electric cutaneous currents in man by means of a very sensitive gal- 
vanometer, together with a special device for preventing spontane- 
ous movements. The electrodes being in position, the production of 
cutaneous currents was determined under the influence of the most 
various excitations, a call in a loud voice, a shock, etc. The psychical 
ecnsations of heat and cohJ suggested to the subject determined ex- 
tremely delicAte reactions of the galvanometer. When the left hand 
was in contact with the electrodes, and it was suggested to the subject 
that his right hand was warm and commencing to perspire, no effect 
was observed ; but when the left hand \vm spoken of, a considerable de» 
viatiou of the needle of the instrumeut at once occurred. Here was 
an electric discharge of purely psychical origin which might to a cer- 
tain extent be compared to the discharge of a torpedo. In prosecuting 
these experiments it was necessary to choose regions rich in sudoriparous 
glands. These glands play a notable part in the production of the 
cutaneous currents. A jierson in a state of expectant attention causes 
» The " Ltuicet," May 25, 1889, p. 1027. 



PHYSIOLOGY OF TBE SKIN, 



37 



the needle to oscillate incessantly. It is necessary, before beginning 
the experiments, to secure the utmost tranquillity in the subject, in 
order to determine the zero of the galvanometer. Another example 
forcibly demonstrates tlie effect of mental effort An pusy act of mul- 
i}>lieation produces no result; but if a person is a^iked to perform a 
lirticull problem of the same kind, the needle is deflected in proportion 
to the difficulty. Muscular movements give rise to deviations which 
must be attributed not merely to the acts themselves— for the effect is 
dii^proportionaie — but to the effort of will which they necessitate. The 
deviation is, in fact, greater when the subject looks at the tip of his 
no6e than when he raises his arm, even if some degree of force be used. 
Fatigued persons produce no reaction. M. Tiirchauot! thinks that the 
idoriparous glands exercise a regulative influence upon the produc- 
ion of these cutaneous currents. lie considers it a thermic regula- 
tion, favoring cutaneous evaporation and disassimilation in the course of 
cerebral acts and dependent upon them.* 

Odor. — A perceptible odor is sometimes emitted by tlie skin of 
healthy Individuals. This is more distinct in some races than in 
others; the negro, for instance, being characterized by a strong, un- 
pleasant odor. But apart from the smell dependent upon uncleanli- 
neSB, a distinct and fragrant scent is exhaled by the bodies of some 
persoDS. In some instances the perfume has been likened to tlnit of 
violetfi. Curious examples have been from time to time reported of 
:- ' '^ .1.4 whose sense of smell was so acute that they were able to 
u ^_ i-h between men and women, young and old, by the sense of 
olfactioQ. 



^355. 



Le Progres Medical," July 6, 1889; *• Medical Bulletin," November, 1880, 



tttt 




08 



DISEASES OF THE SKIN, 



STIVIPTOMATOLOGY. 

Diseases of the skin manifest tlaeniselvca by local and consti- 
tutiioDal symptoms- The constitutional vary in gravity in accord- 
ance with the amount of nutritive or functional disturbances present. 
In some cases they may be so slight as scarcely to attract attention, 
while in otliera they may be so serious tlmt energetic treatment is 
necessary for their relief. Disorders of digestion are tlie most frequent 
constitutional symptomB of 8kin diseases. Disorders of menstruation 
are often present. Functional clisturbances of the urinary and other 
organs may also occur, and if not remedied may lead to serious struct- 
ural changes. Fever is present at times, and some forms of gkin 
diseases are accompanied by increasing debility and i^rogressive ema- 
ciation. 

Tho local symptoms of cutaneous diseases are subjective and ob- 
jective. 

Subjective Symptoilis. — The subjective syniptoms of cutaneous dis- 
eases are tliose which can be recognized by the patient alone. They 
consist of alterations or anomalies in the sensation of a portion of the 
surface, and nn^y be conveniently considered as jmin, hyix^ra'sthesia, 
anaesthesia, and pruritus, or itching. They vary in degree intditler- 
ent diseases, and are sometimes entirely absent. 

The pain may be hot or burning, as in the various inflammatory af- 
fections of the skin, or it may be sharp aiid neuralgic in character, as 
in herpes zoster, neuroma, and carcinoma. Hypera^sthesia, or an in- 
creased sensitiveness of the cutaneous surface, is a prominent symptom 
of both functional and organic derangements of the nervous centres. 
At times it appears to be purely idiopathic, as in dermatalgia. Anses- 
thesia, or a diminished sensitiveness of the skin, is sometimes sympto- 
matic of diseases of the nerve-centres, and sometimes due to local 
causes. It is present to a marked degree in leprosy, and is found occa- 
sionally in connection with syphilis. Pruritus, or itching, is the most 
fre^juent and most prominent of the subjective s^^mptoms of cutaneous 
disease. It occurs in varying degree in a great number of atTections. 
It may be due to the irritation of parasites, or to the reflex action of 
internal causes, as in jaundice, or, as is more commonly the case, to the 
direct action of inflammatory or other morbid processes upon the ter- 
minal filaments of the cutaneous nerv^es. The sensation of itching has 
been carefully studied hy Dr. E. B. Bronson, who has mmle it the snb- 
ject of a paper read before the New York Neurological Association, 
October 7, 1890. This author believes that there is sufficient evidence to 
locate the es.sential seat of pruritus in the epiderm. The sensation may 
be -excited by pathological changes in the epidermis or by certain condi- 
tions of the nerve-centres. Dr. Bronson called attention to the etymo- 



SYMPTOWATOLOGV. 



logical relation 4)etween pruritus and prurience, and remarked that tlio 
impube to scratch was closely akin to a lustful feeling, and one thnt 
eometimes made scratching an actual sensual indulgence. A disposi- 
tion is not infrequently excited to attack the itching surface with a 
vehemence that amounts to a passion. This is particularly the ca^e in 
prnritos of the genitalia, luid serves to explain the sexual excitement or 
depravity associated with that condition. Such sensations, however, 
are not confined to genital pruritus, but may attend itching iu almost 
any sensation. The writ^^r concluded that in pruritus it is the sense 
of contact that is disturbed; that it primarily concerns simple cuta- 
neoos nerves or nerve-endings situated superficially and probably in 
th' 'ills; that in pruritus the disturbance is of the nature of a 

dv- i; and that the voluptuous sensations which may attend 

prnritos are a manifestation of a generalized aphrodisiac sense, and 
repn^sent a phase of common sensation which hits its source in the 
sense of contact. 

Objective STinptoilLS. — The objective symptoms of skin diseases are 
the atnietural lesions which become manifest upon the surface of the 
skin, and can be recognized by the physician as well as by the patient. 
They are the result of the various patlu>logical processes which occur 
in the skin, and by their number and character indicate the nature 
anil intensity of the morbid process. 

They consist of primary and secondary lesions. The primary are 
those which are due to the direct action of various morbid processes 
or to the deposition of morbid products in the skin. The secondary 
are those which follow the primary, and are due to the softening and 
breaking down, or to the organization and metamorphosis of the prod- 
nets of disejiso. 

The primary lesions are: 1. Maculte, macules, spots; 2. Erythema, 
bjperaBmia, rednesa; 3. Pomphi, wheals; 4* Papuhe, papules, pimples; 
5- Tubercula, lumps, tubercles ; G. Tu mo res, tumors; 7. Vesiculffi, vesi- 
cles ; 8. Buihe, blebs ; 9. Pustulie, pustules. 

The secondary lesions are : 1. Excoriationes, excoriations ; 2, 
S(|uainffi, scales; 3. Crustae, crusU, scabs; 4. Rhagades, cracks, fis- 
sures; 5. Ulcera, ulcers; 6. Cicatrices, scars ; 7. Pigmentation. 

Primary Leisons. 

MaeuIaB, Macules, Spots. — Macules are small, circumscribed alter- 
ations in the color of the skin, unaccompanied by any marked eleva- 
tion or depression of the surfa<.^e. They are usually oval or circular, 
bat vary in form as well as in size. They vary in color also in accord- 
ance with the morbid processes of which they are the result. Those 
which are due to simple hyperemia of a ]tortiuu of the papillary layer 
of thje corium are red or rose-colored, and disajipear under pressure. 
They are termed roseola, and are met with in a number of cutaneous 



40 



mSEARES OF THE SKIN. 



and Bjstcmic affections. Those which are accompimM by hiflamma* 
tion and slight exudation are more persistent, and can not be effaced 
so easily by presanre. The hypenT*mic or inllammatory area that en- 
circles a cntaneons lesion is termed an areola. 

Macules which are caused by ha?morrhages into tlie skin Yary in 
color from dark-red to purple and black, and are termed puqnira. If 
the baemorrbagic spots are minute, they are known as petec]iia\ Linear 
hypersemiag or extravasations are called vihrices. The discoloration 
produced by a birge effusion of blood into the subcutaneous connective 
tissue is termed an ecchymosis. 

Those which are caused by an abnormal development and dilata- 
tion of the blood- vesiiels of tlie corium may be either congenital or 
acquired. When they are congenital, they are termed na^vi ; when 
they appear after birth, they are known as telangiectases. They vary 
in color from scarlet to violet, and do not disajipear umler pressure. 

If due to an excessive amount of pignient in the skin they are yel- 
low, brown, or black in color, as in lentigo, chloasma, and na&vus pig- 
mentosus. The latter is sometimes congenital, as in the so-called 
'* mother's marks," but lentigo and chloasma are invariably acquired. 

\Yheu produced by a deficiency of jiigmcnt they are white in color, 
and constitute the disease known as leucoderma. Cotigenital deficiency 
of pigment is known as albinism. 

Macules produced by the microsporon furfur, a vegetable parasite, 
are yellow or yellowish- red in color, and are characteristic of the dis- 
ease called tinea versicolor. If due to the action of heat, or various 
chemical substances, they present all shades of colors. 

If the alteration in color is uniform, and involves all or a large por- 
tion of the skin, it is termed a discoloration. This pathological con- 
dition is the prominent symptom in jaundice, chlorosis, morbus ceru- 
leus, and argyria. It is also present in chronic malaria, leprosy, 
carcinoma, aiul in some forms of ovarian and uterine diseases. 

Erythema, HyperaBmia, RedneBS. — Erythema is a diffused redness 
of a ])ortion of the surface of tlie skin produced by an active conges* 
tion of the capillary plexuses of the corium. It differs from roseola in 
size, and in the greater intensity of it^ exciting cause. The congestion 
in roseola is frequently passive, and is manifested at isolated points on 
the surface. The congestion in erythema is invariably active, and 
involves one or more groups of contiguous vessels. It is also accom- 
panied by more or less heat^ swelling, and pain. 

Erythema may be produced by external causes, as by exposure to 
heat, or by friction or other irritation. At other times it is due to in- 
ternal causes alone. It is always a prominent symptom in the diseases 
with which it is associated, and is frerjuently bo severe as to demand 
special treatment. Sometimes it appears to be the only lesion, and 
constitutes the disease itself. 



I 



^^V SYMPTOMATOLOOY. 4| 

Passive congestion, due to venous obstruction or a weak heart, ran 
jMdiljr be distinguisihcd from Gr}'thema, by the contrust between the 
%oMneas and dull, blue coh)r of the skin in the former, and the heat 
ftnd fiery redness of the surface in the latter. 

PompM, UrticsB, Wheals. — Wheals are flattened, oval, or circular 
elevatiuu:; uf the skin, rapid in formalion, evanescent in character, and 
attended by intense itching. They vary from a few lines to an inch or 
more in diameter. They are usually white or pale-red in color. Fre- 
quently they are pale in the centre and red at tlic {>pripliery. They 
may appear singly, but generally several are developed simultaneoiis^ly. 
Those that are adjjvcent to each other manifest a teiideney to coalesce 
and form a large patch of irregular shape. 

Occasionally gyrate figures result from disappearance of tlie centre, 
together with increase at the periphery and coalescence with a neigh- 
boring wheal. They are attended by a sensation of heat or tingling. 
Scrutching or rubbing only serves to increase and enlarge them. The 
distinctive pectiliarities of wheals are their extremely rapid development, 
the brief period during which, in many iiit^tanees, they remain upon the 
eurfaoe, and the sudden manner in which they generally di8a|ipear. 

Tbey are caused by a dilatation of the capillaries and an exudation 
pl serum into the interstices of the corium and rete miicosuni, fol- 
lowed by a spasmodic contraction of the tissues around the periphery 
of the exudation. As soon as the spasm subsides the exudation is ab- 
sorWl, and the wheal vanishes almost as suddenly as it was formed. 
Sometimes a little blood may be found mingled with the serum. Oc- 
casionally the amount of exudation is so great as to form a bulla, as in 
urticaria, bullosum, or a node, as in urticaria nodosum. 

Papulaa, Papules, Piinple3. — Papules are small, solid elevations of 
the skin of new formation, ranging in size from a mustard-seed to a 
split jjea. They may be of any color from red to black, and arc either 
round, flat, cr conical in form. They occur in a great many diseases^ 
and are due to a number of different pathological processes. Papules 
are usually accompanied by more or less desquamution. Sometimes 
they are due to an excessive growth and accumulation of epidermic 
cella around the orifices of the hair- follicles, as in keratosis pilaris. 
At other times they are caused by retention of sebum, as in milium 
and comedo. They may also be due to an abnormal development of 
the papilhe of the corium, as in verruca and iciithyosis, or to a hyper- 
plasia of the rete mucosum, as in psoriasis and cornu ciitaneum. The 
most common variety of papules are those which occur in acne and 
6C2eina,and are due to inflammation and plastic exudation into the skin. 
Papnle-s may also be produced by cell4nfiltration, as in syphilis, or by 
a new cell-growth, as in lupus and carcinoma* Occasionally they are 
due to haemorrhage, as in purpura papulosa. Those which are the result 
of the inflammatory process are usually attended by more or less itch- 



I 



i 



m 



DrSEASES OF THE SKIN. 



ing, and frequently become converted into vesicles or pustules. As 
they recede in size and elevation their color gradoally fades, but spots 
of varied tints are generally present for a considerable period, indi- 
catifig the former location of papules. 

The papule la one of the most important of the primary lesions 
since it is of so common occurrence, due to so many causes, and may 
be transformed into other primary and secondary lesions. Papules 
contain no fluid, but are due to an aggregation of cells. They are 
slightly compressible. The color of papules varies according to the dis- 
ease of which they are a manifestation, and according to the stage of 
the disease. Their hue is generally bright in acne, eczema, and psori- 
asis; violet in lichen planus; copper-colored in syphilis; while in urti- 
caria and prurigo they present the normal color of the skin. In some 
instances they develop rapidly, and the surface is soon covered ; in 
others they make their appearance gradually and in successive crops. 
Papules may occur upon any portion of the bodj^, but in cerUin dis- 
eases they exhibit a predilection for certain regions. Thus, in acne, 
they are most often seen upon the face. The papules of eczema attack 
the flexor surfaces of the limbs, the trunk, and the face; while those 
of psoriasis invade the extensor surfaces of the Hmbs and regions in 
which the epidermis is thick. The distribution of this lesion is varied, 
though a certain symmetry of arrangement can usually be traced. 

Tuberciila, Tubercles. — ^Tubercles are solid elevations of the skin of 
new formiition, vurying in size from a split pea to a hazelnut. They 
are of d liferent colors, but are usually reddish or flesh-colored. They 
are generally circular or oval, but may be flattened or irregular in 
outline. They are caused by an intensification of the same morbid 
processes which are concerned in the production of papules, and differ 
from tliem only in their greater size. In fact, the line of distinction 
is mairdy an arbitrary one. Many of the tubercles met with in disease 
begin as papules, and by involving deeper tissues aud a greater extent 
of surface develop into tubercles. Syphilis, leprosy, lupus, and carci- 
noma present typical examples of this metamorphosis. 

Tubercles undergo various changes after the acme of their develop- 
ment has been reached. Those which are purely inflammatory may 
proceed to complete involution by absorption of their cod tents and 
desquamation of their epidermic covering. If due to the retention of 
sebum, they may become indurated by calcification of their contents, 
or they may soften and suppurate. Syphilitic tubercles usually termi- 
nate in ulceration. Tubercles due to neoplastic growths generally end 
in ulceration, but occasionally they manifest a disposition to remain 
without nnderijoing any change whatever. 

Tumores, Tumors.— Tumors arc large, solid elevations of the skin, 
of all sizes from a hazelnut to a cocoanut, or even larger. They are 
generally sphencal or hemispherical in form, but may be cylindrical 



SrMPTOMATOLOOT. 



or flattened. They are nsually flesh-colored, but at times are brown 
or black. They arise from the corfum or the subcutaneous connective 
tiasue, and by their outward development raise the epidermis to a con- 
siderable decree above the surrounding surface. They are due to a 
namber of pathological processes. Among the more fre<iueiit eicciting 
ctaaes arc new growths in the corium and degeneration of the eeba- 
oeofu glands, with exudation and extravasation into the surrounding 
tlfisae& Large tumors are sometimes formed by retention of sebum, 
and the gradual distention and hypertrophy of the sebaceous g!ands, 

Vesieulffi, Vesicles. — Vesicles are small, round, or conical elevations 
€f the epidermis, in dimension from a mustard-seed to a split pea, 
and contain sernm, or a eero-purulent or bloody licjuid. They vary 
m color in accordance with their contents. The typical vesicle is 
iiansparent, and contains pure serum unmixed with eitliur pus or 
blood. Those that contain lymph or pus-corpuscles are white or 
opaque, and those in which blood is present are dark or dark red in 
color. Their walls are tense when they are completely filled with 
flttid, and flaccid when they are only partially filled. They may he 
saperficial or deep-seabed. Those that are superficial are situated be- 
tween the horny and mucous layers of the epidermis. The others are 
formed between the strata of the rete mucosum. The superficial rup- 
tore easily. Those which are developed in the rete mucosum are sur- 
rounded by thicker wallsj and consequently are more tenacious. 

Ve^sicles are of inflammatory origin as a rule, and are due to an ex- 
udation of fluid from the vessels of the papillary layer of the corium. 
As the exudation is poured out, it passes thn»u;^h and distends the 
intercellular spaces of the mucous layer of the epidermis, and forms a 
Tesicle by elevating the stmtura corneum, or the upper layer of the 
stratum macosum. Occasionally they are produced by simple reten- 
tion of perspiration, as in su dam in a. They may be either simple 
or compouud. The former consist of one chamber, as in eczema ; the 
latter are composed of two or more, as in varicella. Verfieles seldom 
occur singly ; they are generally developed in considerable numbers, 
and are met with in a variety of diseases and on all parts of the body. 
They may be arranged in groups, as in herpes, or irregularly distrib- 
Qted^asin eczema. They are brief in duration, and end by rupture 
of their walls and escape of their contents, or by absorption of the 
fluid and desquamation of their roof ; or else they become filled with 
pns-cells^ and transformed into pustules. 

Bull^ Blebs. — Blebs are large oval or spherical elevations of the 
epidermis, in size from a split pea to a smail cocoanut, and contain 
^H aseronSt sero-puralent, or bloody fluid* 

^™ BullflB may bo regardetd as enlarged vesicles. Their color depends 

I upon the character of their contents, and varies from clear or light- 

I yellow, in those that contain only senim, to dark red or black in those 



u 



DISEASES OF THE SKIJT. 



in which an extravasation of blood has taken place. la consequence of 
their rapid formation their walls are nsually di.*tended at fir^t, but as 
absorption begins they soon become flaccid. Bullae consist as a rule 
of but one chamber ; compound bullae^ which are occasionally met 
with, contain two or more chambers, and are due to the coalition and 
enlargement of a grou]> of adjacent vesicles. Like vesicles, they are 
situated between the horny and mucous layers of the epidurmis, and 
are produced by a sudden and overwhelming exudation from the ves- 
sels of the corium. Ordinarily they do not rupture as easily as vesicles, 
but in pemphigus foliaceus they burst before they are fully formed. 
Sometimes they are attended by marked itching or burning sensa- 
tions ; at other times they are not accompanied by any subjective 
symptoms whatever. Bullae are mot with in pemphigus and jHrniphi- 
goid eroptions, syphilis, leprosy, herpes iris, and in some cases of ery- 
sipelas and acute dermatitis. They are sometimes surrounded by an 
inflammatory areola, but frefjacntly rise abruptly from the surface of 
apparently healthy skin. 

Pust^ilflB, Pustulea. — Pustules are round, flat, or conical elevations 
of the epidermis, varying in size from a mustard-seed to a clierry, and 
containing puSr Thoy are inflammatory in origin, and are produced 
by the migration and proliferation of lymphoid corpuscles from the 
veaaels of the corium. They are usually yellow or yellowish- white in 
color, but arc occasionally dark from lifomorrhagic exudation. They 
have been divided into primary and secondary. The secondary are 
those which are developed from pre-existing papules or vesicles.' The 
primary are those in which the preceding stages of congestion and 
exudation are so brief that they escape notice until suppuration is 
complete, and the resulting pustule appears to be the original le- 
sion. Pustules may originate in the sebaceous glands* as in acne ; or 
in the hair- follicles, as in sycosis ; or in the pajjillary luyer of the 
corium J as in ecthyma and eczema pustulosum. They may also de- 
velop in the horny and mucous layers of the epidermis, as in variola, 
or deep in the corium and subcutaneous connective tissue, as in furun- 
cle and anthrax. Tliey are usually encircled by an inflammatory area, 
and are occasionally attended by marked itching or burning sensations. 
Sometimes they are extremely painful, but generally tliey are not ac- 
companied by atiy marked subjective symptoms. They may be simple, 
as in acne, or cnmpoUTid, as in variola, where they contain two or more 
chambers. Pustules are of comparatively brief dunition, and end by 
absorption, or rupture of their walls and discharge of their contents. 
If the suppurating ]>rocess has been Itraited to the epidermis, no de- 
formity will result ; but, if a considerable portion of the corium has 
been destroyed, permanent scarring or pitting may ensue, as in variola, 
syphilis, and severe cases of acne. Pustules are encountered in acne, 
sycosis, ecthyma, impetigo, variola, scabies, syphilis, and eczema. They 



SYMPTOMATOLOGY, 



45 



may also be produced by tninmatism, and by the application of croton 
oil, tartar emetic, and other irritating substances, 

Secoxdaby Lesions, 

Eicoriationes, Excoriations. — Excoriations aro losses of substance 
from the superficial layers of the skin resulting from traumatic enuses. 
They rary in size and shape, but generally consist of torn points or 
liaeiir furrows from which minute particles of blood and serum are 
oozing, or which have dried up and formed a crust over the lesions. 
Ordinarily they do not extend beneatli the mucouti layer of the epi- 
dennij^ although at times they iBiiy involve the upper portion of the 
conum. They usually heal rapidly without the formation of a cicatrix. 

Excoriations are occasionally produced by superficial incised wounds 
Of by accidental lacerations or abrasions of the surface, but in the 
grcac majority of cases they are the direct result of excessive scratch- 
ing caused by the itching and irritation of a cutaneous affection. As 
itching is a prominent symptom of a number of skin diseases, excori- 
stions are frequently observed, and at times render iniport^mt assist- 
ance in establishing a diagnosis. They occur most abundantly in pru- 
rigo, pruritus, eczema, scabies, and pediculosis, 

SquamsB, Scales. — Scales are masses of dead epidermis which have 
been completely or partially separated by disease from the underlying 
strata. They are usually white or gray in color, but may be yellow or 
hrowB* They diller in form and size and also in number, in accord- 
ance with the situation and intensity of their exciting cause. When 
the morbid process which produces them is superficial, they are small 
and eoonty ; when it is deep-seated, they are larger and more abun- 
dant They are met with in varions parasitic and inflammatory af- 
fections, and in diseases due to perverted nutrition of tlie ei>idermis* 
They are thin, fine, and branny in pityriasis, seborrliOBa sicca, and 
fome forms of eczema. In psoriasis they form large masses of a white 
pearly color, while in ichthyosis they form thick plates. In scarlatina, 
and other diseases, the epidermis is sometimes cast off in large parch- 
ment-like masses several inches in diameter. This extensive exfoli- 
ation is termed desquamation in mass, in contradistinction to the pro- 
iseoB of formation and detachment of fine branny scales, which is known 
ai forfuraceous desquamation. 

Gmsts, Crusts, Scabs. — Crusts or scabs are solid masses formed 
by the drying up of exuded or extravasated tluids, or by tlie collection 
on the surface of sebaceous matter or fungous elements. They vary 
in color as well as in size and form. Tliose which are formed by the 
drying up of a serous exudation, as in vesicular eczema, are thin and 
yellow or light-colored, and have no definite form. Those which re- 
(iult from the drying up of pus are thick and green, or dark yellow in 
color, and are of the same form as the ulcer or broken-down pustule 



4G 



DISEASES OF TUE SKIN. 



upon wliich they are seated. When blood is mixed with the exuda- 
tion, the cnist will be reddish or black. SyphiHtic crusts are thick 
uiid hard and dark green or black in color, and usually present n lameU 
hited appearance. Crusts formed by the drying up of t^ebaceous ma- 
terial vary in color from light to dark yellow, and can be recognized 
at onco by their grea.'^y appearance. The crusts produced by the favua 
parasite are cup-.shaped, yellow, or Bulphur-colored, and exceedingly 
friable. 

Rlia^ades» CrackSi Fissures. — Cracks or fissures are linear wonnds 
of the skill produet^d by muscular action. They are usually limit^^d 
to the horny and mucous layers of the epidermis, but may extend a 
short distance into the corinm. They are caused by muscylar con- 
traction acting on a portion of the skin, whicli from inHanimatory in- 
filtration or abnormal dryness has become inelastic or brittle, and rupt- 
ures instejid of yielding. They may occur on any part of the surface 
which is exposed to tension, but are obseryed most frc<juently on the 
knuckles, the pahns of the hands, the soles of the feet, the knees and 
elbows, and at the angles of the month. They are of different lengths, 
and may run in a straight or irregular direction. Deep tissures bleed 
readily, and are accompanied by more or less pain, which is aggi'a- 
vated by motion. 

Fissures arc present in psoriasis, eczema, lichen ruber, scleroderma, 
and syphilis. They may also bo produced by the use of strong Boaps, 
or the action of cold and other irritiitits. 

Ukera, Ulcers,^ — ^Fleers are inflammatory breaches of continuity 
due to sni>piirative destruction of tho snperflcial tissues. They are 
usually seated in the upper portion of the eorium, but may extend 
into the subcutaneous connective tissue. Tliey yary much in size 
and shape. Small ulcers are usually circular ; large ulcers may 
be round or oval, but are often serpiginous or irregular in outline. 
The walls of an nicer are either perpendicular or sloping, and are fre- 
quently undermined, The base may be smooth, but is generally un- 
even, and is covered by a more or less copious secretion of jnis. Ulcers 
may occur on any part of the botly, but they are found most fre- 
quently on the lower extremities. They vary in color from light-red 
to dark-pnr]ile, according to the intensity and character of the inflam- 
mation of which they are the result. They are surrounded by a mne 
of congestion, and manifest a tendency to enlarge in breadth rather 
than in depth. Ulcers occur in syphilis, lupus, leprosy, carcinoma, 
anthrax^ furuncle, scrofula, and several other diseases. They may 
also be produced by any local cause which seriously interferes with the 
circulation. They arc always secondary to other lesions, and may run 
an acute or chronic course. They heal by granulation and the forma- 
tion of a cicatrix, which floroetiraes remains permanently. Ulcers 
arc attended by more or leea pain. 



SYMrrOMATOLOtiy. 



47 



K GlcatriodS, Scars.^Scars are new formations of connective tissue 
B^liioh occupy the place of lost normal tissue. They are covered 
by a thin Uyer of epidermis, and are supplied with blood-vessels and 
Ijmphatics, but do not contain any hair-fall ieles or sudoriparous or 
Behaceons glands. They are of a pale-red color at first, but generally 
become white. Large cicatrices range in color from gray to brown. 

Superficial cicatrice* jire fimooth and soft, and freely movable ; 
those which are deeper seated are hard, uneven, and immovable. 
Those which are raised above the surrounding surface are termed 
hyi>ertrophic cicatrices ; those which are on a level with it are called 
normal cicatrices ; those which are depressed beneath it are known aa 
atrophic cicatrices. Cicatrices are not characteristic of any one mor- 
bid proce^ ; but are the result of extensive destruction of the corium. 
They are met with in all the ulcerative diseases, and may follow severe 
bums, wonnds, and other injuries. Their size and form depend upon 
the nature and extent of the preceding ulcerative or traumatic lesions. 
They are generally permanent^ although occasionally they may be 
slowly obliterated. They are not gup[>liod with nerves, and in conse- 
qnence are generally devoid of sensation ; but in some rare instances 
they are the seat of excruciating pain. This is due, however, to press- 
ure of the contracting new tissue on a nerve-fibre which has been 
iccidentally inclosed in it. Atrophic cicatrices that are multiple, and 
bean or kidney shaped, are generally the result of syphilis. 

Pigmentation. — Pigmentation is an augmentation in color of a cotj- 
fiiderable portion of the skin. It may be of brief duration, or may 
remain permanently. It may be due to chronic inflammation or long- 
continued congestion. Sometimes it is caused by the formation of 
neoplasms in the skin, and at other times it appears to depend upon 
trophic disturbances. Typical instances of pigmentation are presented 
in Addison's diseaae, and as a result of excessive scratching and con- 
ti&aoQs hypersemia in pediculosis. 

Pigmentation occurs during pregnancy, and is usually limited to the 
face and the vertical median line of the abdomen. The deposit may 
be more unequally and irregularly distributed, as in a case observed by 
Jamier, the pigmentation being scattered over the chest, abdomen, and 
thighi^ bnt di&vpi»oaring after confinement. 

Kaposi expresses the belief that, though hiemoglobin is in many 
OMCO the source of the pigment, yet in others the color is due to a 
pigment-forming function of otlier protoplasmic bodies, particularly to 
the lowest layer of the rote muscosum. This opinion receives support 
frtim the investigations of Lode upon trout and those of Lister and 
Ton Wittich upon frogs. The changes of color manifested in these 
animals under different circumstances was shown to depend upon 
ahemtions in the form and activity of the pigment-cells, the changes 
being under the iutluence of the sympathetic nervous system. 



48 



DISEASES OF TIJE SKIN. 



DIAGNOSIS. 



The importance of making a correct diagnosis in all cases of cu- 
taneous atfcctious can not be overestimated. No satisfiictory plan of 
treatment can be formulated unless tlie disease be definitely recog- 
nized, and un ettdoavor niiide to ascertain its cause. 

Tlie diagnosis of skin-diseases is not difficult as a rule. The most 
essential requisite for success in this respect is a tliuroagh knowledge 
of the caii.se and mode of development and termination of the various 
diseases of this class* and of the signihcaneo of the lesions that oc- 
cur in the progress n( each. Valuable avssist^mce tiiay also be derived 
from a careful consideration of the patient's personal and family 
history. 

In order to elicit all the information possible in reference to each 
case, a systematic method of examination should he adopted. 

Light. — ^ Abundant daylight is indispensable for tiie proj>er exami- 
nation of tlic diseased entancouH surface. Many of t!ie macular erup- 
tions, which can readily be perceived then, appear indistinct or may 
escape recognition in the twilight, or in an irai)tTfectlv liglited room. 
Artitieial light, no matter how brilliant or from what source it may 
be derived, should be avoided, as it always gives an nnnaturai color to 
the skin, and adds to the difficulty of making a correct diagnosis. 

Temperature of the Room. — The temperature of the room should 
be maintained at about 70°. Variations above and below this ]ioinfc 
modify the color of the skin, change the apj»eaninee of the erujition, 
and may be uncomfortable or injurious to the patient 

Inspection. — ^In order to make a correct diagnosis, every portion of 
the aifected surface should be examined. Some diseases present so 
many points of resemblance that the differentiation between them can 
not be made witliout a critical and comprehensive observation of all 
their features. There is a natural reluctance on the part of many pa- 
tients to permit an examination of certain parts of the body, but tin's 
diflicully can be overcome by the exercise of a little tact. If the 
eruption be diffused, and the patient be a man or a child, the clothing 
should bo removed, and the entire surface exposed to view. 

Al! deviations from the normal color or ajvpeaninco of the skin 
should be carefully noted. In some tliseases the surface is dry and scaly, 
while in others it jtresents an extremely greasy and glossy appearance. 
It should be observed whether the natural lines and furrows of the 
skin are lessoned or exaggerated in size ; whether the orifices of the 
sebaceous ducts are closed or pattdous ; whether the growth of hair is 
more or less abundant than normal, and whether the individual hairs 
present a healthy or an unhealthy appearance. It should also he ob- 
served whether the sebaceous and sudoriparous secretions are profuae 



DIAGNOSIS. 

scanty. The degree of muscular deyelopTnent and the amount of 
a4iij)ose tissue present should also bo taken into coiisidcratioru 

Palpation* — The iuforniation obtained by palimtion is of the utmost 

iportance, and is frequently indispensable to the formation of a cor- 

't diagnosis. By it we can recognize whetlicr the skin is cold or hot, 

Iry or moist ; whether it is smooth and soft, or rough and hard ; and 

liether it is abnormally loose and thin, or thickened and infiltrated. 

k i>al[)ation we are also enabled to determine whether the abnormal 

Iness of the akin whieh is present in many affcetions h due to sim- 

►le capillary congcstiou or to hiemorrhagic extravasation ; aud whether 

ic Tarious exudative collections are lluid or solid in character. We 

m also ascertain by it whether the hairs are brittle and loose, or strong 

id resisting, and tirmly imbedded in their follicles. 

Odor. — Valuable information ia sometimes afforded by the sense of 

BmelL The offensive odor of bromidrosis, the ammoniacal odor of 

, nridfosis, and the peculiar odor of favus and small-pox, are so charac- 

^fleristic that a diagnosis can often be made iu these diseases by the 

^Bnnell alone. 

^B Constitiltiottal Symptoms. — The majority of skin-diseases are not 
^ncooQipanied by j^vere constitutional symptoms. Disorders of the ali- 
^rmeDtary canal are frequently met with, and pain is a prominent feat- 
are of herpes zoster and sevenil other cutaneous ailections, but high 
?ver and general malaise rarely occur excei)t in connection with the 
mthemata. It must be remembered, however, that tlie eruption 
Secondary g\'philis is sometimes preceded by marked pyrexia, and 
it severe forms of eczema, pemphigus, urticaria, erythema nodosum. 
ityriasia rubra* anrl lichen ruber, may be attended by violent cou- 
titutional disturbances. Anthrax, furuncles, and erysipelas are also 
rmpanied by more or less fever and pain, 

Ag8, — The age of the patient is an important factor in making a 

^diagnosis. Some diseases are most frequently met with during iufan- 

tiJe life, some occur only at the age of puberty and iu young adults, 

vbile others are found only in advancctl age. Acne, for instance, 

►!y occurs before puberty, psoria-sis has never been observed in an 

:, while epithelioma seldom occurs before the thirtieth year, and 

most frequent from the fiftieth to the seventieth. 

Sex. — The sex of the patient should also be taken into considera- 

Owing to the differences in habit and modes of life and con- 

itatioaal peculiarities of the two sexes, some diseases are found more 

luently in males, others in females. Sycosis is found only in 

Temperaments — The temperament or natural constitution of the 

ktient should be carefully observed, as it is well known that some 

manifciit a predisposition to attack persons of a certain tem- 

it in pfclerenoe to those of a different typo. Psoriasis, erythe- 



J 



DISEASES OF THE SKIN. 

ma nodosum, and chronic eczema generally occur in those of a gouty 
or rheumatic diathesis. lutertrigo, impetigo, aud pustular eczema 
are more commonly met with in lymphatic patients, while diseases of 
the sebaceous glands are more frequent in those of a nervous temper- 
ament. 

General Condition.— The general condition of the patient's health 
should \ye Ciirefiilly ascertained. This can only be done properly by 
thoroughly investigating the manner in which the functions of the 
orgaua of digestion, assimilation, secretion, and excretion arc dis- 
charged. The tongue should be examined, and the condition of the 
mouth and breath observed. Attention should then be directed to 
the stomach, and any disturbance of its functions noted. In<iuiry 
should finally be made as to the present and usual state of the bow- 
els. Irregularities of the meustrual function should be noted. Im- 
portant assistance may sometimes be derived from information ob- 
tained by making an examination of the urine. 

Habits. — The habits of the patient should be carefully iuquired 
into. Many a doubtful point may be cleared up by ascertaining 
whether the patient is an inveterate smoker, or indulges in alcoholic 
or sexual excesses, or is accustomed to use cosmetics* 

OcCMpation.^Tlie occupation of the patient sometimes points di* 
rectly to the diagnosis. Blacksmiths, brick-Iayers, cooks, and grocers 
frequently suffer from erythema and eczema. Butchers, hide-dealers, 
and wool-sorters are especially liable to be attacked by boils and car- 
buncles. Acne is common among persons who lead a sedentary life. 
Various forms of dermatitis occur among workers in dye-stuffs and 
other chemicals. Peculiar forms of eruption have also heen noticed 
in those who are employed iu oil-refineries and tar-distilleries. 

Subjective Symptoms. 

The Bubjective symptoms are of the utmost importance, and fre- 
quently render valuable assistance in making a diagnosis. Inflamma- 
tory diseases, as a rule, are attended by more or less pain and itching. 
Syphilitic eruptions, on tlie contrary, may lx> free from both. Herpes 
zoster aud some other diseases are eliaractcriiied by intense pain. 
Anaesthesia and hyperaestheaia are symptomatic of disorders of inner- 
vation. 

Objective Symptoms. 

General Appearance of tlie Disease.— The general appearance of a 
cutaneous affection is almost invariably characteristic of that affection 
alone. In some diseases the eruption is uniformly macular, in others 
it is papular, in others again it is purely vesicular or pustular, while 
in some, two or more varieties of lesions may be noticed at the same 
time. By careful study, however, of the origin and manner of devel- 
opment of the various diseases, the difficulties of the subject will dia- 



DUGNOSIS. 






^ tai 

r 



ppear, and such proficiency will be obtained that a diagnosis can be 
ade in the majority of cases from the objective symptoms alone. 

Duration, — The duration of the eruption ia a matter of coneider 

ble importance. Some diseases, as lupus, are essentially chronic in 

hAracter ; others, as roseola and erythema, tend to disappear within 

comparatively short time. Inquiry should also be made as to whether 

e eruption ever occurred before, and, if so, how often. 

Color. — The color of the eruption is a valuable aid in making a 

diagnosis. The raw-ham or copper color of syphilitic eruptions ia 

haracteristic. Patches of chloasma vary from dark yellow to brown. 

nthoma is vellow in color. Tinea versicolor varies from light yellow 

to reddiiili brown. 

Arrangement — The form and arrangement of the lesions should be 
refully observed. Those of lichen planus, herpes zoster, heri>ea iris, 
d the various forms of tinea, are characteristic in both respects. 
Location and Extent. — ^The location and extent of the lesions often 
point unerringly to the diagnosis. Home diseases are confined to eer- 
in regions of the body, while others involve the whole snrface. 
Individual Lesions. — The ^iize, shape, and mode of evolution of the 
fndividnal k^sions should be carefully observed, but too much impor- 
tance should not be attached to trilling irregularities in their appear- 
ce or development A correct diagnosis can be made only by a 
i>'^nsive review of the whole eruption and its accompanying 

iilS. 

Microscopic Examination. — Important assistance may be obtained 
n many doubtful eases by making a microscopic examination of a see- 
on of the affected skin. The various parasitic diseases may be recog- 
izNl in this way, and a distinction made between lupus exedens and 
ithelioma. 



JEASES OF THE SKIN. 



PATHOLOGY, 

The skin is subject to the same morbid processes by which otlier 
portions of the body are affected, and conseqnently presents a variety 
of pathological changes, the most important of which are ana?mia, 
bypera^mia, inflammation, bffmorrhage, hypertrophy, atrophy, and 
the formation of new growths. All three layers of the ekin may be 
involved in these changes, but the coriiim ia u&ually primarily and 
principally affected by them because of it^ abundant nervous and vas- 
cular supply. The gkin is also attacked by numerous animal anrl vege- 
table parasites, and is sometimes the seat of various neurotic disturb- 
ances. Functional disorders of the sebaceous and sudoriparous glands 
frequently occur, and structural alterations of the ghmds and their 
duets are often observed. 

The hair-follicles, the hairs, and the nails are also subject to various 
pathological changes, which may be idiopathic in character or second- 
ary to those which afleet the adjacent cutaneous surface. 

Anemia, — Auafmiaof the skin is symptonuitic of a deficient amount 
of blood in the cntaTieous capillaries. It may be the residt of disease, 
or may be due to excessive loss of blood from the general system by 
haamorrhage. It is charcterized by unnatural pallor, which may be 
succeeded by a yellowish or greenish hue involving all or a great por- 
tion of the skin. It is usually attended by a decrease in the surface 
temperature, and may be accompanied by profuse perspimtion. In 
many cases of general cutaneous aniemia the normal sensibility of the 
skin is altered, being usually diminished. The changes of color de- 
pend upon the loss of haamoglobin since Preger has shown by his 
spectroscopic experiments that a concentrated solution of haemoglobin 
transmits only the red rays, while weak solutions transmit the yellow 
and green rays. 

A partial cutaneous ansemia may occur in any portion of the body 
under the influence of various agencies capable of exciting constriction 
of the cai)illary vessels. Tlic effect may be direct, through reflex 
mechanism or by impairment of nutrftion. Among the causes of 
partial ansemia of the skin may be mentioned cold, local anaesthesia, 
injury, and certain trophic disorders. 

HyperBBmia.— Ilypeniimia of the skin is caused by congestion of 
the blood-vessels of the corium. It is usually active in character, but 
may be passive. Active hyperjemia may be produced by internal 
causes, or by the action of heat, cold, or other external irritating in- 
fluences. It is characterized by a more or less diffused bright-red 
color of the skin, which can be effaced by pressure, but returns as soon 
as the pressure is removed. It is accompanied by a sensation of tin- 
gling or burning, and at times by considerable elevation of the temper- 



PATHOLOGY. 



53 



ature of the surface of the afifected part. Active hyperfemia is of 
comparatively brief duration. The excess of blood is usually diverted 
into other channels, the congestion subsides, and the skin regiiins its 
normal appearance witliout the occurrence of either desqvutmation or pig- 
mentation. If the congestion remain for any length of time, exudation 
is apt to occur, and the hyperi"eniic process passes into intlamnitition. 

»Te hypenemia may be due to simple relaxation of the capilla- 
to any local or systemic interference with the venous circula- 
tion. It may be freqnently observed on the lower extremities, and is 
often followed by permanent pigmentation. 

Infiamtnatloa* — The minute phenomena of cutaneous inflammation 
are identical in character with those which accompany inflammation 
of any other organ. There is a preliminary stage of active congestion 
during which the arterioles of the affected part are diluted, and the 
of blood through them is accelerated. This stage is of varying 
ition, but is always present. It is succeeded by retiirdation of the 
Wood-current, and softening or relaxation of the walla of the capil- 
Exudation of the liquor sanguiuia then occurs, followed by 
ition of tlie white and red corpuscles, and comjjlete stasis of the 
circolation The inflammatory process varies, however, in accordance 
with the diathesis of the patient and the nature and intensity of the 
exciting cause, and may be interrupted or modified at any period of 
its development. In some diseases, aa herpes and vesicular eczema, 
the effusion is a serous fluid composed almost entirely of liquor san- 
guinis, and contains very few corpuscles. In diseases characterized 
byf* ' I of papules and tubercles it ia semi-solid, and composed 

aim r of cells, while in pustular diseases it consists largely 

of pus-corpuscles and liquor puris. 

Cutaneous inflammations always originate in the corium or sub- 
cntaneous connective tissue, and involve the epidermis secondarily. 
They are accompanied by more or less discoloration, heat, swelling, 
and pain. They terminate by absorption and resolution, or by sup- 
puration and discharge of the effused material, or by its organization 
and conversion into new tissue. They may be either acute or chronic 
in character. 

Hamoirliage, — Cutaneous haemorrhage may occur by diapedesis, 
but in the great majority of cases it is the result of rupture of the cap- 
dlariea of the corium. In some rare instances the escaped blood oozes 
oat upon the surface of the skin, but usually it la extravasated into 
the substance of the corium or the subcutaneous connective tissue. 
The amount of the haemorrhage is influenced by the condition of the 
Tcaeli) the plasticity of the bloo<l, and the intensity of the exciting 
miBe. In some cases it is limited to a few drops, in others it may be 
il> Imrge that one or more aggregations of several ounces each may be 
fbrnisd. The minute extrtivasations are usually circular, but are oo- 



64 



DISEASES OF THE SKIN. 



casionally linear in form ; tlie large extravasations are of all shapes 
and Bizes. When a consitlerablc quantity of blood is effused, the epi- 
dermis may be elevated by it, and hiemorrlnigic papnles, vesicles, and 
tubercles formed^ but in the majority of cases the 3ia?morrhagic spota 
are not raised above the surface of the surrounding skin. 

They can readily be distinguished from pigmentary deposits by the 
suddenness of their appearance, and, unlike the discolorattons pro- 
duced by capillary congestion, they can not be elTaced by pressure. 
They vary in color from dark red to purple at first, but change to 
black, yellow, green, or brown, before they disappear. They are usu- 
ally of conij>aratively brief duration, and are entirely removed by ab- 
sorption in a few weeks. Sometimes a slight permanent diecoloration 
may remain, bnt this is of rare occurrence. 

Hypertrophy. — Ilypertropiiy consists of an abnormal increase in 
size of the normal tissues. It may be produced by an excessive devel- 
opment of tlie pre-existing elements, or hy the formation of new ele- 
ments of the same tissues. It may be limited to one of the layers of 
the skin, or occur simuUaneously in all tliree layers. In callosities, 
the epidernua alone is involved. In ichthyosis, clavus, cornu cuta- 
neum, and verruca, hypertropliy of both the epidermis and the corinra 
occurs. Lentigo, chloasma, and nrevus pigmentosus are caused by an 
increase in the amount of pigment in the rete mucosum. The epi- 
dermis, the corium, and the subcutaneous connective tisane are all 
involved in elephantiasis arabum, while in scleroderma the morbid 
process is limited to the corium and subcutaneous connective tissue, 
H\^>ertrop!iy of t!ie substance of the hair and nails occurs under vari- 
ous circumstances. 

Atrophy,— Atrophy is a decTea>se in either the size or number of the 
elements of a tissue. When it affects only the size of the tissues, it is 
termed simple atrophy; when their ninnber is lessened, it is known jis 
numerical atrophy. It may involve the greater portion of the surface, 
as in senile atrophy ; or it may be limited to a few spots, as in vitiligo. 
It is most frequently observed in connection with the appendages of 
the skin, as in canities and alopecia, and in atrophy of the nails. It is 
probably due to a disturbance of the trophic system- 
New Formations, — Xew formations are produced by the deposition 
of new material and the development of new tissues in the substance 
of an organized structure. They may be composed of simple connect- 
ive tissue, like the part in which they are developed, or they may con- 
sist entirely of cellular material. The former are found in xanthoma^ 
keloid, and molluscum fibrosum and cicatrices, and arc benign in char- 
acter. The latter occur in lupus, leprosy, carcinoma, sarcoma, syphilis, 
and rhinosclcronia, and are nudignant in the majority of cases. 

The lymphatics, blood-vessels, and nerves are sometimes invaded by 
new formations, as in lymphangioma^ angioma, and neuroma. 



M 



PATHOLOGY. 



55 



The 



Farasit8B. — The skin is infested at times by animul and vegetable 

iites, which prey upon ita structiiros and produce more or less an- 

loyancc smd inflummation by their prt38cnce and habits. The animal 

inisitea which are most freqaeiitly met witli are tlie Pediculus^ or 

mse, and the Sarvopten i^cabiei^ or itch-mite. The Vimex kcittlariutty 

bed-bag; the Pwfcir i m/am*, or common flea; the Puhx penetrans^ 

»r sand-flea, and yarious other insects, also attack the skiu and produce 

)n«iderable irritation. 

The vegetable parasites are mirroacopic fungi which attiich them- 

Arv9> to the skin, and continue to develop on its surface. They rarely 

'netnite l>etween the layers of the epidermis, but they frequently in- 

raile the hair-follicles and attack the hairs. They sometimes attack 

le nails also. 

Three varieties of vegetable parasites have been recognized. They 

le Microsporonfnrftii'y whi<!h producen the disease kiiown as tinea 

?olor ; the Achorion Schonhinii,, the fungus of tinea favoi?u; and 

Trirhophijfon^ the fungus of tinea circinata, tinea sycosis, and tinea 

msnraus. They act in varying degree as irritants to the skin. Tinea 

fersicolor is a trivial affection, but tint-*a syccsis and tinea tonsurans 

produce extensive inflammation and suppuration. Tinea favosa 

be followed by permanent loss of hair. 

development of bacteriological research has inevitably modified 

L^nlarged our conceptions of the etiology and pathogenesis of dis- 

of the skim It has been already clearly demonstrated that many 

either directly or indirectly, the results of infectious processes. It 

reasonable to assume that tlie list of infectious dermatoses will be ex- 

ided considerably from the investigations cnustantly being carried on 

numerous and independent observers. Clinical facts had already 

jured us that cutaneous manifestations were in many instances ex- 

by the preienco in the blood of products of tissue change. Being 

within the organism, these substances have the power of excit- 

in tlio integument as well as in other tissues. The erup- 

i^ cooaequently, Ls bat a part of a general disorder, such as gout, 

natiam, diabetes, syphilis, scrofula, or tuberculosis. These dis- 

are engendered by chemical compounds elaborated within the 

body, and not necessarily or always of microphytic origin. In another 

clflffi of cases the cut-aneons malady seems to depend upon the direct 

■dion of micro-organiisms which have lodged upon the skin, and there 

ilVound a lilting soil for development. It ia probiibU? tluit here as else- 

^■rbere the two causes are often conjoined, and that, as a rule, the skin 

^Btxly proves a fitting soil w hen it^ vitality has been previously impaired 

^Ky oaQBes acting from within the organism. E.^ternal agencies, also, 

^paeliafl hest^ cold, clothing, etc., have their share of influence in pre- 

pilring % field apon wbich parasitic organisms may flourish. 

In Borae instances, therefore, disciise of the skin is but one of the 



ji 




DISEASES OF THE SKIN. 



many consequences of a systemic infection, and, thongh valnable in 
itself as a diagnostic sign, is generiilly of les5 importunce than the de- 
rangement of more important organs. Such is tJiecase in the eruptive 
fevers, syphilis, tuberculosis, and leprosy. On the other hand» in cer- 
tain forms of eczema, in acne, furuncle, carbuncle, acute abscess, in 
some forms of ulceration, and, possibly, carcinoma in its early stage, 
we see the direct effects of pathogenic bacteria. In either case, in that 
of systemic or that of local infection, the malady is duo to the action 
of poisonous producljs which the parasite has elaborated at the expense 
of the tissue in which it is lodged. These chemical substances, of 
definite though often complicated composition, act as direct irritants to 
the skin, whether originally deposited in or upon that tissue or brought 
to it by the blood. In their elleets ujyou the skin, therefore, they may 
be compared to the action of those drugs which have the power of ex- 
citing eruptions when applied to the integument or when ingested. 

In those cutaneous disorders atteudeil by the formation of pus the 
pyogenic bacteria have often been detected in the lesions. Three dis- 
tinct organisms have been recognized as the most frequent exciting 
causes of suppuratiou, viz., the staphylococcus pyogenes aureus^ the 
gtapliylococcus pyogenes albus, aiul the streptococcus pyogenes. Of 
these, the first-named has been most frequently found. This appears 
in the form of small, roundish cells which are so aggi'egated as to bear 
ii resemblance to a bunch of grapes, and hence the name which has 
been bestowed upon it, from (rra<^uA^, a grape. Sporuhition has never 
been observed in this species, which thrives at the ordinary temperature 
of living-rooms. When cultivated it produces an orange-yellow color. 
The staphylococcus albus differs from the foregoing species only in not 
producing the yellow pigment. It appears, likewise, to be somewhat 
less virulent iu its action. The streptococcus pvogenes, though some- 
times associated with staphylococci, ie more frequently observed alone 
iu purulent collections. It can not satisfactorily be distinguished either 
in form or behavior from the streptococcus of erysipelas described by 
Fehleisen. Certaiu or all of these micro-organisms have been discov- 
ered in the lesions of acne, impetigo, ecthyma, furuncle, carbuticle, and 
aliscess. Prof. Leloir has plausibly suggested that the ulceration of 
lupous nodules is due to the activity of pyogenic bacteria, though the 
tubercle itself depends upon the presence of the tubercle bacillus. The 
pustules of variola contain the ordinary microbes of suppuration, 
though the specitic exciting cause of the eruptive fever has not yet 
been isolated. Anthrax, or malif^nant pustule, depends upon I he 
growth of a specific bacillus of marked infective properties. Fehleisen 
has demonstrated that the specific cause of erysipelas is aTi organism 
developing in the form of small, globular cells which manifest a de- 
cided tendency to link themselves together and produce the appear- 
ance of extended chains. This characteristic arrangement is per- 



PATHOLOGY. 



57 



when the organism is studied oithor in artificitil cuUurea or dis- 
tiisues, Gibier asserts bis belief that he has detected specific 
paraaites in the lesions of pemj^higus and hydroa. Pityriasis rubra is 
}]y of microphytic origin, though an organism has not yet been 
Owing to the presence of the bacillus tuberculosis in the 
todales of lapns, that disease is now generally looked upon as a peculiar 
form of tuberculosis of the skin. Though its clinical manifestations 
liffer in decided respects from other forms of cutaneous tuberculosis, 
»t the present tendency is to consider the several varieties as falling 
inder one and the same category. A fuller discussion of this subject 
rill be given in connection with the account of the pathology and eti- 
of lupus in the body of this work. Leprosy iias boon jiroved to 
md ujwn the activity of a certain bacilhis, which is described with 
siiflSfdent detail for the purposes of this book in the section on leprosy. 
That syphilitic infection is due to bacterial agency seems in entire ac- 
conlance with the nature and course of the disease. The hypothesis, 
however, ia; as yet very far from having been demonstrated. Lust- 
garten has detected in sypliilitic lesions an organism which he con- 
iders t«> l)e the material cause of the disesise. According to his 
Ipiion, the cells resemble the tubercle bacilli iii form, though 
may be distinguished from the latter by the fact that they are 
more cnrred and that they are marked by nodose Bwellings. It has 
heen claimed, however, that his methods of preparation are com- 
plicated and unsatisfactory, and that many competent observers have 
[iailed to confirm his discovery. We must, therefore, regard ourselves 
is gtill in the dark concerning the origin of the sypliilitic virus. Many 
flacts in its natural history suggest that cancer shuuhl be classed among 
diaeftses of parasitic origin. The investigations of Jhirier relative 
the pathogenesis of Paget^s disease of the nipple, those of Albarran, 
[Wickham^ ComiU and others respecting carcinoma, render it probable 
t^ least in some cases, the multiplication and activity of protozoa 
'Ab to carcinomatous formations. The lesions of molkiscum 
nthcUiile, likewise, have been thought to depend upon the same cx- 
tCiting cause. The interpretation of these observations hiis been denied by 
' T6r«Vk, PitTard, and other writers. From a study of the effect of polarized 
ight upon the supposed protozoa, PifTard has concluded that, as regards 
lolln^um opitheliale, and probably the other affections, the suj)posed 
»rot02oa are merely rete cells undergoing a species of horny degenera- 
iou. T' ' r<jnce of a micro-organism in the newly formed tissue 

)( rhinu- i wna first announced by Frisch and subsequently con- 

by other authorities, though it still remains uncertain whether 
Jcrobe should be regarded as tlie specific exciting cause of the 
rc. Some forms of eczema seem to depend upon the development 
hacteria, while bacilli and micrococci have been found by several 
■era in the blood of subjects suffering from purpura. 



DISEASES OF THE SKIN. 



ETIOLOGY. 



Diseases of tlie skin are prod need bv a variety of causes. A great 
immber are Becondary to morbid ebaiiges or fimctioiial disturbances in 
other organs or tissues, but many are the result of proceasea affecting 
the skin alone. The former are termed symptomatic or sympathetic 
affections, and arc illustnited by urticaria, erythema nodosum, and the 
various exanthemata. The latter are known a.«! idiopathic diseasee, and 
may be produced by either internal or external causes. They are typi- 
cally represented by the erythemas of heat and cold, and a niunbcr of 
the local hypertrophies. The relation between the skin and the other 
organs of the body is so intimate, however^ that the distinction be- 
tween these two classes can not always bo made. In some cases the 
local causes predominate, but in others the constitutional changes are 
the most important. A correct appreciation of the etiological value 
of eacli can be obtained only by a comprehensive review of the origin 
and development of the eruption. 

The causes concerned in the production of diseases of the skin may 
be conveniently divided into predisposing and exciting. 

Predisposing Cacses. 

The predisposing causes are those wliich produce certain alterations 
or comJilions uf the general system or the cutiineous surface, by which 
the individual lial)ility to the development of certain diseases is in- 
creased. They do not produce disease, but render liability to it greater. 
The most important of the predisposing causes of cutaneous diseases 
are age, sex^ diathesis, occupation, seasons, climate^ plethora, debility, 
and heredity. 

Age. — Many cutaneous diseases occur only during certain periods 
of life. Tluis, tinea versicolor is a disease of adult age, while tinea 
tonsurans is more common in ehiklliood. Ichthyosis, sclerema neo- 
natorum, and the congenital syphilodermata appear at birth, or with- 
in a short time afterward. Strophulus is an affection of tlie first week 
of infantile life. Erythema, urticaria, and erzcma capitis are fre- 
quently observed during dentition. Acne, seboirha^a, and psoriasis 
rarely appear before the age of puberty. Carcinoma, eiuthelioma, and 
the majority of cases of pruritus arc maladies of advanced life. Impe- 
tigo and intertrigo are affections of early cluldhood. Hhinoscleroma, 
morplio3a, scleroderma, and acne rosacea are diseases of adult age. 

Sex. — Some cutaneous diseases occur more frequently, or excln- 
sively, in the male sex, while others are more often observed in females. 
Sycosis, for instance, is found only in man. Chloasma and lupus 
erythematosus occur more frequently in woman, epithelioma and her- 
pes in man. 



ETIOLOG^ 



59 



Diatliesis.— Psoriasis, eczenui, and erythema nodosum can fre- 
jueutly be traced to a rheumatic or a ^outy diatlieHia, Persons of a 
lymphatic temperament are liable to recurrent attacks of intertrigo, 
tifif tigo, and pustuhir acne and eczema. Eczema, hipus, and scrofu- 
loderma are common in those of a strumous diathesis, 

Occupatioii. — Varioua occupations are prolific predisposing causes 
;<jus diseii^es. Stone-cuttei*8, shoemakers, carpenters, machin- 
rilliQT artisans, present more or less hypertroj>liy of the palmar 
tidermis. Blacksmiths, cooks, brick-layers, and firemen are frequent 
ferers from erythema, eczema, and dermatitis. Fissured eczema of 
hands from the use of strong soaps is often observed among washer- 
»n- Eczema of the hands is very common among bartenders, 
jrers and stone-masons are also subject to the same affection. 
[ackmen are particularly prone to suffer from rosacea. Confection- 
l^rs are liable to a form of onychia produced by the action of sugar, 
riiijj, and heat Eczema occurs in grocers ami sugar warchousemeu 
[from handling raw sugar which generally contains an acarua closely 
•mbling the acarus scabiei. Butchers, tanners, and wool-sorters are 
lie to ecthyma and antlirax. Workers in aniline manufactories, 
il-refineries, and tar-distilleries are often attacked by violent der- 
matitis. 

Seasons.— Many cutaneous diseases occur more frequently or are 
fgniTate<l in intensity during particular seasons of the year. Inter- 
igo and miliaria are rarely encountered except in warm weather. 
Jryihema multiforme and furuncles are more frequently observed in 
•pring and autumn months. Pruritus is usually most severe in 
►winter. Eczema and psoriasis have been frequently noticed to dis- 
appear in summer, only to reappear witli the first week of cold weather, 
rborrhoea and ichthyosis are also worse during the winter. 

Climate. — ^The influences exerted by climate in the development of 
itaneous diseases is analogous to that of the various seasons of the 
Some discuses m*e peculiar to cold climates, others occur more 
[oently in the temperate zone, and some are almost exclusively lira- 
' lie tropical regions. The relative dryness or humidity of the 
M-re is also an imj)ortant factor, and the clothing, diet, hygiene^ 
ni liabits of the people in the difterent climatic regions must also bo 
ik*-n into consideration as exercising more or less inllnence upon the 
igin anci progress of the prevalent diseases. 
Plethora. — Plethoric patients are }icculiurly liable to be attacked 
the superficial inflammations of the skin. Intertrigo, erythema, 
\d eczema develop in them upon the slightest cause, or frequently 
any apparent cause, and in many cases prove rebellious to 
,.L Pruritus and hyperidrosis are also observed in this class 
>( pdiientfl. 

Debility, — Debility is the essential predisposing cause of a great 



60 



;ases of the skin. 



number of skin -diseases. Impetigo, ecthyma, and pemphigus rarely 
tK'Cur except iu the weak and iil-nourifihed. Furuncles and carbuncles 
are generally more severe in the debilitated than the robust. Sebor- 
rhea and comedo usually accompany a weak and relaxed condition of 
the system. 

Heredity.— Heredity exercises an important inlinence in the pro- 
duction of many cutaneous diseases. The peculiar linbility of some 
persons to be attacked by a variety of skin-diseases, while enjoying 
good health iu every other respect, can be most satisfactorily explained 
by the supposition that they inherited a weak or susceptible skin. 
Among the dij^eases which are directly transmitted from parents to 
children are scrofula, sypliilis, leiirosy, and ichthyosis, raoriasis and 
eczema frequently appear to be hereditary also. 



ExciTixr. Causes. 

The exciting causes of diseases of the skin are those which di 
rectly or indirectly produce the disease. They may be divided into 
internal and external. 






IXTERNAL EXCITING CAUSES. 

The internul exciting causes are those that act from within the 
hody. They are varied and numerous, and at times are so obscure as 
to escape recognition. They may be seated in the alTected jwrtion of 
the surface, but more frequently they are to he found in disorders of 
distant organs and tissues, or in derangements of the general system. 
The most prominent of the internal causea of diseruses of the skin are 
the systemic disturbances produced by pregnancy, dentition, vaticina- 
tion, and certain medicinal substances; dietetic errors, neurotic dis- 
turbances, constitutional diseases, and disorders of internal organs. 

Pregnancy. — Many women suffer during the latter months of preg- 
nancy from lierpes, eczema, or pruritus, for which no other cause can 
be observed than the physiological alterations which occur at that 
period in the blood and other tissues. Patches of chloasma are also 
frequently developed at the same time. The treatment in these cases 
should he merely palliative in character, as all the symjitoms usually 
disappear s])ontaneously as soon as the pregnancy is ended. 

It is a curioos fact that psoriasis and other chronic alTections fre- 
quently disappear during pregnancy, or are lessened in extent and 
severity. Lactation also exerts considerable influence on the progress 
of psoriasis, eczema, acne, and other disorders of the sebaceous glands. 
In some cases these affections are aggravated by lactation, hut in the 
great majority of cases marked improvement is perceptible. 

Dentition, ^The systemic irritation produced by dentition is fre- 
quently the only observable cause of urticaria, erythema, eczema capi- 
tis, and other cutaneous diseases, but its importance must not be ex- 



ETIOLOGY- 



Close inTcstigation will often result in the discovery of 
ftntl more important disorders. 

Vaccination. — Vaccination is occasionally followed by the appear- 
ed of extensive erythematous or iiiflsinimatory cruptioTis. They aro 

lally benign in character, and disappear in a few duyg» Some- 
times, however, owing to the use of impure lymph, or to the depraved 
state of the patient's constitution, deep-seated erysipelatous inflamma- 
tion may be developed, and run a.tedioua course, during which much 
destruction of tissue may occur. 

Medicines. — Various cutaneous disorders have been observed to fol- 
low the nse of certain medicinal substances. It is well known that an 
olistiuate form of acne is produced by the prolonged administration 
of either the bromide or the iodide of potusli. Auti]jyriu, copaiba, 
Cfibeb, and santonine frequently give rise to an urticarial eruption. 
Turpentine, quinine, chloral, opium, and bclludouna sometimes pro- 
duce? an extensive erythema resembling the eruption of scarlet fever. 

Dietetic Errors. — A great number of cutaneous diseases are pro* 
ducod by errors of diet. In some cases the food habitually partaken of 
18 loo rich or too highly seasoned \ in others it is too poor in quality, 
and insufficient in quantity, to furninh an adequate amount of nour- 
iahmeut to the tissues. In many persons cutaneous eruptions are in- 
IKBnably produced by special articles of food. Urticaria is frequently 
dateloped after a meal during which tish, oysters, or strawberries have 
been eat«n» Obstinate pruritus, erythema, and eczema are known to 
he frequently due to a diet of oatmeal or buckwheat. Acne and urti- 
caria are often produced or aggravated by fish, cheese, piistry, ale, 
and beer. 

tfenrotio Disturbances. — Xeurotic disturbances are the principal 
factors in the production of a greiit many cutaneous diseases. In 
some cases the morbid process is seated in the central nervous system, 
but in others it involves only the peripheral terminations of the nerves 
of the affected part. Prominent among the affections wliich aro due 
to disturbances of innervation are urticaria, herpes, dermatalgia, pru- 
ritus^ and a ntimber of hypertrophies, atrophies, and new formationa. 
As indicative of the nervous origin of a akin-disease Mr. Jonathan 
Hutchinson points to the corymbiform or branched disposition of the 
lesions as corresponding to the distribution of cutaneous nerve-fibrila. 
Moreover, a neurotic affection does not propagate itself by direct ex- 
tension or infection of adjacent parts, and the malady likewise develops 
iimhU fully in the first instance. Erythema, eczema, pemphigiis, 
ecthyma, scleroderma, vitiligo, and other affections may also be the 
reiiik of alterations of the nervous system. From the same cause the 
glands and the appendages of the skin may become diseased, llyperi- 
droaia, anldrosis, grayne^ baldness, and loss or deformity of the nails 
not iofreqiiently depend upon lesion of some portion of the nervous 



DISEASES OF THE SKIN. 



system. Functional nervous disorders, reflex excitation, and etrong 
emotion often oi't'sision eruptions upon the skin. 

Constitutional Diseases. — Among the constitutional diseases which 
produce eutaneoug disorders are pyaemia, syphilis^ ecrofula, scurvy, 
luahiria, chlorosis, Addiaon'a disease, and the variout? exautliemata. 

Disturbances of Internal Organs, — Functional and* organic disturb- 
ancea of internal organs are the exciting causes of a number of cutane- 
ous eruptions. Pruritus and eczema of the lower extremities are fre- 
cjuently due to cardiac degeneration or valvular disease. Diabetes ia 
a frequent cause of pruritus and furuncles. Acne, eczema, and urti- 
caria are often dependent upon some genito-urinary disorder, and dis- 
appear Avhen it is removed. Bright's disease and otirer atTections of the 
kidneys are frefiuently the direct exciting cause of erythema and ec- 
zema. Uridrosis is the result of complete suppression of the urinary 
secretion. Acne, eczema, and erythema nodosum are often produced 
by disorders of the liver. Derangements of the alimentary canal, 
however, are the most frequent causes of all cutaneous diseases of an 
erytliematous or in flan i nut to ry type, and should bo invariably sought 
for and promptly relieved. 

The external exeiting causes of diseases of the skin are those which 
act from without the body. They are varied and numerous. The 
most imjxirtant aro improper clothing, extremes of heat and cold, 
mochauical and cliemical irritants, personal habits, scratching, para- 
sites, and contagion. 

Improper Clothing. — Improper clothing is a common cause of cu- 
taneous diseaiies, Erythemji, eczema, pruritus, and miliaria are often 
developed and perpetuated by the use of flannel under-clothing. Col- 
ored stockings dyed witli impure or irritating materials frequently 
produce severe and extensive cutaneous inflammations. Dr. J. Leslie 
Foley, in a paper read before the Medico-Chirnrgical Society of Mont- 
real,* has enumerated a number of modes ia which disease of the skin 
is excited by clothing. Silk underwear nuiy disturb or excite the elec- 
tricity of the skin and has been known to set up a dermatosis. Tight 
garters may give rise to varicose veins, chilblains, or eczema. Irrita- 
tion of corsets or friction of under-clothing may induce a circumscribed 
scleroderma, as Crocker has showu. According to Hutchinson, the irri- 
tation of a new woolen vest may bring out an eruption upon the trunk 
in a syiihilitic subject. A non-specific eruption resembling syi^hilis 
may be produced by like cause. Dr. Hobein has, at the instance of 
Prof. Koch, investigated the receptivity of various kinds of underwear 
for micro-organisms. These bodies reach the underwear by means of 
particles of dust, and are caught in the interstices of the cloth or ad- 
here to its surface. The looser the woof the more readily are microbes 
retained. Smooth and finely woven linen and cotton materials retain 
* "Montreal Medical Journal/' December, 1R90. 



roix>GY. 



68 



fewer organisms and can be most thoroughly cleansed by boiling. 
Under ordinary circumstuuccs tiio germs do not develop and multiply 
in the clotliing.* 

Heat and Cold* — Heat and cold are also itiipnrtniit factors in the 
|Mt)daction of cutaneous dise^es. Exposure to iuteose heat, whether 
artificial or that of the sun, is u frequent cause of erythema, derma- 
titis, eczema, and miliaria. A variety of fissured eczema, onlinarily 
known as ^-ohiipptug of the hands," is a commou result of exposure to 
cold. If the cold be intense it may bo followed by the development 
of chilblains, or the death of the exposed part. 

Mdetianical and Chemical IrritantB.^Many cutaneous diseases are 
the result of mechanical irritation. Tight shoes or stockings produce 
e^inia and various excoriations or ulcerations of the feet. Tight gar- 
ters often give rise to an eczematous condition of the lower extremities. 
Extensive erythemas and eczemas are sometimes caused by ill-litting 
under-clothing. Various callosities and other hypertrophies are de- 
veloped in carpenters, stone-cutters, shoemakers, and other artisans, by 
the ppeesure and friction to which certain portions of the integument 
are constantly subjected during working-hours. Intertrigo is produced 
and aggravateil by the pressure and friction of the apposing surfaces. 

Chemical irritation is a more frequent and more serious cause of 
cutaneous dise^es. Severe inflammations may result from the use of 
arsenical cosmetics or depilatories Artificial- flower makers, manu- 
factnrera of wall-paper, and workers in acids, alkalies, aniline dyes, 
and other chemicals, are subject to vai'ioua eruptions which arc the 
resnlt of the irritating action of these materials on the skin. Bakei*8 and 
workmen in sugar refineries are subject to eczema of tlie fingers and 
hands, spinners to eczema and a peculiar form of dernuititis. l>r. Paul 
Fabre, in his studies of diseases of miners, describes, among others, 
miliary eruptions, erythema, furuncles, and prurigo. f Dermatitis of 
the legs is not infrequently produced by colored stockings. 

Severe cutaneous inflammation may also be caused by the incau- 
tioDS application of any of the ordinary rubefacients or epispastics, or 
by ooDtiict with various poisonous plants. Various eruptions nuky like- 
wise result from the external use of arnica or the sulphur and mer- 
eorial preparations. 

Personal Habits. — The habits of the individuid are often important 
factors in the production of cutaneous diseases. Eczema and acne 
ri>i^aci*Ji are frequently the result of alcoholic indulgence. Acne may 
be due to excessive smoking. Personal uncleanliness is also a cause 
of cotaneon^ disease in some cases; but, on the other hand, too much 
attention may be given to cleanliness, and the integument injured by 
the frcfjucnt use of strong soaps. 

* »* Weekly Medirnl Reviow." Febnmry 28, 1801. 
t " Le ProgrC's Modical," June 15, 1^89. 



DISEASES OF THE SKIN. 



Scratching. — Many cutaneous lesions are produced, and all pre- 
existing eruptions are inteiisitied^ b}' scratchiDg, In urticurla it in- 
creases the size and number of the wheals, and in eczema it augments 
the inflammfition and exudation. Scabies, prurigo^ and pediculosis 
are increased in severity by it, and an insignifieaut pruritus may be 
converted by it into an extensive inllamniatorj disease. In protracted 
cases it may produce considerable pigmentation and thickening of the 
skin. 

Parasites,— A number of cutaneous diseases are produced by animal 
and vegetable parasites. The hair and nails also suffer from their 
ravages. Those organisms which are the best known and most com- 
mon exciting causes of disease of the integument have been eiuimer- 
ated on page i>5, under the section upon general Pathology. They 
need not, therefore, be repeated in this place. Numerous microphytes 
are constantly present upon the general surface. Of these, some spe- 
cies are probably inca}>ab]e of thriving npon the human skin ; others 
are pathogenic under favorable circum8tance.«i. When the pro|)er con- 
ditions are lacking they are unable to multiply, and remain innocuous. 

Contagion.— Contagion is a prolific source of cutaneous diseases. 
Impetigo contagiosa, small-pox, measles, scarlet- fever, equinia, and 
erysipelas are frerjuently communicated by direct contact. Many of 
the cutaneons lesions of syphilis m'e contagious ; likewise the parasitic 
diseases, but some are more readily transmitted than others. Indi- 
vidual susceptibility is an important factor in the propagation of all 
diseases of this nature. Some persons are readily affected by the poi- 
sonons germs or spores, while others nniy be exposed to them with im- 
punity. Many diseases of the akiu are brought to this country by 
immigrants. Ca&es of parasitic disorders are readily contracted on 
ship-board. To prevent the spread of these the persons and clothing 
should be scrupulously cleansed upon arrival. Diseases of uncommon 
occurrence in this country are also not infrequently imported, 



TREATMENT. 



6s 



TREATAIENT, 

Thk adaptation of the proper treatment to diseases of the skin 

Ires on the part of the pliysieirtii it thoroiififli knowledge of general 

jine. The previous history — including any idiosyncra«^ies which 

'the patient may have, the present constitutional and local condition, 

I the nature of the affection and it^ cause, if apparent — should all be 

"kwiked into from the standpoint of general mediriue, and rational de- 

duclions drawn from these considerations as to the proper method of 

ttment, Aa a rule, the deductions, after careful inquiry into rJl 

circumstances just briefly recounted, will lead the physician in the 

"majority of cases to employ both constitutional and local remediee. 

The most decided, rapid, and certain results are generally obtained 

from constitutional treatment^ which assists frequently the action of 

the topical remedies which may be employed. In some affections it 

alone may be demandwi, or simple local treatment will suffit*e, while 

in fttill others it liecomes necessary to employ both at the game time. 

Again, constitutional and local in conjunction may be necessary at 

one stage of the disease, and should only be used singly at another. 

Fariheff the remedy or remedies employed, whether for systemic or 

local action, may be proper at one period and useless or harmful at 

another. Great care must, therefore, be exercised to be able to know 

from a general knowledge of medicine just what to do at the proper 

dine. 

CONSTITUTIOXAL TREATMENT. 

Tfje general health should be carefully examined, and, if impaired 
or deranged in the least, should be corrected by suitable constitutional 
tnsatmenL It may be necessary to administer acids, or one of the va- 
toaic9, or alkalies — particularly the natural alkaline waters — al- 

^ivea, anodynes, or hypnotics, or various other remedies, to make 
a thorough impre^ion and relieve or cure the eruption. It. often be- 
come* necessary likewise to use diaphoretics, or to increase the action 
of organs of the body by the employment of aperients, cathartics, and 
diuretics, particularly in inflamnuitory diseases in which there may be 
imperfect or defective secretion and excretion. The principal means 
employed may be referred to as follows : 

Hygiene, *^ — The observance of the commonly accepted hygienic laws 
in disejises of the skin is all-important, especially after the eruption 
is develofjod^ or has become chronic. Tlie first and most essential 
neaearos which should receive attention are ventilation and bathing. 
The latter will be found in eotue acute affections to be coiitra-indi- 

• See puppr by mithor on " ny^iene ol the Skin in Health and DiseA5»e," in 
of Ctttaneouft and Geoiio-Urinary Diseases," 1889, vol. vi, pp. 373 and 410. 
6 



ym 



06 



DISEASES OF THE SKIN. 



ciited, wliile in others, especially those of a subacute or clironic natnre, 
it may be followed by the most happy effect. Dress for all parts of the 
btnly, but more partietikrly for those which come iu contact with the 
atfected surface, requires just what may be suitable to the case under 
couisideraiion* 

Clothing baa an influence upon the health of the integument. 
That worn during the thiy should bo entirely removed before retiring 
to rest, and each piece Imog up separately, in order that the abisorbed 
perspiration nmy evaporate and the garments be ventilated. Cutaneous 
disease is apt to be occasioned by dyed hosiery or underwear. 

Next in importance to ilress are rest and exercise, the former being 
very frequently necessary in some of the inllammatory diseases, espe- 
cially in their beginning, and the latter, judiciously and properly U4*ed 
in later stjigea, or in the chronic forms. Outdoor exercise, with plenty 
of good freali air and suidight, should be taken, if possible; or, if not, 
passive exercise, or massage, may bo resorted to, if necesfitary. A 
change of climate will often in some of the more obstinate diseases, es- 
pecially those due to impairment of the nervous system, be followed by 
bcneticial results. 

Climate has an undoubted influence upon the well-being of tlie 
skin. The customary temperature of the atmosphere, joined with the 
modifications of dress, diet, and general habits of life which it creates, 
establish a pretHsposition to certain forms of disease. The skin cer- 
tainly requires somewhat dilTerent treatment, both in health and dis- 
ease, according to whether the climate be cold and dry or moist and 
warm. 

The health of the hair is promoted by the use, in winter, of soft 
hats pierced with numerous holes or, in summer, of light straw hats of 
open structure. 

Sleep is also a hygienic measure which concerns the skin no less 
than the nerve-centres. Cheerfulness should be cultivated, since cuta- 
neous disturbances of sensibility or of circulation are often the out- 
come of long-continued mental strain. Frequent ablutions are neces- 
sary to the health and beauty of tlie skin. 

Diet. — Attention to diet is often more important than the admin- 
istration of remedies. The quality and quantity of the food must bo 
regulated according to the disease and the condition of the patient. 
A diet restricted to certain articles of food may be demanded, or a 
special dietetic course be necessary. Each case requires to be carefully 
looked into by the physician, and the amount and character of food * 
regulated as may seem suitable and judicious. Imjierfect digestion is, 
either directly or indirectly, an important factor in the etiology of 
many diseases of the skin. The nutritive condition of the skin is, in- 

* S<*e paper on ** Pood in Health and Disease/* " The Medical Bulletin,'* Janu- 
arv. 1801. 



a 



TREATMENT. 97 

^Bed* sm index to that of the organism generally, and a characteristic 
appearance of the integument is produced by any grave perverBion of 
geuend nutrition, as, for instance, chlorosis, amyloid degeneration, 
chronic mahiria, leukemia, jaundice, Addison's disease, purpura, 
scurTT, cancer, or pyajtnia. Cutaneous malstdies are common in scrof- 
ula and diabetes mellitus. In syi)hilis and the exanthemata a diagnos- 
tic import-ance attaches to the cutaneous lesions. A less severe sys- 
temic intoxication results from the retention in the blood of »excre- 
mentitions products, the results of faulty elaboration of food. When 
tbeee are produced in excess the excretory glands arc unable to elimi- 
imte them completely, and their presence excites disease in variotis organs 
and tissues, including the skin. The secerning glands eventually be- 
come involved, when diminished elimination adds to the effect of in- 
creased production. The habitual ingestion of excessive quantities of 
BitrogeDoos food and the constant consumption of alcoholic beverages 
are productive of many disorders of the integument. Functional or 
organic disease of the stomach, liver, pancreas, or intestinal mucous 
membrane genei*ates a host of cutaneous maladies. The imperfect 
digestion of starchy and fatty substances leads to consequences scarcely 
less deleterious. There appears to be no direct relation between partic- 
ular affections of the alimentary canal and disease of the skin notwith- 
ffanding ihe fact that many of the latter ni^pear under modified forms 
upon the mucous membrane of the gastro-intestinal tract. CataiTh 
of the stomach or bowel is not necessarily rejiresented upon the skin 
by eczema* but may give rise to urticaria or otlun* lesion. 

The beneficial effect of an approjniate and reguhited diet upon dis- 
easeB of the skin is not always justly ajipreciated. Unless the general 
health is obviously impaired, close iufjuiry concerning the state of the 
digestive functions is apt to be negh^ded. Ureat care should be en- 
joined as to the use of articles which, like animal food, may embarrass 
the liver or those which, like fatty, amylaceous, or saccharine materials, 
feadily undergo fermentative changes in the alimentary canid. Alco- 
holic liquors, as a rule, should be forl)iddeu. In tlie lithic-aeid diath- 
esis a highly nitrogenized diet is inadvisable. In acute eczema, espe- 
cially when a large extent of surface is involved and when the patient 
is young, the condition may approach, in severity and constitutional 
redaction, that of an essential fever. In tliis case a bland, unirritating, 
and easily digestible diet is indicated, such as milk, milk toast, boiled 
or baked potatoes, tapioca, arrowroot, etc. When eczema occurs in a 
iibjeet, meats should be sparingly given and alco!iol prnhibitcd. 
t should be composed chiefly of vegetables and frint with bread 
and butter. In rheumatic eczema, articles which readily undergo fer- 
mentation should be eliminated as fjir as possihle from the food. A 
acrufulons patient reqaires liberal eustenanee. Fat in some form or 
other fihould be as freely supplied as the state of the digestive organs 



^ 



68 



DIKEASES OF THE SKIN. 



will permit. Moat (except the more iudigestible kinds, as veal), 
soups, broths, eggs, ciisttmie, milk, and vegetabk^s should form the 
dietary. I regard cod-liver oil, so universally given in any scrofolons 
manifestatioTi, as a fcrne food, and it is noteworthy that strumous pa- 
tients, even children, will often tiike the oil without repugnance. 
Milk is donbtless the most general pabulum in all the protean varie- 
ties of eczema. Unfortunately, however, patients will often tiro of a 
rigid ly monotonous milk diet. We may often, however, vary the reg- 
imen by the us© of puddings prepared with milk, ae bread, apple, or 
tapioca pudding, custard, or by ice cream. When eczema is produced 
by diabetes mellitus, it is evident that its relief most depend upon the 
success of our treatment, chiefly dietetic, of the underlying condition. 
Affections of the glandular system of the skin generally require food 
of a supporting character as an important adjunct in their treatment. 
Their internal medication often resolves itself into the effort to improve 
digestion and assimilation. In sehorrhwa tlie food must be sufficient, 
nutritious, and digestible. Beef, mutton, eggB, poultry, rabbit, soups, 
pigeon, sweetbread, venison, oysters, fresh tish, and the more digestible 
vegetables are especially valuable. The subjects of acne generally pre- 
sent evidences of impaired nutrition in the form of anaemia, chlorosis, 
general debility induced by gcmital defects, or suffer from some consti- 
tutional taint, not4ibly scrofula- The dietary in this disease should be 
constructed upon the same plan as that already outlined for seborrhcra. 
Ilyperidrosis and anidrosis usually occur in debilitated individuals, 
whose diet, therefore, should be of a supporting nature. Rosacea gen- 
erally depends upon long-continued irritation of the walls of minute 
blood-vessels by waste products, the result of incomplete digestion or 
upon the presence of alcohol in the blood. The food should there- 
fore be simple and substantial, and alcoholic beverages should, in most 
cases, be interdicted. In purpura, which is precedetJ or accompanied 
by considerable or even grave prostration, an abundant supply of nu- 
trient material, such as milk, soups, broths, and oysters, is demanded. 
Lichen planus is often due to impaired digestion, and recovery is accel- 
lerated by a liberal diet, consisting of animal food, eggs, milk, poultry, 
fruit, and vegetables. Lichen ruber is benefited by a similar regimen* 
Herpes zoster calls for an abundant supply of fatty articles of food, as 
milk, cream, butter, eggs, animal fats, vegetable oils, cocoa, etc., not 
forgetting cod-liver oil. In pemphigus and hydroa the bill of fare 
should be composed of soups, poultry, the more digestible meats and 
vegetables, eggs, and milk. Nutritious food should bo an essential 
part of any plan of treatment in sycosis. In the pustular affectiona, 
impetigo, impetigo contagiosa, and ecthyma the bill of fare should be 
constructed upon the same plan as tliat recommended for pemi>higus. 
Pityriasis nibra demands vigorous alimentation. The digestible meats, 
the fat as well as the lean, strong soups, milk, cream, eggs, and vegeta- 



TREATMENT. 0g 

bles should be given as freely as the digestive powers of the patient will 
admit. If furuncles occur in the course of dinhGtea mellitiis the reg- 
imen suitable to that disease is required ; if in a rheutnatie, gouty, 
icrof ulona, or tuberculous condition of the system, the diet sliould he 
arranged in reference to the undeilying diathesis. Boils may be the 
expression of malnutrition arising from dyspepsia, in which case a 
selection of foods should be made in accordance with the form which 
the indigestion tissumes. The necessity of a generous diet is even 
more urgent in carbuncle, which calls imperatively for animal broths, 
with the addition, as a rule, of alcoholic stimulation. Alimentary 
principles are demanded in the management of the hypertrophic skin- 
diseases. In psoriasis a great deal depetitls uj)0u attention to the gas- 
tro-intestinal tract, and the effect of any medicinal measures is greatly 
enhanced when digestive failures are first corrected. In recent cases 
it is wise to limit the quantity of nitrogenous substances consumed, 
and depend for support rather upon the carbohydrates, supplemented 
by bread and butter, fruits, and vegetables. Ichthyosis is essentially 
LBcomble, but in addition to local treatment, which is our main de- 
pendence, it seems advisable that the diet should be rich in fats, in 
the hope of aiding the nutritive etfects of the unguents applied exter- 
naJlj' Scleroderma may also be favorably modified by the use of fatty 
articles of food. Regulation of diet should enter into our treatment of 
alopecia, especially of alopecia c ircuniscripta. In scrofuloderma, lupus 
erTthematosos, and hipua vulgaris the food should consist of the siib- 
etaaces already mentioned as appropriate to eczema. Even in such fatal 
diseases as lepra, epithelioma, and stircorna the use of suitable food is 
not entirely wnthout advantage. In lepra the diet should be bland and 
nutritious; in epithelioma and in sarcoma bread, milk, eggs, vegetables, 
and fruits may be allowed, but it is advisable to limit the consumption 
of animal food. In the more severe forms of the exanthemata so great 
is the febrile reaction that gastric intolerance is a prominent symptom. 
Milk, or milk and Hme-water, is often all that will be borne. Fortu- 
nately, in scarlatina the fever is of brief duration, and in view of the 
frefpient occurrence of nephritis as a sequela, no article is better adapted 
to the disease than milk. After the subsidence of the fever, however, 
beef soup, mutton broth, or milk toast may be added. Rubeola aud 
rotheln generally require less scrupulous attention, but in malignant 
or black measles the same sustaining diet is necessary as in any other 
rinilent specific fever. Confluent nnd malignant small-pox demand 
systematic nourishment from the beginning of the attack. In erysipe- 
las, vitality must be supported by the same nutritious and assimilable 
diet demanded in variola, typhoid and typhus fevers, and diphtheria. 
The neuroses of the skin are not infrequently due to chronic iudiges- 
tJotu Whatever may be the origin, it is nearly always of such a nature 
as to indicate a generous diet, rich in fatty foods. 




ro 



DISEASES OF THE PKIX. 



In fliseases of the gkin jilinK'utation i«, indeetl, but atiother mode of 
iiietlk'ution. The miiiunil giibstuiiccfi contained in fuods are identical 
with those demanded for the composition of the blood and tissues. As 
fur as they arc absorbed from tlio food, to that extent are drngs to be 
looked upon as merely supplementary. 

Cod-liver OU. — ^Iti diseases of the skin, cod -liver oil is both a good 
food and a valuable remedy. It is the remedy above all to employ in 
those cases in which the health luis become affected through faulty as* 
similation, as in eczema, scrofuloderma, and eyphilis. It is also ser- 
viceable in many of the chronic forms of skin-disciises. It may be ad- 
ministered in from ono tluid drachm to half an ounce, either alone or 
as an emulsion. A few drops of ether to the dose may overcome any 
unpleasant effect from it, and assist its absorption . If the oil cjiii 
neither be retained nor assimilated, it may be given* hypodermatically, 
one or two drachms being injected into the loose cellular tissue of the 
back. I have recommended and demonstrated the utility of employ- 
ing it in this manner in scrofuloderma, ]iara^sthesia, and other cuta- 
neous diseases depending upon a lack of nutrition of the system. If 
a large-sized hypodermic syringe be used, and the oil dejiosited deep 
into the celluUir tissue, it usually disapj^ears in from twelve to twen- 
ty-four hours witliont any unfavorable results. That the oil is ab- 
sorbed and assimilated can be demonstrated by injecting the same 
quantity of castor-oil, its viscidity being lessened with an equal amount 
of almond oil, and the result will generally be a satisfactory laxative 
action within one or two hours* time. 

Phospliorus and its Fr6paratloES.=Phoi5phonis is known to have 
a special action in cutaneous diseases depending upon nerve-debility. 
It has been followed by benefit in psoriasis, eczema, ln]nis, herpes zo9» 
ter, and pemphigus, due to the nbove condition. Piilard recorrvmends 
it in large doses to promote the rash in exanthematous diseases. The 
dose of phosphorus is from one twelfth to one one-hundredth of a 
grain dissolved in almond- or sweet-oil, or given as a pill. Instead of 
phosphorus, the ])hos}»hide of zinc is frec|nently prescribed in form of 
pill in ono thirtieth to one fiftieth of a grain. The best jrreparations 
of pliospliorua are the sirup of the lacto-phosphate of lime, compound 
sirup of the phospliates, and the sirup of the hypophosi>liites. These 
compounds are especially serviceable in eczema of children depending 
upon malnutrition, and in boils, carbuncles, and some cases of papu- 
lar and jKistuhir acno. 

Iron and its Preparationa.— The preparations of iron are invaluable 
in a numlicr of skin-diseiises. They aro indicated in all eruptions, as 
eczema, psoriasis, sycosis, syphilis, and scrofula, which aro due to a 

* " Tlie Treotment of Dis€iise by the nypodermiitic Injetnion of Oil." Roiid bj tho 
author b{*f<>re tlie ^^oLttoii of Practical Medidnc, Hi the meeting of the Americaii Medictl 
Associ&lion^ Jime, 1885. 



TREATMENT. 



y 



Bepraved state of the system. The iodide of iron or the sirup ex- 
ercises at time^ a henelicial effuct over pustular eczema, and io chron- 
ic cases of syphilis. Many cataneous eruptions due to ansemia aud 
chlorosis are favorably influenced by one of the preparations of iron. 
The thicture of the chloride in large doses, one lialf to two draehms 
©very two or three hours, certainly assistJi in arresting erysipela^s. 
Iron may be advantageously combined with strychnia, arsenic, qui- 
nine, and other remedies, or admiuistered in the form of a chalybeate 
water. 

Qniniiie. — Quinine, by ita action upon various intlammatory diseases 
of the skin, is one of the most valiuible agents at our disposal. In 
errsipelas it is a remedy of great utility. In variolu, scarlatina, ty- 
phoid fever, and rubeohi, it can bo used with advantage in reducing 
excessiire fever. It is an appropriate remedy to em]iloy in diseases 
arising from malaria, or from an impoverished state of the systenij as 
in impetigo, im|>etigo contagiosa, ectliyma, buil^, and sycosis. Affec- 
tions depending upon a derangement of the nervous system may also 
be benefited by it. 

Arsenic* — Arsenic is useful in some affections of the skin, and 
nMlefis in others. It is also valuable in some stages of eruptions, and 
aiMolnteh' injurious in others. The disease, as well as the stage of 
e enipfcion, mast be carefully considered before it is employed, 
t lias been shown to possess an action upon the epidermis, and is 
l*ecjally beneficial in diseases involving that part of the skin. 
dmiuistered to animals, especially the horse, it improves nutrition 
nd jxiwer, and gives a sleek and glossy appearance to the coat. 
Oublenf in speaking of this effect, says Tschudy, in his account 
of the arsenic-eaters of Lower Austria, remarks that it improves their 
ippearaiic€ and gives them additional jiower : *' They acquire great 
strength, have remarkable agility, climbing the steepest mountain- 
sides;. , . the young girls, veritable ro>-cbuds, a.s colored as ripened 
apples ; they acuuire flesh oven ; aud, m fine skin is never seen in their 
people, over bones thinly covered, their skin becomes clearer and trans- 
parent ** Arsenic, the same author states, will not always give such 
admirable results, and, when its kabifues come to require congiderable 
dose?* serious effects may ensue. From w^hat has been recounted, the 

I wondeKnl power w*ill be observed that this metal possesses of modify- 

I ing and changing the epidermis, 

^H Administered for its effect upon the skin, the action of arsenic is 

^HtiBaally slow, often requiring some time before a given result is ob- 

^^m •"The Fsi'fiil Adminietrfttfon of Ari«cnic in Di&t^ftses of the Skin," 1>t Edwai-d L. 
EcjCA, M. D. Journal of Cutaneous and Vent'rr;!.! Hisea-^oM, Aiij^i-t, lS8fl, New York, 
'•Tlie Qucfitlon of the Value of Arscnio in Diseases of the Skin^" bj' W. A. Ilardft^aT, 

M.D. m<t 

f GnbleKi Thcrapetitlct, fm^ 273. 



DISEASES OF THE BKIN, 



tained. When an impression luis resulted from its use, it should' 
be persistently continued, but in snitilier doses, for a time after a\l 
symptoms of the eruption have vanished. It is contra-indicuted 
in tlie inflammatory or acute at^ige of all eruptions, and if em- 
ployed then may be followed by lujuriousi effects from its stimulating 
action on the epidermis. In other words, it should not be given in 
active ccU-proiiferation, but during the singe of decline or chronic 
period of eruption, in which the affection is gitnated in tlie super- 
ficial portion of the skin. It ia a useful remedy in psoriasis and 
eczema, after the infiammatory period of these diseases. It often 
acts happily in obstinate and chronic cases of papular eczema, i>em- 
phigus> lichen ruber, and at times in secondary syphilis. It can be 
taken by most persons, or administered hypudermatically for a very 
long time, without injury to the health. Some persons are at times 
quickly and easily affected by small doses ; others, who have some ali- 
mentary disorders, will not tolerate its internal administratioTK Its 
success, therefore, often depends upon a judicious manner of admin* 
istration so as to overcome these objections and permit it to be accept- 
ably received by the tissues. If the subject has a peculiar idiosyn- 
crasy, beginning with a minimum dose, or combining with it either 
opium, bromide of j)otassium, quinine, pepper, etc., or a bitter, or an 
aperient, will often cause it to be better borue^ and at times enhance 
ite therapeutic value. 

If arsenic is not tolerated by the alimentary canal, the same result 
may be reached by the hypodermatic method of administration. It 
may therefore bo employed according to the indications in each case, 
either given by the stomach or hypodcrmatically, to produce its sys- 
temic effects. The preparations of arsenic usually employed are 
arsenious acid, the arseniate of sodium, and the solution of arsonite 
of potassium (Fowler's solution), or the solution of arseniate of so- 
dium (Pearson's solution). In the majority of cases I prefer using 
the arseninus acid or the arseniate of sodium to any one of the solu- 
tions of arsenic. My reason for this ])reference is, that arsenic solu- 
tions are often uncertain, being poorly or improperly prepared, or, 
if kept on hand too long, a chemical change may take place, which 
lessens their activity. Arsenic prej^aratioua are often thus given 
by the most skilful without producing any decided eilect. If the 
physician is certain beyond all doubt that the solution is fresh and 
properly prepared, it will be ei^ually effective with the ai-senioua 
acid or the arseniate of sodium. The advantage, however, in giving 
the latter is that their effectiveness, if arsenic will have any over the 
disease, is certain beyond all doubt. While I have employed the 
imiide of arsenic, and the solutions of the arseniate of sodium, and 
the iodide of arsenic and mercury (Donovan's solution), I have not 
had as good results from their use as from the other preparations 



TREATUENT. 



n 



k 



already named. Arsenious acid and the arseniate of sodium are not 
only preferuble for their therapeutic effect, but they are likewise a 
ready and convenient form of administering arsenic either alone or 
combined. They can be pre.<crjbed to begin witli in a wry minimum 
dofe, from one one-hundredth to one tenth of a grain, given as pille 
three times daily, which can be carried around and readily taken 
by patients without the lea.st trouble. It is best to administer the 
pills immediately after a meal, when, according to the views of Rin- 
ger, the arsenic becomes absorbed by the lacteals, and throngh them 
mixed with the blood ; while, if the stomach is empty, it is absorbed 
by the veins, and, passing into the liver, is sejiaruted witli the tjile. 
The doee of arsenioas acid or its t^ait can be increased, given in the 
alK)ve manner, until it reaches the limit of toleration, which maybe 
recognized by the metallic taste, increased flow of saliva, itching and 
swelling of the eyelids, and an unjileasant sensation over tiie ejjigaa- 
trium. The patient during tbe period that ar^^enic is being adminis- 
tered ahonld have all the secretions kept in an active condition, and 
should be nnder the constant observation of a physician. In the 
event that the medicine shows the slightest evidence of producing its 
constitutional effect, the dose should be decrciii^ed, or the remedy 
withdrawn, and one of the bitter tonics aubstttuied for a time until 
it can again be safely resumed. If these precautions be observed, nt) 
unexpected or vitdent action need result from its administration. I 
have had numerous cases in which arsenic in one of tliese forms has 
been given for a very long time with great tolerance and without the 
least injurious effect. I believe that, in many instances in wliieh it 
has suddenly given rise to toxic effects, ilte accident has been due to 
nibjects pursuing an arsenic course of treatment without being under 
the constant observation of the physician. The prescription ordered 
Iwo, three, or four weeks previously has been renewed time and again, 
the patient requesting advice only when Bome unexpected symptom 
appears. 

In using the solutions of arsenic for their systemic effect, the best 
and moet serviceable are the solutions of the arseiiitc of potassium 
(Fowler^s) or the nrseniate of sodium (Pearson's), from one to twenty 
drop doses after meals, either administered alone or given witli an 
aromatic water, or simple bitters. 

It is well, in order to avoid any idiosyncrasy that the patient may 
have, to begin always with the minimum dose, viz., from one to three 
drops. 

Some practitioners prefer, In giving arsenic in a solution, to use 
the arseniate of sodium, which it is said is better and more easily ab- 
sorbed than that of the arscnite of potassium. Tbe solutions of ar- 

c, for the same reason that has been mentioned when sjieaking 
of arsenious acid and the arseniate of sodium, should always be given 



ma^ 



7-1: 



DISEASES OF THE SKIN. 



after a meaL If tliey agree with tlie putient, the dose can be gradn- 
ally iucrca-scd, drop by drop, until a decided effect is apparent on the 
eruption. 

The solutions of arsenic, like the eolid preparations, can often be 
advantageously eoinbined with other drugs, which generally enhance 
their value and render tbeni easily borne. They can be prescribed 
with the tinctures of cinchona and serpentaria, the bromide of potas- 
sium, etc. In cases in winch the use of arsenic produces disfiguring 
acne-8pot>', the addition of the bromide of potassium to the prescrip- 
tion will either prevent or lessen their development, D\\ T. N. Mc- 
Laughlin, of Washington, D. C, Inis derived advantage from the ad- 
mi nistratitui of realgar or bisulpliide of arsenic in psoriasis, chronic 
eczema, and Bcrof uluilerma. He also prescribes it in suppurative affec- 
tions, as acne and furuneulus, in which ho considers it to fulfill the 
same purposes as sulphide of calcium, 

I will now pas;8 to the consideration of the systemic effect occa- 
sioned by the introduction of arsenic beneath the skin into the sub» 
cutaneous areolar tissue. liy this method tbe same physiological and 
therapeutic effects occur as when the metal is given by the stomach. 
This fact was fully demonstrated by Dr. 0. B. Radcliffe,* who injected 
for the first time on January 12, XSUO, tlie solution of the arsenite of 
potassium under the skin of a patient suffering from chorea, with good 
results. Later, JL Lippf injected arsenious acid in psoriasis and 
chronic eczenui, which he reported as successful. 8ince that time the 
same method has been used and commended in various parts of the 
world. It is, however, to be regretted that this ready means of intro- 
ducing arsenic rajjidly and beneficially into the system is so little used 
by physicians, I regard it as being the very best manner for ]in)dueing 
a speedy, powerful, and effective impression upon the diseased skin. 
The arsenic is not altered, changed, or lessened in its action, iis by a 
diseased stomach, tbe presence of food, the contlition of the fluids, the 
veins, tbe nerves, ami the liver, and consequently its therapeutic effects 
are produced to the fullest degree. This metliod is especially adapted 
to the treatment of obstinate cases of psoriasis and eczema. It will 
spare the digestive organs, and will abridge very much the duration of 
treatment. 

I first tested this excellent method in 187G, and after some years 
of experience have found that I can often arrest and cure some obsti- 
nate cases which resist arsenic given by the stomach. ^Mercury admin- 
istered by the stomach for syphilis will sometimes prove ineffective, but 
when used hypodermatically, cures often follow; so also arsenic given 
hypotiermutically will in some instiinees produce more marked sys- 
temic effects. I began by using the solution of the arsenite of potas- 

* Reynolds's "System of McdiciRe." vol. i. p. 712. 

t "^rehiv fQr I>©rniatologie und SyphiL," No, 3. 1869, 



TKEATMEXT. 



75 



diluted ; later, a weak solution of arsenious acid ; and now I geti- 
eg^y admiiiister either the arseniousj acid or tho arseniate of sodium 
in fiolntion. Some pbysicians regard the latter preparation as the 
most acceptable to use, as it is a higher oxido than the arseuiate of 
potassium, ie less irritant in its local action, and not so liable to be fol- 
lowed by toxic symptoms. I usually have thearseniate of sodium made 
into pellets of various strengths, beginning with one tenth of a grain, 
one of which is dissolved in ordinary water (distilled water, however, 
aa a medium is always regarded £is the best), and deposited daily into 
the areolar tissue over some part of the back. In the course of a few 
daja the dose is gradually increased, until some evidence of the action 
of the metAl is observed either upon the disease or by its constitutional 
effect, I have in this manner given as high as from one quarter to a 
half and in one instance one grain daily, without any injurious results. 
The effect la usually very speedy, varying, of course, in diifcrent indi- 
riduald; in some it waa observed in two weeks, in others from six to 
eight weeks. As aoou as either the system le or local action of arsenic 
is noticed, the dose should be decreased until the minimum amount is 
reached. In case the disease persists, it can again be gradually in- 
creased until an impression is once more apparent. It is proper fur 
the practitioner to bear in mind the fact that in exceptional causes ar- 
aenic gives rLse to certain cutaneous manifestiitions. These may occur 
irrespective of any signs of systemic intoxication. A diiluse, more or 
leas general, erythema is sometimes produced by a few df)ses. This 
nab maj or may not attack the face. Prof. James Stewart * met witli 
• |Nitient in whom wart-like excresenccs formed upon tho dorsal siir- 
£ice6 of the hands and fingers. A brawn pigmentiition occasionally 
develops in consequence of an arsenical course. The discnloration may 
iip(>ear on any portion of the body. It may exist as disseminated 
patches or may be bo generalized as to present the appearance charac- 
teristic of Addison''s disease, Thh pigmentation gradually disajipears 
after the remedy has been suspended. Mr. Jonathan Hutchinson sup* 
poses that a course of arsenic prolonged for years is capable of ])roduc- 
ing epithelioma. The evidence upon which he founds this belief 
seems inconclusive, and the result, if really due to the drug, must be of 
Terv rare occurrence. 

Antiinony. — Tartar emetic, a well-known and useful drug, fell, 
owring to its constitutional effects in many cutaneous diseases?, into dis- 
use until recently, when excellent results were reported from its admin- 
istration by Morris, of London, It is quii'kly dilTusod into the circida- 
tion, which it lessens, and assists in eliminating the waste products by 
the aliraentary canal, the kidneys, and the skin. In most of the inflam- 
matorv affections, with elevation of temperature, it will be found to 
exercise a beneficial influence in reducing the exudation and the tem- 
• *• Canada ^ledJcal and Surgical Journal/' April, 1888. 






76 



DISEASES OF THE SKIN. 



peratore. It ig 'of undoubted value in the eruptive fevers, and also 
in acute eczema uud psoriasis, by allaying the irritation and congestion 
of the skiu. It often acts well in clironic eczema, psoriasis, scrofulo- 
derma, syphilid, and other cutaneous eruptions. Antimony is best 
given aa the tartrate of antimony and potiisstum in from one twen- 
tieth to one tenth of a grain dose every four to six houra; or the 
wine of antinionj, in from five drops to half a drachm, repeated in 
the same manner. 

Turpentine. — Clinical experience has demongtrated that turpentine 
is a valuable remedy both in its direct and indirect action upon the 
skin. In moderate doses it stimulates the vaso-motor nervous sys- 
tem, leading to an incre^Lse, followed by a diminution, of the capillary 
circulation. This important action of torpentiue rendei-s it one of 
the most useful drugs in lessening inflammation of the skin in psori- 
asis and eczema, attended with much dilatation of the arterioles and 
thickening of the skin. Crocker* reports very good results from its 
employment in the diseases just named, lie recommends the oil of 
turpentine in from ten to forty minima given in an emulsion three 
timeij daily after meals. liarley- water, usually about a quart a day, 
is recommended from the beginning of the treatment by him, to 
avoid irritation of the urinary organs ; the Chian turpentine in from 
five to fifteen grains was followed by improvement in pityriasis rubra. 
Gould aim reported througli Crocker good results from the latter prep- 
aration in a case of epithelioma and seirrhus ; tlie pain in both was 
said to be lessened and the growth retarded. Renefit has resulted in 
my experience in chronic psoriasis, eczema, and purpura from tlie use 
of both the oil and the Venice turpentine. 

Mercury and its Preparations. — Mercury is an cfTective antiphlo- 
gistic agent. In small doses it improves the quality of the blood, es- 
pecially increasing the red corpuscles. By this action it forms a pow- 
erful agent for combating and treating syphilis. It can be employed 
with advantage in minnte doses in the treatment of eczema accom- 
panied with severe inflammatory symptoms, particularly in children 
having the pustular variety. It is also of value in small doses in the 
treatment of many other inflammatory affections of the integument, 
among which may be mentioned lupus, sycosis, chronic eczema, psoria- 
sis, and scrofuloderma. Mercury may be introduced into the system by 
inunction, fumigation, the byf>odermatic method, or by the stomach. 
In tlie treatment of obstinate and chronic forms of syphilis, the hypo- 
dermatic method is to be preferred. It is cleanly, more economical, 
and more rapid in its action in arresting the disease. If mercury is 
administered by the mouth, the corrosive chloride, the mild chloride, 
blue pill, mercury with chalk, the protiodide, and the biniodide are 

• ** On the Internal Administration of Turpentine in Cutaneous Diseases." 
Bead before the fhinterian Stwiety, London, January 14, 1888, 



TIIEATMENT. 



TT 



I 



the preparations ordiuarily used. Tho drug should usually he givea in 
the beginning in very small doses, and its effect wutclied in order to pre- 
vent ptyalism. A minute quantity, as the one twentieth to the one 
fitxtieth^ for instance, of the corrosive chloride, or the mild chloride, 
well rubbed up with sugar, or triturated, as recommended hy Piffard,* 
snd giren in frequently repeated doses, acts more decidedly than larger 
doses at longer intervals. Mercury may he administered alone or given 
in combination with other fiubstanct^s; the best example of which ia 
the liquor arsenici et hydrargyri iodidi, which in from five to fifteen 
drop doaes is of utility in syphilis, sycosis, and in the various forms of 
cancer. 

Chlorate of Potassium.t^ — This powerful but valuable remedy is 
uaefnl in che treatment of all diseases depending upon suhoxidation 
or defective nutrition, secretion, excretion, aeration, and molecular 
metamorphosis. In gmail doses it increases the appetite, and in large 
or exceesivo doses it may, like any other potent but vahmhie remedy, 
produce an injurious or poiijonoua action. Given in small or mod- 
erate portions^ it ia a most effective remedy for abating and often cur- 
ing many piistular diseases. It is beneficiul in ecthyma in debilitated 
subjects. In boils, carbuncles, sties, pustular acne, pustular eczema, 
and sycosis it diminishes tlie tendency to suppuration, and if the latter 
stagB has been reached, will assist largely in arresting it. A happy 
eflbct from the drug will frequently be experienced from its employ- 
roent in scrofulous subject*? suffering from enlarged and su]»j>u rating 
glands, unhealthy ulcers, papules, pustules, and other lesions arising 
from this peculiar state of the system, and accompanied with more or 
kas constitutional impairment. In many such tyiucal cjises, and some 
eren less so, the continued use of the drug in moderate doses will tone 
up the digestive organs, increase the appetite, and lessen the forma- 
tion of pus. It will, by thus adding tone and vigor to a previously 
weakened system, prepare the patient for the use of other measures, 
each aa good, nourishing food, exercise, fresh air, aurl perhaps tonics, 
all of which are so necessary for thoroughly eradicating scrofula. 
Purpuric and broken-down syphilitic patients are often benefited by 
chlorate of potassium. It will also inerease the quantity of urine, and 
may be discovered in that secretion. The dose of the drug is usually 
from one half to thirty grains, freely diluted with water, every three or 
four hours. The dose will have to be graded according to the condi* 
Uon of the patient ; the pale, weak, and enfeebled bear much larger 
doses than the apparently vifjoroua. 

Iodine and its Preparations, — The preparations of iodine have a 

• ** A Treatise on the Materia .M^tliea and Therapcutios of the Skin,*' pp. 6 1-63, 
New York, Williiun Wood & Co., 1881. 

f See paper by the author, " The Therapoutio Action of Pota«pium Chlorate.** 
TnoMOtioDS of the Amencnn Me^lical Association^ vol. xixiil, pp. 131-140. 




78 



DISEASES OF THE SKIN. 



large range of usefulness in affections of the skin. They are said to 
influence the elmiination of waste products from the system. Iodine 
is effective in small doses in the treatment of scrofula andlnpus. The 
iodide of potassium or the iodide of sodium, but preferably the former 
salt, is one of the most effective remedies in the treatment of the ter- 
tiary stage of syphilis. As iodine and its preparations may produce a 
variety of entaneous eruptions, they should tie cautiously used. The 
usual dose of the tincture of iodine is from one to five drops, and of 
the iodide of potassium or sodium from five to sixty grains. In the 
tertiary form of syphilis, particularly if attended with ulceration, large, 
doses should be administered, in order to produce a decided eifect. To 
avoid the gastric disturbance which not infrequently results from the 
prolonged administration of iodine or its salts, we are now provided 
with an admirable remedy in the sirup of hydriodic acid. One fluid 
ounce of this preparation contains about six and a Ixalf grains of iodine, 
and the dose is from half a fluid drachm to half a fluid ounce. It is 
relatively more powerful than iodide of potassium, since nascent iodine 
is liberated in the stonmeh. Tlie sirup of hydriodic acid * is valuable 
in syphilis, especially in the latter stages of tlie disease, and is tol- 
erated when the stomach has become rebellious to the iodide. It is 
of great efficacy in the eczema of feeble or scrofulous children. In 
scrofuloderma and lupus vulgaris it is likewise of service. Dr. Hugh 
Woods of Highgate, has introdneed another substitute for the iodides 
ill the hypiodite of potassium (lif[Uor potassje iodinatie). Each ounce 
of the solution contains about twenty-eight grains of iodine in a loose 
combination, and nascent iodine is set free by the action of the gastric 
juice. It is given in doses of five to ten minims. When shaken up 
with an equal quantity of olive-oil, it forms a soapy liniment which is a 
useful antiseptic remedy for external uscf 

Sulphur I and Calx Sulphurata.— Sulphur given internally in from 
one grain to two drachma in sirup, honey, or milk, may produce ex- 
cellent results in alopecia, diseases of the nails, glandular affections, 
eczema, and psoriasis. The most elegant and useful {trepamtion of 
sulphur is calx snlpbnrata. It will, in from one-quarter to one-grain 
doseSj three or four times daily, prove a useful remedy in acne, and 
in boils and abscesses. It will lessen the formation of pus. A nat- 
ural sulj>hur-wator, as the Blue Lick water, of Kentucky, can be pre- 
scribed with advantage in the stime class of affections. 

Tar, Carbolic Acid, and Creasotet^Theae remedies are sometimeB 
serviceable given internally. Tar, or one of its products, may in some 
cases lessen cutaneous irritation, but in others increase it. Chronic 

« " Ilydricwiic Acfd,'' by the author. "The Medical Bufletin" August. 1889. 
f " BritisJi Mi?dical Journni;' April 26, IStJO. 

I See paper by author on " Tho Physiolog^ical and Therapeutic Action of Sul- 
phur." *' Transactions of the Pennsylvania State Medical Society," 1800. 



^^^^m TREATMENT. 'J'Q 

eczema, psoriasis, lichen, and prurigo may be inflneiiped favorably by 
the mlminiatration of either ttir, carbolic acid, or ercasote in small 
doses. Dr. Augagneur speaks particularly of the goml effects of the 
internal administration of carbolic acid in alleviating the troublesome 
itching which often accompanies eczema and psoriaeis. 

Local Tkeatment. 

The external means which are employed for relieving or curing 
cutaneous diseases are innumerable. 8ome have value, while others are 
useless and hardly worth describing. Among those that have been 
found effective are the following: 

Baths. — Bathg are essential for the preservation of health, as well 
as to prevent and assist in eradicating disease, by draining from the 
•ystem effete products which are often the active fnctor^s in many 
affections of the skin. They not only have this general elTect, but by 
iheir local action they remove from the skin all abnormal products, 
such aa irritating disc^harges, scales, cnists, and all extraneous matter. 
They soften the hardened integument, lessen vascular excitement, 
riflai muscular tension, soothe, astringe, or stimulate the organ, relieve 
irritation and inflammation, and assist the action of both the constitu- 
tional and additional local treatment to be employed. 

Among the various forms of baths that are serviceable are the water, 
the mediented water, the hot-air, the vapor, simple and medicated, and 
the electro- vapor bath. Brief reference will be made to those just 
mentioned, and some others, as follows : 

The water-bath should be composed of soft or rain water, procured 
from tubs, tanks, or cisterns in which it is caught, or from creeks, 
riveTS, and most springs. Hard water, if possible, should always be 
avoided, or made soft by adding potash or soda in the proportion of 
one hundred grains of either to the gallon of water, as, owing to the 
presence especially of lime sulphate in it, the skin, particularly if sen- 
sitive, may be irritated or inflamed. The water-bath, if properly 
used, either cold, tepid, warm, or hot, is often of great value in the in- 
flammatory and hypertrophic affections, as in eczema, psoriasis, pity- 
fiBOA, dermatitis, and ichthyosis. Hot water baths restore the function 
of the glands in acne, relieve the abnormal sensibility of dermatalgia 
and para^thesiji, are beneficial in pityriasis, prurigo, pediculosis, and 
scabies. Warm baths are of service in ecthyma and syphilis. 

The continuous water-bath, recommended by Ilebra, so arranged 
that patients can remain in it for a long time, is useful in the treat- 
ment of pemphigus, chronic eczema, psoriasis, and burns. 

Medicated WATEFi-BAXHs.—These baths generally consist of from 
^^ twenty to thirty gallons of water, which may be of any temperature, 
^H hat usually about 95' Fahr. The following are the principal varieties 
^^ tad the formula employed in their preparation; 



• 



m 



DISEASES OF THE SKIN. 



Acid Balks. — Hydrochloric, nitric, or one of the mineral acids, 
one ounce. Serviceable in prurigo, lichen, and chronic scrofuloderma 
and syphilis. 

Alkaline Bulks. — Bicarbonate of sodium or borax, two to ten 
ounces, but generally about six ouuccrs. Useful in very many varieties 
of cutaneous diseases attended with irritation of the part, especially in 
eczema, dermatitis, psoriasis, paraasthesia, erythema, urticaria, licben, 
and prurif,^o. 

Asiringeiii Balks. — Alum, from four to six ounces, or a decoction 
made with half a pound of white-oak bark, added to the usual quan- 
tity of water. Used in chronic eruptions, esjx^cially in eczema and 
in purpura. 

Bromine and lodhw Balks.— ThQ former is prepared by using 
twenty to forty drops of bromine with two to four ounces of iodide of 
potassium, and the latter by adding one half to one drachm of iodine 
to one or two ounces of lifpior potassa and the required quantity of 
water. Employed in scrofuloderma, syphilis, elephantiasis Arabum, 
vitiligo, and in excess of pigment. 

Emollieiil jyff/A.'f.^Potato-fitarch, gelatine, linseed, or marsh-mallow^ 
from one to four pounds* They often allay active irritation and in- 
flammation, and can be used in conjunction with the alkaline bafn 
with decided effect. Of value in erythema, eczema, urticaria, derma- 
titis, herpes, and psoriasis. 

Mercurial Baihs. — One or two drachms of the corrosive chloride 
of mercury with a drachm of hydrochloric acid. 

FolasMum Sulphurel ^fif^A*.— From one to six ounces of the aboTe 
salt to each bath. 

llie Hot-Air Bath, as constructed in the Hospital for Diseases of 
the Skin, in Philadelphia, consists of a closed chamber, six feet square 
by eight feet in height, provided with ventilators. The heat is car- 
ried to it by flues which surround all sides, and thus radiates from all 
parts of the chamber. The temperature is indicated by a thermometer 
fixed in the room, which can be watched by an attendant from the out- 
side, and is usually maintained at from 130° to 140"^ Fahr, It may be 
inconvenient for patients at times to leave their homes to visit an in- 
stitution for this form of hath. For those so situated the bath can 
be constructed as follows : The patient is placed in a nude condition 
on a perforated or cane-bottom chair, and the body from the neck is 
enveloped in a blanket. A lighted spirit-lamp of good size is then 
placed Ijctieath the chain and, care being exercised to retain as much 
as possible of the heated air in contact with the body, free perspira- 
tion soon follows, the procedure being continued fur from ten to 
twenty minutes, aft^r which the patient is rubbed dry and placed be- 
tween warm blankets or sheets. This form of bath is of value in ecae- 
ma, psoriasis, pityriasis, ichthyosis, and paraeathesia. It makes the su* 



TREATMENT. 



81 



id sebaceous glands active, equalizes capillary circulation, 
ttn^ ^ eoa tii s the skin of all abnormal products. 

The Vapor-Bath^ Simple ami AledimMy is arranged in a sim- 
ilar manner to the hot-air bath ; tho vapor bc^ing conveyed by a 
series of pipes instead of hot-air flues. The temperature is indicated 
in the same way, and is maintained at from 115** to 140° Fahr. 
Given at home, the patient is prepared in the same manner as for 
the hot-air bath. An oidiuiiry tin pau^ or any vessel containing 
boiling water, is 6rst placed under the chair, and a brick or good- 
eized stone, previously heated I'cd hot, is next carefully deposited in 
the water, a portion of it bein*^ left uncovered by the fluid, if it ia 
denized to gprinkle over the surface a drug with which to medicate 
the hath. The vapor quickly a^ncends, causiiijj copious perspi nation, 
which may be continued from ten to thirty minutes, and the patient 
is afterward treated aa in the hot-air bath. If the medicinal sub- 
sUoce employed to impregiiate the bath is diUicult to volatilize, it 
may be better accompliiihed by placing a small tray and spirit-lamp 
beneath the chair, as tho drug may he dissolved m water and after- 
ward evaporated by the lamp. Tlio following medicinal agents can 
be Tolatijized and used in the f[uantitieH named : Mercury and it^ salts, 
more particularly calomel or the red sulpliiiret of mercury, from one 
half to a drachm ; tar, naphthol, the balsams, e^specially Peruvian bal- 
sam, one to four dnichras ; carbolic acid, and the essential oiln, five to 
thirty dropi ; sulphur, from one half to two ounces. The simple 
vapor-bath is similar iu action to the hot-air buth, with the addition 
of slightly Btimnlating and making the skin more soft and pliable. 
It is benctjcial in acne, eczema, and prurigo, aud lu all disea.^es accom- 
ponied by heat, dryness, aud irritability of the skin. Of the medi- 
cated vapor-baths, the mercurial is invaluable in syphilitic eruptions, 
especially when mercury is not well borne by the alimentary canal ; 
the tar and others, in clironic erufitions, particularly in eczema and 
y&o/nmis. The sulphur va]«>r-bath h useful in soothing the irritated 
wartao^ m obstinate and chronic cases of scabies. Finally, during a 
Tspor-bath, electricity may be brought in contact with the skin, either 
as the galvanic or farad ic current, Tiie so-called eleetro-vapor bath 
may give good results in hypertrophies of the skin and in the neuroses, 
e«|)ecia11y in paresthesia. 

As it has been shown that the fluid aud the medicinal substances 
contained in baths are absorbed by the skin, wme benefit may re- 
sult from their direct systemic action. The principal value of 
hathsy however, is in their direct effect upon the skin and their 
indirect impression upon the system. They should always lie used, 
however, with caution, and never given or persisted in if contra- 
indicated by any constitutional weakness or disease. With the 
Aged and the very young they should be nsed carefully. Baths 
6 



imuk 



a 



DISEASES OF TIIE SKIN. 



should neTcr be pfiven upon a full stomach ; the period for con- 
tinuiog in the bath should usually be short, and the bather should 
be guided by the temperature of the medium in rehitiou to the 
heat of the body* The various baths, if u>ed judiciously, are im- 
porUmt aud useful auxiliaries iu the treatment of diseases of the 
gkiii. 

Soaps. — ^Soaps* are uscfol in assistiDg to maintain Uve skio and 
the body iu a healthy condition, aud are frequently valuable aids in 
th6 treatment of diseases of the integument. They can be employed 
either lis the potash or soft, or the soda or hard* 

Soft Soap,—Fotash. soap* sapo mollis, sapo viridis, brown Boap^ 
black i^oap, soft soap, Pota,sh soap, which contains a certain excess 
of alkali, is made with citlier an animiil fat or a vegetable oil ; 
olive-oil with potash being often employed. When well and prop- 
erly made^ it should be of the consistence of jelly, and Khould not 
flow out if tlie vessel containing it is inverted. It ought to bo of a 
brownish, greenish, or oHve-green color, soft and perfectly homo- 
geneous, with a strong, caustic odor, aud an acrid, alkaline taste. 
It shotdd contain no particles of sand, and readily dissolve in alco- 
hol with little or no residue. These characteristics will, of course, 
vary ranch according to the manner in which the soap is made. 
The best ]>ota8h soap which ha^ a definite strength is imported 
from Europe, and obtained from either Duvernois, of Stuttgart, or 
from Bassermann and llerschel, Mannheim, Germany. Potash soap, 
when applied to the skin, softens and macerates the epidermis, or 
even destroys it — the effect on the cotanemis surface varying according 
to its application lightly or with great friction, as well as to the length 
of time it is left in contact with the parts. The variable and unccr- 
tain effect that occasionally follows its use, denuding the epidermis at 
one spot and making no impression whatever at another, is due to 
the soap being neither properly nor well prepared. Potash soap may 
be used alone or dissolved iu akohuU a^ recommended by Hebra, 
in the proportion of two parts of soap to one of alcohol, which will 
remove its unideasant smell. To make it more elegant, and free 
from any particles of sand that may be present, the solution is 
allowed to settle, or filtered aud scented with the spiritus lavandula?, 
and it is then known as spiritus saponatus kalimis, or Hebra's spirit 
of soap, 

Mviliu.f which is a modified soft Poai>, has recently been highly ex- 

* The hrU'f clc^ciir^tuin of FonpH is tittstracled from my paper " On Sonp?, efspecimlljr 
Mediciiied, in DisoascB of the Skiiu" For a detailed account, sec Transactions of tbe 
Aledical Society of Penneylvuniu, vol. xvii., pp, IWViOB. 

f "Molliii,'' J.ickson adds, io the New York Medical Journal, November 6^ 1888, 
*'is prcpiiretl from thr' botit and frcslicst kidney-fat and auct iind the finest Cochin ooooa- 
nut-oil- The fat is saponifiinl cold with pot ash and some soda, so th&t to one hundred 
parta of fut there are forty parts of lye. Into the raas** tliirty percent of glycerine is 



TREATMENT. 



83 



^Hed In Gefmany as a useful vehicle for applying various substances 
to Uie skin. 

SocUi or hard soap, which contiiins soda as the base, and is gen- 
cmllj a nearly neutral sofip, may also be made with either an animal 
or mineral fat or a vegetable oil. From the investigations of Dr. B. 11. 
Paul* we learn that a perfectly neutral soda soap made with ordinary 
iat consisting principally of oleic and stearic acids contains ubout eleven 
|Nirt£ of soda for every one hundred parts of fatty acid, But a neutnd 
floda Boap made with cocoa-nut oil, in which palmitic acid preponder- 
ates^ contains a larger proportion of alkali. According to the sapie 
writer* the proportions of soda and potash given in the formula for 
Unna'fl super- fatted soap suffice for the complete saponification of the 
fat though it has been supposed that this preparation contained four 
per cent of nnsaponified fat. 

It differs from the potash soap in being hard, or comparatively so, 
and in having a less stimulating or destructive action on tlie skin. If 
soap is needed, either to cleanse tlie surface or for its local effect, it 
b often best to employ first the soda and then subsef^oently, if necessary, 
the potash soap. The field of usefulness of both may be rendered more 
extensive and effective by medicating them with such agents as alum, 
amic-a, boro-glyceride, camphor, carbolic acid, chamomile, eucalyptol, 
naphthol, salicylic acid, mercury, sulphur, and tar. In making tliese med- 
! " ips, chemical reriuirements nuust be carefully observed or useless 
: ^ ions result. It has been stated that soap containing free iodine 
remains unaltered but a short time, Resorcin can be preserved only in 
a neutral soap, wliile in a neutral or alkaline soap hydroxylamine under- 
goes progressive decomposition, cvidunced by the continual evolution 
of gas. Chrysarobin is not soluble in a neutral but readily soluble 
in an alkaline soap. A toilet soap shoidd not contaiti free alkali, 
which removes too much of the cutaneous fat ami causes jiremature 
•n of the corneous epidermic cells. It should be neutral in 
, and P. J. Eichhoff points out that a few drops of a iiot solu- 
tion of mercuric cliloride let fall upon the soap will develop a yellow- 
ish discoloration if any free alkali be present. Eichhoff describes four 
methods in which medicated soaps may be used in the treatment of 
disease: by simple washing; by allowing the lather to remain upon 
the skin for a short time and then rubbing it ot! with a dry cloth ; by 
permitting the lather to dry upon the surface; and, finally, which he 

worked, ond the wholr carefully heated. Wlioij properly made, mollin has a pale- 
white color with a *light1y yellow lint, and an nj^rwable, smooth, soft coiisisteiife. 
It is not essentially affected by exposure lo chjiii^es of teniperutiire or by being 
krpt in «peo vessols. It is supt^rior loan oitUinent in beinj^ perfectly elean. not 
»iling the under-clothing and not bc»conun<j ratickl, and in bein^ readily removed 
from the skin by warm or cold wjiter, leaving it. :?oft and Binonth.** 

* ** Toflet Soap considered from ii Chemical Point of View," Brkisli Journal 
of Dtrmatologf^ March, 1890. 



gmm 



M 



DISEASES OF THE SKIN. 



considers the most effective, by covering the dry lather with an ira- 
pervious layer of rubber cloth or tissue. He stutes that resoroin soup 
may be preserved by the addition of salicylic acid, and incorporates 
three parts of each substance in ninety-four jiiirts of soap to form 
resorcin-salicylic-acid soap. Tliis preparation he finds advantageous 
in parasitic skin-diseaiieB, especially those in which epithelial hyperplasia 
is a marked feature, as seborrhieic eczema, psoriasis, and ichthyosis. A 
salicylic-aeid-resorciD-sulphur soap contains three parts each of sali- 
cylic acid and resorcin, and ten parts of precipitated sulphur to eiglity- 
four parts of soap. Acne, rosacea, psoriasis, ichthyosis, ringworm, and 
favus are benefited by this application. The addition of fire parts of 
tar to the preceding soap constitutes his salieylic-acid-resorcin-sulphur* 
tar snap,\vhich is deleterious in acute inflammations but useful in para- 
sitic atfections, squamous eczema, and psoriasis. Three per cent- of qui- 
nine added to soap is recommended for eliromophytosis, used morning 
and evening and the lather allowed to renuiiu. A soap containing three 
percent, of liydroxylamine ia serviceable in psoriasis, seborrheeal ec- 
zema, and tinea sycosis. A flve-per-cent. iodoform soap may be used 
in cleansing common and syphilitic ulcers. One containing five per 
cent, of creolin is efficacious in scabies, impetigo contagiosii, intertrigo, 
hyperidrosis, and bromidrosis. Eiehholf employs an ergotin soap of 
the same strength in the treatment of varicose ulcere, frost-bite, and 
rosacea. A preparation in which three parts of iodine and 1*5 part of 
iodide of potassium are present is emfjloyed to reduce enlarged scrofu- 
lous glands, and is of avail in psoriasis. A suUeylic-acid-creasote soap 
into which enter five per cent of salicylic acid and two per cent, of 
pure creasote is of value in lupiis^ ring- worm, and seborrhonc eczema. 

Oils.— The oils employed locally in the treatment of cutaneous dis- 
eases are either bland or stimulating. Among the former are olive- 
oil, linseed- oil, oil of sweet almonds, cotton-seed oil, and cod-liver oiL 
They are valuable for softeniug and removing scales, crusts, and extra- 
neons matter from the surface. They are tdso useful for protecting 
and soothing the irritated and inflamed skin in the eruptive fevers. 
The tar- oils, as the oil of cade, the oil of juniper, the oil of ergot, 
and chlorinated oil, are examples of the stimulating Viiriety. They 
are particularly serviceable in niatiy afTections of the skin. Chlori- 
nated oil, as I have demonstrated, often acts well in animal parasitic 
difleaaes, especially scabies. The oil of ergot * is also a valuable remedy 
in seborrhfini of tlie scalp and loss of hair. 

Poultices or Cataplasms. — Various substances which retain heat 
and moisture can be used as poultices, such as bread, flaxseed-meal, 
potato-starch, etc. Water, milk, or some other boiling fluid, should 

* See pajHjr by the author, *' Now Reined iea in the Treatment of Skin Diseases," 
Transactions of the Medical Society of the State of Fennsylvnaia, vol. xiii^ part 1, 
p. 85. 



TREATMENT. 



85 




used in preparing poultices. They should be applied as 

mfort will permit, and should be covered, if possible, with 

iled eilk to retain the heat and moisture, or be frequently changed. 

lotlK dipped in boiling water, partially wrung- out and at once ap- 

lied to the part, and covered with oiled silk, make an excellent poul- 

ce. The moat soothing and the most effective of all poultices to 

to in cutaneous diseases is composed of starch. It is important, 

Terras M. Brocq points out, that this poultice should be properly 

made* In tlie first place, enou;^']i tepid water should be mixed with 

the starch to form a paste. Boiling water should then be added, the 

mixtare be left on the fire for about a minute, being briskly stirred in 

Ofder to make it homogeneous. It should then be spread upon tarlatan 

preriously deprived of its stiffening. Poultices act very often in a 

appy manner in dilating vessels, relaxing the muscular tension, and 

ng in removing the hard, tense, and high inflammation and the 

tive condition of the nerves of the part. In infiltrated and dor- 

mflZit conditions of the integument they soften and soothe the parts, 

«roDse the absorbents, and assist the action of other local remedies 

which may be subsequently employed. Poultices relieve the pain and 

promote suppuration in deep inflammation of the integument, as in 

fonmclcs and earbnncles. They are also of great utility in limited 

cases of chronic eczema, psoriasis, sycosis, warts, corns, callosities, 

nl^^^rs, and in many other affections, particularly for removing scales, 

cruets, and extraneous matter. 

Dusting-Powders. =-Dnsting-powders are employed, alone or com- 
ined, to protect the skin ; and, at times, to produce a soothing, 
imnlaiing, or astringent action upon the parts. The most useful 
gtarch, whcaten and huck wheat flour, corn-starch, orris-root, arrow- 
carbonate of magnesia, carbonate of lead, the impure carbonate 
of zinc, carbonate of zinc, oxide of zinc, subnitrate of bismuth, lycopo- 
dium, boracic acid, salicylic acid, alum, French chalk, talc, red cinchona 
powder, oleate of zinc, and prepared earth. The latter two are espe- 
cially valuable; the oleate of zinc being particularly effective in many 
inflammatory cutaneous diseases, either alone or mixed with one of 
the other soothing powders. Prepared earth — which was so long and 
favorably employed by the late Dr AddincU Hewson in the treats 
ent of old ulcers, epithelioma, small-pox, and other diseases of the 
kin — has a beneficial effect, not only in relieving but often in abso- 
Htely curing the eruption to which it has been applied. Dusting- 
wdera .should be carefully prepared before use. They must be 
thoroughly ground, and afterward sifted through fine bolting-cloth. 
It is importiint that they should be smooth and free from grit. 

Dusting-powders, by protecting the skin from the air and all irri- 
tating substances which may come in contact with it, and by absorb- 
ing the exudation, are of great value in certain stages of erythema, 




i 



86 DISEASES OF THE SKIN, 

eczema, herpes, herpes zoster, pemphigus, and the various disorders of 
secretion. 

Lotions, — Lotions are Hqiiid propai-atjou*? intended for external ap- 
plieatiou. They are best adapted for use upon diseiises involving a 
large surface, and where other applications, as ointments, are contra- 
iudicated. They also constitute a cleanly and an economical method 
of nu'dicating the skin, particularly if the eruption is extensive. 

Lotions may be prepared with water, aleoliol, spirits, glycerine, oils^ 
and other fluid substances, and may be divided into those which are 
sedative, astringent, and atimulating. 

Sedative lotions diminish or relieve the irritability of the sur- 
face. They are employed in inflammatory diseases, as eczema, erythe- 
ma, sycosis, dermatitis, and in the neurotic and parasitic affections. 
Among the most valuable are lead-water and latj<laiuim, elder-flower 
water, camphor- water, black- and jellow-wash, glycerine and rose- 
water, glycerine and lime-water, glycerolc of lead, weak solutions 
of the alkalies, and of boracic, hydrocyanic, and carbolic acids, and 
thymol. 

Astringent lotions contract the tissues of the parts to which they 
are applieil, and thus lessen or arrest discharge and moderate or con* 
trol inflammation. Tiiey can be made with one of the fluids already 
named, and may contain tannic or gallic acid, catechu, ergot, kino, 
rlmtany ; the various acids, the preparations of lead, alum, iron, and 
utlier drugs, having a Bimilar action. 

They are used largely in certain varieties of eczema, purpura, 
sehorrhopa oleosa, the disorders of secretion, and in many chronic 
forms of cutaneous diseases. 

Stimulating lotions are irritant in character and arouse the tor- 
pid integument to activity. They are prepared with one or more 
of the following drugs in varying proportions; tar and its products, 
stimulating oils, alkalies, the preparations of ammonia, benzoic acid, 
clirysarobin, arnica, rosemary, menthol, thymol, camjJior, horo- 
glyceride, sulphur and its preparations, and similar drugs. They 
are most clTcctive in chronic eczema, psoriasis, acne, rosacea, and 
sehorrhn^a. 

Ointments, — Ointments may be made from various fatty suhstanees, 
but lard, butter, suet, lanolin, and petroleum-jelly are usually employed. 
An ointment may be simple, consisting of only one of the above mate- 
rials, or it may be medicated by the adtlitiou of various remedies. Sim- 
ple and medicated ointments are, no doubt, among the most effective 
means of making an impression upon the diseased skin. In reference 
to the proper base to employ for ointments, I repeat what I have again 
and again demonstrated clinically, wdiich is thus briefly stated in my 
small book on the oleates : The fatty vehicles intended for ointment 
bases are a matter of choice according to the indications of tlic case. 



TREATilE! 



sr 



While, DO doubt, the moat elegant preparations can he made with 
the petroleum fats, they form, in my opinion and in that of others, 
the least desirable substances for such use.* In my paper, read be- 
fore the Medical Society of the State of Pennsylvania, f I stated tliat I 
considered the petroleum products as objectionable for such a purpose; 
and Dr. Robson, of England, has made a similar observation on the 
n^ of vaseline as a surgical dressing. I also consider them to possess 
ft feebler penetrative power, if any at all, than animal fats, which have 
more affinity for the integument They usually contain some irritating 
constituent, which lessens or destroys their emollient action, and con- 
stitutes a great source of hindrance to their use as external remedies in 
active infliimnuition. 

The investigations of Liehreich confirm the conclusions which I 
came to some years ago. I place them side by side, for comparison : 



LiSrekk't Intettigati^ru on the Action 
of Mineral FaU, 

'•Quite atiarl from the fact that 
the nlworptioQ of medicament«i, when 
mired with pure fat is hut imperfectly 
effected, fat-oiDtments are subjected to 
decomposition, which may lead to irri- 
tAtioD of tlie skin. It is true that vaae- 
line does not decompose, but it prevents 
th* entrance of medicaments into the 
skin, to that even poisonous substances, 
when mixed with vaseline and nibl>ed 
into the *kin, produce neitlier local 
nor constitutioiial symptoms of pui- 



My mm Incatiffationa on the Action of 
Mi/i^ml FatSj rfported in 1882, 1884, 
ami 1885. 

" Petroleum products, vaseline, co3- 
moline, etc., possess feebler power to 
penetrate the akin, if any at all, than 
animal fats, which have more affinity 
ffir the integument. Their absorptive 
power for penetrative action into the 
skin is so foelik' a.H almost to cause them 
to be excluded ;i8 s^uch. Irritant oint- 
ments of veratria and other substances 
which I had made respectively of va^- 
linc, cosraoline, and of simple cerate, 
manifested themi^elvcs in the former 
two pre]mrations as almost inert; while 
the activity of those made \vith Himple 
cerate very booh bccBnieeviiient. Fur- 
ther, the petroleum products retain 
some stimulating constituent left after 
their manufacture." 

From Liebreicb*8 experiments and conclusions, and my own, the 
Bobstance to employ as a basis for ointments should possess the power 
of ]>enetrating tlie integument and not irritating it. Lard, suet, and 
lanolin are all animal fats, which are therefore best adapted for this 
purpose. Lard is the most economical and the most commonly used ; 

* .See an article on the •• Irritation of the Skin folio wingf the Application of 
Vnelioe,*' in the London Lancet, of November 8, 1884- 

t Trausaelions of the Medical Society of the State of Pennsylvania, vol. xiv., 
]».130. 

I ** An Addr«si on Lanolin ; a New Basis for Ointments," Britbh Medical Jour- 
UMl Jftnuarj 16, 188<k 



■MiMIMI 




DISEASES OF THE SKIN. 



tbo objection against its becoming rancid quickly can be overcome by 
prescribiDg a sufficient quantity to last but a few days, and it rarely 
undergoes change before it is utilized ; or the addition of benzoin or a 
small quantity of /3-nupluhol will prevent it from becoming mncid for 
a long time. Digestion with freshly bruised poplar-buda will idso iic- 
co?nplish the same purpose. It is sometimes of advantage to stiffen the 
lard by the addition of white wax or spermaceti. The latter substance, 
however, is prone to become rancid. Suet also forms a valuable oint- 
ment, and a serviceable vehicle for the application of many medicinal 
substances to the skin. Jjanolin,* or wool-fat, a new basis for oint- 
ments, introduced by Liebrcich in 188G,f is one of the most desirable 
vehicles for limited applications. I quote from investigations ivhich 1 
made some years ago, and published in a paper on lanolin,J as follows: 
" Lanolin possesses great absorptive action, and through its neutrality, 
its own tlecom position is out of the questiouj and consequently it will 
not irriUite the skin." 

Liebrcich states that it has its origin in keratinous tissue, and is 
manufactured chiefly from wool by ** transforming the wool-fat into a 
milk and then subjecting it to a centrifugal action." By this process, 
he further adds, '' a thin milk and cream are obtained, just as when milk 
is subjected to centrifugal action, and the cream con tains lanolin in a 
pure condition. More than one hundred per cent, of water can be 
kneaded with it, the result being a yellow, very plastic ointment.*' It 
is neutml in reaction, and has the consistency of ordinary citrine oint- 
ment, which it very much resembles, and is soft, smooth, and slightly 
tenacious. In order to overcome this stickiness, Mr. H. Helbing has 
suggested a mixture of sixty-five parts of anhydrous lanolin, thirty 
parts of li<iuid paraffine, ami five parts of cemsin. Prof. P. 1). Keyser, 
of this city, with the same object in view, combines one part of ben- 
zoated lard with three parts of lanolin. We may in some cases take 
advantage of the tenacious consistence of lanolin to render certiiin 
ointments stifFcr and more adhesive by the addition ol about twenty 
per cent. On applying it to the skin with slight friction it rapidly 
disappears. It is decomposed, it is claimed, with great difficulty, and 
it readily combines with other fats, oils, and glycerine, forming many 
excellent ointments and liniments. Ptischkis recomniends what he 
terms ^Manolin milk*' as an excellent application to dry, harsh skins, 
and useful, moreover, as covering the skin with a thin layer of fatty 
material, to which dusting-powders will readily adhere. Lanolin milk 

* The best lannUii is inanufacturetl at Landlm Works, Martinikenfekte, Ger- 
many. Burroufjrhs, Welcnme & Co.^ Snow Hill Buildings, Londnti, arp the* agents, and 
hftve placed before the profession snmo elegant prepnrations of Hiis fatty siibstant'e. 

4 See Liebruirh's paper read iM^foro the Section of Tlierapcutics of ihe Brilisb 
Medical Assj>t;iiition, August. 188(J, with discussion by the author, in British Medi- 
cal Journnl, October 23, 1886. 

$ The Medical and Surgical Reporter^ Phikdelphia, April S, 1886. 



TREATMENT. 



m 



u made by rubbing up seventy-five grains of lanolin with about a fluid 
ounce of water, gently warming and udding to the mixture four 
grammes neutral soup dissolved in an ounre of water. This is then again 
rubbed up, enough warm water added to make about twelve tiuid ounces, 
and the whole thoroughly agitated* If desirable, a litlle tincture of 
benzoin or borax dissolved in a small quantity of warm water may be 
added. The mixture needs to >)e strained. As used in medicine, lano- 
lin e^ntains from twenty-five to thirty per cent, of water^ not, however, 
in a etate of ehemieal combination. Made according to the latest im- 
proved processes, the odor is almost entirely overcome and the substance 
id of a whitish color. Lanolin servos a double puqiose as an excipient 
for mercury. The metal is readily incorporated with woul-fat, and the 
prolonged manipulations formerly necessary in the preparation of nier- 
carial ointment are now succeeded by a more rajiid atnl easy process. 
m, the absorbability of lanolin promntes the efficiency of the mercury 
dch it may contain. On account of the miscibility of lanolin with 
water, an aqueous solution of any drug may bo intimately and uni- 
formly united with the fat.* Lanolin is impermeable to micro-organ- 
isms, and is consequently an aseptic material, liy virtue of this prop- 
erty, it is well adapted for use in burns, scalds, frost-bites, and erysipe- 
las. Gottstein has taken advantage of its remarkable power for ab- 
sorbing water to incorporate with it aqueous solutions of corrosive 
sablimate. It thus constitutes an admirable disinfectant application to 
wounds and ulcers. In the same way it may be impregnated with 
other medicinal substances. According to Lassar, lanolin promotes or 
intensifiea the action of chrysjirobin. Lanolin is a valuable unguent in 
senile atrophy of the skin, ichthyosis, scleroderma, psoriasis, anidrosis, 
chronic eczema, and impetigo contagiosa. Its penetrative quality ren- 
ders it an excellent vehicle for germicides in the treatment of tinea 
trichophyiina and for mercury when inunction is pnicticed for syphilis. 
Lanolin is useful in improving depressed nntritiun of the hair and 
mulfl. Thia substance has lately been produced in the form of a pow- 
der by the following procedure : The lanolin is dissolved in ether^ al- 
cohol, chloroform, or acetone ; the solution mixed with nuignesia and 
dried* The mixture is additionally pulverized, and starch can be atlded 
in any proportion. Oxide of zinc, talc, alum, or bismuth may be used 
instead of magnesia. f The preparation may be serviceably employed 
as a dusting-powder. 

According to the statements of Unna, fats, glycerine, lanolin, and 
vaseline diminish evaporation of water from the skin. Caoutchouc and 
gutta-percha have the same effect. As a result of diminished trans- 
piration a corresponding quantity of water is driven to the kidneys. 

• See Ointment-s aad Oleates. e^peciully in Di<cas<*sof the Skin, by Jobn Y, Shoe- 
maker. A, M., M. D., second odition, Philmlclphift. 1890, F. A. Davis, p. 14 et j<f'q. 
f Zeilschrift dca Allgemein. Oesterreich. Apotht^ker-Vereins, April 20, 1890. 



■Mtt 



mm 



90 



PHYSIOLOGY OF THE SKIX 



Wlienever ointments are prescribed^ it is essential that the ingredi- 
ents should be thoroughly trituruted and intimately mixed with the 
excipient. Exact directions, moreover, should be given to the patient 
as to the mode of applicutioo. Jf used at all, it should be in a proper 
manner. Otherwise, an appropriate preparation may work injury in- 
stead of benefit An ointment generally needs to be kept in constant 
contact with the affected surface as long as the indications are tlie Siirae 
which suggested its employment in the first place. As a rule, an abun- 
dance of material should be ap]jlied, spread thickly upon the woolly side 
of the lint, which will not absorb the medicament and leave the integu- 
ment almost or entirely urimedicatcd. TJie dressing is then he!d in 
position by a bandage. Again, in reference to the strength of oint- 
ments, it is obvious tliat no absolute rule can be formulated. The skin 
of individuals differs normally in sensibility, and the difference becomes 
more marked when the integument is the seat of disease. If the offici- 
nal ointments are used, it will frequently be found that some are too 
strong, while othei's are too weak. In beginning the treatment of a 
cjise, therefore, it is advisable to use mild preparations, winch can be 
gradually strengthened if necessary. 

Ointments, like lotions, may be sedative, aatriugent, and stimu- 
lating. 

Sedative Ointments, — Simple ointment, suet, lanolin, iinsalted but- 
ter, ordinary cerates, spermaceti, cacao-btitter, lead, zinc, and cucum- 
ber ointments, are examples of this class. They are employed for their 
bland action in protecting the surfaces, and in soothing and allaying 
irritation and inflammation in many cutaneous diseases. 

The rose-water ointment or cold cream is bland, elegant, and effi- 
cient. In certain cases, as Bulkley points out,* when the skin is too 
dry, a portion of the water which it contains may be serviceably re- 
placed by glycerine. 

Asfrififjent Or/f ///(a «/.*?. —Ointments of this class are employed for 
the purpose of contracting the integument to which they are applied, 
lessening discharge, and arresting or modifying inflammation. Tliey 
are composed of lead, bismuth, tiinuic acid, kino, ergot, and various 
other astringent substjinces mixed with a fatty base. 

Stimulaiifig Oinf meats, — Ointments containing a stimulating ingre- 
dient are to be used in the conditions already alluded to in speaking of 
stimulating lotions. They are most essential, especially in the subacute 
and chronic stages of many eruptions. Tar, naphthol, carbolic acid, ere- 
Bsote, thymol, sulphur, the mercurials, chrysarobin and pyrogallic acid, 
are among some of the most valuable agents which can be used alone 
or combined for their stimulating action upon the skin. Great precau- 
tions must be exercised in employing chrystirobin and pyrogallic acid 
aver a large surface, as severe constitutional symptoma may follow from 
♦ Therftpeutic Gaxette, August 15, 1801. 



TREATMENT. 



01 



1^ 



tlie application of the latter, especiiilly after extensive use. Eiesner 
and others have reported marked toxic action from its application. 

The petroleum-fats also can be employed for stimuhititig purposes, 
proriding penetrative action is not desired for any substaucc which 
may k>e mixed with them. 

Oleates.* — The history and origin of this class of remedies, which 
were fir^t pointed out by AttHeld and Marshall, togetlK^r with their 
prt)cesa of niunufacture, their physiological action, and tlicir thi>rapeu- 
tic effect, are fully considered in my little work devoted to thia sub- 
ject. I do not* however, and never did claim, as has been unjustly 
charged by some uriin formed writers, that tlie oleatcs were original 
with rae. An examination of the various psipers I have written, as 
well *13 the book just referred to, will clearly i?how that I make no 
such pretensions. J do, however, claim that my physiological and 
therapeutic investigations are original, as set forth in the contribu- 
tioDB referred to. The oleates, particularly those of arsenic, copper, 
lead, mercory, and zinc, are most valuable remedies, and the professed 
lack of faith in and condemnation of them by a few arc due entirely 
to the fact that they have been used imprn])crly and hastily, and 
erroneous conclusions drawn from imperfect experience with them. 
The following alphabetical arrangement of the oleates, with descrip- 
tion of their therapeutic action, has been extracted from my book : 

Arontfirmt Okate, — Aconitine oleate has a slight locxd action, its 
effect is, however, very feeble ; it can be used in mild cases of ucu- 
raigia, where a weak aua^sthetic impression is desired. 

Atropine Oleate. — Atropine oleate has a mild action upon the in- 
tegument, the toxic etTect of the drug being almost impossible, unless 
it be applied freely over a large surface. 

Aluminium Olmir. — ^Aluminium oleate, melted with an equal pro- 
portfon of lard and some fatty substance, represents the ointment of 
aluminium oleate. It is serviceable in checking the rauco-purulent 
discharges that occur in dermatitis and in eczema. In hj-pcridrosis 
it lessens and frequently removes the excessive secretion, while in 
bromidrosis the fetid discharge will cither be entirely overcome by ita 
use, or ver}' much diminished. It is beneficiid as a dressing in foul 
nIoer8» ab^cesKes, sinuses, chilblains, and burns. 

Arsenicum Oleate. — Arsenicum oleate, melted in the proportion of 
ooe part to dido parts of lard as an unguent base, or one part in four, 
according to the strength desired, forms the ointment of arsenic oleate. 

* Trjinpactians of the Medical S<>ciety of the State of PcmisTtvania, vol. ill, p. 707. 
&?!• papers on oltsntea wifh disciissifm, rt^ad befiirc: ihe Sn'ciian of Phnrraacola^y and Thera- 
p»?ijllcs, Qt the Fiftr-secood Annual Meeting of the Biiti.^h Midical AMt*oc'iatioii, iq the 
, British Medical Journal, October 18. 1884, pp. 749-751. "The Ohatcs/' by J, V, i^boe* 
ik*r, A. M., M. D., Philadclpliia, F. A. Dnvii?, 1885. "EIoniciitH of rhmmacy. Materia 
la, aod Therapeutics," by Willtara Wlntln, M. D., Belfa**!, 1885, pp. SOO, 310. 



92 



DISEASES OF THE SKBf. 



It is bofch a vftluable alterative and an escliarotic, butslioiild always 
be used with caution. Applied to llie normal 8kin, little or no change 
k produced, but when used muderatcly strong on abrasions, wounds, 
and niceratiiig and grannlating surfaces, it acts as an escbarotic, ex- 
citing active inflamniution, i^nd destroying the tissue to sonae depth. 
In uicerating epithelioma it ia one of the very best remedies, by 
reason of its being better borne for a longer period in its application 
than any other form of arsenic. In lupus it is especially serriceable, 
destroying, by its constant use, cell-intiltration in a comparatively 
mild and painless manner. In old ulcers, especially those of a scrofu- 
lous nature, it is of great utility. 

Bismuth Ole(ft(\^^rhe: ointment of bismuth oleate, a pearl-gray, 
soft, bland substanco, possesses an emollient and slightly astringent 
action, and is nsefnl in soothing and relieving cutaneous irritation. 
It is a valuable remedy in all pustular ernptions. It allays and often 
overcomes the high inflammation in erysipela^i and yiinburn. In acne 
and rosacea it soothes the hyperaemic skin, and relieves the engorge- 
ment of the glands, frequently subduing some of the most intractable 
cai?es. 

Cadmium Ohnfe. — The ointment of cadmium oleate has bad as 
yet but little practical use. It is a very strong stimulant, having an 
almost caustic action upon the denuded integument, re.'^embliug in 
this respect very much the jiction of the ointment of nickel oleate. 
It has been used with some advantage in enlarged gland?*. It has also 
been serviceable at times in cases of chronic eczema, with great infil- 
tration, and in exuberant granulations, and old ulcers. 

Cocaine Olvate. — Cocaine oleate (six per cent, alkaloid) has a slight 
auassthetic action upon the integument. The decided effect, how- 
ever, that has been claimed by some from its apjilication to the skin has 
not been observed iu my CAperienee, even after repeated experiments 
with it in operations on warts, corns, horns, cancer, lupus, and the 
removal of superfluous hairs. 

Copper Oleate. — Copper oleate, melted with either four or nine 
parts of fat or lard, gives respectively a twenty or ten per cent, oint- 
ment Applied to the unbroken skin, it has no visible effect on the 
surface, but penetrates deeply into the follicles, causing slight stimu- 
lation. If brought in contiict with the broken skin it has both an 
astringent and stimulating effect, and an insoluble albuminate is 
formed which coats over the surface, thus eupplyiug the place of 
tlie abraded skin. It condenses the tissues, const ringes the blood- 
vessels, and thus lessens the determination of blood to the part. It 
acts as an irritant to any delicate surface, causing inflammation 
aud pain. It is a most effective application to arrest bleeding, par- 
ticularly in irritable sores and indolent ulcers j obstinate granula- 
tions will often yield to it It is an excellent antiseptic, as well as 



A 



TRILlTltEKT. 



93 



isitic agent. Tlie most successful results, hnwcTer, hare 
use upon vegetable parasitic affections, both in my own ex- 
pericnee, and in that of .Sawyer, Harries,* Startin,t and Alder Smith. 

In tinea versicolor, or chroroophytosis, it acta in a decided man- 
ner, rapidly removing the parasite from the surface, as well as from 
the follicles. It is equally effective in favus, which often yields 
quickly to its application. In all vegetable parasitic affectiong to 
which it is applied, care should be taken to avoid the use of water to 
the parts^ which may prevent the copper olcato from penetrating to 
the lowest depth of the follicle, and thus interfere with its action on 
the fungus, 

Copjier oleat^r, melted and spread as plaster, will relieve, and very 
often cure, hard and horny warts, corns, bunions, and thickened con- 
ditioDfi of the epidermi'^ to which it is ap>plied. The ointntent of cop- 
per oleate is a useful remedy for fi*eckles and other yellowish-brown 
or blackish patches of the skin. 

Iron Olrafr. — Iron oleate is readily soluble in fats. It is a \alu^ 
able styptic aod astringent. In the infiammatory form of eczema, in 
which the surface lias become denuded, red, raw, and bleeding, the 
Application of a weak ointment of iron oleate, or the oleute itself used 
in other soothing and slightly a^tringont combinations, will prove of 
the greatest vale, its styptic and astringent action having a very 
happy effect upon the parts. It has a marked action in pustular 
eczema, sycosis, furuncles, and in scrofulous ulcers and sinuses. The 
firet and second stages of acne rosacea are promjitly beneflted and 
often entirely relieved by its application. The lesions that result from 
nrsenical poisoning, especially the pustules and ulcers, are more bene- 
iit€?d by this ointment than by any other remedy that I have used in 
SQch conditions. 

Lead Olmtfi. —Ijesid oleate, melted with equal parts of lard or lard- 
oiJ, gives a cream-colored, semi^solid ointment of the consistence of 
simple cerate. It is more easily and cheaply prepared than either 
Goulard's cerate, or Ilebra's litharge*ointment, or any of the later 
modification"* ; it is more readily absorbed, and is superior to all of 
them. 

The ointment nf lead oleate, when applied to the denuded skin, 
tins both an astringent and sedative action, arresting morbul discharges 
mad allaying irritation. It soothes effectually the intense irritation 
that is often present in papular eczema; it is equally beneficial in 
fltBnrpd eczema of the palmar and plantar surfaces. It is a useful 
Tcmedj in hard and indurated papular acne of the face, neck, and 
back, and in rosacea. 

• BriLi«h ireilical .Toiimal, ?fovenil»r 28, 1885. 

f JVc AD mtcrc^tinp^ papf r on " Oleatp of Chopper in Ringworm," by James SULrtiO| 
of EnglADd, reaii t>eforc tlie WlUan Society, December, 1884. 



DISEASES OF TOE SKIX, 



Mercuric Oleate,— The ointment of mercuric oleate is a yellowish 
chemical combination having a fiitty smell, and an unctuous consist- 
ence. It has a stimulating^ resolvent, and altemtiye action on the 
integument, especially njion tumors, glandular enlargements, indnra- 
tiona, and thickening of the skin. In some old cases of eczema, in 
which the skin ha^ become greatly infiltrated, the twofold action of 
the ointment of mercuric oleate is often attended with happy effects. 
It is an acceptable and, at the same time, benetieial agent in obistinate 
ulcers and indolent papules, tiibcrcleii, and in infilrration attendant 
upon abscesses, in inflammation of the hair-follicles of the beard, and 
scrofuloderma. It can be used with success in excess and deHcieney 
of pigment. It is a useful remedy in both the animal and vegetable 
parasitic affections. In all varietieH of vegetable parasites, it is not 
only effective on the eurfiice, but possesses the power of penetrating 
into the hairs, the follicles, and sebaceous glands, and tlms killing tha^H 
fungus that has passed into these parts. ^| 

Afercurous Ohate. — The ointment of mercurous oleate is very much 
stronger m mercury than that of mercuric oleate — in the ratio of 41 'G 
to 20 '2, or about one and a half time as strong. It has marked stimu* 
lating action bordering on congestion of the iutegument, and has a 
decided resolvent and alterative effect. It is, therefore, applicable to 
the same class of affections in which the ointment of mercuric oleate 
is used, particularly if it is desirable to make a more decided impres- 
sion. 

Morphine O^'a/^.^— M(»ri)hino oleate has, like all the alkaloidal ole- 
ates, a feeble action, and only upon the part to which it is apidied. It 
can be employed in all irritable conditions of the integument, but many 
other stronger sedatives are preferable. 

Nickel Oleate. — Nickel oleate mixed with a fatty base, in the pro- 
portion of from one to sixty grains to the ounce, lias a very decided 
astringent action, almost bordering upon tliat of a caustic on abmded 
stirfaces. The ointment of nickel oleate of a weak strength, from five 
to twenty grains to the ounce of lard, acts at times xqtx well in epi- 
thelial ulcerations. It is often nseful in exuberant granulations and 
in old callous ulcers. 

Qxiinine Oleate, — Quinine oleate, both from phy-'^iological experi- 
ments and from repeated clinical experience, hi^is proved with me of 
little, if any, service. 

Silver Oleate, — Silver oleate, applied in its natural form to the 
abraded skin or sores.* combines with the albumen and fibrin of the 
parts, forming a coat and thus excluding the air. It likewise causes a 
powerful contraction of the blood-vessels, and condenses and super- 
ficially destroys the tissue. Siker oleate sprinkled over ulcers, bed- 
sores, and exuberant gi^anulations, will set up a healthier action of the 
surface. When previously dissolved with an equal amount of oleia 



^^^^^^^^^^^^ TREATMENT. ^^^^^ 1)5 

licidTand then mixed with lard in the proportion of from five to sixty 
gmins to the ounce, it forms a dark-brown, soft, and ]>liitble ointment. 
The ointment of this oleate is a safe and efficacious remedy applied 
over the inflamed surface of erysipelas, or around the margiua, to pre- 
vent the disease from spreading. 

Slrychnine Oleafe. — Stryclinine oleate can bo applied to the integu- 
ment in large quantities and for some time without producing any i^ys- 
teraic action. Its local im|>re.ssion is weak, and it iis a remedy of but 
little value. 

Till Oim/r.— Tin oleate, mixed w^ith lard or a fattv base, in the 
proportion of from ten to sixty grains of the former to one ounce of 
the latter, forms a grayish-brown ointment, possessing an astringeot 
action. It renders good service in papular and fissnred eczema. 
The ointment of tin oleate is of great utility in diseases of the 
nails. It assists in such cases in overcoming the brittle, sjdit. and 
eoft conditions that result from injury to the parts, or that follow 
oertJUD affections of the skin. This ointment, especially when com- 
bined with a little carmine, forms an elegant article of toilet for the 
nails and surrounding parts, giving thera a beautiful lustre. Agnail, 
or the ragged and attenuated skin at the base of the nail, that is so 
frequently observed from neglecting these appeudagei!, can be relieved 
or checked by it 

Yeratrinc 0/m/r.— Voratrine oleate has a valuable action as a coun- 
ter-irritant when used upon the integument. 

Zinc Olca/f*, — Zinc oleate occurs as a fine, pearl-colored powder, 
irith a soft, soapy feel, very much like powdered French chalk. It Jiaa 
both an astringent and stimulating action. In hyperidrosia and osmi- 
dnjsis, or excessive sweating, fetid or otherwise, it k one of the very 
best remedial for topical use. It is especially applicable to those who 
iuffer from an increased flow of sweat around the axillsB, genitalia, and 
palmar and plantar surfaces. Dr, AVilliam Murrell, in the ** London 
Medical Record/' of November 15, 1883, also calls Httontion to its 
value in local sweating. He reports that when mixed with thymol (1 
in 5(H)), and used as a dusting-powder, it forms an excellent applica- 
tion in many varieties of local sweating. 

In acute vesicular eczema, in which the parts become covered with 
small vesicles, swollen, hot, inflamed or raw, weeping, and attended 
with intense itching, the combined protecting, astringent, and stimu- 
lating action of the zinc oleate will usually cause all the infiammatory 
ajmptomd to abate, the discharge to dry up, and the swollen skin to 
le^me itB normal condition. Dr. McCall Anderson has referred to its 
ntility in eczema, especially of the nares, in an article published in the 
"Journal nt Cntaneous and Venerea! Diseases." The great advantage 
and value of the zinc oleate among the same class uf cutaneous affec- 
trons have been referred to by Dr. James Sawyer, in a commuoication 




I 



|)4j DISEASES OF TUE SKIN. ^^^^^^ 

to the'* British Medical Journul," of February 10, 1883, and also in 
another to the *' Birmiiighuin Medical Review/* pMblished a year later. 
It forms au excellent and useful toilet powder for ladies who are 
truwbled with shining faces or seborrho^a oleosa, dusted over the parte 
either aiooe or mixed with an equal tjuantity of arrow-root, bismnth 
subnitrate, or lead carbonate, and scented with the oil of verbena or 
rose. It likewise act^ in an efficacious manner on an inflamed sur- 
face that is hot and tumid ; in cases of erythema about the groins and 
axilbe ; and is also beneficial in her])cs autl herpes zoster. One part 
of the powdered zinc oleate melted with four parts of a fatty vehicle 
yields the ointment which can be used in the same class of affections 
just enumerated, and in acne, rosacea, and in aubacute and chronic 
forms of eczenui.* 

Sulpholeate of Sodium.— Br. Fox, of New York, has called atten- 
tion to this substance as a local remedy. Sulpholeic acid is obtained 
by slowly mixing without the aid of heat sulphuric acid with any fixed 
oil or fat. The result is a thick and viscid mass of a brownish color and 
strongly acid reaction. By slowly adding a solution of carbonate of 
sodium to this mass and constantly stirring, the stdpholeate of sodium 
is formed. The combination has a nearly neutral reaction, is a bland, 
oily fluid, and contains about thirty percent, water, which is easily ex- 
pelled by evaporation. It is very niiscible with water, is rapidly ab- 
sorbed by the skin, and is an excellent solvent for many drugs. It 
dissolves at least two per cent of sulphur or chrysarobin. This com* 
pound may bo ai>plied to the skin as a liniment or, mixed with gelatine 
and sprejid upon muslin, as a plaster. If its water is driven oflf, its ap- 
pearance and consistency are similar to those of vaseline and it may be 
employed as an oiutmcnt basis. 

ABSBSthetics.— Applications can be made to the skin for the purpose 
of benumbing or suspending the action of the sensory nerves, either to 
allay great local irritation from disease, or to avoid pain in minor oper- 
ations. Rbigolene has been specially recommended by Richardson for 
its local anaesthetic action. In bums he relieved rapidly the pain by ap- 
plying on cotton-wool a combination consisting of camphor and 
spermaceti, each one drachm, mixed in two ounces of rbigolene. Chloro- 
form and ether applied to the skin act as local anaesthetics. The for- 
mer can be brushed over the surface with lint, and often relieves tlie 
intolerable itching of some of the neuroses, as occur, for instance, in 
panesthcsia ; and it is also useful for the same elToct in urticariiu 
Ether is better employed with a spray, and is applicahie in operations 
on the integument. Ice applied for some time to the skin, or cold 
lotions, wall produce an anaesthetic action similar to ether ; vcratrine 
ointment, thirty to sixty graius to the ounce of lard, often benumbs 

♦ See report on " Ole^ite of Zinc in Eczemn;' by I>r. A, A. Wells, Boston, Muss*, 
in the New Englwnd Medical Munthly, January, 1885. 



TREATHBNT. ^f 

the sensibility of the skin, and may be resorted to also in some of the 
neuroses. 

Another yalaable local anfesthetic is cocaine hydrochloratef applied 
directly to the part in the form of a lotion or injected nii«ler the in- 
tegament; employed upon the unbroken skin as a lulion, it produces 
little or no impression, but upon a denuded surface, in from a two to a 
five per cent solution, it often has a good effect Tiic local anies- 
thetic action of this remedy as a lotion is most marked in eczema of the 
mncons outlets, burns, cancer, syphilis, herpes, herpes zoster, and other 
painful and inflammatory affections. Murrell, liiuger, and others 
have demonstrated its decided local anesthetic action upon the skin 
when employed hypodermaticiilly. Brock and Arkic, house physicians 
to Ringer and Wilson Fox, reported in the "Loudon Lancet "most 
marked effects from hypodernuitic injections upon themselves of from 
one twentieth to one half grain of hydroclilorate of cocaine, and have 
obtained good results from one twentieth to one tenth of a grain in 
cases of herpes zoster. 

Carbolic acid and crcasote in weak solutions arc also pronounced 
ana^thetics. Alcohol and menthol, alone or combined, and the tincfc- 
are of aconite and the ointment of aconitine, are likewise useful, but 
the latter should be applied with caution, Dobisch recommends spmy- 
ing the parts with a mixture consisting of chloroform, ten parts; ether, 
fifteen parts ; and menthol, one part. Aniesthesia results in one minute, 
and continues from two to six minutes. 

Plasters. — The use of simple or medicated plasters is a desirable 
means of keeping various medicinal substances in continuous contact 
with the skin. They are particularly adtiptcil to chronicj and local- 
ized forms of skin diseases. They fulfil the triple purpose of protec- 
tion with compression and medical application at the same time. They 
are likewise cleanly, and can be used upon certain regions, us the lips, 
bands, and feet, where it is ahnost impossible to secure the continuous 
application of ointments. In fissured eczema of the lips, palms, and 
Bolea^ common adhesive, opium, belladonna, lead, and salicylic-acid 
plasterd are all useful. They often heal fissnres of these part^ after all 
other applications have completely failed. Aconite, aconite and bella- 
donna, Peruvian balsam, bryonia, and soap plasters are serviceable in 
trost-hiUsB, Mercurial and copper plasters act happily in local spots of 
scrofula, keloid, wart.^, burns, corns, and callosities, Witch- 

»1, hemlock, and ammoniac and mercurial plasters are useful in 

inic eczema and psoriasis. Ergot, iron, lead, arnica, asafo?tida, 
and Phytolacca plasters are beneficial in indolent ulcers and bed-sores. 
Optmn and arnica, opium and belladonna, and soap plasters often 
TBloable in boils and carbuncles. Opitmi and iodine plaster fre- 

itly assists in removing deep spots of infiltration, especially in 
^qrphilitic sabjects, 

r 



DISEASES? OF THE SKIN. 



Antiparasitics. — This class of remedies destroys both animal and 
vegetable purasites of the skin. 

The mercurials are, no doubt, the most potent of nil medicines in 
their effective action on all forms of parasitic life. The best prepara- 
tion of mercury to employ is, perhaps, the oijitment of mercuric oleate. 
Tlie corrosive chloride, tlie mild chloride, the ammoniated, the red 
sulphuret, the yellow oxide, and the yellow sulphuret of mercury are 
also useful. 

Chhrinnit'd oil, or olive-oii saturated with chlorine, is Bcrvieeable 
in scabies, acting without irritating the skin. Pernvian balsam, sty- 
rax, and sulphur are valuable for scabies, and cocculus Indicus andi 
staphisagria for pciliculosis, Copj)er, in the form of the suljdiate, or 
better the oleate, ia a good remedy for cxtermiuating vegetable piira- 
gites, especially ringworm, favus, and tinea versicolor. Boric acid 
and alcohol also hold a high place in the treatment of the latter ehids 
of diseases. Among the many other antiparasitic remcilies wliich may 
likewise be employed are sulphur, sulpliito of Bodium, hyposulphite of 
sodium, sulplvuret of potassium or lime, salicylic acid, naphthol, thy- 
mol, chrysarobin, Goa powder, creasote, carbolic acid, tar, croton-oiJ, 
cantharidcs, and iodine. 

Caustics or EscharotiDS. — These are agents which destroy the tissue 
with which they come in contact, mainly by abstracting moisture from 
it. The mineral acids, particularly nitric, hydrochloric, and sulphuric, 
are generally nsed, and are very certain in their action on venereal 
sores, warts, and iudolent ulcers, ""i'lie acid nitrate of mercury is espe- 
cially valuable for application to all venereal growths. The painful 
effect of nitric acid is said to be lessened by saturating a small quan- 
tity of it witii hydrochlorate of cocaine preparatory to ajiplying it to 
the skin. Chromic acid is also a caustic which Inis a mild but useful 
action in growths on mucous surfaces, and is serviceable in ulcerations 
of the tonsfuo, the buccal cavitv, and other mucous outlets. Lactic 
and glacial acetic acids have recently been employed with good result 
in epithelioma and like morbid growths. Probably one of the most 
effective of all caustics used at this time is ethylate of sodium. It htis 
a deep and penetrating action, abstracting rapidly the water from the 
tissues, especially if the surface to which it is applied has been denuded. 
It is beneficial in lupus, epithelioma, na-vi, and in various ulcers. 
Caustic potash in the solid form, or as a solution, is endowed with 
powerful destructive action, and sliould be apjtiied with caution. It 
can be nsed either alone or in combination with lime or other sub- 
stances. The chloride of zine and arsenic are two effective escharotics 
which may be employed alone or mixed with other remedies to form 
many of the caustic pastes. They are both very iminful applied in 
lupus, the various forms of cancer, and in old ulcers. The great ad- 
vantage of arsenic, however — which can be nsed either as a powder or 



aildc'd to some fatty base — is its property of acting upon morbid in 
preference to healthy tissue. It has the disadvantage of sotnetinios acU 
iug slowly. There are a number of agents wliit'h are to he reeominended 
for snperliciol caustic effect, such as sajio viridis, the merciiriuls, espe- 
cially the corrosive chloride, acetate and sulphate of zinc, acetic acid, 
oollodion, iodine, and carbolic acid. The external hijer of the skin, 
the epidermis, when necessarv, may be destroyed by one or the other 
of the last-named remedies. 

The following liave also been shown to have some special local ac- 
tion in diseases of the skin : 

Hydrasttne Hydrochlorate.* — This salt combines well with water, 
aleoliol, or fats, and 1 have experienced good results from it in hyperi- 
drosis, seborrho^a, acne, eczema, and in ulcers. Ten to thirty grains of 
hydrastiue hydrochlorate in five ounces of water or distilled extract of 
witch-hazel have a beneficial action on excessive secretion about the 
axillary or inguinal regions and on the palmar and plantar surfaces. 

This solution likewise removes the otfensive odor of bromidrosis. 

Weak alcoholic or aqueous solutions of it also act well in M^borrhcsa 
BOCa and acne. From five to thirty grains of the salt incorporated in 
HR ounce of fatty substance is a good ajjplication in chronic eczema 
and in scrofulous and varicose ulcers, and allays the fetor of ])hage- 
dffitiic and malignant ulcers, Hydrastine ointment may also he bene- 
ficially Hjiplied to fissured nipples and chancroids. 

Erythroxylou Coea.t — The fluid extract and the extract of ery- 
throxylon ccKia, I have found, after a thorough trial, will produce a 
sedative action upon irritable conditions of the integument. The fluid 
extract can bo used alone or eondjined with oil, glycerine, or water ; 
one bo three drachms to the ounce of either w*ill be useful In acute ec- 
zema, demiatitis, herpes, rosiicea, and urticaria. The extract is best 
employed mixed with some fatty substance in the proportion of one 
half to two or more draclims to the ounce. It is applicable to the same 
I'lass of affections referre<l to above, and also in neuroses of the skin, 
particolarly parsesthesia. 

The active principle, cocaine, in the form of cocaine hydrochlorate, 
13 an fidmirable local ai»|ilicatiun to burns, erystpehis, fissured eczema, 
herpes zoster, imtable ulcers, and is useful in allaying the pain of ul- 
cerated epithelioma. It may be employed in aqueous solution or as an 
ointment, rubbed up with lanolin or other suitable exeipient. 

NaphthoLJ — Naphthol is probably the most effective topical remedy 

*SnB piipcr by the author on " llydra'^tis and Hydmstino TTvtlroohlomte in 
MwMi of (he Skin," Drugs and MedUinea uf North America, C'inciiinuti, Septem- 
ber. 1885. 

t The Medical Bulletin, December, 1884, Pbiladclpliift. 

I Soe fwper by the author on •* Naphthol ; its Mfdiritial Use and Value," in 
Jimniid of I be American Medical Association, Novemijer iJ, IBt^J. 



t 



I 




DlSEAiSES OF TOE SKIN. 



of all substancea recently introduced. It is a deodorant, and lias a 
stimulating, followed by some an[estlietic action upon the skin. This 
effect can easily be demonstrated by rubbing tlie sensitive ends of the 
fingers tbrongh a quantity of naphthol for a few monients, when a 
numb feeling will soon be experienced. It also possesses useful de- 
tergent and deodorant properties. Scabies, pediculosis, and all animal 
parasitic diseases are not only relieved by application of lotions or 
ointments of naphthol, but they nve frequently cured. It is for these 
affections the most certain of all the remedies which we possess. 
Naphthol* is likevFise efficacious in the different forms of tinea. It 
relieves itching in nrticarin, paresthesia, pemphigus, and prurigo, and 
is of value in the treatment of acne, sycosis, alopecia circumscripta, 
and both forms of lupus. To wounds, ulcei*s, chancres, and chancroids 
this substance is a beneficial application. The fetor of cancer is mip- 
pressed by the use of naphtliol. It may be used in the form of pow- 
der, solution, or ointment, according to the nature of the case. Naph- 
thol is practically insoluble in water, hut dissolves freely in alcohol, 
ether, chloroform, and fixed oils. Cantphorated na])hthol, a creamy 
fluid made by nibbing together one part of naphthol and two parts of 
camphor, is a good antiseptic dressing for wounds and ulcers. Naph- 
thol used in the form of a five or twenty jier cent, ointment lessens the 
infiltratton and itching of chronic eczema. It produces equally good 
results in chronic psoriasis. It can also be employed combined with 
talc, starch, or other powdei-s, in excessive sweating or foetid |)erspira- 
tion in al! parts of the body, with the most happy effect. Naphthol 
can be added to ointments in the proportion of one to ten grains to 
the ounce for the purpose of simply preserving them— as it will for a 
very long time— from decoinposition. Toxic effects will not follow, as 
I have shown, from either the internal or external use of properly pre- 
pared naphthol. 

A compound of ^-naphthol and mercury has been recommended &3 
an ideal antiseptic, though it does not seem to have made its way into 
general nse. This substsince occurs in the form of lemon-yellow crys- 
tals or powder, is neutral and odorless, insoluble in the usual solvents. 
It contains 30*8 per cent, of mercury, and may be applied as an oint- 
ment or, rubbed up with white of egg and water, as an emulsion. 
Naphthol-inercury is an excellent stimulant to chronic ulcers, abscesses, 
sinust5S, etc. Favorable reports have been made concerning its internal 
administration in syphilis, 

Ichthyol.t— Ichthyol, which is a substance having the appearance 
of tar, with an odor of gas, was brought to the notice of the profession 

* See piiper by llie niithor, ThpriipfuHe Gazette, October lo, 1880. 

f Ichthyol is aLso useful sometimes administered internally in chronic eczema, 
pBorii^is. and other cutftucoua diBMses. The do«e is from two to ten drops three 
ttmes a duv. 




TREATMENT. 



101 



» 






through Unna, of Hamburg. It is procured from a bituminous rock 
in the Tyrol, which is said to contain deconiposod animal material. 
It contains, according to Schmidtj* carbon, 55*05 ; hydrogen, GOfJ ; 
gulphnr, 15-27; sodiuin, ^'TS; oxygen, 15'S3; and combines well with 
adcohoU ether, and all fatty substances. It has a similar elTeet to that 
of both salphur and tar, with often even a more decided and beneficial 
•t'tion. Unna states that it will not pro*Uice ordinarily in chrojuc 
akin aflfeetions, in which it is a useful remedy, imy irritating action. 
But this aasertion requires qualification, for I liave, not infrequently, 
Been it irritate the integument. Nor is it, in generjil, well absorbed 
acoarding to my experience. In from a live to a thirty per cent. 
mntment it is serviceable in psoriasis, eczema, rosacea, furu nonius, 
lichen, keloid, and ichthyosis. 

Ichthyol is serviceable in that stage of acne which demands stimu- 
don, and has been used with advantage in frost-bite, burns, and nlcers, 
hia remedy will sometimes ameliorate urticaria and para^sthcsia and 

y be a good dressing in erysi]>elas. In the last-named affection it may 
be used as an ointment or dissolved in a mi:xture of ether and glycerine 
or ether and coUmlion. 

Sinclair reports a deep stupor following its application in an infant ; 
this case, however, recovered. 

Thiol, a substance of similar chemical composition to ichthyol, has 
been intro^luced as a substitute for the latter substance. Thiol is a mixt- 
ure of sulphuretted hydrocarbons rendered soluble in water by treatment 
with sulphuric acid. It is estimated to contain about twelve per cent. 

Rof sulphur. As made by Riedel, it occurs in the form of a soft gray pow- 
der or as a watery solution, of the consistence of a thick sirup. The 
powder is obtained by evaporating the liriuid. The compound is de- 

tToid of odor, and can easily be removed from the skin or clothing. 
The powder is an excellent absorbent for use in moist eczema, erythema 
muhifomje, erysipelas, burns, and pemphigus. Prof. Sehwimmer ob- 
tained especially good results in dermatitis her|iotiformis and herpes 
»o«ter from a ten-per-cent. solution painted twice daily upon the affected 
parts. The liquid is likewise serviceable in papular and pustular 
eczema. In acne and rosacea good results have attended the use 
ihe same remedy. 

Thio-resorcin, a sulphur substitution-compound of resorcin, an 
ber*yellow crystalline body, without odor, has been used as a substi- 
te for iodoform in the dressing of wounds. This substance is insolu- 
•le in wat<?r and only partially Boluble in alcohol and ether. 

TameiloL^ — A substance bearing this title has recently been discov- 

red by Spiegel, and has been closely studied by Keisser, who recom- 

nds it aa of value in certain affections of the skin. Tumenol is 

to ichthyol, and, like the latter, is obtained from mineral oils, to 

• The Therapeutic Gazette, June 15, lb80. 



102 



DISEASES OF THE SEIN. 



which circumstance it owes its name, au amalgamation of bitumen and 
oleum. The impure mother substanne occurs among the unsaturated 
hydrocarbons of tlio oik, and U separated by tho additioti of Bulphunt 
acid, a process of eulphonation taking place with the production of 
compound which contains tumenol sulphon and tumenol sulphonie 
acid. Tliese are scparulcd by j»roccssc8 unuccc«sary to repeat here, and 
it is the af|Ucoufl s(»hition of the latter substance with which Neisser 
has experimented* He has used it in the form of solution in sul- 
phuric ether and alcohol, as a powder, ointment, or plaster, and has 
found it beneficial m acute eczeuia accompanied by weeping, erythem- 
atous and bullous burns, partesthesia, and guperficial or deep ulcera- 
tion, 

Jequirity.* — This vegetable bean, when propei'ly prepared, has a 
powerful action upon morbid conditions of the skin. 1 herewith give 
my method : Two hundred grains of the beau are decorticated by being 
slightly bruised and cracked in a mortar; the red hulls are then care- 
fully picked from the cotyledons, phiced in a bottle, and covered with 
water. They are thus macerated for twenty-four hours, after which 
they are again transferred to a mortar and thoroughly triturated until 
they are reduced to a smooth paste, when sufficient water is added to 
make the whole weigh eight hundred grains. Prepared in this man- 
ner, the product has the appearance of au emulsion, and can be eai?ily 
applied to the diseased surface. It is painless on ap|>Ucation, but very 
soon seta up irritation and severe local innammation, and at time^ 
8onie systemic symptoms, as lieudache, pains through the body, ele- 
vated temperature, and high puhse. In from twelve to forty-eight 
hours the inflammatory jietion becomes most abundant A cuirass- 
like crust soon forms, followed by a free flow of pus. In the course 
of five or six days the discharge lessens, the crusts may become gradu- 
ally detached, or can be removed by suitable dressings, exposing a sur- 
face studded with healthy granulations wliich before the application 
nniy have been the seat of exuberant ones. The virtue of the remedy 
is in its puwer to destroy the latter. I have therefore found it to be 
of the utmost value in specific ulcerations, indolent, scrofulous, and 
epitheliat ulcers, and in ulcerating lupus. In truth, it is a powerful 
remedy in unhealthy and granulating surfaces, on which it exercises a 
destructive change, and favors the development nipidly of healthy tis- 
sue. It should, owing to the erysipelatous inflammation and constitu- 
tional symptoms which it may occasion, be applied with caution in weak 
and irritable patients. 

Gelatine.^The use of white gelatine dissolved in twice its weight 
of water, by means of a water-bath, and spread upon diseased parts of 
the skin, has been recommended by Pick, of Prague. The solution 

• " Jcquirity ; Its Use in DIsenses of the Skhi," by tho author. See Transactions 
of the Medical Society of the State of Pentisylvaiiia, vol xvl.. pp. 25»-267. 



TREATMENT, 



103 



is a useful vehicle for suspending chrv'sarobin, mercury, naphth<»l, and 
other remedies for a more or less coiitiniu^d applieiition to tlie skin. It 
is valuable la limited chronic affections^ esjjccially in piruriusis and 
eczema — the medicated gelutine solution forming not only a protection 
for the skin, hut at the sauits time having, through the contained drug, 
valuable ueliou upon it. 

As a result of his experimonti!, Unna states that thin layers of gela- 
tiDe or collodiou augment perspiration, lie, therefore, considers the 
application of gelatine useful in fever, diminishing temperature and 
relieving the kidneys, 

Gchitine preparations are largely used by UuTia. For a general 
basis he employs a zinc gelatine, which may he made harder or softer 
by van'ing the proportions of its ingredients. His iiKual formula calls 
for fifteen parts each of zinc oxide and gelatine, twenty-live parts of 
glycerine, and forty- five parts ol water. Other substances may be added 
to the mixture, according to indications. For eczema attended with 
excessive itching, the incorporation of two percent, of ichthyol or five 
per cent, of the extract of cannabis Indica is recommended ; for pruri- 
tas, the addition of cannabis Indica, chloral hydrate, carbolic acid, 
camphor, salicylic acid, etc. 

Pa^es. — These preparations are similar to ointments, but of a firmer 
consistence^ owing to the large proportion of powder which they con- 
tain. Both mineral and vegetalde substances are used in the making of 
pastes* Among minerals the oxide of Kinc, cartjonate of calcium or 
magnesium, and talc are most fre<|Liently employed, while those de- 
rived from the vegetable kingdom are starch and lycopodium. 

Pastes, like ointments, protect tlio surface from atmospheric con- 
tact, and have the additional advantage of absorbing the secretions of 
the diseased part. They should be gently rubbed with the finger upon 
the affected area, and spread upon the epiderm in a moderately thick 
layer. This class of local remedies was introduced by Laasar and 
tJuna, and is particularly adapted to the treatment of certain forms 
of eczema. Unna* has lately compounded a number of pastes having 
as a basis bassorin (an ingredient of tragacanth and other gums), 
cafieiu, castor-oil mixed with shellac, collodion, or lead, etc. With 
these mixtures may be incorporated various medicaments efficacious in 
the treatment of diseases of the skin, such as oxide of zinc, sulphur, 
aalicylic acid, resorcin, chrysarohin, etc. 

Formula^ for some of these pastes are given in the body of this book. 

Outta-Percha. — Auspitz recommended one part of gutta-percha 
with ten of chloroform as a permanent application in the same class 
of affections as mentioned in the paragraph on gelatine. The solution 
eo prepared is known as trauraaticin, and various drugs may be mixed 
with it and applied to the skin. 

♦ Thempeutische Monatshefte, November, 18©1. 



jjlj 



104 DISEASES OF THE SKIN. 

Resorcili- — ^Tlns drug is frequentlj of utility in benefiting the skia 
or leading to a cure of many of iU diseases. It can be employed either 
in the form of a powder, sohition, or ointment. Good effect may follow 
from the application of the powder to ulcers, epithelioma, the open lesions 
of syphilis, and siaughing wounds. CavSes of complete cicatrization of 
epithelioma by resorciu have been reported by Luciaui, Antonio, and 
Chaaseand. Resorcin destroys the offensive odor of carcinoma, aud is a 
Berviceable local remedy in variola, erysipelas, anthrax, psoriasis, and 
lupua erythematosus. Dr. M. I hie,* of Leipsic, reports that it is espe- 
cially a good remedy as a disinfectant, by destroying tlie germs of dis- 
ease, lie has used it effectively in heriM3s tonsurans, in parasitic sycosis, 
and in wounds and ulcers. 

He prefers to use it in the form of a paste, which I have modified, 
as follows : 

5 Resorcini puri Z ijss (lO'O). 

Ungt. simpiicis Z xiij (50*0), 

Zinci oxidat., 

Amyli. . , , ,,.,>,.. ua 3 vj (afi 25"0)- 

M, ¥L pasta. 

lie also suggests the following, made of resorcin, and recommends 
it spread on a piece of flannel and used in alopecia areata and sebor- 
rba^a, attended with falling of the hair; 

5 Resorciui piiri gr. Isxvij-cliv (5-0-10'0). 

01. rieini .f 3 xjss (45-0). 

Spirit, vini f 5 iv (150-0). 

Bals. Peruvian gr« vtij (0*5). M. 

Besorcin is also usefnl in tinea versicolor and iu eczema margi- 
natum. Pointed condylomata may be removed by a salvo contain- 
ing fifty to eighty per cent, of the drug, applied daily* Resorcin 
may be irritating to the healthy surrounding tissue, which shonld be 
protected on its application to the diseased part. Wlicn pure it is 
white in color ; impure, it assumes a yellow appearance and is useless 
for application. 

Hamamelis^t— Witeh-liazcl is a valuable remedy to employ either in 
the form of the tincture, the fluid extract, or the extract. It can bo 
used alone, diluted with water, or the extract can be combined with 
some fatty vehicle. Hamamelis has both an astringent and a sedative 

♦ MoniUscb. L pr. Dermat., 12, 1880. Mtdicul ami Surpcal Reporter, April 17, 
ISm, p. 501. 

t Hamamelis oft4?n acts with good effect given inlL*rnaIly— iii acute and sub- 
acute eczema, erysipelas, psoriasis, and varicose ulcers. S<?e paf^ers by the author, 
on "Hanmnielis," read before the Section of Thempeiitics, British Medical Associa- 
tion* Brighton, August, 1886. "Hamamelis in the Treatment of Diseases of tlia 
Skin/' read before the Section of Dermatology at the meeting of the Association 
of German Naturaliiits and Physicians, helt] in Berlin, September, 1886. The Med- 
ical Bulletin, December, 18SG- 



TREATMENT. 



105 



action on the tissnes, and will often lessen inftamniatory action in the 
part to which it is applied. It is a remedy of much value in eczema, 
erysipelas, rosacea, seborrhcea, and varicoge ulcers. 

An oiniment of hamamehs is a usefii! dressing to burns* The di- 
luted fluid extract is of value in hyperidrosis, carbuncle, and chancroid. 

CluysarobilL— This substance is obtained from Goa powder, and is a 
mixture of proximate principles, having an orange-yellow color and 
being free from odor. It is insoluble in water and alcohol, hot solu- 
ble in ether and alkaline soliitiona. Chrysarobin ointment is decidedly 
irritant to the healthy skin, and eommiinieates a yellowish-brown stain 
to both skin and clothing.* The color may be removed by means of a 
weak solution of chlorinated lime or soda. (Iin-siarobin also excites 
conjunctivitis if accidentally brought into contact with the eye. 

Chrysarobin is principally employed in the treatment of psoriasis, 
in which it is one of the most efficient local remedies at an command. 
The officinal ointment is too strong for general use. Chrysarobin is 
likewise a useful application in chronic eczema, lupus vulgaris, rosacea, 
and tinea trichophytosis. 

Anthrarobin. — A compound related to chr}*sarobin and known as 
anthrarobin has been introduced by Liebcrmaun, a chemist of Ber- 
lin, as a substitute for the former substance. Anthrarobin is a j^el- 
lowigh powder, slightly soluble in chloroform and ether, but freely 
soluble in alkalies and alcohol. It produces less irritation and stain- 
ing than chrysarobin. Anthrarobin hiis been used locally witli suc- 
cess in psoriasis, chronic eczema, tinea versicolor, and tinea tonsurans. 
It is employed in the form of a ten*per-cent. ointment or sultitioji in 
olcohoL 

SaUeylie Acid, — Thi^ substjince is valuable on account of its anti- 
septic and germicidal properties and its power of softening the epiderm. 
It hkewise allap pruritus. Salicylic acid is a serviceable application 
in chronic eczema and psoriasis, bromidrosis, sloughing wounds or 
olcers, and in open cancer. In tinea versicolor and the diiTerent forms 
of tinea trichophytina it may be applied with benefit. Salicylic acid 
removes freckles and is somtimes of benefit in lupus viilgaris. This 
remedy may be used in the powder form, iis an ointment, dissolved in 
collodion or mixed with gelatine and glycerine. The powder requires, 
as a rule, to be dilute I with rice^ chalk, talc, or other inert substance. 
The ointment may be made to contain from five to sixty grains to the 
"ir-e. An ointment of sal icylated camphor, containing eleven parts 
' f the acid and fourteen parts of camphor, is a useful dressing to un- 
healthy, syphilitic, or malignant ulcers and lupus. 

Salol is likewise an excellent application to chancroids, chancres, 
common or syphilitic ulcers, wounds, burns, impetigo, and eczema 
pogtuloflum. It is generally employed as a dusting-pov^rder diluted with 
etarch. 



Iftf 



DISEASES OF THE SKIN. 



lodofonn.—Tho antiseptic und ana?sthetic properties of iodoform 
i-ender it a \erv valuable application in many diseases of the skin. 
This substance is etticient, not by destroying the micro-organisms of 
disease, but by rendering the tissne upon which it is spread an unfav- 
orable soil for bacterial development It is probably also able to coun- 
teract the effect of microbian products. 

Iodoform is a decidedly beneficial topical renledy in variuus inflam- 
matory conditions, especially after suppuration or ulceration has oc- 
curred. In chancroidal bubo or in scrofulous adenitia it may prevent 
the formation of pus or degenerative tissue changes. It may be lightly 
powdered over the affected surface, spread upon the integument in the 
form of an ointment or, mixed with oil or glycerine, be injected into 
the focus of inflammation. If tissue has been destroyed the granula- 
tions are stimulated and sterilized by a covering of iodoform. Ulcer- 
ated bubo, chronic iileera of the leg, scrofuloderma, and bed-sores are 
markedly improved by tlie use of this agent. In abscess, ecthyma, 
furuncle, and carbuncle it is of no less service. Iodoform luis been ex- 
tensively and successfully employed in the treatment of venereal ulcers. 
This substance is one of the best applications to chancroids and is of 
particular efficacy in phagedania. 8y|diilitie lesions also are amenable 
to itd inlluence. Open chancres, moist papules, nlcerated tubercles, 
and the ulcers of the tertiary form are very advantageously treated by 
means of the compound under consideration. It is likewise a valuable 
remedy in burns. The exposed surface is protected from the attacks 
of micro-organisms, while at the same time the dressing acts as a hx^al 
anfPsthetic and reduces suffering. To the open lesions of lupus vul- 
garis iodoform is a beneficial application. The pain of ulcerated car- 
cinoma is api)reciably assuaged by means of this agent. The applica- 
tion of iodoform is at times attended by satisfactory results in chronic 
eczema, and lias been advised in prurigo. 

The forma in wliicb iodoform has been used as a local remedy 
have been already mentioned. ''Jlie particular metliods according 
to which it is employed in the various affections to which I have 
alluded will be detailed in the sections on the treatment of those 
d iseases. 

Notwithstanding the inuleniable efficacy of this substance in a 
variety of conditions, two serious drawbacks attend its use. The first 
consists in its peculiar, penetrating, and offensive odor. Many ex|>e- 
dieuts have been devised for the purpose of overcoming this character- 
istic property. The combinations which have proved most successful 
are enumerated upon a subsequent page, A more grave objection is 
the toxicity of iodoform. Its absorption may be followed by prostra- 
tion, headache, faintness, elevation of temperature, delirium, suiciihil 
mania, or death. In eases ending fatally the kidneys, liver, heart, and 
voluntary muscles have been found in a state of fatty degeneration. 






TREATMENT. 



ll>' 



Circnmgpecfcion, therefore, Bhouid always be observed in the employ- 
Bient of tlii^ potent drug. 

lodoL — This com pounds which contains about ninety per cent, of 
ine, was introduced as a substitute for iodoform. lodol is almost 
nsoliible in water, soluble in chloroform, ether^ and fiitty oils. It is 
destitute of odor, alowly absorbed but rapidly eliminated, and ia much 
less apt than iodoform to produce toxic effects. It has been given 
with advantage internally in doseB from one quarter to live grains for 
he manifestations of scrofula and tertiary syphilis. lodol has cliiefly 
n used, however, as a topical remedy. This substance is destructive 
lo microphytes, and is therefore etiicacious in diseases attended by sup- 
uration as well as in those whieh depend upon the growth of a vcget^i- 
le parasite. Venereal, syphilitic, or common ulcers, lupus, impetigo, 
uruucle, and carbuncle are benefited by the applicittiun of iodol. In 
la it moderates the intensity of tlie eruption, is an excellent dress- 
to enlarged or degenerated glands, and is of service in psoriasia. 
Iwlol has been employed with success in tinea tonsurans. 

I lodol may be used as a dusting-powder, an ointment, or in solution. 
One part of iodol dissolved in sixteen of alcohol ami thirty-four of 
glycerine constitutes an excellent preparatioTi for local use. 
Aristol. — ^In this substance we have another excellent antiseptic and 
germicide, which has already proved itself a valuable addition to our 
therapeutical resources. Discovered in 1.S80 by Messinger and Vort- 
roann, of Aix-la-Chapelle, it was first employed clinically by Eichhoff, 
of Elberfeld. Aristol is a compound of iodine and thymol, containing 
45*8 ]ier c£*nt. of the former substance. It is a soft, fawn-colored pow- 
der, having a faint and not uiipleasaiit odor. It is insoluble in water 
and glycerine, but readily soluble in ether, chloroform, fi.xed oils, and 
li<^uid petroleum. It adheres readily to the surface of the skin, wound, 
or ulcer, is a mild stimulant but not a decided irrihiut, and possesses 
some local anesthetic power. It stimuhites the absorbent vessels, though 
it is not itself absorbed by skin, nuicous membranes, or raw surfaces, 
and therefore exerts no toxic action, 

Aristol promotes the absorption of inflammatory exudates, and is a 
useful application in thickened conditions of the integument It ia of 
special service in the treatment of varicose-leg ulcers and the ulcers of 
late Hvphilis. In ulcerated lupus, likewise, it ia of decided benefit, but 
IB naeless while the skin ia still unbroken. Spread upon chancres and 
ulcerated buboes, it hastens cicatrization. It not infre^juently causes 
retrocession of enlarged lymphatic glands, and promotes absorption 
after degeneration has occurred. Aristol is efficacious in ulcerated 
epithelioma. This remedy is of avail also in the treatment of burns, 
tcalds, frost bite, squamous and seborrhoeic eczema. In psoriasis it 
is of eqoal value to chrysarobin, though less rapid in its action. Its 
eidal property renders it useful in tinea trichophytina. Aristol 



108 



OF THE SKI 



is also productive of benefit in hyperidrosia and bromidrosis, in acne, 
and rosacea. 

Thia substance may be employed as a dns ting-powder either alone 
or combined with tlio impure carbonate of zinc or subnitrute of bismuth, 
or as an ointment, ttu per cent, or more being rubbed up with any 
suitable excipient. 

Peroxide of Hydrogen.-— This compound, in the fifteen-volume so- 
lution iis prepared by Charles Marchund, of New York, id a very effi- 
cient oxidizing and antiseptic agent. Its special value consists in its 
power of decomposing pus. When ])laced in contact with pui? it ciiuses 
a frothing, the cessation of this action indicating that the pathological 
product has been destroyed. 

Tliia fluid is a simple, cleanly, and efficacious application to ulcer- 
ated Burfaces. In the management of many diseases of the skin at- 
tended by suppuration and destruction of tissue, lotions of Iiydrogeu 
peroxide are of decitled service^ as in the suppurative stage of acne, in 
impetigo, ecthyma, furuncle, carbuncle, and lupus. Properly diluted 
it may be used to disinfect the surface in confluent small-pox. It has 
been found benelicial in acute eczema, although, to be gratefal to the 
inflamed surface, the solution needs to be considerably weakened. 
Applied by means of a camera-hair brush, it has given good results in 
chloa-sma. Disinfection of the throat and nose is accomplished in 
scarlatina by means of a spray of hydrogen peroxide. In tluit most 
distressing affection, paroisthesia of the female genital organs, thia 
agent is advantageously employed in the form of a vaginal injection 
consisting of one part to three of water. A spray has been found a 
remarkiibly beneficial application to the surface stung by a hornet. 
Unna has found it useful in the treatment of comedones. 

Antiseptics. — The therapeutical resources of dermatology have been 
greatly enlarged by the introduction of many substances belonging to 
this class, which have the power either of destroying the specific micro- 
organisms of disease or of neutrtdizing their effects. In addition to 
those diseases which were long ago demonstrated to be due to the 
presence of a parasite, we liave more lutelj learned much concerning 
the part played by microbes in the production of numerous other 
cutaneous nudadies. The micro-organisms of suppuration have been 
found in acne, impetigo, ecthyma, boils, carbuncles, abscesses, sycosis, 
and in the pus of v:iri<.tla. Another class of diseases, such as lupus, 
scrofuiodermii, onychia maligna, and the other varieties of local tuber- 
culosis, we now know to depend upon the development of Kocli'a 
bacillus. Strong reasons exist for the belief that at least certain forma 
of eczema, purpura in some cases, psoriasis, the exanthemata, and 
syphilis, originate in the siime manner. Abraded, excoriated, blistered, 
or burned surfaces furnish an excellent soil for the growth of many 
forms of bacteria. The problem of topical medication, therefore, is to 



TREATMENT. 



109 









destroy the bacteria in .^itu^ or at leiist inhibit their further develop- 
jnent and prevent the absorption of their poisonous protlucte. These 
ibjects are more eflFectively accomplished when tlie presence of un open 
rfiice allows our remedies to be brought into immediate rontact with 
the pathogenic organisms than when these are protected by an intact 
epitbelinia. As, however, in nearly all cases the proceases inaugumted 
by the organized germs lead to the destruction of tisvsuo, we are often able 
to shorten the duration of the ease by anticipating the course of na- 
ture, by the removal of crusts, the erosion of neoplastic deposits^ or by 
the injection of an antiseptic agent into the substance of the lesion. 
In lapua Tulgaris an effective plan consists in destroying the nodules 
and sprinkling the surface of the artiticial ulcer with aristol, naphtbol, 
or iodoform, or the same substances in ointment form, or the appli- 
cation of camphorated naphthol or lysol. Prior to softening of the 
n<.>dule, injections of iodoform or the introduction of iodine have been 
found of advantage. Iodoform in the form of a tlve-per-cent. sotn- 
on in oleic acid has an excellent effect in preventiug the degeneration 
f enlarged lymphatic glands. The injection of caiiqihorated naphthol 
has also been followed by good results. Lupous ulcers are benefited, 
moreover, by the appliciition of Balicyktcd camphor, iodol, iodosul- 
phate of cinchonine, and other antiseptic substiinces, which are men- 
tione<l in detail in the section relating to the treatment of that disease. 
^KfTfae same substances are available in the management of serofuloderma. 
^■barbolic acid, salicylic acid, pyoktaniu, etc., are frequently snccessful 
^^Bi aborting the progress of a boil. Carbolic acid has been the most 
^^widely employed for this purpose. It has been made use of in the 
form of a spray, of compresses soaked in a solution of suitable strength 
and kept in constant contact with the inflamed area, and by injection 
into the interior of the boil. Similar procedures have been advan- 
tageous "in the case of carb uncle, carbolic acid or tincture of iodine 
being injected into the cribriform openings and pyoktanin, campho- 
pbenique, or iodol laid upon the stirface. Subcutaneous injections of 
an antiseptic solution promise well in malignant pustule. The local 
treatment of ervsipelas has been revolutionized. Whereas, a few years 
mcef external remedies were geuendly looked upon as of slight avail, 
great stress is now laid upon the use of certain agents, which have 
shown themselves remarkably eflicacioua in limiting the extent and 
sevprity of the disease. The most valuable of these substances are 
tesorcin, carbolic acid, creasote, creolin, alcohol, corrosive sublimate, 
cvHc acid, and salol. The methods in which they are used are 
bed in the section relating to the treatment of erysipelas. It 
the ntmost importance that the surfaces of burns and ulcers 
oald be covered by dressings impregnated with substauces able to 
prevent the activity of microphytes. The local therapy of the pnstidnr 
diafftseg of the skin is to be conducted upon analogous principles. The 



WM 



DISEASES OF TUE SKIN. 



adoption of antiseptic precautions lu performing the trifling operation 
of viiccinatioii has reduced to a reniarkiible extent tlie occurrence of 
tliose accidents which have sometimes hrouglit undeserved discredit 
upon the most valuable prophyluctic measure yet known to medical 
science. In small -pox decided benefit is obtained by the u^e of paniniti- 
cides in the form of lotions, powders, ointments, or pastes. Suppura- 
tion is lessened, the virus weakened or destroyed, fever diminished, and 
pitting reduced. Tlie severity of scarlatina may be mitigated and its 
extension restrained hy the Bednlous adoption of antiseptic measures. 

As the ii'chnique of disinfectant applications will be described 
separately in the treatment of the individual disorders of the skin, 
it is unnecessary to dwell at length upnu the subject in this place. 
For farther information, therefore, the reader is ruferred to the body 
of the work. 

COXSTITUTIONAL AXD LoCAL TrEATMEXT. 

The following mechanical remedies, the consideration of which I 
have largely extracted from one of my papers* treating of them, can 
be employed either for their systemic or local action, or both, or as an 
assistant to topical medication. I shall sjieak of these remedies under 
the following headings, and for a more detailed description of them 
will refer to my paper read before the American Medical Association, 
June, 1883. 

Maasaga — As a general remedy, massage has been long and favor- 
ably known, but has been seldom employed as a method of treating 
diseases of the skin. In certain morbid states of the integument, it is, 
when properly used, attended with a most benelicial effect, and often 
results in restoring the surface to its natural condition. The func- 
tions of the skin are roused into full activity. The volume and rapidity 
of the cutaneous circulation are increased. Tlie secretions of the skin 
are augmented and cutimeous respiration is promoted. From the sen- 
sory and tactile end-organs a beneficial elTect is ])roduced upon the 
central nervous system. A simuHaueous or successive conduction of 
iniluence from many parts of the surface, affecting many centres, di- 
ref'tly contributes to the restoration of exhausted energy. The practice 
of massage increases muscular strength. Manipulation of the abdomen, 
properly performed, exalts the functions of the vi.scera contained within 
its cavity. It excites peristalsis, stimulates the menstrual function, and, 
in man, invigorates tlie testes. The appetite and digestion are im- 
proved, ''ilio urine is increased in quantity antl variously altered. Mas- 
sage not only acts directly on the part, but by \\a indirect effect, when 
employed over tlie general surface, will impart tone and vigor to the 

* Eitmcled from a paper read by the author before the Secelon of Dermatology and 
Bjphilis, at tlie meetiDg of Ihe loteroationftl Medical Congresa at Copenhagen, Denmark, 
August 12, 1884» 



TREATMENT. 






tire system* This direct m wvW as indipoct action of massage 
it uvailable both for its locul and coiistitutioniil effect in miiuj 
of the skin. Massage is a most important and valuable adju- 
nt in promoting and increasing oxidation in psoriasis and &crofiilo- 
enna. In tliest? and otlier similar pathological conditions the skin is 
rendered more active by its use, the effete products are removed, and 
I be red corpuscles of the blood arc increased. It is especially advan- 
Ugeons for its effect in neuralgia, in perverted sensibility, and trophic 
isturbances of tbc skin. In these neuroses it relievcji pain by its 
©edatire aod counter-irritant effects, and hns a tonic action ujion the 
nenroiis sjstem. In some of the subacute forms of eczema, in which 
the integnment is covered with groups of papules somewhat thickened 
and dry, the application of massage will often arouse the activity of 
the absorbents, increase the circulation, lessen or arrest the itching, 
:^d restore the skin to itxS natural condition. It is, however, in the 
hfonic form of eczema that massage has been» according to my ex- 
perience* both effective and curative. In chronic cases of eczema, 
where the integument h deeply infiltrated, rougli, thickened even 
to a leathery state, hard and dry, upon which medication has been 
w*ithout any result, the application of massage breaks up the 
xudation, stimulates the a!>sorbeiit9, removes the inllammatory 
products from the part^, and restores them to their natural condi- 
iion. It is equally efficacious in the same disease when the integu- 
ent is covered w^ith conlluent patches of papules, and more or less 
filtration with dryness of the surface, and attended with an intense 
d persistent itching. The abnormal and pent-up products arc gen- 
ly speedily removed, the massage having a sedative action on the 
ell as on the entire body, a pleasant state of repose fnllowing. 
aasage is a useful and beneficial application in the dry form of sebor- 
flea and in thinning and loss of hair ; the sluggish circulation being 
ented, the absorbents made active, and tone and vigor being im- 
parted to the glands and hair-follielef^. It ia like- 
wise a valuable agent in indurated acne, in glandu- 
lar swelling, and in excessive and deficient pig- 
mentation of the skin ; the choked-up absorbents 
are aroused to activity, and the parts are soon re- 
stored to their normal condition. Massage not only 
acts in this local manner, but it is an important 
remedy applied over the general surface in curing 
or assisting to remove many functional derange- 
ments such as gastric and intestinal disorders, with 
or without constipation, which are insidious factors 

*'i.»JcJr''Xr"bind- *" "^^"y cutaneous diseases. 
ftc«.aMHi in»pf*lT- Compression.— Compression, which is very use- 

tbc lAin-miLitw. ful ID the treatment of diseases of the skm, can be 



112 



DISEASES OF TUE SKIN. 



applied by means of any substance that will afford rest and support to 
the affected parts. In maoy atEections of the skin It will either prove 
curative or assist medication in overcoming the morbid state of the tis- 
sue, which often resists for a long time the action of drugs. Compres- 




Tia. ©.^Dcrmatolosrienl cA.se» u-ied by the author, f-howintr *» lena^ 
pmben, knivwi, forct-p, aowHors"!, Hpoon, eurctle, hypodermic 
ByriDgQ tJid needle J holder and needles, 

fiion is a valuable means to use in eczema, especially 
that form which involves the abdomen, the nates, 
and the genital regions. It serves in these affections 
to protect the parts, prevents friction with tlie ad- 
joining portion of the integuments, and limits the 
spread of disease. It relieves the congestion in 
snch eases, and arrests the eflfnsion. It is also very 
effective m acute and subacute eczema by soothing 
muscular irritation, toning up the dilated capilla- 
riea, and preventing the eseapo of serum. Com- 
pression is an important adjuvant in the treatment 
of certjiiti eniptive fevers, for oBdema after erysipe- 
las, as well oa in eczema, fnrnncular and glandular 
affections, borpe?, berimes zoster, and urticaria. It 
can be employed with muslin, gum, or woven band- 
ages — ^the latter being especially serviceable-— or with 
simple or medicated plasters. 

Blood-letting. — The abstraction of blood is bene- 
ficial in diseiises of the skin, both for its general 
and local effect. It is a jiowerful antiphlogistic 
remedy, and acts in a speedy manner in relieving 
and in arresting morbid changes of the skin. Blood-letting is not only 
valuable as an adjuvant in treating certain obstinate cutaneous di* 



Flo. 10.— 1. The tlcr- 
miit«:>me or needle- 
knilt% Vrith ipooQ 
upon one end. SL 
Thti derttiat^mio of 
neodlo - knife with 
tMtrett<* opon the ex 



^ 



TEEATMEKT. 



113 



. of the a 




t 



eases, but it is also useful in cbronic affections, after medication hns 
been exhausted without having any cfFeet upon the parts. Blood may 
be abstra<:ted either topically, aa from the capillaries of the inter- 
ment, or generally from a vein or artery. Local depletion is a com- 
mon and useful form of abstracting blood for the treatment of diseases 
of the akin, general blood-letting only lieing used in a very few in- 
Topical blood-letting may be performed by puncturing, 
tcarification, or leeching. 

PunetoriDg* — The integument can be depleted either by a bistoury, 
a tenotome, or a short pointed needle ; the one which I use in my 
practice I have termed the *• dermatome." (See Fig. 1(1) Punctur- 
ing the skin relieves the congestion and stagnation of the blood in the 
Teasels, by equalizing the circulation, stimulating the action of the 
rbent«, and thus removing all deposits from the tisi^ne. It is de- 
ciiiedly effective in chronic eczema, acne, j^crofuloderma, carbuncles, 
erysipelas, excess of pigment, and in the neuroses. 

Se&riflcation. — Scarification, although not as frequently employed as 
uncturing in the treatment of dii^eases of the skin, is nevertheless an im- 
rtant means to use over an inllamed surface, the relief brought to the 
ta from dividing the engorged blood-vessels being often most decided. 
Leeollilig. — ^Leeching, while inferior to puncturing and scarifica- 
tion for the abstraction of blood, can be resorted to lu nervous pcr- 
S4)ns, who feur the use of the knife or the needle, 

Veadsection. — Venesection will bring a decided relief in certain 
cutaneous eruptions, especially in strong, robust subjects bearing every 
vidence of a plethoric state of the aystxnn. I have employed it with 
aoccess in general eczema and psoriasis. 

Incisions. — Incisions are made upon the integument for the pur- 

of exposing, dividing, or removing the parts. They are valu- 

in sebaceous cysts, lymphatic enlargemeu ts^ in local intlamma- 

tory patches, to relieve the tension of the integument, to divide 

tenmtive nerves, and to give a free exit to pent-up inflammatory 

rodacts. Incisions are employed with advantage in sycosis, rosacea, 

ipelas, boils, and carbuncles. 

Excision. — Excision, or the removal of a part, can be accomplished 
by either incision with the knife, by ligature, or by crushing benign 
And malignant tumors of the skin as well as warts. It is also useful 
r the removal of horns and moles. 
Enucleation. — Enucleation is employed to rapidly peel out diseased 
structures, especially after the skin and capsules have been divided 
over morbid growths. 

Scooping. — Scooping is a form of enucleation. It is usually per- 
formed with a smooth, sharp spoon, and is an efficient metliod for 
n?moviDg broken-down products and pent-up secretions, especially in 
cataneottB abeceases, sinuses, and strumous glands. 



ible 



114 



DISEASES OF TOE SKIN. 



Scraping. — Scraping is but a modification of scooping, and can 
performed with almost any rough Fubstanco. The curette is, how- 
ever, the instrument generally used. Morbid products can be re- 
moved by scraping, as in lupus, cancers, etc, thus facilitating the 
application or assisting the action of local remedies. 

Cauterization. — Cauterization can be performed by the use of a 
metallic substance heated to a high degree of temperature, or through 
the action of the solar rays and a lens, or by the galvana-cautery, as 
well as by any of the various caustic medicinal agents. The mechani- 
cal cautery, as usually employed, consists of variously shaped pieces of 
iron, needles, pins, or any metallic eubstance heated to either a white 
or dull-red heat and applied to the affected integument. The success 
of the actiml cautery in morbid growths of the skin, especially in lupua 
and cancerous affection s, is already well known to every practitioner, 
and simply needs to be mentioned in referring to the great value of 
this useful mechanical agent. 

The mechanical remedies that I have thus briefly enumerated can 
be used alone or combined. They will be found to be invaluable 
adjuvants, and oft^n powerful agents in arresting and removing some 
of the most obstinate diseases of the skin after medicines have entirely 
failed. 

Electricity. — In the treatment of diseases of the skin, electricity* 
has an extensive and interesting field of application ; and all the usual 
forms in which this agent is used in general medicine f and surgery 
have been utilized, to a greater or less extent, in dermatology. The 
faradic or induced currents are more frequently employed than the 
currents of high potential from the static apparatus, but tlie most use- 
ful of all forms is the galvanic or voltaic current, the cell current, 
which is of comparatively low potential but of large volume. 

The current from the storage battery, or the Edison dynamo, may 
be substituted for the galvanic or cell current in connection with the 
current controller and milliamperemetre for all purposes to which the 
former is applicable, and is coming more and more into use by phy- 
sicians in their offices. 

The moist structures of the human body are as a rule good con- 
ductors of electricity; but the dry skin, on the contrary, is a very ])oor 
conductor, and otfers the principal obstacle to the medical employment 
of this force. Since the dry skin exhibits such decided resistance, it is 
customary to moisten the part to which electricity is to be applied, and 
this is accomplished best by having the electrodes in the form of 
sponges set on handles, or, what is better, moistened cotton may be 

* See paper by author, on *' Ele^tricJty in Skin and Venereal Disctsca," tlie Uedicd 
Bulletin, October, 1«89. 

+ Sec paper by lujthor, on ** Tlie TlK^rnpcutic Uses of EJectricity," JourDul of the 
Amertctil Mi;:dljcal Association, August 17, ISSH. 



TREATMENT. 



115 



D§etl instead of the sponge. Saline solutions being much better con- 
ductor than pure water, it is considered advisable to employ salt water 
for this purpose when it is desireil to have electricity penetrate tlie 
&kia. Where the effect is especially intended for tbe epidermic struct- 
ur^a, or where the cutaneous nerves and capillaries are principally to 
be impressed, dry metallic electrodes may be used. These may be had 
of different sizes and shapes; one in the form of a sphere, half an iiieh 
or more in diameter, made of stee! which may be nickel-plated, is useful 
in dermatology for applying electricity to the various diseases of the skin. 
The roller electrode of l*r. Butler is employed for general electriza- 
tion of a portion of the surface to improve the nutrition of the skin, or 
the wire brush may be used, which is very stimulating, IxMUg agreeable 
to some and rather painful to others. In electrolytic work the needle- 
holder is convenient, not only for epilation, but also in the treatment 
of hjpertrophied scars, and for obliterating the dilated vessels in 
roeacea. For galvano-cautery applications to ntevi and malignant 
growthj in the skin, the ordinary forms of iustruments are employed. 

Electricity not only acts, when properly applied, as a nervous stim- 
ulant, and to some extent as a vital energizer of growing cellrf, but also 
■s an alterative where cell-action is abnormal. That during life there 
are phTsiological electrical currents generated in the human body is 
now g^anerally conceded, and these currents undoubtedly play an inj- 
portant part in carrving on the functions of cells and orguns, C'linical 
«xp€rienc4J shows that the passage of t^lectricity through the body by 
mclndiog portions of organs in the circuit, when currents of a certain 
Btrength are used, has a decided effect upon the blood-supply and the 
nerve force, as manifested by physiological and therajteutic cfFecta 
npon the parts thus included between the electrodes. The discovery of 
electro-capillary phenomena and the effects of so-called currents of 
polarization, within recent years, has shown the identity of the electri- 
cal phenomena occurring normally in the human organism, and those 
induced by the passage of the current. According to Becquerel, 
Dujardin-Boaumctz, and other well-known clinical authorities, the 
nmscles and nerves have electrical eurrentn of their own, and when 
tlieee have been altered by disease, the clinical application of farad ism 
and galranism may restore lost function in nerve or muscle. This is 
probably trtie also of the skin, which in some disorders is defieient in 
it^ bhxKl-supply and sensation, both of which are notably increased l*y 
electrical stimulation. Not only are motor and sensory nerves stim- 
ulated, but the trophic nerves and vaso-motor fibres have their functions 
[Hkeirue increased, so that in atrophic affections and disorders of the 
ion (paraesthesia, etc.) electricity is frequently of advantage. As 
fn^ardathe forms of currents to use, according toDujardin-Beaumetz :* 

• Clloicml Thcraf^euticii, Diijardin-BeftumetEf translated by E. P, llurd. George S. 
- ^f^ pabUdier, Detroit, Micb,, ISSB^ p. 36. 



110 



DISEASES OF THE SKTS. 



" When we desire to modify the cutaneous sensibility and nutrition in 
generiil, we make use of fiUitic electricity ; when we wish to limit 
electricity to a j^roup of muscles, or when we wish to restore con- 
tractility to certain mogcles, we use the furadic machine; wlien, tinallj, 
we wish to modify the moleetdar stiite of eertiiiii nerves, or to give a 
new activity to certain tissues, we employ galvanism." The latter 
form ia also used in pe informing electrolysis for the destruction of hair- 
follirles or removal of new grow^ths. Since in experiments in electrical 
decomposition of chemical compounds (electrolysis) the acids always 
go to the positive pole, and alkalies and similar basic bodies go to the 
negative pole, the former is sometimes called the acid pole and the 
latter the alkaline pole. 

Similar modifications tend to occur in living tissues under the in- 
fluence of strong currents, and this is made more effective if the 
electrodes are wet with saline solutions wdiich are decomposed by the 
current. When this occurs, part of the nieilicament passes directly 
into tiie skin and may flow with the current entirely through the body, 
as demonstrated conclusively by Munk, Yon Bruns, Adamkiewicz, 
Peterson, and others. This procedure is known m electrical cata- 
phoresis^ and it has recently been utilized for the introduction of 
cliloroform, quinine, mercury, and other agents through the skin. Dr. 
F. Woodbury has used lithium iodide in solution in this way for the 
removal of syphilitic tubercular lesions from the skin with good re- 
sults.* In connection with the polar effects just mentioned, it is in- 
teresting to note that Glatz confirms the clinical observation that, in 
bipolar applications, the positive pole is the more sedative and calma- 
tive in neuralgic affections. f lie applies the positive pole at the seat 
of pain with agmall electrode, while the negative is placed at a conven- 
ient distance with a larger electrode. The current must be of medium 
intensity. In such ciises cldoroforra or cocaine solution can be applied 
to increase the sedative action, and make the relief more lasting. 

Static electricity is very beneficial in many nervous atlections of the 
skin; and the psychological elfeet of the sparks undoubtedly con- 
tributes to the curative action. Parfcsthcsia, or prftriiiiSy is frequently 
relieved by it, especially where it is a symptom of senile or other 
changes in the skin ; and formication aeeompanyirig central nervous 
disease may also be held in abeyance by franklinic electric baths. The 
livid ity of the skin in nervous disorders may be entirely relieved by 
this acceleration of the circulation under a series of short sparks. 
Neuralgia or dermatalgia of the scalp, soles of the feet, and other parts 
of the body, are sometimes benefited by frankliuism after the failure 
of other forma of electrical treatment. Horns, corns, callosities, warts, 

* "On tlie Emplovmcnt of tlic rutai^boric Action of the Gah'anic Current for the 
ReiiiovGil of Syphilitic N*ew lirowthtt,'^ Mpdieal Newa^ June 21, 1890. 
f Revue Mddicale dt- Isi iimssc Uwmantie, May 20, 1889. 



TREATMENT. 



117 



^ 
^ 



■ 



hardened cicatrices, and other hypertrophic developments of the skin, 
are often removed by daily apfilieiitioDs; while a similar result follows in 
^isaaes of the tendency to repeated eruptions of blind boil;?, hard papulesi, 
acne-marks, and sluggish lyoipbatic glunds, by strong sparks. 

In eczema and psoriasis I have rejieatedly observed good reeidts 
from fraiiklinism, especially where infiltration has occurred, and there 
is obstruction to the local circulation by inflammatory deposits, which 
are speedily caused to be absorbed by these applications. Koughuess 
of the skin in scrofuloderma is in a great measure remedied by thorough 
fmnkliiiization, while there is noted a general systemic tonic eifect. 
In hyperidrosis, bromidrosis, in j)arasjitie affections, such us ringworm, 
favus, and tinea versicolor, I have also observed undoubted benefits 
follow from static treatment ; and two instances have been reported in 
which Guinea- worm has been cured by its aid. As a general tonic to 
the skin or as a counter-irritant, franklinism is as reliable as galvanism 
or farad ism. 

Faradic electricity is useful for about the same class of cases as 
8tAtic eJectricity, and stands between ibis and galvanism in its effects 
upon the skin. In haemophilia and ba^matidrosis, faradism causes con- 
traction of the capillaries, and by a similar action it is curative in 
chilblaitis. In acne lesions^ piipidar and chronic eczema, psoriasis, pem- 
phigus^ and parsesthesia or |»niri tus, faradism often relieves the itcbiug 
and reduces the intiltration that may be ]>resent. In scrofuloderma, 
chronic sj-cosis, chronic ulcers, and obstinate syphilitic patches, the 
writer has frequently had marked good results follow the judicious use 
of fani^lism alone, or alternating with frnnkljnization or galvanization. 
It is hardly necessary to say that thorough cleanliness and antisepsis of 
the electrodes are necessary, and tliese may be secured by covering the 
electrodes with absorbent cotton, which is to be clianged for each ^mnee. 

In chronic eczema and psoriasis, especially when the jnitchea are 
much thickened, and attended with marked itclnng, the author has ac- 
complished by daily treatment with galvanism the very best clinical 
re«idts. The infiltration and itching usually lessen, and the skin is 
rendered more active and more amenable to otVier local treatment that 
formerly failed to act. Mild currents are needed, and, if there is liver 
or stomach disorder, the positive pole is to be placed over the affected 
organ, and the negative to the lesions upon tlie skin. Erysipelas may 
be checked by galvanism, the anode being placed in the centre of the 
patch, and the cathode moved slowly around the circumference, Sup- 
pnmtivc swelling of the skin or of the subcutaneous connective tissue, 
inch as boils, incipient abscesses or carbuncles may he averted, aborted, 
or cured by prompt galvanization, if the disorganization has not pro- 
ceeded too far. In psoriasis due to nervous depression the constant 
current acts both as a tonic and ae a local therapeutic agent, and is 
frequently curative. 



m 



lis 



JEASES OF THE t^EOf. 



In berpes, simplex or zoster, mild but oontinued galvaniiMttioil 
removes the inteiii*e burning and prostfatioii, and the progress of the 
disease is retarded. Similar good effecta are seen in rhus-poisoning 
or dermatitis venenata. Discoloration of the skin, lentigo (freckles), 
chloasma, vitiligo, acne, seborrhijea oleosa, rosacea^ and birtb-markg, 
aro generally amenable to galvanic treatment combined in the latter 
two affections with galvano-pnncture, if necessary. 

Galvanization is reqnired for thorongh epilation {electrolysii*),and is 
unequaled as a stimulant in alopecia, if the hair-bnlba are still living. 
Antipartisitic applioationa are more efficient when applied by the 
electrodes, and a moderately strong current is employed to drive them 
into the skin (cataphoresis). In chronic ulcers of the leg, remarkable 
results may be obtained by driving in weak solutions of corrosive 
chloride of mercury in this way. In tinea versicolor and cancer, 
benefit may be looked for in the same direction.* In the treatment of 
cojulylomata and warty growths of the urethra and verrucous pigment 
nievi of the face, Ehrmann, of Vienna, uses a sharp- pointed steelj 
needle for the cathode, which is insert4?d into the mass about to be re- 
moved, while the anode, a moist electrode, is placed indifferently or 
held in the hand. Where the warts are numerous, from three to six 
needles attached to one electrode are inserted at the same time. He 
objects to the use of lancet-shaped needles, preferring round ones, 
whieli are easier to introduce, ami cativ^e less destruction of tissue. 
The strength of current employeii is from one to one and a half 
milliamperes. M. Vogel, of Eisleben, in the treatment of vascular 
nanus, teleangiectasis, employs one electrode wliich contains both in- 
sulated poles, consisting of two or more tine steel needles separated' 
from each other by one milliampc^re. The ail vantage of this is that it 
leaves tlie hand of the operator free. Scarring may be avoided by 
using weak currents, and not continuing the smnces too long. Graefe 
follows Voltolini in having both poles terminate in needle-points, and 
not the cathode only. In fibromata of the skin he thus obtains cure^ 
after several sittings This same authority also reports an interesting 
Oiise of a physician, who during a post-mortem inoculated his index- 
finger with tubercular disojuic, which subsequently manifested itself by 
tubercular nodules. These entirely disappeared by electrolysis without 
any glandular infection taking place. No new nodules were a]jjmrent 
at the cud of nine months. f 

Electro-puncture used by I^fagcndie in the treatment of neuralgia 
has been lately revived in the form of galvano-thermy, which is a most 
powerful revulsive metho<l. By means of a storage battery, a wire 
electrode is heated to redness, and it is then introduce to the depth of 

* See paper, '* Electritiiy iti Carcinntna," by Robert Newman, of New York, ProceediiigB 
Americaa Electro- Tlwrapeiitic As^odfltinn, 1891. 

f Annual of the raireraal Medical Science, F. A Duvi-?, publislitTt vol. v, p. o. 27. 



TREATMENT. 



119 



half a millimetre at points some little distance apart over the tract 
of the affected nervo, They cause coiisidentbly inflammation, bub 
afford marked relief in neuralgia. With the aid of an anfesthetic, 
this nugbt be used in malignant pustule, lupus, epithGlionia^ and 
fare i noma. Among the individual appli<:utioiis of elcetrtcity, it 
should be noted that in scleroderma, Schwimmer reported succeas- 
Ittl results in one case after eighteen months' treatment by subaural 
galranization. 

In morphea, Liobijsj and Rohe* declare that localized applications 
of galvanism hiive long been regarded as the only treatment that 
promises success. In true keloid, as also in simple hyjiertrophied scars, 
sncoess has fuUowed multiple galvano-puncture. If the essential feaU 
ore of all intlammation be the presence of certain forms of bacteria, 
and we have in the positive pole an agent which will remove the caasa 
morbn electricity is destined in the future to play a still more impor- 
tant role in skin diseases than it has hitherto. The tf^tlvano-cantery 
is useful for many minor surgical operations upon the skin in primary 
srphiliH, chancroids, epithelioma, and lupus. 

Prognosis, 

The prognosis of cutaneoud diseases depends upon the nature and 
intensity of the causative morbid processes. It is also influenced by 
the extent of surface involved, and the length of time that may liave 
elapsed between the ap])earance of the lesions and the institution of 
a plan of treatment. Age, sex, occupation, habits of life, and the 
preseooe or absence of the various diatheses are also factors which 
most be taken into consideration. As a general rule, however, the 
prognosis is favorable. A large number of skin-diseases are either 
acute or subacute in character, and tend to a spontaneous cure ; many 
others run a more or less chronic course, but eventually yield to 
judicious and persevering treatment. Some, on the other hand, are 
exceedingly obstinate^ and are not amenable to any known method of 
tKutment ; fatiil results rarely occur except in leprosy, cancer, and tlie 
acute contagions diseases. 

Disorders of the sebaceous, and functional disorders of the sudo- 
riparous secretion, are usually ouly temporary in character, and may 
be readily cured or alleviated by appropriate remedies. Changes in 
ebaraeter of the sudoriparous secretion are more persistent and less 
amenable to treatment. Ilypenemia of the skin is symptomatic of 
congestion of the vessels of the pajvillary layer, and is usually of brief 
duration. 

The acute contagious inflammatory diseases vary in severity. 
Some invariably pursue a benign course, or are only occasionally 

• Pr«ctic*J Elcctridtj in Medicine ftnd Surgery^ F. A. Davis, Philadelphia, I89i>, 



120 



DISEASES OF THE !?KIK. 



fatal, while otliera are noted for their malignancy. The non-con* 
tagious inUaiumatory diseases also vary in course and duration. Many 
of tliem terminate in a few days in complete recovery. Occasionally 
deatli may ensue from the violence of the inflammatory action, or the 
accompanying constitutional debility, as in some cases of pomphigua 
and anthrax. Other diseases of this group, as prurigo and pityriasis 
rubra, are essentially chronic in character, and nuiy remain for years 
without any apparent change. 

Cutaneous hemorrhages are generally small in amount, and of 
trivial iniportauce. Ilypertrophies are usually benign in character 
and slow in development ; they are difficult to remove, and nianLfest a 
tendency to recur. Atrophies of the skin or itis appendages are gener- 
ally permanent. 

The prognosis of neoplastic diseases varies with the benignity or 
malignity of the process concerned in the deposition of new material 
in the skin. Some, as fibrous molluscum and the different forms of 
naevi, are harmless in charac^tor ; others,^ as lupus and scrofuloderma, 
teud to ulceration and destruction of the adjacent tissues ; while lep- 
rosy, carcinoma, and sarcoma generally terminate fatally. 

The neuroses are extremely variable in duration and severity. 
Sometimes thoy disappear as if by magic, after the employment of one 
or two simple remedies, while at other times they resist all treat- 
ment. 

The parasitic aSections are all curable. 



PART IL 



CLASSIFICATION. 



The purpose of ibe following classification is to arraoge the differ- 
ent varieties of skin-diseases so that thej can be readily referred to 
MJid studied in a siraple and practical manner. Numerous Bystoma 
iTe been proposed, all of wliicb, however, are so complex as to be of 
ittle or no utility. Hebra's classification, modified, made upon an 
latomical and pathological basis, \s adopted in this work in order to 
fprcTent any confugioo, as it is the most commonly accepted Bystem 
now in Yogue. 



Class L Disorders of Secretion and Exereiwn {AnomaUm Sccre- 
tionis ei Exereiionis). — Seborrhea, comedo, milium, sebaceous cyst, 
tjperidrosis, anidrosis, broniidrosis, chromodrosis, sudamina. 

Class IL Jli/perfrmia.^ {Hijpermnue), — Erythema simplex, ery- 
thema intertrigo. 

Class III. Hwmorrhages (//tpwtor y-Ao^f ftp).— Purpura, hsemophilia, 
gi hiematidrosis, 

H Class IV. Exudations {Exudtt Hones), — Rubeola, rotheln, scurla- 
^ tina, variola, varicella, vaccinia, typlioid-fover ra.*^h, typhus-fever rash, 
I t*rebro-spinal fever rash, diphtheritic spots, erysipelas, chancroid, syph- 
IK il's, erythema multifomie, erythema nodosum, urticaria, lichen |)la- 
H 10S, lichen scrofulosum, prurigo, herpes, miliaria, pemphigus, hydroa, 
^m pottpholyx^ acne, rosacea, sycosis, impetigo, impetigo contagiosum, ec- 
^Li^fini^.pityriasis rubra, furunculus, carbunculus, anthrax, equina, ab- 
^pwdilif ulcus, eczema, dermatitis, combustio, congelatio. 
r Class V. Hypertrophies {Hypertrophiw), — Jjeutigo, chloasma, 

1^ B»TU8 pigmentosus, eallositas, clavus, cornu cutaneum, keratosis pila- 
^B itt, psoriasis, lichen rubra, verruca, ichthyosis, scleroderma, sclerosis, 
^B iDorphopo, elephant iahis, dormatolysis, birsuties, onychogrypbosis. 
™ Class VL Atrophies (Atrophiie), — Albinismus, vitiligo, canities, 
atrophia cutis, atrophia senilis, striae et maculae atrophicjs, alopecia, 
llope^ia circumscripta, atrophia pilorum propria, onychatroplua. 

Cla^js VIL Tumors (yeopkumata), — Hhinoscleroma, lupus erytbe- 




122 



DISEASES OF TUE SKLV. 



niatosns, liipiig vulgaris, scrofuloderma, moUuscum epitheliale, lepra, 
epithelioma, sarcoma cutis, carcinoma cutis, keloid, molluscum tibro- 
sum, xanthoma, lipoma, angioma, lymplmngioma, neuroma, myoma. 

Class VI IL ^Titro.ses (A^euroses).— II jpQVvesihem&y auaesthi 
paraeathcsia, derniatalgia. 

Class IX.—Paraj^iles {Parmitw), — Animal: scabies, petUeulosis, 
cimex lectiilarius. Vegetable: tinea versicolor, tinea favosa, tinea tri- 
cophytina. 



CLASS I. 



DISORDERS OF SECRETION AND EXCRETION. 

{Ammalm Secreti&nui 6t ExeretUtnU,) 

SUBORRHCEA. 

Stnontms. ^ StcatorrhoMi — PitTriasis — Acne ?cbacea — Seborrhapa — Cutja uoctttosa— . 
Tinea furfuraeea — Ichthyosis ^ebacca — Schrneoi'flass^ Dandruff. 

Seborrhcea is a functional disease of the sebaceous glands, charac- 
terized by an exeosaivo and altered condition of tlie sebaceous secre- 
tion, forming an oily coating, cruat.*, or scales on the skin. 

Symptoms.— SeborrhoBii may oceiir upon any part of the body, but 
is usnitily limited to certain localities. The favorite seats are the 
gcalp, face, back, chest, umbilieug, and the genital regions. It may 
in rare cases as a disease involve the entiix? body, as in the instance 
recorded by Biett, The vcmix caseosa of new-born children, as well 
as that whicli affects certain races, particularly the negro, are ilhietra- 
tions of general seborrhoBa, occuiTing, however, as a physiological and 
not as a diseased process. As a di^^onse, it^ course will be found to 
vary according to tlie region affected and the state of t!ie patient's 
health* It is usually more marked on the scalp, and less so on other 
portions of the body. It is especially liable to occur in those who are 
out of health, particularly the anaemic and chlorotte, and tends to 
lessen or disappear as the system returns to its normal condition. It 
may be so tritling as to require little or no treatment, often vanishing 
with the removal of the cause ; again, it may be extremely severe, 
often lasting months or years, aud even with the most careful atten- 
tion being suhject to frequent relapses. In some instances it may ob- 
stinately persist throughout life, notwithstanding careful treatment. 
The seasons may have an inOuence, it oftt^n disappearing in summer 
and returning in winter. The condition of the integument affected 
will also vary according to the extent of the disease and the state of 
the poured-out secretion. It is mostly of a pale tintj and either dry 



DISORDERS OF SECRETION AND EXCRETION. 



» 



^ 



IjnHiBy. At intervals it may be more or Ipss iuOatried. Subjcct- 
li««mntipng of either itching or burning, or both, may be i>resent, 
or sometimes absent. The disease is encountered in two forma, ac- 
cording to the secretion discharged, whether oily, or firm and dry, 
"Which are known respectively as seborrha.*ii oleosii and seborrhu?a sicca. 
They occur occ^ionally together, either upon the same or different 
regions of the body, but usually receive the subjoined separate consid- 
eration. 

Seborrhoea Sicca, — This is the most common variety of the disease. 
It is chamcterizeil by the formation of dry, yet somewhat greasy, 
dirty-white or yellowish scales or crusts. As it occurs both upon the 
hairy and nou-hairy parts, it will be described under the following 
local forms: 

Seborrhoja Capitis is a local variety of Beborrho'a- It may ap- 
pear in children as a continuation of the verriix cascosa, and persii^t for 
Eome time. It is met with on the vertex, the anterior fontanels, and 
occasiomilly over all the scalp, in the form of thin or thick, dry, fri- 
m fatty scales, crusts, or scabs, which are firmly adherent to the 
The color will vary from a light yellow to a brown or black, 
the tini depending upon the dirt coming in contact with the parts and 
tlie care which they receive. The skin beneath juay be normal, slightl}'' 
macerated, or sometimes complicated with eczema; the hardened, ad- 
lierent material exciting inflammation of the skin. After a time the 
disease genemlly subsides, the scales and crusts disjippearing with the 
growth of the hair. In adults the disease manifests itself by the fornxa- 
tion of thin or thick, gray or yellowish, dry or greasy scales. They are 
either loosely situated or adliorent to the scalp ; in the latter event the 
thick, fatty masses may bind the hair in close contact with the surface. 
As a rule, the disease inva<Jes tho scalp uniformly; occasionally, how- 
ercr, it appears as one or several patches* The scaling will vary — 
scarcely risible in some, and so great in others as to liang loosely upon 
the hair-brusli and drop off on the clothing, causing considerable annoy- 
ance. This abnormal condition of the hair-follicles and the coating 
«pon the scalp may interfere with the growth of the hair. It^the 
hair — may become dry and dull in appearance, the lustre disappearing, 
Bad slowly or rapidly thinning, which may, perhajis, lead to perma- 
nent depillation. In other cases the morbid action may continue, 
often becoming severe without any structural alteration of the folliclea 

k>6s of hair. On the removal of tho scales in this affection, the 
beneath may be normal or of a pale, dull- white tint, or somewliat 
hrp«niamic. Itching or a burning senBation is liable to occur, and is 
aggniYated by errors of diet and loss of sleep. Perspiration of tlie 
sraip JJB common. The disease is chronic in its course, often continu- 
ing for vears or a lifetime, especially upon its favorite scat, the crown 
of the head, probably producing premature baldness. Seborrham oc- 





DISEASES OF THE SKIN. 



curri ng upon other liairy parts of the body, as the eyebrows, mustAolie, 
beard, iind pubic region, follows a similar course to tbat of the scalp. 

Seborrhcea Faciei. — This phase appears chiefly about puberty, 
or between that period and tliirty. It is more frequently observed in 
females than in males, and is met with particularly u]}on the forehead, 
cheeks, and nose. It is apt to occur aa the oily variety, which will be 
referred to under seborrheBa oleosa. In the dry form it appears as thin 
or thick, yellowish, greecisli, brownish, or blackish scides or crusts, 
well adherent to the :?kin, forming sometimes a mask^ and occasioning 
much deformity. Extrancons substances frequently become entangbd 
in the scales. If raised from the surface, they will be seen to reach into 
the follicles. On their removal the skin beneatli will be found to be nor- 
mal or reddened, but the scales quickly reform. Itching luid burning 
sensations may be present. Acne, comedones, and eczema often appear 
at the same time. The disease, also, is a sequence of variola and syphi- 
lis. This form of the disease in the aged may terminate in epitlielioma. 

Sebourhcea Corporis. — Seborrluea of the body calls for special 
consideration, as it has an appearance very ditferent from that ob- 
served on other parts. It generally appears on the back, between the 
BcapuUe, the clavicular and eternal regions, and about the umbilicus, 
in patches of varying size and shape. One or more of these regions 
may be attacked at the same time. These patches are either large or 
small, round or irregular, or sharply or ill defined. They may appear 
isolated, and remain so, or, what is more common, tend to cnalesce, 
developing larger ones, invading the upper jiart of the back about the 
shoulders. In color tliey are pale-reddisli, and partially or generally 
covered with yellowish or greenish scales. The scaling is usually 
scanty, and can be entirely removed, particularly by the friction of 
the clothing. The scales are also loose, or partially detached. The 
follicles of the parts are, in addition, patulous, and there may be aene 
papules and pustules about the margin of the patches. They will 
very often, particularly if the patches assume a circular arraugement 
with a clear centre, look very much like ringworm. Those on the 
chest usually incline to he circular in form, and to be covered with 
slightly shrivelled, yellowish or grayish, greasy or dry scales. There 
is generally only a single one, but several may exist, which sometimes 
continue or coalesfie into one. The disease in this situation very often 
has the appearance also of ringworm, and not infrequently of a syphi- 
litic patch. In Beborrha«a of the umbilicus the collected sebaceous 
material rapidly decomposes, developing an offensive odor, and an irri- 
tation, with often an inflammation of the parts. Itching, and oe(?ii- 
sionally a burning sensation, are generally present in sebon'ho?a of tlic 
body. The course of the disease is essentially chronic, and it is iiablo 
to frequent relapses. 

Seborriiiea GEXiTALicix. — The genital organs in both sexes are 



DISORDEKS OF SECRETION AND EXCRETION. 



125 



: 



alitmdaritly supplied with sebaceoum gliinds, and, owing to a too free 
use of water and soap, or a neglect of cleanliness, or from abuse of the 
parts, not infrequently become affected with seborrha'a. The affection 
may be so slight as not io be considered a diseased slate, or so severe as 
to give rise to marked inflammation of the skin. In males it involvea 
the ginns penis and sulcus, A white, greasy matter, the Becrotion of 
Tyson's glands, caused by the heat and moisture present, rapidly de- 
fjiimposes, producing a fetid odor, and more or less inflammation. A 
di^harge from the inflamed parts very often follows, which closely 
resembles and may be niistaken for gonorrhopa. In females the seba* 
ceous material collects between the labia and nynipiue, and iibout the 
clitoris, occasioning at times an inflammatinn with a similar discharge 
to that just described. Seborrhcea of this region is liable to occur both 
in women and young girls. 

Seboreikea Oleosa. — This form, which is not as frcf|uenf.ly en- 
countered as the other, appears as a fatty cotitiug both on tlie hairy 
and Don-habry portions of the skin. It is, however, more common 
on the latter parts. The skin has a greasy appearance and impres- 
sion to the touch, especiallj on bald heads. It may assume in color a 
dirij, nnctuous look, owing to the dust which readily adheres to the 
snrface. The secretion may be discharged in a sufficient quantity to 
collect in minute drops, which have a yellow color ; or the oily fluid 
can be easily detected when a piece of very thin paper or muslin is ap- 
plied to the skin. There are present sometimes crusts from the con- 
cretion of the poured-out secretion. The integument may have in 
addition a pale or reddened appearance, and patolou=5 or plugged- 
np follicles, and give to the touch a cold sensation. The usual seat 
of the disease is the face, especially tlie nose, forehead, and checks, 
but it may appear upon other portions of the body. Its course of 
development may be slow or rapid. It may be so slight as neither to 
cause any annoyance nor attract any attention. On the other hand, it 
mmy be so severe as to produce an itching or burning sensation, and by 
its diBfigorement give rise to much annoyance, and in some instances 
to very great distress. 

Diagnosis. — Seborrhcea may resemble and be mistaken for eczema, 
psoriaais, lupus erythematosus, epithelioma, syphilis, ringworm, and 
ichthyofiis. On the scalp it is liable to be confounded with eczema. 
The latter affection, if present, ordinarily has a history of discharge ; 
the itching is constant and severe. Seborrhwa, on the other hand, is a 
dry diicase, and the itching is often intermittent and is rarely intense. 
Ei^ma inclines to occur in paiobcs, aod is apt to spread to the ad- 
joining portions of the integument. Seborrhoea, on the contrary, 
w a rolev appears uniformly over the scalp and is likely to be confined 
only to it. In eczema the scales ai*e commonly scanty, dry — being 
made np chiefly of inflammatory products ; in ssborrhcea they are 



DISEASES OF THE SKIN. 



more mimerons, greasy, and are composed of sebaceous matennl. In 
eczema the skin is also red and inflamed, while in seborrlia'a it is 
palo, Seborrhcpa of tbe face occasionally resembles erythematous ecze- 
ma, but the liistory of the disease, togotber with the presence of the 
greasy cmsts, and often patulous follicles beneath, are sufficient for 
diagnosis. 

Seborrhoea and eczema, while differing in many respects as pointed 
ont, may coexist upon the same subject. The one affection may bring 
into existence ttie other^ as in eczema of infants, which is liable to 
excite seborrboea- In a similar way seborrbwa of the face, of the ster- 
nal and genital regions, may develop at tbe same time eczema of these 
parts. 

SeborrboBa is even more likely to resemble psoriasis, either of the 
scalp or body. If seborrhea exists, it generally covers the entire 
scalp ; if psoriasis, the disease appears in patches cireumacribed with 
intervening ijcaltby skin, and similar lesions are present on other parts 
of the body, particularly on tbe extensor surfaces. 

Tbe scales in seborrhtea are small, thin, and of a gray or yellow 
color, while in psoriasis they are larger, thicker, and white in tint. 
The skin of the scalp in seborrhoBa is pale or deadened in color, and 
seldom exhibits any inflammatory symptoms; in psoriasis, upon tbe 
removal of the scales, it is at all times red and infiltrated. Seborrhoea 
may also have the appearance of, and be mistaken for, lupus ery- 
thematosns. The latter, it is known, begins sometimes as a congestive 
seborrhcr-a, but, once formed, its symptoms are cbaracterJstic. Again, 
scborrbcBa, virtnally, is neither sharply limited nor inflamed, as is 
always the ease in lupas. In seborrhoea tbe skin may bo reddened 
and covered with many easily detached, greasy scales ; in lupus it is 
more of a dark, reddened tint, and the scales, which are fewer, are 
also tenacious and dry. The disease is also distinguished from Inpus 
by not being followed by the characteristic cicatricial tissue of the 
latter dise!k>e. Sebnrrhrea and epitliclioma, in their early stage on the 
face of old people, may present such marked similarity as to be easily 
confounded. The attendant atrophy, and tbe slight degeneration 
around and beneath the patch, are usnally di.xtinctive symptoms of 
epithelioma ; but, if the peculiar small nodular lesions of the latter 
occur, the diagnosis can be readily established. Seborrhoea may re- 
semble, both on the scalp and the body, especially on the face and 
chest, some forms of syjdiilis. Tlie histwy of the case, the involve- 
ment of the glands, the dark-red or ham color of the skin beneath 
and around tbe cnists, and the detection of other lesions in the form 
of mucous patches or old scars, would point to conclusive evidence of 
sy]ihilis» It should be remembered, in this connection, that bolh 
diseases may likewise coexist — syphilis frequently exciting seborrbcea. 
Seborrhcea of the body may look very similar, especially on the chest, 



DISORDERS OF SECRETION AND EXCRETION. 



to rirgworm. In ringworm, lioweverj tliere ia the history of con- 
tagion, its rapid course, the circular arraiigemeiit of the patches, the 
tendency to heal in the centre with the iuliammatory periphery, and 
the evidence of a vegetable parasite, by microscopicul examination ; 
which 8hoald serve to prevent any error. Seborrhtca can hardly be 
confonndod with ichthyosis, the latter being a congenital, general, 
j>ermanent disease, while the former is an acquired, local, and curable 
affection. In seborrhoea the nkin, upon the removal of the scaleB, 
presents a soft and natural condition, but in ichthyosis it is dry, 
harsh, and rough, 

Pathology. — SeborrhcEa, which is a functional affection, consists 
in an increased and generally changed secretion of the sebaceous 
glands. There may also be an escape from the glands and their 
follicles of a certain quantity of epithelial scales. The secretion thus 
ponied out may remain oily or solidify, and occasion the oily or 
dry form of the disease. If the disorder be permitted to become 
chronic, it may eventually terminate in atrophy of the glands and 
their ducts, giving rise to loss of hair, which may be permanent. If 
the discharged secretion is placed beneath (he microscope, it will he 
fieen to be made up of an amorphou.?, fatty, somewhat granular 
material, with more or less epithelial cells. 

Etiology. — A normal quantity of the sebaceous material in the 
skin assists in keeping it in a henlthy condition. If the secretion at 
other than the phyi^iological period in the new-born becomes excessive 
or nnnatoral, a diseased state has taken place. The causes which 
prodace this change, while many, are mostly due to some general dis- 
turbance of the system. It may occur a-s the result of tuberculosis, 
cancer, the exanthematoua and other fevers, an ana?mic or chlorotio 
state^ or any cutaneous disease which may impair the general health ; 
or it may depend ujjon alimentary, uterine, or ovarian disorders. 
Again, it may be brought about by any local means which will give 
ziae to an irritation or congestion of the skin in persons who are 
otberwise healthy. Exposure to cold and heat sometimes occasions the 
disease, particularly on the face. Uncleanliness of the scalp, the use 
of hair-powders, dyes, pomades^ irritating lotions and oils, or too severe 
combing and brushing, or the too frequent use of water or soap, or 
both, are no doubt active factors in causing the affection. Occasion- 
ally it occurs in the healthy without any apparent cause, but with 
care may often be traced to one of those I have gtated. It appears at 
ail periods of life, but is more common at the age of puberty, and in 
the female than in the male. The development of one or the other 
variety is not dependent upon any special cause, but upon the tem- 
perament of the person in whom it occurs. For this reason, indi 
vidaals with light hair and complexion are subject to the dry Tariety, 
while those with dark hair and complexion to the oily. 



dl 



128 DISEASES OF THE SKOr.' 

Treatment. — SeborrlaoBa generally requires both constitutional and 
local treatment. The laws of hygiene should bo rigidly enforced. 
Fresh air, sunlight, exercise, and nutritious food are requisites. The 
administration of internal remedies is to be directed against the cause 
upon which the disease depends. The bitter tonics, the prepara- 
tions of malt, arsenic, iron, cod-liver oil, phosphoric acid, and the 
phosphates are indicated in the debilitated, ana?mic, and scrofulous. 
In derangement of the alimentary catial, the preparatious of pepsin 
and mix vomica, with an occasional laxative or cathartic, will be 
found of service. In cases depending upon dyspepsia, especially the 
atonic form, the following combiuatiun will be valuable : 

IJ Pefisini sacch gr. x. 

Strychiiina) BUlph gr. ^. 

01. meuth. pip ai ^, 

M. Ft. chart no, j. 
Sig. : Take after meals. 

If constipation is present, one tenth of a grain of aloin may be ad- 
vantageously added to each powder. Seborrhtpa, occujTiug at the age 
of puberty in those who are otherwise healthy, is often alleviated by 
the iodide of iron, two grains three or four times daily, or the sirup of 
hydriodic acid, one half a teaspoonful three times daily. It is some- 
times of advantage to add from one to five drops of liquor potassii 
arsenitis to each dose of the latter medicine. 8ul]jhur and its com- 
pounds, especially the sulphide of calcinm, in small doses, have also 
been recommended. 

In well-marked seborrh<i?a oleosa, Brocq thinks that he has derived 
some benefit from a combination of ergotin, belladonna, au(l hama- 
melis. Other drugs may be associated with these if indicated by the 
constitutional condition. 

I liave seen decided improvement follow the use of hoang-nan,* 
which seems to exert a tonic effect upon the sebaceous glands. 

The local treatment is of the utmost importance. It will, how- 
ever, vary according to the region involved, the duration of the dis- 
ease, the extent of crusting or scalingj and the irritabdity, if any, of 
the skin. 

As seborrho3a of the scalp is the most common form, it will be re- 
ferred to more in detail. It is not necessary to cut the hair, as it will 
in no way assist or facilitate the treatment The remedies can be 
applied efTectively whether the hair be long or short. A simple or 
medicated oil is, perhaps, the most advisable to employ, parlicularly 
if the hair be long. It Foftcns and loosens the accumulated masses 
of sebum and scales, aud removers them from the surface. The oil 

* ** Notes on HonngNan/* by the author, Tbempeutic Gazette, November 15, 1S99. 
"Notes on Iloaii;];-Nan in DiBeases of the Skin," The Journal of the American Medical 
Asaodation, October 26, 1889, 



^ DISORDERS OF SECRETION AND EXCRETION. 129 

of ergot is the beat agent to use for this purpose, as it possesses not 
only the power of removing the sebaceous material* but, by its astrin- 
gent and filightly stimulating action, proves of benefit to the diseased 
follicles and glands. In ordinary ciises of 8eborrhu»a of the scalp, or 
other parts of the body, it alone generally sufhoes as a local remedy, if 
tlie surface be occasionally washed with water and soap. It may be 
combined with an equal quantity of the fluid oleato of mercHry, oleic 
x^iJ* glycerine, or a tifty-per-cent. solution of boro-glyecride> and 
scented with some agreeable essential oil It will be of advantage to 
stimulate the parts by the addition of a small quantity of carbolic 
acid, balsam of Peru, or similar substauci's. Olive, almond, and other 
bland oils may also bo used for removing the sebnm and scales, but 
they do not iwsaess the raediciual ciualitics of the oil of ergot. In 
ee^ere cases, in which the sebaceous material is thick and caked on the 
scjil[>, it may be necessary to saturate the jiarts with oil in order to 
Boften the mass. The application should be made just before retiriug, 
and the head covered with a flannel cap and then protected with a 
bandage or, even better, oiled silk. On arising, the dressing should 
be removed, and the scalp washed with water and soap. Soft or 
potash Bonp, or spirit of soap, is usually recommended, but I have 
found 8oda soap, particularly when medicated with chamomile and 
snlphur, to be sufficient. If the sebaceous material reform, the ap- 
plication should be repeated. Lotions occasionally prove effective. 
They are to be preferred to oils in seborrhoja oleosa, especially of 
the face. One or two grains of corrosive sublimate to the ounce 
of rose-water is an excellent application. Naphthol, in from throe 
to five grains to the ounce of water, is also valuable. Equal parts of 
gljoerine and alcohol, or a fif ty-per-cent. solution of boro-glyceride have 
been found serviceable. 

Benefit has also been derived from the use of a fifty-per-cent 
^ution of bicarbonate of sodium. Pincus recommends lotions con- 
taining lactic or citric acid. Others prefer acetic acid, solution of 
ammonia, or carbolic acid* Kesorcin is advised by Ihle, who uses 
it diHsolved in olive-oil, castor-oil, or balsam of Peru, some of the 
preparation being rubbed into the scalp every day with friction. A 
solution of ichthyol in alcohol and ether is sometimes of advantage. 
The conjoined internal and external employment of jaborandi has 
likewise been proposed. Treatment should begin etirly in order to 
prevent baldness. 

The following formula? are also recommended : 

5 Tinct. nucis vomicse f 5 ss. 

Chloral, hydratis 3 j. 

Tinct. capsici » . . f 3 ij- 

Spts, rosmarini q. s. ad f t, f J iv. 

M. Big. : Apply night and morning. 
9 



130 



DISEASES OF THE SKIlf. 



5 Tinct quilkia? (1 to 10) f « iij. 

Tiiiet. capsiui f § ss. 

8p. odorati f § j. 

Gljceriiii ^ S ij- 

Amnion, curh 3 j. 

M. 

5 Sp. tttheris ^ 3 ^ij- 

Tinct, bcuzoiii. f 3 ij^ 

Vanillin gr. ss. 

lleliotropin * , , . * gr. jss. 

01. g^oranii , , ^ ij- 

M. 
Spirit of unimoniii, tinctnre of cuntharides, and other stimulating 
substances are useful in the form of lotions. Lime-water also is fre- 
quently of service. 

Ointraents ure sometimes beneficial, especially if bland medica- 
ments are required. As a rule, they seldom yield good results on the 
scalp and hairy parts of the body ; they mat the hair together, and do 
not always reach the diseased scalp. The ointment of mercuric oleate, 
well rubbed in, either alone or combined with naphthol or one of the 
tarry prepanitions, is the most effective. Those of the nitrate and the 
ammonia ted and the red oxide of mercury are wortliy of trial. The 
annexed formula has been prescribed with excellent results; 

I^ 01. anthemidis nt x. 

QuiiiinoB tannat gi*- xv* 

Ungt. bovis, 5 j. 

ir. Sig. : Rub in a small quantity once or twice daily, 
A useful formula for an ointment is : 

IJ Acid, salicylici 3 ss. 

Sodii boratia gr. xv. 

l^algam Peruvian tti xxv. 

01. anisi. M vj. 

01. bergtimii m xx. 

Ungt. aqute rosa^ 3 j. 

M. 

Zinc or lead ointments, with or without opium, may be demanded, 
if there is much irriUition or inflammation of the skin. 

In seborrlio'a sicca of the scalp Vidal advises the following 
preparation : Precipitated sulphur, fifteen parts ; castor-oil, fifty 
parts ; cacao-butter, twelve parts ; balsam of Peru, two parts. The 
ointment should be rubbed into the hairy scalp every morning and 
evening. 

Sulphur is highly esteemed by French dermatologists, and is ap- 
plied in the form of powder, lotion, or ointment. 

In seborrhoia oleosti PifTard has seen advantage from the use of the 



DISORDERS OF SECRETION A^'D EXCRETION. 



131 



oonstAnt electric cnrrent. He also recommends two to four per cent 
jsolations of hydrochloric or chromic acid and precipitated silica made 
by adding a dilute solution of silicate of soda to dilute hydrochloric 
acid. 

Lanolin is an excellent excipient for ointments in this affection. 

Other serviceable ointments in the treatment of seborrlui^aare those 
containing hamamelis, hydraKtino, arsenic olcatc, iind iron olcate. 

Powdei*s which have a combined astringent and soothing action are 
seiriceable in the oily form about the face and in seborrhtea of the 
prepuce. They can be uaed alone, or in connection with a lotion or 
ointment. Powdered zinc oleate, mixed with an equal quantity of 
arrow-root, starch, or bismuth subuitrate, forms an excellent applica- 
tion. Salicylic acid may be usefully added to any of these powdfrs. 

The local treatment of seborrhcea of other parts of tlio body is sim- 
ilar to that of the scalp. The sebaceou.^ material, if acctimtilated, 
should be removed in the manner already described, and suitable appli- 
cations then be made. The selection of remedies and the frequency of 
their application — whether daily, once or twice a week^ or every few 
days — will depend upon the variety of disease and the condition of the 
affected surface. In c^ges in which soap and water increase the irrita- 
tion, their use must be avoided. 

Prognosis. — Seborrhcea is a clironic but generally curable disease. 
It may at times disappear spontaneously, or yield rapidly to treatment. 
Again, it may prove obstinate, requiring a prolonged course of treat- 
ment If it involves the scalp, or other hairy parts of the body, or 
hae continued for some time, temporary and not infrequently per- 
manent loss of hair may follow. The prognosis is very unfavorable in 
cases in which the entire surface is involved, and also in those afHicted 
with carcinoma and tuberculosis. 



COMEDO. 

Comedo is a disease of the sebaceous glands, due to retention of 
eebum within the follicles, and marked by the appearance of whitish, 
yellowish, or blackish points at their orifices. 

SymptoiiLS. — Comedones vary from a pin's point to a pin's head 
or larger in size. They may be elevated or non-elevated, and more 
or less numerous, irreguhirly distributed on the skin. They are situ- 
ated, a^ a rule, about the face, neck, chest, and back. The face, espe- 
cially the foreheatl, nose, and chin, is usually involved, being studded 
with black points, and often also presenting a greasy and muddy ap- 
pearance. 

In some cases double comedones have been observed. In these a 
commnnication exists between the ducts of neighboring glands, or a 
duct may bifurcate before reach iug the surface. Dr. George Thin has 



132 DISEASES OF TBE SKIN. 

described cases of grouped comedouesin which the occluded ducts are 
so closely grouped upon defined ureas of the face as to give a uniform 
dirty-black appearance to the part affected. 

H. Kiidcliffe- Crocker also has met with several cases in which 
grouped comedones were symmetrically arranged upon both sides of 
t!ie face.* 

In rare instances comedones occur on all portions of the body ex- 
cept the hands and feet. 

The disejise is frequently accompanied by acne and seborrhoea 
oleosa, and inflammatory symptoms will at times result It occurs 
chiefly in the ynutig of both sexes, especiully about the age of puberty. 
The course of the disease is very slow, disiippeariug, to again reappear^ 
it may be for years, unless checked by appro|)riate treatment 

Diagnosis.— Comedo miglit possibly be mistaken for acne punctata, 
but inflammatory symptoms exist in tlie latter which are not usually 
present in the former disease. The differentiation between comedo 
and milium is rnferrcd to under the latter affection. 

Pathology.— The disease develops in the sebaceous glands and 
follicles, and consists in the retention of sebum and epithelial cells 
leading to the dilatation of the openings upon the surface. The black 
point upon the skin is generally ascribed to dirt, but Unna states that 
it is produced by pigment. The formed comedones rarely excite any 
inflamnuition, and tf removed and examined are found to consist of 
sebaceous matter, epithelial cells, free fat, occasionaOy one or more 
small hairs, dirt, and at times the Demode.r folUcithritm. The latter 
parasite, which is frequently present in healthy subjects, is not a causa- 
tive element in producing the disease. 

Etiology. — The physiological activity of the glands and the de- 
velopment of the hairs at the age of puberty are doubtless provoca- 
tive of the disease. Chlorosis, scrofula, and menstrual disorders fre- 
quently produce it. Affections of the gaatro-intestinal canal, especially 
dyspepsia and constipation, very often assist in its development. Ac- 
cording to Piffard, comedones at times have their origin in mastur- 
bation. In fact, it may, like acne, be brought about by the func- 
tional derangement of any one of the organs of the body, including 
the skin itself. The action of local irritants npon the skin, as in 
certain occupations, often gives rise to the disease. This result will 
frequently be seen in those working in tar, among chemicals, dyes, 
wooU etc. 

Treatmeat,— Constitutional ami local treatment are of advantage. 
Chlorotic subjects are benefited by cod-liver oil, iron, the simple bit- 
ters, with occasioniilly saline aperients. An appropriute diet and 
proper hygiene are of the greatest value in all cases. Dyspepsia, 
constipation, and uterine disorders should bo corrected by suitable 
♦ Lancet, October 27, 1888, p. 813. 



^ DISORDERS OF SECRETION AXD EXCRETION. 133 

treatment Ergot, and the tincture of the chloride of iron, or dilute 
phosphoric acid, alone or combined, can often be eniplo3'ed with good 
resolte, especially in weak and nervous patients. Local treatment is 
All-important for the purpose of removing the ofTending plugs and 
stimulating cutaneous activity. The comedo-plugs, if a source of an- 
noyance, from the deformity which they occasion, can best be removed 
by nicking the side of the fullicles and scooping out with a needle- 
knife, or gently pressing the contents. If an attempt is made to re- 
move them by srjueezing the comedones between the fingers, or by ap- 
plying a watch-key over them, and by violent pressure forcing out the 
contents, the delicate epiderniis may be kcerated and itiiliirnmation 
result. The nsc of soap and water, followed by friction with rough 
towels once or twice daily, alTords most excellent results; medicinal 
ioaps can also be advantageously employed, especially sulphur, chamo- 
mile, ergot, salicylic acid, and sublimate, eitlier in the form of potash 
or, even better, sodu soap. Soup combined witii alcohol, or any one 
of the spirits, is likewise effective. Stimulating lotions containing 
corrosive sublimate, one of the tarry preparations, sulphur, borax, 
bicarbonate of soda, or aulphate of zinc, are well borne and yield good 
results. 

The French are much in the habit of employing camphorated alco- 
hol. Prof. Hardy recommends a solution of alum, and Brocq has often 
obtained satisfactory results from the use, night and morning, of a de- 
coction of saponaria-root, to which is added about a drachm of Cologne 
wattT and Indf a drachm of water of ammonia. 

I herewith give a formula that hi\s proved useful in my private and 
liospit^il practice, and is well worthy of trial : 

9 Thymol gr. r. 

Acidi borici. , , 3 ij. 

Aquae hamamelis Virg. dest. f 3 iv. 

Aqu£e roste f 3 j, 

M. Sig. : Mop well over the snrface once or twice daily. 
The appended is also a very good application : 

IJ 8ol, boro-glyccride (50-per-cent. solution), 

Spts. vini rectif . ... * , iiu f j ij. 

M, Sig. : Rub well into the part with fhiiincl. 
The various stimulating ointments, particularly those containing 
sulpha r, borax, Peruvian balsam, tar, and the mercurials, or an oint- 
ment composed of one part of C4irbonate of ammonium to eight parts 
of simple cerate may be nsed when soaps or lotiona are not suitable. 
If ilie part has unfortunately been over-stimulated, and the skin as- 
nimes a rough and inflamed appearance, Pootlung and slightly astrin- 
gent ointments or dusting-powders should be cmfdnyed, among the 
best of which is a mixture of erjual j tarts of oleate of zinc and finely 
powdered talc, as proposed by Dr. Jamieson. 



iMyii 



DISEASES OF TnE SKIN. 

ProgBOSis,— Favorable rosultij invariably follow well-directed eUorU 
to remove the disease. Relapses may occur if the exciting cause re- 
maiua, but persistent treatment will restore the skin to its normal 
condition. 

MUilUM. 

SYNONYiia. — Ginitutii — ^Stropliulus albidus — Acoe albida — Tubercula miliaria^ — Tubcrculu 

Bebaeca. 

Milium consists in the development of small, round, whitish forma- 
tions, located beneath and covered by tlie epidermis. 

Symptoms* ^M ilia appear as small, round, flat, or acuminated bodies, 
usually situated on the face, particularly uhout the upper eyelids, 
cheeksj and temples. They may occur, however, on other portions of 
the body, especially on the penis and scrotum. They may or may not 
be elevatetl, and are hard and firm to the touch ; in size they vary from 
a pin's liead to a small pea, but commonly they are about that of a 
millet-seed, from whicJi they derive their name. They are whitish, 
tmnsluceut, pearl, or yellowish in color They may appear singly or 
multiple, but are ordinarily observed as several — usually four to twelve 
— upon one of the regions named. They develop, as a rule, slowly, 
and, after reaching a certain size, remain for years. They occur more 
fref|uently in women than in men, particularly at and after aduH age. 
Milia may exist alone or occasionally in connection with other GTnp- 
tions, as acne, comedo, lujius, and iy]>hilis. They give rise to no sub- 
jective symptoms^ but, simply by their presence, if on the face, accasion 
more or less deformity. 

Diagnosis* — Milia may resemble comedonee, from which, however, 
they nuiy bo distinguished by their aualomical formation. Jlilium, 
anatomir-any, is a very small sebaceous tumor, covered with epidermis; 
while comedo is simply a dilatation of the duct, with a retention of 
the secretion, and a free or open extremity. 

Occasionally the retained material of milium undergoes calcification* 
The little tumor then feels hard and constitutes, in fact, a cutaneous 
calculus. 

Milia usually project from the surface, and occur as the sole dis- 
ease; comedones, on the other hand, liave a smooth surface, with 
prominent black points, and generally coexist with acne or some other 
eruption. 

Pathology,— Milium is thought by many investigators to consist 
in a retention of the sebaceous secretion, together with an oblitera- 
tion of the aperture of the gland, x\n incision through one of the 
formations will demonstrate that it lies beneath, and is covered with 
the epidermis. Virchnw and Kindfleisch believe that the cysts pro- 
ceed from the hair-fullieles. Robinson also states that he considers a 
milium, wdiere superficially located and under certain circumstances, 



^^m 



EDERS OF SECRETION AND EXCRETION. 

may be tttSjfffi wandering embryonio epithelium from a hair-follicle 
or from fee 'me. 

Etiology. — The origin of this disease is in many cases unknown. It 
miiT ariise frum a constitutional derangement, or lowil source of irritation. 

TrBatment.— The free use of soap and water, especially the potash 
soap, will often cause in ilia to disappear. But the best and most radi- 
cal treatment is by means of the knife. A small incision in conjunc- 
tion with an application of Mousel's solution or the tincture of ioiline 
will insure tbeir destruction. They may also be removed by electrolysis. 



SEBACEOUS CYST. 

BT?i03STiia^ — Siealoma — A tlieroma— Sebaceous tiitnor — FoUieular tumor— Encysted 

Sebaceous cviit is a prominent, roundish, or semiglobular tumor, 
situated in the skin or subcutaneous tissue. 

Symptoms. — Sebaceous cysts or wens consist of an accumukition of 
the secretion in the sebaceous glands. They are met with chiefly 
upon the scalp, forehead, eyelid, neck, shoulder, back, buttocks, and 
scrotum. They may occur singly, as is usually the case, or be multiple. 
An nnnsual case of such multiple development has been described 
by Prof. Chiari.* The patient was a man seventy-four years of age. 
The tumors were of all sizes, from an almost imperceptible nodule to 
that of a walnut* In some regions more than twenty were counted 
within an area of about four square inches. 

They vary in size from a pea to a small orange, and are semi- 
globular, rounded, or flattened in shape. They may be firm, soft, or 
fluctuating in consistency, according to the condition of the retained 
material. They are usually freely movable; but this depends upon 
their age, size, and the condition of the tissue in which they are 
seated. The overlying skin is either normal or paler in color, from the 
compression of the blood-vessels. It may ho devoid of hair, and, in the 
aged, rough or red or greasy in appearance. The orilice of the gland- 
duct may remain in .«ome and be oblttcnited in others. They are un- 
attended by pain, slow in their development, and often remain for years 
without producing annoyance. Occasionally, however, they inflame, 
suppurate, and ulcerate, giving rise to an offensive discharge. The 
periods at which they most frequently appear are ehildhuod and mid- 
dlitiige; instances, however, have been known where they have existed 
before birth. They are also said to be hereditary. 

Diagnosis. — Sebaceous cysts are liable to be confounded with fatty 

tumors, Tiie latter, however, seldom invade the scalp, have more of 

a doDghy consistence, their degree of mobility is slight, and they may 

tttuun % Tery large si^e. In case of doubt as to the diagnosis, an iucis- 

♦ Dntish Medical Journal, April 12, 1890. 



136 DISEASES OF THE SKIN. -^^^ 

ion should be resorted to. They iiiay also resemble gtimmata and os- 
teoma ta. Gtimniiita are tisimlly attended by otiier syphilitic led o lis, 
and are both rapid and painful ; but are not as freely movable as the 
sebaceous tnmors. Osteomata are hard and immovable; sebaceous 
cysts are soft and movable. 

Pathology, — A sebaceous tumor is a cyst of the gland, caused by 
retention of the secretion. It consists of a strong sac and its contents 
— the sac being formed by a distention of the gland, producing more 
or less hypertrophy of its walls. The contents are variable both in 
color and consistence — whitish, yellowish, or grayish, and hard and 
friable, or soft» cheesy, and fluid — and composed of sebum, epidermic 
cells, cholesterine, with occasionally a hiiir. The cyst may break down, 
and be attended with a fetid odor, or be partially or entirely filled with 
calcareous matter. 

Treatment.— The most certain remedy is excision. Tlie operation* 
however, should be performed only when the system is in good condi- 
tion, or after proper preparation has been made for it. If this pre- 
caution be not taken, erysipelas may follow with dangerous and pos- 
sibly fatal results. After incision, the cyst- wall shoyld be entirely 
torn or ilissected out; otherwise, the growth may return. The cyst 
may also be dBstroyed by caustic applications or injections of iodine, 
carbolic acid, or other irritating substances, 

A convenient and successful method, according to a writer in the 
"British Medical Journa!," consists in puncturing the cyst with a 
Gra43fe's cataract-knife, gently expressiug the contents, and afterward 
introducing a very small piece of nitrate of silver. On the following 
day, by means of a pair of forceps, the capsule of the cyst cim be with- 
drawn without any portion being left adherent. It is stated that in no 
case has this procedure been followed by return of the growth or ill 
effects. 

Prognosis. — As a rule, the prognosis ia favorable. Fatal results 
may happen in the aged and debilitated, but seldom when they have 
been prepared for the operation. 

HYFCRtDROSIS. 

Sthontms.— Ephidroslfl — HydroBis — IdroBis— Smiatorfu — Increased secretion of sweftL 

Ilyperidrosis is a functional disorder of the sweat-glands, chajucter- 
ized by increased sweating. 

S3rD|ptonis.— Ilyperidrosis may be either acute or chronic. It may 
be general, in which the entire body is affected, or local, and limited 
to certain regions. General sweaiirtf/ may occur in healthy individuals 
from nervous excitement, or from an increase in the surrounding tem- 
perature, especially in corpulent persons. It is often liable to appear 
in connection with tuberculosis, pneumonia, rheumatism, malaria, and 



DISORDERS OF SECRETION AND EXCRETION. 



certain nervous, febrile, and debiliUiting diseases. The temperature 
imder such circumstanceB miiy rise or fall. 

Long-continued hyperidroais may depend upon aBa?mia. In this 
case, according to llebra^ warty thickenings, corns^ or callosities always 
form npon the palms and soles. The fingers may assume a drumstick 
furm, and the nails become large and broad. 

Local hi/pendrosis may occur upon any part of the body, but the 
Bcalp, face, axillae, geiiitals, and palmar and plantar Kurfaeea are most 
frequently involved. It may be temporary, continuous, intermittent, 
or periodicaL It may be flymmetrical or unilateral, Mau}^ cases have 
been recorded in which, owing to some derangement of the nervous 
system, the sweating occurred upon one or opposite sides of the body. 
It may be slight, or it may be so excessive as to saturute the clothing 
and macerate the integument. In the axillary region the poured-out 
sweat, mingling with the sebaceous secretion, particularly in women, 
digeolors and destroys the clothing, creating a most diijagreeable and 
offensive odor. The same annoyijig, and occasionally even more vexa- 
tions, effects follow from hyperidrosis of the genital regions* In the 
involvement of the palms and soles, the sweat may exude in drops, col* 
ltd on the surface, and flow in quantity from the members. The 
palnu when affected are bathed in a profuse perspiration, even after 
drying. The secretion can often be seen issuing from the ducts as a 
clear or yellowish fluid. The amount varies according to the condi- 
tion of tlie health and the state of the temi>enitnre. 

The skin presents a white, wrinkled, and maeerated appearance^ 
and the parts are cold and clammy to the touch. Similar and often 
even more severe symptoms occur in hyperidrosis of the soles. The 
stockings and shoes, or boots, become saturated with the seeretion, 
which decomposes, adding a further source of irritation to the parts. 
The skin becomes macerated, sodden, fissured, especially in the flexures 
of the toes, and strips off, exposing a delicate and tender surface beneath. 

In a case under the care of Vidal, hyperidrosis of the foot was so 
excessive as to cause confluent vesicles with the eventual formation of 
bttllsB as large as an egg at several different points * 

A diaagreeable odor develops, and the pain and suffering may be so 
severe as to interfere partially or entirely with walking. 

Hyperidrosis may at times bo attended with itching, burning, 
pricking, tingling, or other unpleasant sensations. It is often a most 
obstinate and jwrsistent digorder, occurring in both sexes, and usually 
more severe in summer than in winter. It may give rise to other 
cutaneous affections, especially eczema. 

Diaf^osis. — The diagnosis is easy, but the disease may resemble 
eeborrhoea oleosa and prickly heat. In seborrlupa oleosa the ponred- 
out secretion is oily, and in prickly heat vesicles are formed, with at- 
* Journal of Cuuuieoos utd Genito-Urinarj Di^^eases, May, 1S88, 



DISEASES OF THE SKIN. 



teiu!aiit sTirroiinding infliunmation ; in hyperidrosia the secretion is 
soroiis, aiKi vesicles und indummiitiou^ as a rule, are absent. 

Pathology. — In a case of phthisis, attended with hyperidrosis, Yir- 
chow observed that the glands were enlarged, with fatty degeneration 
of the epithelium. The sweat-glands and tissue of the part involved 
are not usually clianged in the least. 

Etiology. — ^Hyperidrosis may sometimes be congenitiil and heredi- 
tary. Functional or organic disease of any of the organs^, or a derange- 
ment of the nervous system, is often the exciting cause. A nervous 
influence has frequently been noted to be active in occasioning it. 
The direct cause can not be ascertained at times, even after careful 
examination into the contlition of the system. 

Jamieson stiites that hypcridrosis of the hands is particularly apt to 
occur in those who are in the daily habit of using spirituous liquors to 
excess. 

Treatmeilt. — The treatment should he appropriate to the case under 
consideration. If the cause of the disease can be detected, it should 
be removed or counteracted. Lung, heart, and kidney alTeetions, or 
hysteria, neuralgia, aniemia, chlorosis, scrofula, or syphilis, may under- 
lie hyjjeridrosis, and they should receive t!ie treatment necessary for 
each individual case. There are a immber of remedies which may l>e 
employed in arresting excessive perspiration, but their eCFect, as a 
rule, is only temporary. Geber refers to the value of white agaric 
(O'l to 0*5 gm.), the extract of aconite (0'03 to 0*00 gm.), and to 
salvia leaves, flor sambuc., the aqueous extnict of strychnine, cai'bolie 
and salicylic acids. Jaborandi has been of service, as well as pilo- 
carpi n and atropia. The hitter is probably the most effective and 
certain general remedy; it maybe given hypoderniatically, in from 
one eightieth to one one hundred and sixtieth of a grain. Ergot, in 
the form of the fluid extract, and faradization have also been followed 
by good results. 

Tannin acid, gallic acid, quinine, sulphuric acid, and digitidis are 
other constitutional remedies which have been employed, Badliinde* 
recommends alcohol in excessive perspiration on account of finding 
that tliis agent diminishes tlie temperature of the skin and the trans- 
piration of Iluid during the course of Ins experiments. 

The pliosphate of calcium has sometimes been advantageously used. 
When the superabundant secretion seems to dejiend upon disorder of 
the nervous system, valerian, the bromitles, and the cold douche may 
prove of service. Khemnatic and gouty patients in whom hyiieridrosis 
18 present may bo benefited by the administration of the iodides. 

Iloang-nan exerts a special tonic influence upon the sudoriparona 
glands and restrains excessive secretion* 

Local treatment is essential in curing or relieving the disease. 
• Zdtsclir. f, klhi. Med., Bd. xtiL, Ikft 5. 



DISORDEaS OF SECRETION AND EXCRETION. 



The constant use of water in the fi^rni of btilhs, or a])j>lie(l directly to 
piirt, fiiniple or medicated, is not usually attended with tlic best 
ilu. lo its iriiJde^t forms, the occasional use of water, as hot as the 
surface can bear, with najdithol, corrosive sublimate, sulphur, or tar 
^ ioap, 13 often produetive of good. In light uud severe cases ducting- 
^■powders are w^ell borne, either alone or after the application of water. 
^BZinc oleat^,) salicylic acid, and uaphthol are perhaps the most useful of 
^Lall powders. The following I have fouud of service : 

^^^^ 3 Pulv. ziiiei oleatis , 3 iij- 

^^^^B PqIv. amyli ^ bs. M. 

^^^^^ ]} Aeidi salicyliei, 

^^^^^^^ BisMiut h Bubiiit ufi 5 ss. M. 

^^^^B B ^\iphihoIi 3 y 

^^^^B Acidi boriei ? sa. M. 

^^^^As soon as the powders become moist ou the surface, they should be 
removed with sweet-oil and reapplied. Care shouhl always be exercised 
to avoid having the affected part too warmly covered or too well pro- 
^^tected. This condition is frequently observed among women who wear 
^■shields in the axillte to protect their clothing, and in men who apply 
^^■llicocele-bags and other means of protection around the genital or- 
^H^IiitlB. These articles may often cause the secretions to be retained, 

aud produce an inflammation of the skin 

^m Lotions are frequently effectual, either alone or in connection with 

^f other medicaments. They may be aqueous or spirituous, and contain 

' tannic acid, camphor, sulphate of zinc, acetate of lead, acetic, sul- 

pharic, boracic, and salicylic acids, corrosive sublimate, porchloride of 

iron, or other drugs. Ten grains of corrosive sublimate, in four ounces 

of Cologne- water or tinctnre of witcb-luizel, forms an elegant and nse- 

ful application. Ahim, one or two drachms to the ]>int of water or 

alcohol, may also be employeil. The tincture of belladonna is said to 

be a valuable remedy. 

A one-per-cent< aqueous solution of chromic acid is often very ef- 
fective in h}^eridrosi8 of the feet. A piece of lint saturated in tho 
solution should from time to time be applied to the soles and the 
spaces between the toes. 

An excellent lotion consists of hydrochlorate of hydrastine in the 
[strength of two to six grains to the ounce of water or distilled witch- 
[liazeh An infusion of soap-bark is also efficacious, 

Unna recommends that before going to bed the patient should 
le the parts in hot water containing camphor, mustard, or vinegar, 
[after which an ointment of turpontinc or ichtbyol, each five parU to 
ten parts of oxide-of-i?inc ointnieiit shonid bo applied. In the morning 
the ointment should be washed off, cold water be rubbed u]>on the sur- 
face until redness and warmth are produced, and then dusted with a 
rder containing mustard -ff our. 




DISEASES OF TOE SKIN. 



In obgtinaite cases, involving the feet, Ilehra obtained good effect 
from the application of diacli^'lon-ointment. The ointmant is spread 
upon pieces of liucii snflicicut to cover etich foot, likewise on sepa- 
rate pieces to be placed between the toes. The entire foot ia then 
covered with linen, bandiiged, and the stocking and shoe put on. The 
same procedure is repeated each day for one or two weeks. The upper 
layer of the skin in the course of a few days after treatment begins to 
be cast off; after this is complete the feet are washed and powdered, 
the hitter process being continued for some weeks after the ointment. 

Stewart advises that after bathing the atfected parts with warm 
water, they should be washed with a solution of permanganate of |>o- 
tassium, then dried, and, when tlie hands and feet are involved, that 
they should be enclosed in bandages spread with cemssii. The plaster 
is to be renewed every twelve hours during ten to sixteen days. Thy- 
mol may be added to tho permanganate solution with advantage. 
Chloral in ten-per-eent solution, or a weak solution of chlorate of 
potassium, has also been recommended as useful in tliis adection. 

Salicylic and boracic acids, lead oleate, and na]>lithol are likewise 
valuable ointments. 

An ointment of liydrastine or aluminium oleate can also be recom- 
mended. Of late I have used aristol * with very satisfactory results. 
Upon sweating feet it may be used alone as a dusting-powder. In 
other localities 1 have mingled it with the impure carbonate of zinc or 
have prescribed it in the form of an ointment made up with the oxide 
of zinc or subLicetate of lead. 

Lint and absorbent cotton, with or without medication, are also use- 
ful, linbiuson endorses the use of borated absorbent cotton without 
other adjuncts. 

Another good plan is to dust subnitrate of bismuth freely into the 
atockings or gloves. 

ProgniosiB. — Hyperidrofiis in many cases can only be alleviated. 
The disease is obstinate and unyielding to the best-known methods of 
treatment. If the cause can be discovered and removed, the prognos; 
is favorable. A cure, however, and very often relief, is not obtained, 
owing to the patient neglecting to thoroughly carry out the treatment 
advised. 

ANIDHOSIS. 
Stkontms. — Hypohidroaig— A decreased or complete cessation of the secretion of sireMk 

Anidrosis ia a functional disorder of the sweat-glands, character- 
ized by a decrease or complete cessation of the secretion of sweat. 

Symptoms.— Anidrosis may be idiopathic or symptomatic, general 
or local. It may be congenital or hereditary, there being a diminution 

♦ See paper on " Arintol," by Jolin V. Shoemaker, A, M., M. D., in the Medical Bul- 
letin tov June, ISt^l, p. 201, 




IISORDERS OF SECKETIOX AND KXCRETION. 



141 



or an absence of sweat, tinder circumstances which generally make 
the sn<ioral secretion most active. Extimplea of general idiopathio 
aniJrosis are to be observed in ichthyosis. The skin in these cases is 
lijirsh and dry, and the palmar and plantar surfaces are thickened, fis- 
sared, and at times puinful. 

Symptomatio Anidrosis, which is far more common, may be either 
general or local, and may occur from impairment of the nervous sya- 
tem, or in the course of other cutaneous aiTcctiong, as eczema, psoria- 
Bii, lichen rubra, and leprosy. It may bo temporary, as in fevers and 
Igiaa, or it may be permanent, as follows sometimes in diabetes, 
Loma, and tuberculosis. The skin, whether the diseuiJO be g-en- 
eril or local, temporary or permanent, is dry, rough, and often the 
seat of itching, burning, and other distressing sensations. Occasion- 
ally, a sudden arrest of the functional activity of the sweat-glands may 
gire rise to more or less unpleasant constitutional symptoms. 

An allusion may not inappropriately jierhaps be nuide in this place to 
a condition described by E. C. Perry under the title of ** Adenoma of 
m the Sweat-glands." A woman bad for twenty-one years been afflicted 
f With white, firm papules upon the face. Tlie lesions varied in size from 
that of a millet-seetl to that of a pea, were puirdess, and bad never 
ulcerated. There was no seborrhoea, and the secretion of sweat from 
the head and face had decreased. The sweat-glands were enormously 
enlarged. The swellings were pricked with a needle and then removed 
with scissors or scalpel. The result was a complete cure. 

■ Treatment — Exercise, especially in the open air, or the use of mas- 
^Uige, is to be atl vised. The general health should also be corrected. 
Hteihs — the cold, hot, steam, hot-air, or Turkish or Hussian — with fric- 

■ tion of the skin, are to be commeudei]. Diaphoretics are advisable. 
™ The most valuable are the fluid extract of jaborandi, in the dose of 

from a few drops to one or two drachms, or its alkaloid, hydrochlorato 
of pOocarpin, given in from one tenth to one half grain. Free diapho- 
resis will follow in a short time, and continue for several hours. From 
its tonic influence upon the glands of the skin hoang-nan is useful in 
this disonJer. Emollient ointnients or oils will often be required when 
the skin is dry and fissured. Lanolin, alone or combined with a few 
drops of oil of eucal>i:ttu8, forms an excellent application. The use of 
dilute glycerine will also sometimes serve a good purpose. 

BHOMlDmOSlS. 

SrHOHnis. — Osmldroeis — Stmking sweat^ — Odorous gwreiit. 

EmmidrosiB is a functional disorder of the sweat-glands, character- 
ized by an offensive or disagreeable odor from the skin, with more or 
less sweating. 

Symptims. — Bromidrosis may occur either as a general or as a local 




iASES 01 



disorder. If general, it may be a physiological condition, as is tlio 
case in the negro, and occasionally iu persons of other races. The 
exhalation may have a characteristic odor, as of decayed cheese, putrid 
flesh, nrme, or rancid, goaty, or sour; or like that of onions, asafwtida, 
musk, sulphur; or it may have a peculiar sweet smell, like violets or 
pineapples, A distinctive scent occurs in certain diseases, as in the 
fevers, in which it is ammoniiical ; in scurvy, putrid ; in syphilis, sweet; 
in rheumatism, acid; in jaundice and peritonitis, musky. In nervous 
affections, also, peculiar odors have heen noted to occur ; Hamilton 
recordin^^ for instance, that of violets perceptible in a lady of hyster-^j 
ical disposition. The ingestion of cerUiin articles of food and dnigJB 
may give rise to others. The local forms of bromidrosis are the most 
common, especially npon those portions of the body abundantly sup* 
jdied with sweat-glands, as the axillae, groin, genital regions, and feet. 
The odor may vary, being slight and hardly apparent, or so penetrat- 
ing and offensive as to interfere with the person's intercourse with his 
fellow-man. It often causes individuals to be shunned by those tbey 
come in contact with in their occupation, as well as in social life. 
The disorder is more severe in the summer than in the winter months. 
It may occur at all ages, but is mure frequently encountered in middle 
life. The feet, which are the most frequently affected, exhale a most 
offensive odor. The disorder is mostly symmetrical. The skin, from 
the irritating action of the decomposed secretion, which is retained in 
the stockings and shoes, becomes red, excoriated, and tender, or whitish 
and sodden, and is sometimes so painful as to interfere with walking. 

Bromidrosiphobia * is a term employed by Piffard to denote that 
the odor complained of is subjective and referable to perverted sensi- 
tiveness of the olfactory organs. Two cases of this disease are reported 
by him. 

Etiology. — The disorder is frequently connected with some nervous 
derangement. At times it will be found impossible to trace it to aujCB 
assignable cause. iM 

Treatment^ Bromidrosis, if physiological, may be relieved by fre- 
qnent ablutions with water and soap, the naphtbol and carbo1ic-aci< 
soaps being serviceable. The same may be said of eucalyptus soaj 
The under-garments should be changed often. When it is dependent 
upon disease, particularly of the nervous system, it should be counter- 
acted by appropriate treatment. The internal administration of hoaug- 
nan will be found of material assistance to the local treatment. Small 
doses of jaborandi by the mouth or of pilocarpin hypoderraically are 
also of iid vantage. The local forms are treated principally in a similar 
manner to byperidrosis. There are, however, certain remedies which 
are particularly efficacious, and to which special attention is ciiHed. 
Naphtliol, boric and salicylic acids are valuable agents, used in the 

• Lof. at. 







BORDERS OF SECRETrON AND EXCRETION. 143 

form or lotions or ointments. From ten to thirty grains of either in 
iiu oance of water, alcohol, lard, lanolin, or suet, form suitable appli- 
cations. Sulphate-of-zinc ointment in the same strength is eflieacious 
in removing the offensive odon An ointment of alum containing 
^ thirty or forty grains to the ounce, or of aluminium oleate mixed with 
^Kequal parts of lard, is of service in thia affection. The sulphate or 
^■KBtatc of copper in the form of ointment or lotion or the oleat<2 made 
^nm^ a ten or twenty per cent, ointment may also be advantageously 
employed. Hydrastine-ointment, made by incorporating from five to 
thirty grains of the hydrochlorate in an ounce of excipient, diminishes 
fetor. Thin recommends, in bromidrosis of the soles, the wearing of 

I cork-soles within the shoes; the cork to be soaked, as well as the 
itoekings, in a solution of boric acid, and to be thoroughly dried be- 
fore wearing A fifty-per-cent solution of boro-glyceriile, used alone 
or rubbed up with carbonate of lead or zinc, often acts well. Tlie per- 
jnanganate of potassium or chloral hydrate, in from five to thirty grains 
in the ounce of water, alcohol, or tincture of witch-hazel, may have a 
beneficial effect. Solutions of oxalic acid, ten to twenty grains to the 
, ounce of water, or chloride of zinc, in from three to ten grains to the 
^ft ounce, may also be recommended. The local application of tincture 
^B of iodiae has likewise been found successful in some cases. 
H Among other lotions which may be employed with more or less 
" benefit may be mentioned limc-wator, and the infusion of soap bark. 
The hands or feet may be bathed in the latter fluid every day or every 
other day, while the face or axillae may be washed with a sponge which 
been dipped in the infusion. 

The following formula is highly recommended by Tehappe : 
^ Zinci sulphat., 

Ferri sulphat afi 450 grammes, 

Cupri sulphat 150 " 

N:iphthol 1-5 ** 

Essen, thym. 3-5 " 

Acid hypophosphor. 5-7 " 

Aq. destillat 2500 " 

The Tarious dusting-powders, especially the oleate of zinc, salicylic 
acid, and powdered red cinchona, singly or combined, either with or 
tithout lotions, often afford much relief. 




CHROMIDROSI3. 

Synonym.— Colored swemi. 



iromidrosis is a functional disorder of the sweat-glands, charac- 
terized by a coloration of the sweat-secretion. 

Symptoms^ — Chromidrosis is a very rare disorder, and consists in 
the commingling of sweat with pigment-matter. The sweat is in- 



144 



diseases' 



creased in qimntity, and may be of a yellowigli, greenisli, reddisli, 
bluish, brownish, or bkckish color. The secretion is not consUnt, 
bnt irregnlar in its periods of development. It comes suddenly, to 
disappear in a brief iriterval, and again reajipear. It nniy occur upon 
various parts of the body, but is most frequently observed on the face, 
chest, abdomen, arms, bands, and feet. It is met with more often in 
females, especially the unmarried and in those suffering from some 
uterine derangement, nervous alleetiun, excitement, or shock. The 
coloring-matter in the secretion is said to be due to Prussiiin-blue, 
indican, or other pigment. Simuhited cases of colored sweating have 
occasionally been reported. 

A valuable paper npon ehromidrosis has been written by Dr. Foot, 
who ascertained tliat since the first case was observed by Dr. Yonge, of 
Plymouth, in 1709, until the year 1888, forty-six genuine cases have 
been placed upon record. Six of these had occurred in men and 
forty in women. He believes that the absorption of indol from the 
intestinal canal is the source of the indican. Red sweat is due to the 
presence of the bacterium prodtgiosum. The discoloration is asso- 
ciated with increased production of sweat 

Treatment. — The general health should lie regulated, and local 
etimulating applications made to the atfected part. Deception may 
be guarded against by adopting the following plan, recommended by 
Spring and f|Hfjted by Geber: '* The spot to be examined is carefully 
cleansed with oil, and, when perfectly dry, collodion is painted on in 
a thin layer, and allowed to remain for a few days. When the ehromi- 
drosis ia actually present, it will show itself after the collodion pel- 
licle is lifted off." 

Abnormal changes of the sweat-secretion, different from those re- 
ferred to, have often been recorilcti. Thus, urinous sweat (uridrosis) 
has been noted in which the nrtnous elements, especially nrea, were 
mingled with tlie ponred-out secretion. The depoi^it in urinous sweat 
consists of colorless or whitish crystalline material, which is slightly 
adherent Uy the skin ; it can be detected by its solubility in alco- 
hol and giving with nitric acid the characteristic crystals of nitrate 
of urea. 

The disorder occnrs from faulty renal action, and has also been 
known to follow the use of jaborandi, 

IlfPmaffdrofiiSy or sweating of blood, another example of abnormal 
secret ion, will be noticed on a succeeding page. Greenish and other 
peculiar changes in the color of sweat may appear after the ingestion 
of copper, iodine, tar, turpentine, and phosphorus, and after eating 
certain s]>ecies of fish, and occasionally in the course of phthisis and 
malaria. The color of the sweat nuvv also become changed from the 
resorption of excrementttious material in jaundice and yellow fever, 
in which case the secretion becomes yellow. 




DISOEIDERS OF SECRETION AXD EXCRETION. 



^ 



8UDAMINA. 

Stkostii,^ — Miliaria cr}'Btallma. 

Sudamina is a non-ioflammatory disease of the sweat-glands, char- 

ruEed by the developmeat of wliitish or pearl-colored vesicles about 
tiie size of millet-seeds. 

Symptoms. — Siulainina appears as discrete vesicles which iiiay form 
Qp<in any part of the body, but are more common on the face, neck, 
jmd trunk. They are about the size of millet-seeds, elevated, trans- 
parent or i>earl -colored, and look like miiuite sweat-ilrops in the skin. 
The lesions may be limited to a small area or may occupy a consider- 
able extent of surface. They develop rapidly, continue discrete but 
crowded together, and distippear after the absorption of their contents, 
with des<jnamatioii of their covering. The alfection is usually unnt- 
lendeti by any subjective symptoms, though in some cases slight burn- 
ing or itching sensatious are experienced. Tlie course of the eruption 
h ?uriable; fresh lesions may ajjpeur frequently and prolong the dura- 
tion of the disease. Siulamina is distinguished from other vesicular 
eruptions, especially eczema and varicella, by the absence of inflam- 
matory symptoms. 

Pathology. — The vesicles are formed by the collection of the sweat 
in some part of the ducts, or between the layers of the epidermis, 
owing to the inability of the fluid to escape upon tlie surface. 

Etiology.— The cause of sudamina is an elevation of temperature, 
which frequently follows in the course of many syptemic atTections, 
especially the fevers. It is observed in tyfihus^ typhoid, and puerperal 
fe?ers, scjirlatiua, variola, rheumatism, pneumonia, tuberculosis, pyai- 
mia, debility, and many other disorders. Exercise, when excessive 
in corpident people, the wearing of a large amount of clothing, and 
sweating from baths or any cause, particularly in hot weather, may 
lead to sudamina. Impermeable coverings, such as rubber or oiled 
silk, may, if too long continued, give rise to sudamina. 

Treatment. — The treatment applies to the disease which occasioned 

Ihe sndamina. Local applications of a saturated solution of boric 

tincture of witch-hazel, or alcohol, alone or with half a drachm 

phor to five ounces, are most acceptable. Bhind dusting-pow- 

as starch, arrow-root, the impure carbonate of zinc, or the sub- 

of bismuth, may also be emj>loycd. 

HTDRASBNmS DESTRUENS STTPFDRATTVA- 

Under this title Dr. S. Pollitzer, of Xew York, describes * an ex- 
ample of a rai*e affection which he has recently observed. The patient 
was a joang man, twenty years of age, of good family and personal 

* Joanukl of Cutaneous and Genito-Urinarj Dis^caBee, Jatiuiiry, 1692. 
10 





I 



DISEASES OF THE SKIN. 



history. About twenty lesions were situated upon the face and neck. 
They begin in the subcutaneoua tissue, the overlying skin being at 
first totally free from alteration. 

S3nnptoill8.~The primary form is that of ii hard, painless nodule 
which, in the eoiirse of ten to fourteen days, attaints tlie eisie of a pea. 
The epiderm becomea raised, producing the appearance of a small, 
Tonnd tumor. As the growth enlarges the skin covering it becomes 
reddened, and a drop of pus issues if the nodule be pierced. A few 
days later retrogratle cliangea commence, the tumor becomes yellowisJi, 
the epiderm gives way, and a few drops of blood-stained pus es<m{)e. 
8mall Bhreds of tissue are sometimes extruded. If the secretion ac- 
cnmulate, it forms a (lisrolored crust which fulls in a few days, leaving 
a dark, reddened skin which remains pigmented for many weeks, a 
slightly depressed scar ultimately occupying the situation of the tumor. 
About four weeks are consumed in this process. Occasionally neigh- 
iKiriug no(Udes coalesce and form a flut tumor as large as an almond, 
which, in breaking down, discharges through a number of small open- 
ings. Some of the lesions may remain quiescent for months without 
enlargement or suppuration. 

The tubercles appeared upon parts marked by a dense gi'owth of 
hair. The hairs, however, were not loosened, and even grew normally 
from the shallow cicatrices, showing that their follicles were not in- 
jured. The growths developed in crops at irregular intervals of a few 
days to several weeks. This process continued for about nine months. 
Adjacent lymphatic glands were not swollen. The temperature was 
unaffected and the urine was free from albumen or sugar. 

Diagnosis. — The subcutaneous origin of the nodules distinguished 
them from acne; no bromides had been administered ; tliey lacked the 
severe inflammatory manifestations of furuncles; and the discharge of 
a central necrosed mass, the non- involvement of the hairs, and the ab- 
sence of its fungus excluded trichophytosis, w*hile the course of the 
malady bore no resemblance to that of a syphilitic deposit 

Pathology. — Two nodules were excised and examined. One of 
these was taken from the subcutaneous tissue, while the other illus- 
trated a later st^ige of development, just prior to rupture of the cuticle. 
The appearances were eascntially the same in both, the tumors con- 
eisting of a dense aggregation of small, round cells, epithelioid cells, 
and large muUinuclear nuisses resembling giant-cells. The small cells 
were of inflammatory origin. Individual epithelioid cells were seen 
containing from tw^o to five nuclei, and forms could be traced which 
merged by indistinguishable gradationa into the giant-cells. These 
were very numerous, and, as a rule, were somewhat smaller than those 
of tulx^reulosis or other granulomata. The nuclei varied in number 
from five to twenty. Most of the cells Tvere of an irregularly round or 
oval shape, but some were very irregular in form. Blood-vessels could 



IRDERS OP SECRETION AND EXCRETION. 



U7 



1)6 traced throughout the entire growth, The endotherium was gen- 
erally swollen, the capillaries occupying the centre of the nodule being 
completely occluded. The hair-follicles were numerous and large in 
d around the tumor, and appeared entirely normal. The sebaceous 
glands also seemed to be unaffected. 'So sudoriparous glands were 
inclnded withia the new growth^ but were observed in its vicinity. 
any of these glands showed peculiar changes. Their epithelium 
as swollen, and in many instances the tubules were obliterated. In 
some no further change liad taken place, in others some infiltration 
bad occurred within the coil, and the swollen epithelium completely 
ed the tube with a homogeneous mass. In such glands the mem- 

propria could not be distinguished. 
The author regards the giant-cells as formed of degenerated and 
broken-nj) fragments of the epithelium of the sweat-glands. The epi- 
thelioid cells are probably formed in the same way by a breaking op of 
the degenerated gland epithelium into fragments smaller than those 
which resemble giant-cells. 

This mode of formation, the author goes on to say, of giant-cells 

fin the skin haa not before been described, but is analogous to that 
pbaenred by Waldstein in tuberculosis of the testicle and by Taylor 
and Van Giesen in diffuse orchitis. The sweat-glands are the starting- 
point of the process. They are the seat of a parenchymatous degen- 
eration which, in all probability, originates primarily within the glands. 
The disease would appear to be of infectious origin, but cultures of 
fresh piia were entirely negative, no organisms whatever being delected. 
The writer was unable to make any inoculation experiments. 

Dr, Pollilzer regards the case which he has so carefully studied as 
being identical with those described by Velpeau, Verneuil, and a few 
other French writers, and, more lately, by Bartheleniy under the name 
of acrilis* Darier found round, epithelioid, and giant-cella in sections 
made from Barthclemy's cases. Lukasiewicz has published a paper 
from Kaposi^s clinic describing an affection which strikingly resembles 
that observed by Pollitzer. 

Etiology. — This disease, according to Verneuil, may result from 
either local or general causes. Among the former are uncleanliness, 
cohl, rough friction, irritating applications, parasites, etc. Constitu- 
tional causes given are " herpetism,'' dyspepsia, constipation, pruritus, 
scrofula, fevers, etc 

Treatment.— Pollitzer in his case prohibited shaving, covered each 
nodule with Unna's mercurial carbolic-acid plaster, incised the nodules 
when they had softened, and washed the affected region frequently 
with a three- per-cent. salicylic-acid alcoholic lotion. I'oward the ter- 
mination of the case he administered corrosive sublimate with iodide 
of potassium. Equal parts of zinc oleate and French chalk together 
with three per cent, of salicylic acid compose a good dusting- powder. 



148 



DISEASES OF THE SKIN. 



CLASS 11. 
HYPEREMIAS. 

The class of hypersBmias includes those disorders which are char- 
acterized mainly by the presence of an increased quatitity of blood 
in the cutaneous vessels. The increase may be univeraiil and affect 
the entire surface, but it la usually limited to certain regions of the 
body. It may be active or passive in character, and idiopathic in 
origin, or symptomatic of disturbiuicea in remote portions of the 
system. 

The increased blood-supply i^ always productive of changes in the 
color of the affected portion of the skin. The color of liyperaMuic 
ernptions varies from light-red to dark-red or purple, but dis«ppears 
upon pressure, to return aa soon as the pressure is removed. Active 
hyperaemic eruptions may be accompanied by slight burning or itch- 
ing sensations, and usually pursue an a«!Ute course. 

Passive hypera^mia is usually indicative of mechanical or functional 
interference with the circulation. In the former case tight garters, 
banda<|es, or clothing may be the cause, and the affection disappears 
wlien they are removed ; in the latter case, cardiac or valvular disease 
or varicosity of the veins may be tlie producing cause, when the hy- 
pera^niia is apt to remain for an indefinite period, and linally result in 
permanent pigmentation of the surface. 



BRrrHfSMA SIMPL12X. 

Erythema simplex is a hypera&mic cutaneoue affection characterized 
by the formation of redilish, nun -elevated macules or patches on the 
general surface of the body. 

Sjrniptoms. — There are two varieties of erythema simplex, the idio- 
pathic and the symptomatic. Tlie idiopathic variety is generally sub* 
divided into the three groups of erythema traumaticum, erythema 
caloricum, and eryethema venenatum. The symptoms differ some- 
what according to the form of the affection wliich may be present. 
In erythenui traumaticum the skin is reddened and tender at the 
point which has been subjected to pressure or friction, but normal 
elsewhere. In erytfiema caloricum the skin is reddened, and more or 
less painful, hnt oidy at the point which has been exposed to intense 
Bolar or artificial heat In erythema venenatum the eruption is more 
diffused, but it is painful, and limited to the regions with \vhir-h the 
irritating or poisonous material has been placed in contact. In ery- 
thema symptomatica there is no pain or itching, and the eruption may 



II YPER.EMI AS, 



appear tipftn any part of the surfaue. In some cases the abdomtui is 
iiiTolved, in others Uie face, or perhaps the limbs, and occasioniilly the 
whole surface is invaded. The lesions of erythema symptomatica are 
exceedinglj numerous, and of all shapes aud sizes, but they are ephe- 
meral in character, frequently disappearing in a few hours, and rarely 
remaining longer than two or three days. In erythema traumaticom, 
Tenenatum, and caloricum the lesions are but few in number and more 
persistent. Erythema symptomutieu is mostly preceded or accom- 
panied by gastric or intestiiuil derangements. 

Bia^OSis. — The diagnosis of erythema simplex is usually easy. 
The only affections with which it could be confounded are rutheln, 
macular syphilis, and simple dermatitis, Itothelu, however, is accom- 
panied by fever and cartarrhal symptoms, phenomena which do not 
occur in erythema simplex. In macular sypiiilis tlie lesions are equal 
in s\te^ circular in shape, aud arranged in groups. In erytliema symp- 
tomatica the lesions are of ail shapes and i<izes, and irregularly dis- 
tributed. There is no specific history, and evidences of ga.stro-intes- 
tinal irritation are present. In dermatitis there is no severe pain, and 
more or lees increase of temperature. 

Pathology. — The redness of tlie epidermis is due to dilatation of 
the ciipillaries of the superficial layer of the corium. 

Etiology. — ^The causes of erythema simplex are numerous and 
varied. The idiopathic varieties are produced by the action of heat 
or cold, or by friction or pressure in any fornix or by contact with 
acids, strong alkalies, aniline dyes, mustard, sulphur, arnica, can- 
tharides, arsenic, antimony, poisonous plants, and other irritating 
substances. Symptomatic erythema results from the ingestion of im- 
proper food, or from worms, or from constipatinn, or other disordei*s 
of the gastro-intestinal tract. It may also arise from the irritation of 
dentition, or any disturbance of the nervous system. 

M. Perrin iK'lieves that erythema occurs in a certain number of 
cases of gonorrha'a independent of treatment by copaiba or cobeb, and 
that the action of those substances in producing a rash is at least as- 
sisted bj a tendency of the disease.* 

Treatment — The treatment varies with the cause and extent of 
the disease. Erythema symptomatica rarely requires any treatment 
beyond the administration of a gentle laxative. If worms exist, they 
fihouM be removed by the employment of appropriate anthelmintic 
remedies. In idiopathic erythema no internal medication is requi- 
site. In many cases the local irrittition is removed by the applica- 
tion of cold water alone. In others, soothing ointments or lotions 
will usually bring immediate relief. 

Prognosis.— The eruption is always trivial in character and speedily 
diaappeva. 

* Annale dc Derm, et de Sypb., November, 1890. 



150 



LEASES OF THE SKIN. 



ERYTHEMA INTERTRIOO. 

Erythema intertrigo is a hyperEemic cutaneous affection produced 
l>y beat and tlie conUict of opposing surfaces. It is characterized by 
a reddened condition of tho skin, and aecompanicd by a sensation of 
heut or burning. 

Symptoms.— Erythema intertrigo is tliat forni of erythema whieli 
occurs in tlie natural folds of tlie skin, and wlierever two opposing 
surfaces come in contact with each other; e. ^., as between the nates, 
beneath the mammae, and in the axillary and inguinal regions. It is 
observed most frequently during the summer months, but may appear 
during any season of the year. It oeeura especially in fleshy }iersons 
and in infants. The skin in the affected regions becomes reddened 
and chafed, and is more or less hot and painful to the touch. If tbtj 
exciting cause be removed, or if remedial measures be institnted, the 
affection may be arrested in this stage. In many cases, however, it 
passes into a mild form of dermatitis* Occasionally it terminates in 
eczema. 

The duration of erytliema intertrigo varies from a day or two to 
eeveral week^. In some it remains throughout the heated term, and 
irf a source of muc!i annoyance and suffering. When it occurs in in- 
fants it is more or less obstinate to treatment, especially if the erup- 
tion is situated between the nates. The perspiration which usually 
accompanies the eruption may Bometiml^«^ be so excessive and acrid 
as to produce extensive maceration and desquamation of the epi- 
dermis. 

DiagE0si3,^The diagnosis of erythema intertrigo is usually self- 
evident. The location and eliaracter of the eruption are suflicient to 
distinguish it from the lesions of any other disease. The erythema- 
tous patches of infantile syphilis occasionally simulate those of the 
innocent affection, but the existence or speedy appearance of other 
syphilitic lesions unerringly indicates the true natnre of the dis- 
ease. 

Pathology.— The oidy pathological change that occurs in the great 
majority of cases of the eruption is dilatation of the blood-vessels of 
the eorium. Excessive perspiration may ])rodace maceration and sep- 
aration of the epidermis, or of its sui)crlicial layers. 

Etiology* — The exciting causes of erythema intertrigo are heat, 
and the friction or pressure of two opposing cutaneons surfaces. The 
predisposing causes are numerous, and include all c in mm stances which 
increase the temperature of the body or of the affected region, or 
which produce an irritable or sensitive couflition of the skin. Among 
direct or indirect causes may be mentioned summer weather, unusual 
exercise, heavy underclothing, tight or ill-fitting garments, sedentary 
habits, and constipation. In infants the irritation produced by worms 



nvrER^MIAS. ^1 

and by acrid discharges from the howels leads frequently to the dis- 
ease. 

Treatment — No internal treatment is required, as a rule, except 
when constipation exists. In some cases, howerer, oceurnng in very 
fat persons, the best treatment consists in the daily administration, for 
two or three weeks, of full doses of any of the saline purgatives, in 
order to produce copious intestinal discharges. The local treatment ia 
of tht; simplest possible character^ and consists chiefly of cleanliness 
and rest. The affected surfaces should be bathed with cold water two 
or three times a day, and gently mopped dry with a soft cloth. Soap 
and friction are injurious, and j^hould not be used. If practicable, the 
erythematous surfaces shonld be kejit separate by the interposition of 
a piece of linen or soft musUn. Where this can not be done, they 
should be dusted over with any astringent non-irritating powder, as in 
the following formnlse : 

3 Bismuthi subnitratis, 

Plumbi carb aa | ss. M. 

3 Pnlv. maranta^ 3 i j. 

Zinci oxidi. . , * 3 vj. M. 

In many cases more benefit will be derived from the application of 
a bland ointment : 

3 Bismuthi subnitratis 3 iij. 

Plumbi earb , , . . 3 ij. 

Ung, zinci oxidi bcnz | isa. 

M. Ft ungt. 
Lotions of lead-w^atcr and laudanum, of alum, borax, or sulphate of 
xinCt will be found serviceable in some cases. 

Pro^OSis. — The eruption sjieedily disappears nnder treatment, or 
withoDt treatment when the exciting or predisposing cause is removed. 



UMi 



152 



DISEASES OF THE SKIN. 



CLASS III. 

HuEMOKHTTAGES. 

( Iln'morrha^itF.) 

Cutaneous hnemoiTbagos may occur from a rupture of the blood- 
vessels, as from exteriml injury, or the blood-corpuscles may escape 
through the capillary walls and pass into the skin. 

The lesions formed from haemorrhages into the skin may assnme 
certain appearances, which are known by the following name^ : 

PefechifP consist of small round or irregular spots, varying in size 
from a pin's point to a linger- nail. 

Vihices are long, narrow, streak-Hke spots. 

Eerlii/iiioses arc irregular patches, from the size of a coin to that of 
the palm of the hand, or hirgcr. 

Eccki/momafa appear as variously sized and shaped patches or 
tumors, which may be flat or elevated. 

HaBmorrhagGa into the skin which result from external injury are 
known as idiopathic, and those which occur from internal disease are 
termed gym p to m a t i e. 

Idiopathic Hflemorrhage. — Here the hiiemorrhage is usually the re- 
sult of traumatism. Wounds, contusions, and all forms of injury may 
c^use a ru]>ture of the blood-vessels, and an extravasation of more or 
less blood into the skin and even the underlying tissue. The bites of 
numerous insects, particularly of the louse, bed-bug, and flca^ are also 
causes of idiopathic hemorrhages. The treatment consists in the ap- 
plication of remeilies to hasten absorption. Occabionally stimulating 
ointments and lotions are of advantage- Mercurial ointment.s, espe- 
cially the oleate, have proved of service. Localized hccnjorrhagic 
spots which are on the face or exposed parta can be relieved and ab- 
sor])tinn hastened by leeching or puncturing, and painting them with 
a thick paste of earbouatc of lead. 

Symptomatic HaBmorrhage. — To this form belong all ha-morrhagea 
which arise fium sys'temic disturbance. They occur in connection 
with small-pox^ typhus and cerebro-spjual fevers, and other diseases, 
and also at times in the course of urticaria, erythema nodosum, and 
pemphigus. There are several forms which are recognized as inde- 
pendent disejises, and call for separate description. 



PURPURA, 

Synosysis,^ — HBDmorrbit'a pL'techiallB— BtnlfleckenUrankhcit. 

Purpura consists in the formal ion of hipmorrhagic patches on the 
skin of different sizes and shapes, slightly elevated or non-elevated, 
and not disappearing on pressure. 



B^fiMORRrUGES. 



153 



Symptoms — Purpura may occur in three Tarieties, and, as they 
diflft^r very much in their symptoms^ it has been consiilereii better to 
describe them separately, as follows : 

PuBPURA Simplex. — Purpura eirnplex is seldom ushered in with 
constitutional disturbance. Rarely, it is preceded by lassitude, loss of 
appetite, and slight fever. The eruption may appear suddenly, usually 
overnight, or gi*adually in the course of several days. The hi«mor- 
rhagic spots are bright or deep red or purplish in color, and are vari- 
ously shaped, and in size from a pin*a point to that of a pea. They 
are not elevated, but are situated deep in the skin, and will not disap- 
pear on pressure. They occur mostly in numbers, irregularly over the 
surface, but have a predilection for the lower extremities, especially the 
thighs. Subjective symptoms, excepting a general soreness of the 
skin, are absent. Occasionally they may be accompanied by moderate 
itching, but seldom by pain. Wheals, however, at times develop as a 
complication, the itching being marked, and the condition is then 
known as purpura urtieaus. Blebs have also been observed in this va- 
riety of purpura. The disease usually runs its course in one or two 
weeks; but it may be prolonged for months by the formation of suc- 
cessive crops of the eruption. It occurs generally in the debilitated, 
and especially in old persons. 

Dr. E. Morin has given the particulars of a case in which, during 
ten years, an eruption of purpura simplex made its appearance two or 
three days before each menstrual period, reached its height in twenty- 
four hours, and disappeared at the end of eight or ten days. The pa- 
tient was otherwise healthy and had never been subject to hiemorrhage 
prior to the development of the purpura.* Purpura simplex has been 
known to resnlt from the use of certain drugs, us quinine, chloral, sali- 
cylic acid, and iodide of potassium. 

PuRPFRA RiiEUMATicA, Peliosis Rheumatica.— Purpura rheu- 
matica is, as a rule, preceded or accompanied by lassitude, despond- 
ency, impairment of appetite, constipation, fever, and rheumatic pains, 
especially about the joints. Swelling of one or more joints sometimes 
occurs. After a time, mostly in several days or a week, an eruption 
suddenly appears over the body, being more profuse on the abdomen 
and limbs. The hjemorrlnigic spots, which are usually well defined, 
are somewhat raised or on a level with the skin, and the only subjective 
symptom which accompanies them is soreness of the skin. In color 
the sjwts are light-rod or purplish, and in size they are generally about 
that of a finger-naiL They will not disappear on pressure; but in 
time, as the blood is gradually absorbed, they change into yellowish and 
grijcnish tints, until finally they fade away entirely. In rare instances 
u hipmorrhagic spot becomes gangrenous. The rheumatic pains some- 
times abate, or disappear with the appearance of the eruption. In 
• Sec Medical Biilletin, May, IS&L 



l54 DISEASES OF THE SKIN, * 

many cases, however, tlie constitutional symptoms continue throughout 
the diseuse, or appear in the form of rekpses together with Buccessive 
crops of the eruption. The course and duration of the disease are un- 
oertikin, cootinuing weeks or months, or pndonged for a gfrcater period. 
Ha^morrliago from the internal organs, especially the kidneys, may 
happen as a complication, and occasionally prove fatal. Certain ease»| 
are accompanied by gastro-intestinal disturhnnces, such as colic, vomit- 
ing, diarrhii^a and occasionally lm;nioiThage. There may be hremor- 
rhage from the stomach or bi>wels, and the latter may be so violent as 
to induce local necrosis, perforation, and peritonitis. 

The disease is rare, and heara some I'clation to erythema multiforme, 
with which it has been associated at times. It occurs in both sexes 
about middle life, and is seen more frequently in women. It is some- 
times met with in children and young adults. The cause is obscure* 
I have seen several eases in which it was due to great nervous exhaus- 
tion, and in one instance to excessive ventry. No relatitin can be 
traced between this form of purpura and cardiac disease. It never 
seems to give rise to endocarditis or pericarditis. Kinnicut, indeed, 
has detected endocardial murmurs, but these were probably due either 
to auoeraia or to a pre-existent valvular lesion, 

A very remarkable case of purpura rheumatica complicated with 
suppurating irido-ehoroiditis of both eyes has been published by Dr. 
J. H. Thompson, of Kansas City, Mo.* A girl, eight years of age, of 
previous good healtli, born of healthly parents, was suddenly attacked 
with chill, high fever, followed by coma. At the end of about thirty 
hours, the fever having nioderated and consciousness being restored, 
the light wsis painful to the eyes. About twelve hours later she was 
totally blind in both eyes, the anterior chamber was half filled with pus, 
a purulent deposit and gelatinous layer of inllanimatory exudation cov- 
ering the iridea. At the same time a slight ha^morrhagic eruption was 
discovered upon the arms and legs, together with some swelling of the 
wrist-joints and fingers. The inner surface of the lips and anterior half 
of the tongue were covered by a herpetic eruption, which was so con- 
fluent that it made one continuous mass covering the mucous surface 
and the skin from the nose around the mouth to the chin. At the 
time it was yellowish- white, but in twenty- four hours turned black be- 
cause of the extravasated blood. The general condition of the patient 
indicated profound depression, hut constitutional improvement wi 
rapid, and in a week from the day of attack the child was well The 
blindness, however, permanently remained. 

Dr. Andr6 Moussous hii& lately reported two cases of purpura 

rheumatica associated with severe nephritis. In one, tiiat of a child 

thirteen years of age, a fatal result took place, and there was 

found chronic endocarditis, probably due to an antecedent attaci 

* Kansas City Medical Record, November, 188». 



H-EMORRIIAGKa 



155 



of rhenmfttkm. Microscopic cxamiaation revealed general diffuse 
nephritic* 

Pt-RPURA II-«MORRHAGlCA — MORBUS MaCULOSUS WeRLHOFH, €>a 

LAKl>-ScrRVY- — Purpura ha^inorrhagk'a is a severe form of the dis- 
ease. It is generally preceded or accompanied by pronounced consti- 
tiit tonal gymptonis, as lassitude, languor, debility, headache, loss of ap- 
petite, and fever- Suddenly haemorrhag^ic spots appear^ usually first 
on the limbs and afterward upou other parts of the body. The spots 
appear mostly in numbers, and of all sizes and shapes. In rare in- 
stances an extravasation takes place between the derm and epiderm, 
giving rise to a blood-filled vesicle. At the same time, or sliortly afi^r 
the appearance of tlie eruption, hjvmorrhagcs may take jiluee from the 
macoQS membranes, esj>ecially the mouth, gums, nose, fauces, and kid- 
neys. Metrorrhagia, hannoptysis, and effusions beneath the conjunc- 
tiva into the retina, choroid or sclerotic, have likewise been observed. 
Epileptiform attacks and paralysis may result from meningeal or 
cerebral hsemorrhage. 

The disease is uncertain in its course and duration. It may ter- 
minate favorably, suddenly or gradually, in a short time, generally in 
from otie to four weeks, or lasting, with relapses, for quite a period. 
It is a dangerous diseuse, and will sometimes incline to a fatal termina- 
tion* Death may occur from anji^niia, heart- failure with itHlcma of the 
Inng^ or from cerebral hiemorrhage. It occurs in the badly nourished, 
the debilitated, especially from nervous exJiaustion, and also in those 
apparently of robu«t health. The duration of purpura ha?morrhagica 
lA inilefinite, but its average course may be stated as from two to ten 
weeks. Relapses are not infrequent. 

Diabetes mellitus Inis once been seen as a sequela, perhaps in con- 
sequence of hiemorrhage into the diabetic area of the medulla oblon- 
gata. In six cases Fagge has seen it followed by sarcoma of various 
organs. Repeated losses of blood may produce decided anaemia. The 
number of red blood-corpuscles may be diminished and that of the 
white increased. Marked |)allor, exhaustion, shortness of breath, ver- 
ligOy palpitation of the heart, syncope, and anlema may residt from the 
iinpoverijshed state of the blood. 

An interesting case in which the disease ran an acute course has 
been described by Zanetti. A woman, aged twcTity-three years, after 
suffering for some time from lumbar pains and lu'adat*he, Ku<!denly grew 
worse, with intense sacral pain, prostration, fever, ha»matemesis, ha^ina- 
turia, metrorrhagia, and abundant liaBmorrliagic spots upou the skin- 
Death took place from syncope on the thirtl day. Hemorrhages were 
found into the bowel, peritoneal cavity, and ventricles, the spleen was 
ilightly enlarged, and the liver in the early s!:i 1:0 of fatty degenera- 
Itun. 

* BHUbH MtHUoal Journal, Fcbninr; ^ ; 



DISEASES OF THE SKIN. 



Under the title of purpura fulmiiKiiiK or pfirpura foudroyant a 
number of cases occurring ia children have been described by llenoch 
and Ilervc and other observers, ten cases in all having been reported. 
This form of tlic disease is characterized by its sudden onset, pain in the 
limbs which were swollen, oBdematous, and cyanotic. There was no 
hiBUiorrhago from mucous membranes, and death resulted in twenty- 
four hours to two or three days. Some of these cases had been pre- 
ceded by illness of another nature, as pneumonia or scarlet fever. To 
the list recorded, a similar instance has been added by Dr. Henry 
Jackson, of Boston.* A boy, five years old, about tliree weeks after 
a mild attack of mea^sles from which he had entirely recovered, and 
while apparently in good health, became slightly indisposed for two 
days, after which a few purpuric spots were seen upon tJic skin. Dur- 
ing the next four days haemorrhages occurred from the bowels, bladder, 
stomach, and nose. The spots upon the skin increased in number and 
size, and death occurred upon the fourth day. The severe hieuiorrhages 
by which it was accompanied distinguislied l)r. Jackson's case from 
those of Henoch, to which, however, it seems allied by the rapidity 
and fatality of its course. 

Dr. W. A. Phillips, of Evanston, 111., has reported f ^ ease in which 
purpura occurred as a complieaiion of gonorrhieal rheumatism. There 
was no previous history of rheumatism. It is noted that, though most 
of the lesions were purely of a hstmorrhagic nature, yet some bore a re- 
semblance to tliosc of erythema nodosum. 

Scorbutus, true sctirvy, or sea-scurvy, may, in this connection^ be 
briefly mentioned. The constitutional symptoms are more marked in 
Bcurvy, iis a rule, hut the purpura which it occasions is moie apt to 
involve the deeper structures — the muscles, fascia, and subcutaneous 
cellular tissue. The internal organs may show in scurvy some com- 
plication ; but there is less liability to haemorrhage from the mucous 
membranes than there is in purpura ha^morrhagica. The gums in 
8curv3^ are, however, more decidedly atfected, they are spongy, soft- 
ened, and painful, and become the seat of ecchymomata and ulcera- 
tions. The disciise arises from poor hygiene and food, particularly 
from an insufliciency of frci^h vegetables and fresh meat, especially on 
vessels and in institutions. It appears slowly, and is chronic in its 
course, but inclines to disappear with the removal of the exciting 
cause and the use of appropriate remedies. 

Dn Colcott Fox described to the Pathological Society of London 
the results of an autopsy which he had made upon the body of a boy, 
thirteen years of age, who died of scurvy. There was extreme atrophy 
of tlie fibulie, tibia?, femora, and to a less extent of the bones of the 
upper extremity ; wasting of the muscles; circumscribed scanty hfiemor- 

* Archivt*9 of Pedriaticft, December, 1890. 

I Journal of the Araetreaii Medical Asfiodation, March 4» 1889. 



iMORRHAGES. 



157 



rliages between tlie periostoum of those bones as well as others ; eccby- 
moses beneath the pleura ; separation of tliu lower epiphyses of the 
tibise, and loosening- of the upper ones of the femorii,* 

Pathology. — In purpura the extravasation of bloody as a rule, takes 
place suddeuly, and piissee into the different layers of the skin* It is 
usually found accumulated in the cerium or in the subcutaneous cellu- 
lar tissue. It occasions spots of various sizes and shape^^ according to 
the quantity effused and the permeability of the tissues. The blood, 
after leaving the vessels, at once becomes a foreign body in the skin. 
Absorption occurs very slowly, the fluid portiou being first removed. 
The corpuscles and coloring-matter which remain occaj^ion various 
changes in hue — blue, purple, dark or brig-ht red to green or yellow 
— OS absorption gradually takes place, imd the skin returns to its 
natnral condition. 

Ko definite or constant change has been discovered in the constitu- 
tion of the bloody thougli it is probable that iilteratiun exists. Nor is 
the condition dependent upon any recognized lesion of vascular walls, 
Bigal and Comil attribute the haemorrhage to disturbance of the vaso- 
motor centre. The viscera are found very pale after death, and not 
infrequently contain cxtnivasationa. The spleen is often enlarged, and 
b^morrbages have been found in the medullary cavities of the bones. 

Etiology. — ^licro-organisms have been detected in the blood in 
purpura by several observers. Blood from patients suffering from 
purpura, injected by Petrone into the veins of rabbits, produced a 
genera] haemorrhagic condition. Letzerich has isolated a bacillus 
which has sharp angles and edges, which he cultivated in gelatine, and 
the pure cultures of which injected into rabbits occasioned hiemor- 
rhages, either spontaneously or upon slight trauma. Steinheil, of Paris, 
has found a micrococcus in the blood, and has succeeded in mak- 
ing cultivations. He ascribes the hiumorrhago to occlusion of small 
veaaela by colonies of micrococci, together with consecutive inflamma- 
tory eoftening. Martin de Guimard (These de Paris, 1888), who 
stadied twelve cases of purpura in children under tlie care of Prof. 
G rancher, found a micrococcus in the blood during life and in the 
haemorrhagic spots after death. Cultures of these organisms when in- 
jected into a guinea-pig caused haemorrhages in various parts of the 
body. An accumulation of the cocci occupied the centre of the ex- 
trarasation. Watson Chcyne found bacilli in one and micrococci in 
another case of purpura. 

Uanot and Luzet have reported f a case in which purpura was 
transmitted from mother to fcBtus. The woman died, and, though no 
purpuric spoti! were found upon the skin of the child, the serous cavi- 
tiea contained a reddish fluid, and disseminated extravasations were 

« Laooet, Ma? 2i, 38^). 

f Annales da Dermatolo^e et de Sypbilologio, Febraarj^ 1891. 



^A 



DISEASES OF THE SKIS. 



found in the Inng and thymus gland* A streptococcus was recognized 
in the viscera and blood bath of mother mid cliiid. 

Treatment,— The treatment will depend upon the cause of the dis- 
ease. Attention to diet and hygiene is essential. Rest is alwuys of 
advantage, and if the haemorrhage be extensive it is absolutely neces- 
sary that the jmtient be kept in the recumbent position. 

In purpura simplex the preparations of iron, especially the tinct- 
ure of the chloride in full doses, one or two drachms, from three to six 
times a day, are valuable. Equal parts of the tincture of the chloride 
of iron and the fluid extract of ergot often act most decidedly. Qui- 
nine, belladonna, and the mineral acids are also to be commended, A 
prescription that has often been serviceable is ten drops of dilute phos- 
phoric acid with one eighlietli of a grain of sulphate of strychnine in 
water, three timea daily. The chlorate of potiissium is also usefal in 
from five- to twenty-grain doses, well dihited. Harkin claims for it 
excellent results. The fluid extract of witch-hazel in from teu- to thirty- 
drop doses, ter dicmy has also been productive of benefit Friction 
with spirits, tincture of wntch-hazel, salt and water, vinegar and water, 
solutions of aliini or tannic acid, cold water or ice, is most suitable 
and ativantageouB. 

Pl'1ipl:ra Eueumatica demands the most careful attention to hy- 
giene, and often requires rest in bed or a complete change of air, and 
occasionally nUo of occupation- The diet must be niiti'itious, with the 
addition of some stimulant The remedies above recommended may 
also be used. Salicylic acid or digitalis will aho be found beneficial. 
Ergotine can be employed hypodermatically if necessary. 

PiTRpuRA ILEMORitiiAGicA is daugerous and often fatal, and de- 
mands active and energetic treatment. Kest in bed is imj>erative, 
with nutritious food and stimulation. Any of the remedies already 
mentioned may bo employed. Digitalis and the tincture of the chlo- 
ride of iron, in divided doses, often act promptly. Hypodermatic in- 
jections of ergotine have also been followed by good results. Oil of 
turpentine, acetate of lead with opium, tiinnic and gallic acids, and 
large doses of quinine, have all been used witb success. Electricity is 
said to have proved serviceable after other remeilies had failed. The 
external applications, already referred to, can also be resorted to with 
good effect 

True Scurvy requires fresh air, acids, fresh vegetables, fruits, 
and meats. Quinine, iron, and strychnine are serviceable remedies 
to employ. The condition of the gums and moyth may be promptly 
relieved by chlorate of potassium ta.ken internally, and used also as a 
wash. 

Prognosis. — In purpura simplex the prognosis is always favorable, 
although the caae may be tedious in recovery. Purpura rheumatica 
likewise inclines to recovery. It is, however, obstinate, liable to fre- 



O.T-MOfimiAGES. 



159 




mt relapses, and may remain indefinitely. Purpura hDemorrhagica 
a dangerous and at times a fatal disease, and it is often impossible 
to foretell its termiuation ; hence, the prognosis should be given with 
great caution. 

HEMOPHILIA. 

Haemophilia is a congenital and frequently an hereditary affection, 
confiisting in a proneness to unusual hiemorrhagea from the skin and 
mucous membrane. Men are noticed to be more frequently affected by 
it thuQ women. It may take jjhice spontaneously, or from some trau- 
matic cause. It mostly occurs from some slight injury* lis from wounds 
and contusions. Vaccination and leeching are known to excite it, giv- 
ing rise to ecchymosis and immoderate bleeding from the capillaries. 
Swelling of the joints sometimes coexists ivith the biemon*hage from 
blood being poured out in them. Bleeders rarely attain old age. 
Miiny die during childhood, although in some instances the disposi- 
tioi; is gradually lost after the twenty-fifth year. Legg* states that 
microscopic examination of the blood and vessels has shown no appar- 
ent change, yet, he further atlds, It is probably the vessels tliat are at 
fault. According to Virchow and Immerman, the walls of the blood- 
TeaseU are abnormally thin. 

The treatment consists in large doses of either the tincture of the 
perchloride of iron or the fluid extract of ergot. Locally the same 
styptics may be employed, with compression. Cold douches or the ap- 
plication of ice are also valuable. After the attack, the patient should 
take for a period large doses of iron, with cod-liver oil, in conjunction 
with a nutritious diet The prognosis should be carefully guarded, aa 
death has been reported in some instances to follow the slightest in- 
jury, from excessive and continuous haimorrliage. 



RJSMATEDROSIS. 

STNOTfTva. — naemidrfisU — Sudor sungumeus, or bloody sweat. 

Uaematidrogis^a rare diseiisc — is characterized by the escape of a 
fluid containing blood through tlic sweat-glands. The discharge is 
generally small in quantity, and the condition localized. Bleeding 
stigmata and neurotic excoriations are only forms of hEematidrosis. 
The disease is seen most frequently in hysterical women, and during 
menstrual derangement. Debility of the nervous system is also an 
exciting cause, and it has been known to follow outbursts of passion 
and great nervous strain. The treatment is similar to that of purpura. 
BelladoDna has , been recommended as a remedy, and reported to have 
been successfully employed. 

• A Dictionary gf Medicine, pp. 668, 666. D. Applcton k Co., 1884. 



DISEASES OF THE SKIN. 



CLASS IV. 



EXUDATIONS. 

{Exud^ltimles.) 

Synonym*.— MOTbilli — ^Measles. 

RrBEOLA is an acute, contagions, febrile disease, characterized by 
tlie development of a papular eruption over the surface of the bod?, 
and aueunipanic'd by catarrhal inflammation of the mucous membranes 
of tlie respimtory passages. 

Symptoms, — After an incubative period of from nine to eleven days, 
but which in some cases is prolonged to the fifteenth, nineteenth, or 
twentieth day, the discjise commences with a feeling of eliilliness or 
general malaise, followed in a few hours after by fever^ headache, mus- 
cular soreness, and all the symptoms of a severe cold. The eyes are 
injected and watery. The nasal mucous membrane is dry and tumid 
at first, but soon becomes the seat of a .soro- purulent discharge. 
Sneezing is frequent. The pharyngeal and laryngeal mucous mem- 
branes are red and swollen. There is a harsh, dry, irritating cough, 
and more or less sub-stcnial tenderness. The face is flushed, and the 
pulse is inerea^^ed in frequency. The urine is high-colored, and the 
bowels arc eonBtipated. The temperature rises rapidly, often reaching 
103*' or 104° Fahr. on the evening of the first day. It then remains 
stationary until the end of the second or the beginning of the third 
day, when a murlved remission of the fever occurs, the temperature 
falling to almost normal. The headache lessens in severity, but the 
other aymptoma do not abate. The eyes become swollen and sensitive 
to light, and ladirymation is profuse. The voice is hoarse and husky, 
and respiration is iucreased. The broucliial mucous membmue be- 
comes involved, and the sensation of soreness and constriction in the 
chest is decided. Coughing is frequent and painful, and auscultation 
reveals tlie ])resence of numerous large and small mucous rales. This 
febrile remission lasts about twenty-four hoors^ when the temperature 
rises again to it« former height, and remains there until the character- 
istic eruption has been fully developed. It usually appears on the 
fourth day, but may be delayed until tlie fifth, and consists of nnnier- 
ouB coarse, red papules, wliich vary in size from a pin's head to a sruall 
shot. These papules are somewhat crescenti;" in shai>o, and arc slightly 
elevated above the snrronnding healthy skin. They arc generally no- 
ticed first on tlie face and chest, hut spread in twenty -four hours over 
the entire surface of the body. They are developed more abuntlantly 
upon the face, where they are arranged in groups or clusters. In some 



EXUDATIONS. 



UM 



the adjacent papules coalesce, forming one or more large, irregii- 
lar blotehcs. The eruption remains at its heiglit for about forty-ei^^hfc 
hours, or until the seventh or eighth day of the tliaease, when it eoiu- 
mences to fade in the order of its development, and iisnaily disappears 
entirely in two or three days. A slight discoloration will probably re- 
main for a week or twu at the site of each papule, and in some cases 
more or less desquamation of the epidermis occurs. The febrile and 
catarriial symptoms decline when the eruption begins to fade, so that 
oonralescence, as a rule, takes place in ten or eleven days from the 
beginning of tlie disease. A slight bronchial cough, however, may 
remain for a week or two longer. 

In more severe cases all the symptoms are aggravated by the develop- 
ment of the eruption. The temperature rises to 105^ or 106° Fahr., the 
inflammation spreads to the finer bronehiid t.ube.s, or even to the luiig- 
strocture itself, producing ca]>illary bronchitis or pneumonia. Diar- 
rboBa may appear, and the urine become scanty and albuminous. Con- 
junctivitis, iritis, and otitis also sonietimea occur. Ejiistaxis ocoiisionally 
tjike.3 place either during the prndroniic or eruptive period. Herpes 
zoster, pemphigus, optic neuritis, inflammation of Cowper's glands, 
hsematemesis, and acute nephritis are among the rarer complications of 
the disease. Unna and Morel- Lavalle iiave e^ich recorded a ca.^e of the 
coexistence of measles and urtic:uia pigmentosa. Endocarditis has been 
occasionally mot with as a complication of measles, and Sanaom men- 
tionsa case in which chorea, associated with perieanlitis and endocarditis, 
developed during convalescence from an attack of measles. In the va- 
riety known as black measles the eruption is dark reil or purplish in 
color, and so abundant as to almost cover the entire surface. The tem- 
perature rises to luB"* or 108° Fahr., the pnlse is mpid and feeble, the 
breathing shallow and irregular, and the catarrhal symptoms intense. 
The tongue is brown and dry, and the teeth are covered with sordes. 
Blood 00269 from the gums and lips, and haemorrhagic extravjisations 
arlae beneath the mucous and cutaneous surfaces. The urine i.s scanty 
or Buppressed, and offensive or bloody discharges take place involun- 
tarily from the bowels. The patient soon becomes coniatoso, or passes 
into a low, muttering delirium, and death may ensue on the second or 
third day after the appearance of the eruption. Ciises are occasionally 
met with in which measles coexist-s with some other exanthem — as, for 
im^tiince, chicken-pox or scarlet fever. 

Genaer reports three cases in one family in which rotheln was 
immediately followed by measles. A similar account is given in the 
-Northwestern Lancet" for May 15, 18iH), of successivti utiacks of 
rotheln and measles occuring in the eliildren of nn orphan asylum. 
FqUy a dozen of the children had first one disease atrd then the 
other. In some mea^^les, in others rotheln, was the first to develop* 
Daring the wide-spread and severe e]>idemtc of measles which pre- 
U 



m 



i»a 



162 



DISEASES OF THE SKIN. 



vailed in Paris in 1890, Dr. Cauvefc closely studied the buccal pheno- 
mena and corn plications. Two varieties of lesions may occur, one di- 
rectly dependent upon the infection of the disease, another which has 
no direct ruliition but is a superadded complication. The manifesta- 
tions which depend npon the infection of measles are: 1, Buccal ery- 
thema, generally at the same time as the misul catarrh, and which 
may attack the tongue, and is often followed by dcsf|Uumation of 
the tongue; 2. Follicular stomatitis from glandular hypersecretion, 
together with obstruction of the excretory duets. The superadded 
complications are: L Muguet; 2. Aphthae; 3. Ulcerative stomatitis; 
4. Diphtheria, which, in consecpience of the de^squamution following 
buccal erytliema, often primarily attacks the tongue; 5. Gangrene of 
the mouth, a severe and rare complication.* 

Diagnosis. — The diagnosis of measles is comparatively easy. The 
only diseases for %vhich it might be mistaken are variola, rothein, ty- 
phus fever, and influenza- in variola, liowever» tlie eruption appears 
on the third day, respectively in the following order: papular, vesicu- 
lar, and pustular. There are no catarrhal symptoms, and the fever 
declines as soon as the eruption appears. In rubeola it is seen on the 
fourth or fifth day, and never becomes vesicular or pustular, but re- 
mains papular until its disappearance. The catarrhal symptoms are 
marked, and the fever, which remits on the second or third day of the 
discjise, becomes aggravated prior to or during the appearance of the 
eruption, and remains high until all the pai)ules have come out. In 
doubtful cases a day's delay will enable an accurate diagnosis to be made. 

In rdthcln the eruption may appear at any time during tlie first 
three days of the disease, but it is irregularly distributed over tlie sur- 
face, and consists of rose-colored spots and blotches, which are unlike 
the coarse crescentie papules of rubeola* In rothein, moreover, the 
fever and catjirrhal sym|>toms are comparatively insigniticant, and 
bronchitis, pneumonia, and the other complications of rubeola, do not 
occur. 

In typhus fever the eruption is coarsely papular, but is scanty, and 
limited to the body and limbs, never appearing upon the face. There 
are no catarrhal symptoms, but the cerebral are intense. The remis- 
eion of the fever on the second or third day, and the appearance of the 
eruption on the fourth day, suffice to distinguish rubeola from in- 
fluenza. 

Pathology. — ^The pathological changes in rubeola consist of intense 
hypera?mia of the capilhiry vessels of the cutaneous papilUe, followed 
by a slight serous exudation into the surmnnding tissue. The respir- 
atory mucous membranes also become actively congested, and dotted 
with dark-red spots, apparently similar in character to the cutaneous 
manifestations. The dark color of the eruption, in the mal'giiant 
* Archives of PcdrialFcs, February, 1891. 



r EXUDATIONS. 1^3 

Tmriety^ is ^rmptomatic of morbid changes in the blood. The hfemor- 
rhagic extravasations are due to rnptpre of the capillary vessels. In 
some cases the spleen is swollen and hyperannic^ ant] the kidneys are 
enlarged and filled with blood. 

Etiology. — Rubeola may occur sporadically or as an epidemic. It 
prevails in all countries and at all seasons of the year, hut it happens 
most frequently during tbe spring and autumn months. It is a dis- 
ease of childhood especially, but ia occasionally observed in adults. 
Infants less than six months of age are not usually attacked. Dr. 
Lomer» of Hamburg, describes the ease of a child born with measleg, 
the mother having manifested the disease the preceding day. Measles 
is produced by a specific poison, and is contagious. It may be communi- 
cated not only by actual contact of the &ick with the healthy, but also 
through the medium of wearing apparel and other articles in use by 
the patient. It is also spread by atmospheric diffusion. The secre- 
tions of the nasal and broucho-puhnonary mucous membranes appear 
to be the principal agents in spreading the disease. The disease is 
doabtless due to the growtli of a specific micro-organism, and is con- 
tagiouB during the prodromic period prior to the apiK^arance of the 
catarrhal symptoms or eruption. 

Treatment — The patient should be given a mild, nourishing diet, 
consisting chiefly of milk-toast and light soups, and allowed to drink 
freely of cool water and lemonade. The room should be well venti- 
lated« but kept moderately warm, and the face and neck sponged with 
cold water four or ^\e times a day. Should there be other children in 
the honse, of a weak or scrofulous constitution, it is prudent to send 
them away at once; if otherwise healthy, they may be permitted to 
remain. 

The medicinal treatment should be directed to moderate the fever 
and catarrhal symptoms, alleviate the cough, promote expectoration, 
and prevent the development of further com plications. 

In ordinary cases I usually direct the patient to take— 
3 Tinct. aconit rad ................. . ia xlj. 

Syr. ipecac f 3 ss. 

Syr. scillie. comp f 3 ij. 

Syr. lactucarii. f 3 x, 

M. Sig. : One teasjmouful every four bours. 

I who order the following powders, one to be taken every second or 
third Bight at bedtime: 

IJ Ilydrarg. chlor. raitis. gr iij* 

Kesina^ jalapa? gr. vj. 

Pulv. sacchar gr. x. 

M- Ft. chartie no. vj. 

If restlessness is exhibited, five to ten grains of sodium bromide 
may be given three times a day, or from two to five grains of Dover's 



mi DISE.ISES OF TOE SKIN. 

powder at bedtime. In the more severe cases, wlien the fever is high 
atid the enijitioti scanty or late in development, ice-bags should be 
applied to the head, and the patient placed in a cohi bath or wet pack, 
if necessary. 

When the eruption begins to decline, and the febrile and otlier 
Bymptonis abate, it is good practice to give from tliree to ten grains of 
quinine daily, for a week or more. A stimulating expectorant mixt- 
ure, like the following, is advisable during convalescence : 

5 Tinct. capsici rq, v. 

Tinct. sanguinaria? f 3 sa. 

Tinct. nucis vomicte f 3 sa. 

Tinet. cinchome corap. f 3 Jij* 

M, Sig. : Half a teaspoonftd to a teaspoonful fonr times a day. 

In black measles, or the maligmmt variety of rubeola, the high 
temperature should be reduced by the wet pack or cold bath, and tur- 
j)eiUine, quinine, and the tincture of the chloride of iron freely ad- 
ministered. Benefit has also been derived from the use of camphor 
and the carbonate of ammonia. Carbolic acid and chlorate of potas- 
sium have also been recommended. 

On account of the liability of buccal complications, Can vet advises 
the free use of disinfectant month -washes from the very beginning of 
the disease. A saturated solutioii of boric acid will be found of service. 
In an article upon The Broncho- Pneumonia of Measles: its Nature 
and Prevention, Dr. L. Bard * stales his conviction that this compli- 
cation 18 not due directly to the measles, but to a secondary infection 
to which the exanthem predisposes- Since broncho-pneumonia may 
become engrafted upon mild cases, Dr. Bard lays stress upon the 
prophylactic importance of rigid separation of complicated from un- 
complicated cases. As an illustration, he compares the general harm- 
lessness of a mild epidemic wdiieh prevailed in one of the French can- 
tons with the fatality attendant upon the broncho-pulmoiiary compli- 
cation which, in a certain limited locality, wae transmitted from one to 
another patient. Scparatitui of the two varieties is more particularly 
demanded in hospital practice, as is shown by the fact that in the Hopi- 
tal dcs Kufants Assistes, where cases of measles are placed in a special 
ward, the average mortality between the years 1867 and 1872 ib stated 
to Iiave been 42•7^*^ ])er cent., attaining a maximum of 00*81 per cent 
in 1871. 

The complications of rubeola must be met as they arise. In pneu- 
monia and capillary bronchitis, turpentine, carborjate of ammonia* 
and stimulants will be found indispensable. When the bronchiiil 
tubes are clogged with mucus, emetics will he of service. When the 
urine becomes suj>pressed, free diaphoresis and purgation should be 
produced. If diarrhcea occur, opium and the mineral acids are indi- 
Laou M^^dical, January 13, 1889. 



EXUDATIONS. 



165 



rj^ted. Patients of an anaemic or scrofulous disposition should ha 
"pTeti ood-li^er oil, chlontte of potassium, quinine, and other tonics, 
far mouths after convalescence lias been establislied, in order to re- 
store the tone of the system, 

ProgBOSis. — Tlie prognosis is favorable in simple, niicomplicuted 
c&ses. The deaths which occur are due rather to pneumonia and other 
complications than to the disease itself. As a rule, the older the pa- 
tient the severer the case. Weak and acrof iilous persons bear the dis- 
ease badly, and are extremely liable to be attacked by iritis, otitis, or 
other distressing aifections. Tliey are also i>eculiarly liable to develop 
phthisis after convalescence. 

The malignant or piirpurons variety of rubeola is very dangerous. 
Over one half of the sporadic cases end fatally, and when it occurs in 
lui epidemic form over ninety per cetit. of those ajfected die. 



ROTHULN, 

Sthostm. — GcrmiiQ measles. 

Hotheln is a mild, contagious, febrile disease, characterized by the 
development of rose-colored spots, of various shapes and sizes, on the 
general cutaneous surface. 

Symptoms. — The disease usually begins with a slight fever, accom- 
panied by moderate headache and a feeling of general malaise. The 
pulse is increased in frequency, and the temperature varies from 09® 
to 101' Fahr. The mucous membrane covering the fauces and tonsils 
ia reddened and tumid, and there is some stiffness and soreness at the 
angle of the jaws* In many cases the conjunctiva is injected, and 
there is increased lachrymation. The cervical glands are swollen occa- 
aoHAtly. The eruption usually ap|>ears on the lirst or second day, but 
may not be observed until the third day. It consists at first of a num- 
ber of small, round, rose-colored spots, which turn white on pressure. 
They vary in size from a pin's head to a small pea. They are arranged 
in clusters or groups, and are slightly elevated above the surrounding 
healthy skin. They generally appear first ou the face and scalp, and 
rapidly extend over the renuiitider of tlie body. Some of the clusters 
on the body and limbs coalesce, forming large, irregularly shaped red 
blotches; but the facial spots almost invariably remain discrete. The 
eruptioti attains its maximum development in twenty-four hours. It 
remains stationary for a day or two longer, and then commences to 
fade, disappearing completely on the fifth or sixth day of the disease. 
In some cases a slight disculoratiun remains for a short time at the site 
of each spot, but desquamation rarely occurs. The febrile and other 
symptoms pass away with the eruption. 

Diagnosis. — The only diseases with which rotheln could be con- 
foanded are scarlatina, measles, and erythema symptomatica. In scar- 



106 



DISEASES OF TUE SKIN. 



latina, however, the fever is liigher, tho throat symptoms are more 
intense, and the eruption consists of a difftised scarlet efflorescence, 
which appears first on the neck and chest, and then spreads over the 
whole body, In raetisles the eruption is crescentic and coarsely papu- 
lar. It appears on the fourth day of tlie disease, and is accompanied 
by a marked exacerbation of the fever. Severe coryza and bronchitis 
are also present. 

In erythema symptomatica the spots are rose-colored, but they are 
larger in size and fewer in number than tliose of rOthehi, and they 
rarely appear on tho face. They are nsually serondary to some gastric 
dorangenient, and are not accompanied by febrile symptoms. 

Pathology.^Au active congestion of the capillaries of a niimljer of 
groups of the cutaneous papilhe occurs, but exudation does liot ensue, 
and the dii^coloration disappears when the congestion subsides. 

Etiology.— Itotheln is almost exclusively a disease of childhood, 
but it may occur in adult life. It is produced by a specific poison, 
nnd projiagated by contagion. One attack is protective uguinsl the 
subsequent development of rotheln, but will not secure immunity from 
measles or scarlatina. 

Treatment* — The majority of cases do not require any treatment 
but rest and a light diet, and confinement to the house for a few days, 
la the more severe, where the patient is restless and decidedly fever- 
ish, and complains of sore throat, a mild diaphoretic mixture should 
lie ordered, and the bowels opened freely by a i^aline laxative. 

PrognOBis. — The prognosis is always favorable. 

SCARLATINA. 

Sthontms. — Sotrlet fever — Scarlet mab. 

Scarlatina is an acute, contagious febrile disease, characterized by 
the development of a diffused scarlet rasli over the whole or the greater 
part of the body> accompanied by iiiflammation of the throat and vari- 
ous nervous phenomena, and terminating in desquamation of the outer 
layers of the epidermis. 

Symptoms.^ — There are three well*marked varieties of the disease: 
scarlatina simplex, sciirlatina anginosan and scarlatina maligna. The 
invasion is exceedingly brief in all three varieties. The period of in- 
cubation varies from three to seven days ; that of contagion extends 
from the beginning of the initial fever until about a week after all 
febrile symptoms have disappeared. 

In scarlatina simplex the disease is ushered in by a slight chill, or 
by an attack of apparently causeless vomiting; or, in nervous children, 
by convulsions. These symptoms pass away in an hotir or two, and are 
immediately followed by fever, which soon becomes high. The face is 
flushed, the skin hot and dry, t!ie pulse rapid and full, and the respi- 



g|g^ 



EXtJOATIONa 



167 



nuions Dccome more frequent. The urine is scanty and liigh-colorcd, 
and the bowels are usually constiputed. The tong^ue is red itt tlie tip 
and edges, but covered in the centre with a white or jellowish fur. 
The throat is reddened, the cervieul glunds are enlarged, and there is 
some pain on swallowing* More or less headache and reatlcssuess are 
also pn.-sent. The temperature varies from 101° to 103° Fahn, with a 
slight morning remission and eveuini^ (exacerbation. The jndse yaries 
with the height of the fever and the age of the patient. In some 
cases it reaches 130, in others it does not rise above 100. 

The characteristic eruption appears on the second day of the fever. 
It consists of a fine pale-red or scarlet efHorcscencc, which appearts first 
an the face and neck and upper part of the chest, and within twenty- 
fonr honrs diffuses over the entire surface of the body. In some cases 
it may present a punctated appeamnce, but it is not elevated, and it 
disappears upon pressure. It is most intense in the flexures of the 
jointa. In exceptional instances small vesicles are seen either in iso- 
lated patches or scattered over the entire surface of the body. A rare 
manifestation has lately been described by Prof. F. C. Curtis.* On 
the fourth day after the appeamnce of a typical scarlatinal eruption, a 
Tesicular rash developed upon various parts of the body, the vesicles 
varying in size from a pin's head to that of a split pea. 

During its development the throat symptoms iricreiLse in severity, 
and the tongue becomes red and papillated, forming the characteristic 
'* strawberry tongue '* of the disease. The fever is uninfluenced by the 
eruption, and remains at its height until the fifth or sixth day of the 
disease, when it begins to decline. The throat symptoms also lessen, 
the restlessness passes away, and the eruption disappears first from the 
face and neck, and then from the other portions of the body. The 
period of decline usually occupies about three ilays, so that the eruj>- 
tion and the fever disappear and the patient is convalescent on the 
eighth or ninth day of the disease. Some desquamation of the epi- 
derznis *x;curs, but it may be so slight as almost to escape notice, or to 
pnxluee only a roughened appearance. 

In severer cases the mode of onset is the same, but all the symptoms 
are more intense. The fever may reach 105** Fahr., the pulse ranging 
from 110 to 140; the fauces and tonsils become red, swollen, and cov- 
ered by a pnltaceoug deposit. Swallowing is difTicult and painful* 
The urine is dark-colored and albuminous, and more or less delirium 

Iis present Convalescence does not occur until the ninth or tenth day, 
and is accompanied by considerable desquamation. 
In scarlatina anginosa the temperature may reach 10?- Falir., the 
poise varying from liiO to 160, but the throat symptoms are prominent 
early in the attack, and soon become intense. The cervical glands are 
hard and swollen. The fauces, tonsils, and pharynx become inflamed, 
• Albany Mcdicaf Annals, Fcbrunryj 189L 



us 



DISEASES OF THE SKIN. 



swollen, and covered by un offensive tenacious diplitheritje depu-Jt. 
Superiieiul olcemtion occurs at various points, rendering deglutition 
painfnl or almost impossible. In some patients the nincous membrane 
lining the posterior nares and the Enstaehian tubes become involved, 
resulting in serious impairment of gmell and hearing. 

In a nuijority of cases of this type the disejise reaches its height 
about the eighth or ninth day. The fever then slowly lessens, the 
swelling of the mucous membrane subsides, the ulcerative process 
ceases, and reparative action begins. The eruption also gradually dis- 
appeai^s, so that the eonvaleseent stage begins about the fourteenth day 
of the disease. The desquamation of the epidermis which then occurs 
is usually profuse, and iiuiy continue for several weeks. Occasionally 
the hair and nails are shed after an attack of scarlet fever. 

In unfavorable cases the tonsils and fauces become enormously 
swollen, or attacked by gangi-ene. The temperature rises rapidly, 
and the symptoms assume a typhoid type. The pulse becomes small, 
rapid, and feeble, and the respiration quick and irregular. The urine 
is either suppressed or scanty and albuminous, t'ouia alternates with 
delirium, arui death takes place between the fifth and tenth days from 
exhaustion or urreniic poisoning. 

In scarlatina maligna the temperature is extremely high from the 
beginning, frequently rising to 110^ Fahr. The pulse varies from 150 
to 200. The respiration is irregular and sighing. Convulsions are 
frequent, but in some cases the patient lies profoundly comatose. The 
throat is swollen, and covered by a membranous deposit. The glands of 
the neck are enlarged. The eruption is developed in patches of a dark- 
red or purplish color, and may not appear until the fourth or fifth day. 
Somotimes haemorrhages take place in the skin and mucous membranes. 
Recovery is rare, and tk^ath usually occurs about the third or fourth day. 

Anomalous cases of scarlatina are occasionally encountered. Dr. 
Wertheimer and T)r. Heetz have each reported two cases in which all 
the symptoms of scarlet fever were present, with but little or no eleva- 
tion of tem|>crature. The pulse, liowever, was very rapid, and Dr. 
Wertheimer suggests that a persistently rapid pulse in the absence of 
fever is of diagnostic value in these rare cases of apyrexial scarlatina.* 
Again, under the designation of searlaiina m'tte t^ruptione, cases have 
been described in wliich tlie throat symptoms and fever occur, but the 
eruptitin is absent. 

In rare instances relapse has been observed, attended with sore 
throat, fever, characteristic tongue and rash, and followed by desqua- 
mation, IJelaiise occurred from the second to the seventh week, and 
in one case was more severe than the primary attack. f 

♦ New York Medical Journal, November 16, 1890. 

f An annlpia of 1,008 cases of scarlet fever admitted into the Southwestern Fever 
Hoapital during the year IS&O. Bj Dr. J. Foord Caiger. Lttncel, June la, 18MI. 



^ ^^ EXtTDATIOXS. 100 

^^T^a liissertation by Dr. 1). Astley Grcsswell, entitled the "Natural 
History of Scai'latitia," the chief symptoms and coniplieations of 588 
rases are carefully anulyzeii. The. mithor tl era oust rates that the severity 
(»f an epidemic may vary decidedly from month to iiioiith. Delusions 
occurred in fonrteeu per cent, of his cases, and generally in males above 
ten years of age. Endocarditis was not seen in any of tlie twenty- 
eight of hifi patients who were attacked with arthritis and wlio had not 
previously suflfered from rheumatism. There was no case of arthritis 
in children under three years of age. 

According to a statistical table contained in the second annual re- 
port of the Metropoliian Asylums lioard of London> the mortality 
from 8(tajlatina among children under five years of age is nearly five 
times as great as among those between ten and fifteen. Another table 
records the nature and frequency of com]tlications observed during 
1888 in 3,497 cases of scarlet fever. There were 302 cases of otitis, 338 
of rhinitis, 867 of albuminuria, 55 of measles, 36 of whooping-cough, 
and 35 of diphtheria. Other complications liable to occur are adenitis, 
rheumatism, eczema, bronchitis, and conjunctivitis. 

The belief has long been held by most British and American physi- 
cians that puerperal women when exposed to the virus of scarlatina were 
extremely liable to become the subjects of peritoniti.s, though the dis- 
tinctive rash and sore throat of scarlet fever might fail to appear. The 
relation of acorlatina to pregnant and puerperal women has lately been 
investigated anew by Boxalh From an experience of sixteen cases, he 
infers that predisposition to the disease is greatest during the first week 
after delivery. Most cases occur during the first week, while a few de- 
velop shortly before the beginning of labor. During or after parturition 
the stage of incubation is short, but during pregnancy this stage is 
longer than normal. Angina is present, iis usual, during pregnuncy, 
but is infrequent when the disease occurs after hvbor. If parturition 
take place during an attack, the uterine contractions are feeble and 
there ia a tendency to haemorrhaga Scarlatina in a puerperal woman 
diminishes or suppresses the secretion of milk. An attack during 
pregnancy may or may not affect the foetus in ufero. Itching is often 
present in scarlet fever. From a cousideratioii of forty cases in which 
this symptom occurred, St. PhUlippe conchidea that it indicates the 
eruption is not intense, or the cutaneous manifestation very profuund, 
and that, therefore, the prognosis may be regarded ns favorable in 
cafflw attended by pruritus. The tables of Dr.. Caiger show that des- 
quamation may continue from six to sixteen weeks. It is generally 
ilig'ht and of short duration in infants. 

SeqnellB. — Dropsy, rheumatism, and otitis are the most frequent 
aecpels^ of scarlatina. Chorea and valvular disease have also been ob- 
•erred to follow it. The otitis is usually purulent in character, and 
may result In permanent deafness, but a spontaneous cure may follow 



170 



DISEASE:? OF THE SKL\. 



after montlis or years. The rlieumatism is generally subacute, but 
may assume the at;ute form. Dropsy is the most important ami tlie 
most frequent sequela of scarlatina. It generally appears after the end 
of the acute stage, when desquamation has been well establislied. In 
some cases it is ilcveloped after exposure to cold, but frequently occurs 
without any apparent exciting cause. It is first mauifestod by oedema 
of the eyelids and face, hut s<jon becomes general in cliuracter. The 
shortness of breath which usually accompanies it is ejiused by the press- 
ure of the fluid which has been effused into the pleural and peritoneal 
cavities. Scarlatinal dropsy is due in the majority of cases to acute 
Bright's disease, but in a small percentage it is symptomatic of a slight 
congestion of the kidneys. The urine is Bcanty, albuminous, and 
high-colored, but rarely suppressed. Kecovery is the rule. 

Dr. C. Henry Willcy opposes the view tlmt the albuminuria of 
scarlatina always points to the existence of nephritis. He has analyzed 
the histories of twentv-seven cases, and believes that tliey may be dl- 
vided, in reference to this symptom, into three main groups. In the 
first of these nervous and vascular causes, and in the second itifluences 
of a still more general character, are responsible for the ajuiearance of 
the albuminuria. In the third group, inflammation of the kidney ia 
undoubtedly present. The albumen, in the first class of cases, gener- 
ally appears in large quantity, but almost at once begins to diminish, 
Tlie prognosis is favorable. In the second group, fever, diarrhcea, and 
delirium were prominent, and two cases out of four terminated in 
death. When dependent upon acute nepdiritis, the albumen begins as 
a trace and steadily increases,* JSeptic phenomena, as pleuro-pneu- 
monia and arthritis, occurred in consequence of suppuration of the 
cervical glands in a case reported by Dr. Caigcr.f 

Diagnosis. — It has been said that gcarlatina can be diagnosed dnr- 
ing the prodromal stage by the extreme rapidity of the pulse. This 
will not hold good in all cases, however. The rapidity of the pulse de- 
pends upon the age of the patient and the height of the fever, and not 
upon the precise nature of the disease. I have seen several cases of 
scarlatina in children, aged from five to seven years, in which the pulse 
never rose above 100. On the other hand, I have observed many of 
the same age who had simple or ephemeral fever, in which the pidse 
varied from 120 to I'lO, Still, if the pulse is 13U or over, and the fever 
has been preceded by convulsions, or by an attack of causeless vomit- 
ing, scarlatina may bo suspected, and then the patient should be iso- 
lated, in order to prevent the possible spreml of the disease. 

After the eruption has appeared, the diaguosis is easy. The high 
fever, the sore throat, and the di^tused scarlet efflorescence appearing 
on the second day, form a trio of symptoms which point unerringly to 
the true nature of the malady, lloseola and rothein are characterized 

* Lauoct, December 28, 1889. f ^^ Western Medical Reporter, Mar, 1891. 






EXCDATIOXS. 



171 



I 



by the development of irregular scarlet blotches which present a su- 
perficial reeemblauce to the eriiptioji of scarlatina, biat the high fever 
and throat symptoms of the latter disease are absent. In dengue, or 
break-bone fever, the eruption is red and diffused, and the tempera- 
tore high, but the Joints are swollen and painful, wliile the throat is 
not involved. 

The rash of dengue generally appears first upon tlie hands, wrists* 
and forearms, may occur at any time from the first to the fifth day of 
the disease, is not characteristic, but assumes a number of forma, and is, 
in many casea, altogether absent. In some cuscs of measles the erup- 
tion consists at first of a large number of bright-red spots, which 
when closely aggregated present a striiiing resemblance to scarlatina. 
In measles, however, there are no tliroat eymptouis, but coryza and 
bronchitis are present, and the eruption appears on the fourth day; 
and, if not papular when first observed^ beeomes so within a few 
hours. 

Pathology. — The eruption of scarlatina is produced by active con- 
gestion of the capillaries of the papillary layer of the corium. The 
differences in the intensity of the color in vainons regions of the body 
are due to variations in the intensity of the morbid process. Exuda- 
tion of serum does not occur to any marked degree, but the dilated 
blood-vesseh) compress the surrounding tissues and narrow^ the calibre 
of the lymph-spaces, so that the nutritive supply of the epidermis is 
diminished or cut off. The exfoliation or desrjuaination which follows 
is due in great part to this interference with nutrition, and probably 
in part also to a disturbance of the terminal filaments of the trophic 
nerres. It may be bo slight as to escape notice^ or merely produce a 
roughened condition of a portion of the surface, or it may be profuse 
and continue for months after convalescence. In some cases the skin 
peels off in large flakes ; in others, the hair falls out and the nails drop 
off. The hsemorrhagic extravasations which occur in scarlatina ma- 
ligna are due to rupture of the capillary vessels. 

The mucous membrane lining tiie pharynx and the buccal cavity 
become hypenemic and swollen. The tonsils become enlarged and 
covered with a purulent exudation. In severe cases suppuration en- 
toes, or a diphtheritic membrane is formed, and rapidly extends to the 
adjacent structures. This false membrane ia not, however, of true 
diphtheritic character, according to the researches of MM. Wurtz and 
Boorges, who examined material taken from the throats of nine chil- 
dren in whom the angina was severe. In all these cases the strepto- 
coccus pyogenes was found associated with other microbes of suppura- 
tion. The bacillus of Klebs and Loeffler, which is believed to be the 
caosative germ of diphtherio, was in no instance detected. The au- 
thors conclude that the early throat trouble of scarlet fever, however 
serere, is not, at least in the great majority of cases, of a diphtheritic 



■■M 



172 DISEASES OF THE SKIN. ^^^^^^ 

nature,* A fiimilv came under the observation of Mr. J. Holroyde, 
of Cluitham, England, in which, within about a month's time, case^ of 
diplitheria and scarlatina alternately attacked three different children. 

Ulceration of the soft palate and of the Eustachian tubes, followed 
by destruction of the tympanum, may occur. (Edenui of the pharynx 
or larynx may be produced by the infUtnition of serum, ami either 
seriously interfere with breathing or suddenly prove fatal. In other 
viiscs suppurative inflammation of the areolar tissue, followed by the 
formation of abscesses in distant portions of the neek, has been ob- 
served. Granular degeneration of the gastric tubules and of Pcyer's 
patches often follows. Pneumonia, bronchitis, pericarditis, or endo- 
carditis may take pljice, but present no special alterations at the autopsy. 

The changes in the kidneys vary with the type of the disease. In 
malignant ciisos, in which death results during the first two or three 
days, the kidneys appear paler than nornml when cut, but dotted by a 
few minute hasmorrhages. When death is deferred for several days, 
more hemorrhagic spots will be found, and occasionally minute ab- 
scesses are observed. These are the ca^es in which death ensues be- 
fore the development of dropsical symptoms. The dropsy of scarla- 
tina is due usually to acute parenchymatous nephritis^ and sometimes 
to simple congestion of the kidneys. In the latter the kidney-tubules 
are filled with the epithelium which has been exfoliated from their 
walls. The capillaries are engorged and tortuous, and the cortical 
substance presents evidences of beginning granular degeneration . 

Etiology,— Scarlatina may occur sporadically or in the form of an 
epidemic, but never originates spontaneously, Xow and then a case 
occurs in which it is difficult, or, it may be, impossible, to discover the 
source of infection, Sue!i a one has been idaced upon record by Sur- 
geon-Major R, I). Murray, of the British army, serving in Bengal. f 
Scarlatina is excessively rare in India, and it is said that there is 
no record of an authentic case occnrring in a native, Br. ilurray*s 
patient was a young English lady, who resided on a lonely iu<ligo 
plantation, who had not been in Europe for six years, and had not, as 
far as could be learned, received letters or parcels from infected houses 
in England. The cows from whicli the family's milk was obtained 
were carefully examined, but no trace of disease could be tliscovered 
upon their teats or udders. 

Scarlatina is always produced by a specific poison which is contained 
in the breath, in the saliva, in the epidermis, and in the excretions of 
scarlatina patients. The disease may be communicated by the breath 
of a patient before the eruption hiis made its appearance. Contagion is 
likewise active until the close of the desquamative period. This poi- 

* La TrSbanc Medk'nle, May 16, 1890 ; Meiiical Bulletin, Jiilj, 1890, p. 2U. 
f A Case of Sporadic Scarlet Fever, originating de novo^ Lancet, October 27, 1^88, 
p. 813. 



EXUDATIONS. 



1T3 



pipl 13 extremely diffusive, and attaches itself not only to the clothing, 
tet also to the furniture, eariiots, and other articles in the room, and even 
to the walls of the apartment. Cuiitagion is aLso spread by means of 
picture-book^, letters, and clothing of patient, nurse, or even physiciaiu 
The medical attendant should take every precaution to disinfect hia 
person before visiting anotlier juvenile patient or a woman iu labor. 
It is also wafted from place to place by the atmospliere. It h exceed* 
ingly tenacious of life, and may retain its activity for years. The 
virus, however, unless carried by a current of air, does not extend many 
feet from the patient. Hence, isolation is of more value in scarlatina 
than in many other contagious alTcetions. 

Scarlatina may be contracted by direct contact with an infected 
person, or through the medium of clothing, furniture, or walls, but 
there is reason to l>elieve that its propagation is largely due to atmos- 
pheric diffusion of the epidermic scales of patients suffering from the 
disease. Dr. L. IL Miller has reported twenty- four cases in which the 
origin of the disease was traced to drinking infected milk. Its devel- 
opment is favored by bad liygienc and weakened vitality. Scarlatina 
may occur at any age, but is most frequently met with between the 
second and twelfth year, and is rarely observed after the fortieth year. 

Out of 854 cases of scarlatina tahulated by the Superintendent of 
Health of Providence, U. I., in 1889, over fifty-seven per cent, occurred 
in children between the second and eighth years. It has occusionally 
been transmitted to the fa^tus in utero. An instance of this fact has 
been commnnicated by Dr. W. B. Dorsett, of St. Louis, Mo,* A woman 
bad suffered from a mild attack of scarlet fever about two months prior 
to delivery, which occurred at full term. The chiltrs skin at birth pre- 
sented a typical desquamation, forfurticeoiis upon tlie trunk, arms, and 
kgs, and scaly upon the pal ins and soles, A few similar cases have 
been recorded by other observers. One attack is protective, as a rule, 
against subsequent attacks, but exceptions have been noticed. The 
disease occurs most frequently in the months of early autumn. 

Treatment ^^An appropriate diet is of the utmost importance. 
The patient's stomaeli should not be overloaded, but his vital forces 
most be sustained. With this end in view a moderate quantity of 
milk, milk-toast, beef -juice, or light, nourishing eonp should be given 
regularly every four hours through the day. In order to prevent the 
spread of the disease, if there are other chihlren in the household they 
should be sent away, and the patient placed in a cuol, well -vent dated 
room, as near the top of the dwelling as pos8ibh\ All clothing, car- 
pets, pictures, and unnecessary articles of furniture should be removed 
from the chamber, and no one but the physician and nurse permitted 
to enter until convalescence has been well established and the room 
tlioroaghly disinfected. The clothing and other articles that have 
*St. Lottla Medical and SurgicaL Journal, February, 1686. 



m 



174 DISEASES OF TEE SKIN. 

been in contact with the patient should be disinfected or destroyed, the 
epidermic scales collected and burned, and the saliva and excreta dis- 
infected and removed ivs soon as possible. 

I)r J* Lewis Smith, of New York, recommends* that tlie room of 
the patient should be continuously disinfected by means of the follow- 
ing mixture : 

5 Acidi carbolici, 

01. eucalypti iia f 3 j. 

01. terebinth. f 3 vij. 

M. 
This forma a mixture of no decidedly unpleasant odor. Two tabl»- 
spoonfuls are added to a quart of water in a flat-bottomed tin Tcseetj 
and kept simmering over a gas or oil stove 

Medicinally, the aim should be to secure the elimination of the 
poison, moderate the intensity of the fever, alleviate the throat symp- 
toms, and prevent the occurrence or lessen the severity of the cerebral, 
renal, and other complications. 

In ordinary cases of scarlatina simplex I usually begin the treat- 
ment by directing from half a teaspoonful to a dessertspoonful of the 
following mi.xture to be taken every four hourSj according to the age 
of the patient : 

IJ Tinct. aconiti rad ni xxiv. 

Potassii chloratis 3 ss. 

Infus. digitalis* f 3 lij. 

M. 
I also order three powders, eacli containing one grain of calomel 
and five grains of bicarbonate of soda, one powder to be taken every 
other night. I advise the entire body to be sponged three or four 
times a day with cokl water, and to be thoroughly anointed every 
morning with a mixture composed of ten minims of oil of peppermint 
and three ounces of cod-liver oil. 

During the febrile stage inunction moderates the feven The use of 
an unguent during desquamation hinders dissemination of the scales, 
and therefore cheeks the spread of the disejise. Since the scales from 
the scalp are fine and shed early, inunction should be applied to that 
as well as to other portions of the body. Instead of the foregoing 
combination, the formula of Dr. J. Lewis Smith may be used: 
IJ Acidi carbolici, 

01. eucalypti aa f 3 j. 

01. olivjK f 3 vij, 

M. 
The throat symptoms are generally light, and can usually be alle- 
viated by permittiug the patient to swallow small pieces of ice from 
time to time, or to drink freely of cool water. When the fever sub- 
♦ Archivca oF Pedlntriia, December, IBW. 



EXUDATIONS. V^^f 175 

gides, wliich generally occurs on the fifth or sixth day, I discontinue 
the aconite mixture, and substitute the following prescription, to be 
taken iu tbe same doses and in the same manner : 

IJ Tinct. liucis Yomicffi. ^ xij. 

TincL digitalis f 3 as. 

Potassii chloratis 3 83. 

Aqu^ ,,,..,, f 5 iij. 

M. 
Three or four days later, when convalescence is fully established, 
I place the patient upon quinine, chloride of iron, or other tonic 
treatment. 

In cases of greater severity, preseuting high fever with delirium, and 
difficulty and pain in swallowing, I increase the amount of aconite and 
digitalis, place ice-bags to the head and throat, and folio tv the calomel and 
eoda with a purgative dose of sulphate of magnesia or sulphate of soda. 
M, Vidal, of Hy^res, speaks very favorably of the use of acetate of 
ammonium in large doses, one gramme for each year of the child's age, 
the maximum dose for adults being thirty-five grammes. 

In scarlatina anginosa the fever and delirium can be moderated in 
the same manner. Phenacetin is valuable when the tempentture is 
very high, though it should be cautiously used, or not at all, when 
there is a tendency to malignancy. The throat syniptoms require 
qiecial and vigorous treatment. The offensive pultaceous deposits 
fihoald be removed by mopping or gargling the surface four or five 
times daily with a soliition of common sjUt, chlorate of potassium, boric 
acid, or thymol. Corrosive sublimate, two grains to the pint of water, is 
also effic^icioos in this condition. It may be used as a gargle or a spray 
every second hour. The same solution may be advantageously ai^plied 
to the nasal mucous membrane wlien it is red, swollen, and the seat of 
a discharge. The peroxide of hydrogen, applied in the form of a spray, 
is another good remedy. It may be used in the proportion of one part 
to four parts of water. The nares should also be disinfected, either by 
means of peroxide of hydrogen, one to eight, or the wash reeommeuded 
by Dr. J. Lewis Sraitli, of which the formula is : 

IJ Acidi borici 3 ij. 

Sodii borat 3 ij. 

Sodii chloridi 3 j. 

Aq. purse. Oj. 

M. Sig. : One teaspoonful to be injected warm into each nostril hourly. 
If the swelling of the tonsils becomes excessive, they should be 
painted with tincture of the chloride of iron or a thirty-grain solution 
of nitrate of silver. If suppuration occur:?, the ])us should be lei out 
at once. If a diphtheritic membrane forms on the tonsils or fauces, 
equal parts of the sohition of chlorinated soda and water should be 
used as a gargle, or applied, full strengtli, to the affected surface with 



ire 



DISEASES OF TOE SEIN. 



a camelVhair brush. Benefit can also be obtained by gargling the 
throat with yeast or with a solution of capsicum. Immediate and 
permiinent improvement sometimes follows tlie use of an tmetic of 
ipeciic, apomorfjhia, or of common salt and water. The stomach is 
emptied by this means of a nitiss of foul pns wliich has gradually 
oozed down into it, and, without this precantion, would be absorbed 
i!ito and poison the general system, and the membrane ia detached 
from the pharynx und fauces, and a clean surface left, to which appro- 
priate applications can then be made. 

If anlenia of the pharynx or of the glottis occurs, the affected part 
should be freely searilied, or tracheotomy jjerformcd. Ulcerations of 
the tonsils, fauces, and soft palate can be treated by the application 
of a five-grain solution of nitrate of isilver. In cases of scarlatina in 
which the jmlse is quick and feeble, aconite should not be employed. 
Instead, I give the ]mtient small doses of turpentine or of belladonna 
and digitalis every three hours, and from one lialf to two grains of 
quinine in combination with half a gnun of capsicum every four 
honrs. (.'amphor or carbonate of ammonia may sometimes be used 
witli benefit. According to Dr. Illiugworth,* Ihe biniodide of mercury 
will yield excellent results. 

In the '^British Medical Journar' for October 2i\ 1881>, Mr. J. 
Brendon Curgenven warmly praises the internal and external employ- 
ment of the oil of eucalyptus. He admiuisters it in one to four dnjp 
doses ererj four hours in an emulsion. Externally the remedy is 
atomized and vaporized in t!je sick-room and applied to the patient's 
body by inunr-tion night and morning for the first few days, subse- 
quently at night only until ten days have elapsed. Dr. Shakowaki 
claims excellent reatdts from the administration of salicylic acid. He 
states that in 125 grave cases occurring in children the mortality under 
this treatment was but three and a half per cent. 

Barkes and subsequently De Rossa have attributed prophylactic 
powers to salicylic acid in scarlatina. The latter administered it in 
daily doses of from one and a lialf to four and a half grains according to 
age to sixty-six children wlio had been exposed to contagion, and in 
only three eases did the disciise develop, lie believes that given in 
time and in sufhcient quantity it is cajMible af averting an attack, while 
if employed too hite in too small a dose it mitigates the severity of the 
disease. It luis been objecled to the use of salicylate of sodium, how- 
ever, that it is liable to jjroduce relapse or excite nephritis. Sulphonal 
is reported as being useful in the relief of restlessness and insomnia. 

In scarlatina maligna every effort should be made to reduce the 
hiErh temperature — the cause of all the other eompHcations of this va- 
riety of the disease. The patient should be placed in a cold bath, or 
wrapped in a wet pack and ice applied to the head and neck. The 

* Provincial Medical Joumnl, Atjgust, 188ft. 



mmm 



EXtTDATlONa 



m 



I 



bowels should be freely opened, and aconite, venitrum viride, or other 
arterial sedatives promptly administered. After the temperature hah 
been redaced to the safety limit, the treiitment may he condueted in 
the manner indicated for the other varieties of the disease. 

In the treatment of 3,4tJ0 cases of scarlatina, Keinier made use 
in 978 of different forms of hydrotherapy. According to this large 
experience, culd compresses or cold envelopment exerted a favoraltle 
influence upon the respiration and circidation, but little upon the 
temperature. In cases attended by cyanosis, stupor, and collapse, cold 
envelopment combined with affusions of water having a temperature 
of 12^ to 14"* C. (r>3*<;'' to 5;*2'=' R), generally gave good results, but 
did not lower the temperature. Immersion in a bath of 1*^*^ to 14'^ 
C., however, frequently caused the temperature to fall 2° C\ After 
being removed from the bath^ the patients were rubbed briskly and 
wrapped in a woolen blanket. Of untipyretic drugs this writer de- 
rived most benefit from antipyrin, but advises that it be used cautiously, 
aft it is liable to produce collapse. The same remark should be made 
concerning the use of acetanilitle and phemicetiue, which are not de- 
void of toxic influence, t'ases have been reported in which these 
agents have also proilueed colhipse. In the eni])loyment, therefore, of 
all the coal-tar products in this disease, especially in children, they 
ibeed be administered with great circumspection. 

In scarlatinal dropsy small doses of digitalis and acetate of potaa- 
eiam may be given with bcnelit, and the patient permitted to drink 
water and cream -of- tar tar lemonade freely, but gti mutating diuretics 
should he avoided. Diaphoretics and hydragogue cathartics are main- 
ly to be relied on to secure the elimination of effete material, and re- 
lieve the engorged kidneys. In addition, leeches or cups are useful, 
applied to the lumbar region. 

The convulsions that occur in the early stages of scarlatina are 
due to cerebral congestion arising from the height of the fever or 
the excessive arterial pressure, and cau bo relieved by the a[>plication 
of ice to the head, and the administration of purgatives and arte- 
rial sedatives ; chloral and the bromides are also of service. Convul- 
sions in the later stages of the disease are usually due to ura?mic poi- 
aoning from the suppression of urine, and can only be relieved by 
tree diaphoresis and catharsis, followed by a re-establish men t of the 
functions of the kidneys. 

Prog^nosis* — The prognosis varies with the type of the disease and 
the age of the patient. The average niurtality in all cases has been 
estimated from seven to ten j^r cent In some epidemics over half 
of those who are attacked die in spite of all treatment. Cases of 
Fcarlatina simplex generally recover* The greatest danger in this 
form of the disease is from nephritis, which may be severe in an other- 
wice mild case. The majority of patients, however, recover under 
12 



ITS 



DISEASES OF THE mm. 



appropriate treatment, even after the dropsical accumulation has be- 
come extensive. A guarded prognosis eliould be given in the cases 
of adults aud very young children. Pregnancy also exerts an unfavor- 
able inOiience. 

In scarlatina anginosa the prognosis is always grave, but from 
twenty-five to fifty per cent, usually recover. 

Scarlatina maligna almost invariably terminates fatally, 

VARIOLA. 

StnoktmS. — SmaJl-poi — ^Blaltcrn — Variolc 

Variola is an acute, specific, conhigious, febrile disease, charactx»r- 
ized by the development of an eruption which is papular at first, but 
speedily becomes vesicular, and then pustular. 

Til ere are four well-marked varieties — variola discretii, variola eon- 
iuens, variola maligna, and varioloid— all of which are preceded by a 
period of incubation ^ varying from five to fourteen days. 

Symptoms. — Variola Discketa. — This form of the disease is gen- 
erally ushered in by a moderate chill, accompanied by a dull^ aching 
pain in the lumbar region^*. The pulse is small and feeble, the face 
pale, and there k more or less nausea. The chill m of ^hort duration, 
and is usually succeeded, in an hour or two, by fever, which soon be- 
comes high. The pain in the lower portion of the hack increases in 
severity as the temperature rises, and extends into the hips and thighs. 
The respiration ia increased, the face is flushed, the conjunctivae are 
injected, and more or less headache sujierveties. The patient is disin- 
clined to take food, but sulTei-s from thirst. The tongue is coated 
with a thick, white fur, the stomach becomes disordered, aud vomit- 
ing is frequent. The skin is dry and hot. The urine is scanty and 
high-colored, micturition is painful, and the bowels are constipated. 
The patient is restless, and in some cases slight delirium occurs. 
The temperature may reach 106°, but usually ranges between 103** 
and lOi"", with a slight morning remission and an evening exacerba- 
tion. The pulse varies in accordance with the heiglit of the fever. 
In iwlnlts it ranges from 100 to 140, and in children from 120 to 
180. About the end of tJie third or the beginning of the fourth day 
of the fever the characteristic eruption appears. It consists of a 
number of coarse, reddish, papular spots, which feel like particles of 
small shot imbedded in the skin. They are hard, and slightly elevated 
above the surrounding surface, and become pale on pressure. They 
first appear around the Hpa and on the cheeks and forehead, and 
then on the chest and arms and remaining portions of the body. 
They may also appear on the pharynx, larynx, trachea, and other 
mucous surfaces. They are isolated, or arranged in clusters, as in 
the so-called corymbic variety, but do not manifest any disposition 



ito 



^ 



^V EXUDATIOXa iY9 

to ooalesoe^ as in variola conilucns. As soon as the eruption appears 
the ferer declines, the nausea, lieadache, and backache become less 
serere, and, in mild caseis, almost completely disappear. The pap- 
ules, however, produce more or less itching and discomfort. Ordi- 
narilv, thej are all developed within twenty-four hourj?, and no new- 
ones appear after that time. On the second day of the eruption, or 
the fourth or fifth day of the disease, the top of each papule may 
be obaerved to present a vesicular appearance, and, on the fullowing 
day, each papule is completely transformed into a vesicle which con- 
tains a clear, serous fluid. The vesicles inoreai«e in size until the 
fourth or fifth day of the eruption, wliich corresponds with the sev- 
enth or eighth day of the disease. They are then Burrounded by an 
indurated inflammatory areola, and present an umhilicak'd appear- 
ance. Their contents undergo a marked change at this time, first be- 
coming turbid, then milky^ and finally purulent in character. This 
process marks the beginning of the stage of suppuration, and the 
transformation of the vesicles into pustules, and is accompanied by 
marked symptomatic or secondary fever. The tcm]ierature rises higlier 
than ever, even reaching 105'^ or 100''. The pulse and respiration 
increase in a corresponding ratio. The headache, backache, nausea, 
and vomiting return in an aggravated degree. The pustules enlarge, 
aod the surrounding skin becomes intensely swollen. The mucous 
membrane lining the nasal passage:^ and the buccal and pliaryngeal cavi- 
ties is irritated and inflamed. Swallowing is painful, and bronchitis, 
pneumonia, or pleurisy may occur. Some of the pu.stulcs rupture 
spontaneou.^ly, or from the pressure of the clothing ; others are torn 
by the patient in his endeavor to obtain relief from the heat and 
itching. The remainder begin to dry up about the eleventh day of 
the oniption, or the fourteenth day of the disease. A dark-brown 
spot appears in the centre of each, which increases in size until it 
forms a brown crust or scab which covers the whole area of the pust- 
ule, and is firmly adherent to the underlying surface. The febrile 
symptoms lessen as soon as the process of desiccation commences, 
the tumefaction gradually rli. -^appears, and the patient passes into the 
stage of convalescence. The process of healing continues beneath the 
tcsbs, but, as more or less of the corinm is destroyed by the sup- 
purative process, minute cicatrices or pits are formed at the site of 
each pustule. The scabs finally drop off about the sixth or seventh 
day after desiccation begins. The surface is then seen to be rough- 
ened and reddened ; the face is esjiecially disfigured. The hair fre- 
qnently falls out daring convulcscence, and the nails occasionally 
drop off, 

V^ABiOLi. CojfFLtTEN'S. — Thts variety is marked by the greater 
■everity of the symptoms of every stage of the disease, and by the 
earlier development and confluent character of the eruption. The 



180 



DISEASES OF THE SKIK. 



initial chill ia violent and protracted, and the precursor of others. 
The primary fever, the backache, headaclie, and gastric disorders then 
follow ill painful succession. Delirium ia usually present, and con- 
Yulsions may occur. The eruption appeal's on the third day, and 
in a few liours spreads over the whole buJy. The adjacent papules 
coalesce to form lar^e elevation a, wliich are soon transformed into 
broad blehs filled with a sero-purulent fluid. The face presents an 
extremely repugnant appearance. The mucous membranes are also 
involved. The fauces, pharynx, naso-pharynx, larynx, and tongue be- 
come swollen and covered with pustules, and cederaa of the glottis 
may result. The piirotid and sublingual glands are likewise afTected. 
The conjunctiva and the cornea suffer, with sometimes ulceration 
and perforation of the latter. Erysipelas is a frequent complication 
of this variety of the disease, and exteus'ive sloughing and gangrene 
often ensue. The temperature, which may reach 107" during the 
primary fever, falls only slightly or not at all when the eruption ap- 
pears, and rises higher than ever when suppuration begins. The urine 
is scanty and loaded with albumen. Delirium is usual, and pneu- 
monia, bronchitis, and pleurisy often occur. The disease may assume 
a typhoid type, ending with suppression of urine and unemic poison- 
ing. A few recover after protracted convalescence, but with more 
or less deformity from the destruction of tissue by suppuration and 
sloughing. 

Variola Maligna. — Variola maligna is characterized by the in- 
tensity of its symptoms and the irregularity of their development. 
The initial chill is very severe, and is followed by violent fever, the 
temperature rising during the first flay to WS"^ or llu''". The res]>iration 
is quick, feeble* and irregular. The pulse is rapid and tremulous, vary- 
ing from 190 to l?l>. The face and neck are deeply suffused. The head- 
ache and backache are distressingly severe. Vomiting is constant. 
The urine is scanty or suppressed. The bowels may he loose. Delirium 
is usually present, but in some cases the patient is apparently comatose. 
In many cases a scarlatiniform or an erythematous eruption appears on 
various portions of the body on the second day of the disea,se. On the 
third day the characteristic papular eruption appears and rapidly be- 
comes diffused over the entire surface, but the fever does not sub- 
side. The papules, which are black or dark-blue in color, increase 
in size, and become surrounded by hajmorrhagic extritvasations, which 
vary in size from a pin*t? point to an inch or more. Those which are 
atljaeent coalesce, forming iarge» irregular masses. The face is swollen 
and distorted, the conjuuctiva? are injected, and the eyelids are turgid 
with blood. The tongue is thick and coated. The buccal and pha- 
ryngeal raucous membrane is covered by a purulent hsBmorrhagic exu- 
dation, from which a sickening odor emanat<y8. Bronchitis or pnea- 
monia is usual. Hmmorrhage from the stomach or the bowels is not 



k 



EXUDATIONS. 



181 



rafreqncnt. The urine is loaded witli albumen, and finally becomes 
dark and bloody. Death generally takes place in this variety of the 
disease between the third and the eighth day after the development of 
the initial symptoms. Indeed^ sorne malignant cases end fatally be- 
fore the appearance of the ernption, in which event the body turns 
black. 

In a contribution on ba^morrhagic variola as observed in Paris in 
1887, M* de Gnindmaison describes a com]»aratively benign form whieh 
he terms cutaneous hajmorrhagic variola. The lurniorrhagoa are lim- 
ited to the pustules, the eruption is discrete, constitutional reaction is 
not extreme, and recovery generally takes place. 

Varioloid. — Varioloid is a mild or benign form of variola, occur- 
ring in those whose susceptibility to the action of the disease baa been 
modified by vaccination or by a previous attack of variola, It is ush- 
ered in by a slight cliill, followed by a moderate fever. The clKiracter- 
ktio lumbar pain is also present, but not severe, There are alt^o slight 
headache and nausea. The papular eruption is apt to be a day late, 
appearing on the evening of the fourth day, rather than on the tliird, 
and is accompanied by complete relief from the other symptoms of the 
disease. The number of papnles vary from live or six to a hundred or 
more. They increase in size, and are converted first into vesicles, then 
into pustules. Many of the latter become aborted as soon as lormeil, 
and the remainder are rarely more than half-filled with pus. The 
suppurative process is consequently very short, and the secondary 
fever is absent. There is a slight inilamraatory areola around each 
puatnle, but the adjacent skin is Tiot swollen. The mucous mem- 
branea may be involved, but only slightly. Desiccation commences 
from the fifth to the seventh day of the eruption, or tlje nintli to the 
eleventh day of the disetiise, and is usually complete in four or five 
days. The majority of the pustules dry up without rupturing, and, as 
there is not much destruction of tissue, there is usually little or no pit- 
ting. Convalescence is generally rapid. Some cases are so mild tJuit 
the patient does not suspect the nature of the disease until informed 
of it 

Gubler and Robin have determined that, in variola, urea is generally 
increased duriQg the first few days. The increase may be more marked 
in light than in severe Ciisos. Uric acid is usually increased in the 
early stage and diminished after the occurrence of suppn ration. Dur- 
ing the stage of invasion the quantity of Urine is diminished and its 
density increased. The chlorides, at first diminished, arc increased 
daring suppuration. Phosphoric acid progressively increases from the 
beginning and diminishes suddenly with the cessation of the fever. 
The snlphates increase slightly during the course of the disease. Va- 
lerianic acid, fatty acids, leucine, and t^TOsine have been detected. In 
severe cases indican is increased. The liquid and uon-crystallizable 



DISEASES OF THE SKUT. 



oxtnictiye matters are increased, and from them Ponchet has obtained 
a very toxic ptomaine. 

Diagnosis, — While it is impossible to make a certain diagnosis of 
vnriolii bi-fore the crnption, the occnrrenre of high fever, vomiting, 
and severe lumbar puins, preceded by a chil!, arc inglily sigiiilleanl, 
and may be considered pathognomonic if the patient has been exposed 
to the contagion of the disease, or if other cases have previously been 
observed in tlie neigliborhood. When the eruption k fully developed, 
the diagnosis is coraparatively easy. The only diseases with which it 
could tiien be confonnded are measles, scarlet fever, varicella, typhus 
fever, and pustular syphilis. The papules of variola bear a superficial 
resemblance at first to those of measles, but the former become vesic- 
ular within twenty-four hours, and then pustular, whiie the latter re- 
main unchanged. The papules of measles are also larger than those 
of variola, and are crescent-shaped. The constitutional symptoms are 
also widely different. In variola the temperature is high during the 
initial stage, and falls to nearly nornud when the eruption develops. 
In measles the temperature is only moderately liigli during the initial 
stage, and rises rapi<lly a few hours before the eruption ap]>e!ir8, and re- 
mains at its maximum height for from twelve to twenty-four hours 
after the rash is all out. Measles is invariably accompanied by a 
"' watery eye," and other symptoms of coryza. More or leas bronchitis 
is also present. Coryza is absent in variula, and bronchitis occurs 
only as a complication of the later stages. The malignant form of 
variola is frequently preceded by an erythematous rash which might be 
mistaken for that of scarlet fever, but it is less diffused and more ir- 
regular in development, and is followed in a few hours by the charac- 
teristic papular eruption. TJie gravity of the constitutional symptoms 
is also significant. 

M. GrisoUe states that while the papular stage of the eruption may 
present a very similar appearance, if the paptde become impal]>able 
to the touch when the akin is stretclied, the eruption is caused by 
measles; whereas, if the papule is still felt when the skin is drawn 
out, the eruption is due to small -pox. 

The vesicles of varicella may resemble those of variola, but they 
begin as vesicles, and remain as such until they dry up. They appear 
on the second day of the disease. They are usually developed upon 
the body and scalp, and are rarely seen upon the face. The accom- 
panying constitutional symptoms are very slight. The cruj)tion of ty- 
phus fever is either macular or papular in character. It apj^ears from 
the fifth to the seventh day of the disease, and ia never seen upon the 
face. 

The pustules of syphilis have been mistaken for those of small -pox. 
Several years ago a sailor, who was covered from liearl to foot with 
pustular lesions, was sent to the Philadelphia Health-Office as a small- 



EXUDATIONS. 



183 



pox patient. The attendant ]>liysicmn, recognizing the nature of the 
malady, immediately procured his ailniission in the Hospital for Skiu 
and Venereal Disease^?. Several other ph3*8iciaU8 had previously seen 
the case and pronounced it one of small-pox. Itupury into the his- 
tory of the patient, and a consideraliou of the symptoms presented by 
him, would have rendered the nitdtake impossible. 

In gvphili.'i a history of infection cjiii UHually be obtained, and an 
examination will reveal some traces of the primary sore or its accom- 
panying bubo, The eruption, moreover^ is seldom purely pustular; 
maculet^ papules, vesico-pustules, and other lesions usually coexisting 
in varying numbers. In some rare cases, however, as the one just 
referred to, it consists solely of pustules identical in aijpeanince with 
those of variola. The patient may also be weak and feverish, and 
complain of pain in the back and loins. The elevation of tempemture 
docs not exceed one or two degrees, however, and the constitutional 
symptoms partake more of the nature of general mfthtifiv than of a 
violent infectious disease. Further, the pustules in syphilis are chronic 
in character, often remaining for some time, and arc not accompanied, aa 
a rale, by pain or itching. In variola the fever is high, the prostration 
profound, and the eruption is acute in character, accompanied by in- 
tense itching, and disappearing by maturation in from eleven to four- 
teen days* 

Pathology. — The first step in the production of the eruption con- 
sUts of iiciive congestitm ol tbe capillary vessels of a ninuher of the 
papillae of the corium. Exudation then takes place into the connect- 
ive tissue and the rete muscosmn, by which the outer layers of the 
epidermis are elevated and papules formed. As the inflammatory 
process continues, more fluid oozes out, the epidermic layers are sepii- 
rafced from each other and from the corium, and vesiclea result The 
contents of the vesicles consist at first of pure serum, but in a day or 
two pns-corimseles transmigrate, and tbe former become transformed 
into pustules. The umbilicated app*.'arance wliich they present is duo 
to the fact that the epidermis in the centre of each pustule ia continu- 
ous with the duct of a hair-follicle or a cutaneous gland. The pus 
does not differ, microseopically, from that of any ordinary inflamma- 
tion* Guttmann found it to contain the onlinary microbes of suppura- 
tion, to the action of which he attributes the cutaneous lesions, though 
they fail to account for the contagion. 

In variola confluens great numbers of adjacent papilln? become in- 
vdvod. The hfemorrhagic extravasations of the malignant variety are 
doe to rupture of cutaneous vessels. The dark or purple color which 
the papules and extravasations sometimes assume is significant of disso- 
lution of the blood. The pustules which form on the mucous mem- 
branes may incite general catarrlml, croupous, or diphtheritic inflam- 
mation of the regions in whicb they are found. After death, the 



DISEASES OF THE SKIN. 



liver, spleen, kidneys, and heart are found to be the seat of grannlar 
and i'diiy degeneration. No pustules have ever been ub&eryed on tlie 
gastric mucous membrane. 

Etiology.^"\^ariolu oceiirs at all ages aTid in all countries. It la 
produced by a specific poij^on, the exact nature of which has not yet 
been discovered. Analogical reasoning wouhl lead us to conchide that 
the source of the infection is to be foun<i in a specific micro-organ- 
ism which has uot at this time been isohited. A curious observation 
has been made uf>on this subject by Dr. A, VoitofF^ of Moscow, who 
found in the contents of variolous pustules several species of micro- 
organisms which had been already recognized and described. Inocu- 
lation of calves with culturoi* of each of these microbes produced no 
result But if a mixture of tlie cultures was used, characterislic vario- 
hnis pustules were developed. These experiments would seem to indi- 
cate that variola may be due to the Rimultaueous development within 
the body of several microbes, each of which may individually be harm- 
less.* One attack is protective, as a rule, airainst subscijuent out- 
breaks of the disease, but exceptious occur. Vaccination affords al- 
most complete protection. Variola is highly contagious. It may be 
communicated Ijy inoculation with the contents of the pustules, but 
is spread principally by the diffusicm through the atmosphere of the 
emanations from the patient. 

Dujardin-Bcaunietz states that although Brouardcl has detected in 
the air of hospital wards solid particles derived from dried variolous 
crusts, yet that these particles are soon lost in the air surrounding the hos- 
pital. Colin has fixed one hundred metres (about twenty rods) as the 
distance at wliich the air ceases to be contaminated. From these facts 
contagion seems to be most often propagated by direct f*ontact, and not 
by atmospheric diffusion. The transportation of rags often conveys the 
virus from one country to another, and Dr. Matthew II ay has reported 
a case f in which raw llax and jute acted as the carrier of infection from 
ttussia to Aberdeen. It is infectious at every stage, from the begin- 
ning of the disease until the process of desquamation has been com- 
pleted, but it is esjjeeially dangerous during the period of suppuration, 
when the secondary fever is at its height. The poison is active and 
virulent, and retains its power for a long time. Even contact with the 
bodies of those who have died of the disease may result in its develop- 
ment. The clothing and other articles in contact with the patient be- 
come saturated with the poison, and, unless destroyed or thoroughly 
disinfected, will become the foci for future epidemics. 

An apposite example of the mode of infection and the length of 
time during which infected rags remain virulent is given by Dr. W. F. 
Suiter, of I^ Crosse, Wisconsin. A man convalescent from a broken 

* Journal of the American Medical Association, Maj 26, 1889. 
t British Mcdiciil Journal, May 25, 1889. 



■ EXUDATIONS, f 85 

[leg but still confined to bed was seized with smiill-pox. Upon inquiry 
' it \va« found that he liad pulled out from t!ie wall near his bed a piece 
of rag which covered a wooden pin, and had idly picked the mg to 
pieces. It was afterward learned that a family liad died of variola 
in the same room twenty-ei^iit years previous^ly, and tlie rag had in all 
probability becm handled by one of those patients. 

Treatment. — ^T>iet is of the utmost importance. Milk, niilk-loast, 
eggs, oysters, or beef-juice should be administered regularly every four 
hours from the beginning of the disease. Lemonade will be found 
agn.*eable and cooling, and may be given freely. Cold water or ice- 
water can be taken without restriction. 

The medicinal treatment is mainly symptomatic, as no remedy has 
yet been discovered by which variola can be aborted or its duration 
leneDed. Cerni and Ory have lately claimed admirable results from 
the use of cocaine in doses of from two to five centigrammes (one 
third to three quarter grain). Ory gives to adults ten drops of a tive- 
per-cent golution of hydrochlomte of cocaine four times daily, and to 
children eight drops of a one-per-cent. solution four limes a day. It 
is asserted that by this treatment the suppurative stage is remarkably 
abridged and ameliorated and pitting much reduced. Dr. Montefero, 
of Naples, has reported favorably of the internal employment of small 
doses of carbolic acid. lie asserts that this drug aborts or limits pus- 
tolalion and reduces fever. Adynaoua is a contra-indieation to its use, 

kand it failed entirely in hivmorrhfigic variola, 'i'he 8ul])ho-€arbolates 
have been recommended by some authorities. Hydrochloric acid in 
docics of ten to twenty drops every two or three hours may be adrriiuts- 
tered in order to assist digestion. Some practitioners rely upun the 
carbonate of ammonium. 

During the stage of invasion the aim should be to lower tlie temper- 
atare, lessen the arterial tension, allay gastric irritability, and quiet the 
nervous system. In the stage of supjuiration the treatment should be 
directed not only to meet the foregoing indications, but also to prevent 
or counterafft the development of pyiemic poisoning. The complica- 
lions that arise at this period must be promptly met, and means taken 
to prevent or lessen the disfigurement ciiiised by the formation of pits. 

In ordinary cases of variola the most efficient treatment consists in 
the administration of small doses of aconite and morphine during the 
primary fever, and the same drugs in alternation with quinine and 
tincture of the chlorifle of iron during the secondary fever. The 
bowels should be freely opened, in the beginning of the disease, by 
a purgative dose of calomel and soda, and one or two passages secured 
every day afterward by the assistance of saline laxatives. If pharyngi- 
tiii or other throat symptoms develop, the patient should be directed to 
«BB a gargle of chlorate of potassium, ten grains to tlie ounce, four or 
fire times a day. The bronchitis can be most elTectively relieved by a 




196 DISBA8ES 6f the SI 

conibinatioB of sanguiiiaria, capsicum, and squilk, or other stimulatiug 
expectorants, rather than by opiates and depressants. Nervous exalta- 
tion can usually be allayed by the bromides and cliloral, but in some 
cases full doses of J*over's powder will be found more eiticient. Occa- 
sionally it may be necessary to resort to the hypodermic use of mor- 
phine. Du Cftstel treats variola by means of hypodermic injections of 
ether night and morning, full doses of the tincture of the chloride of 
iron, and the extract of opium, which are itu^reased in case of deli mm. 
This method is adapted to relieve prostration, and is claimed to exert a 
favorable influence upon the eruiition. The irritiibility of the skin ia 
relieved by frequent sponging with cold water. Inunctions of cod-liver 
oil are also grateful. According to Dr. Galewouslii, of Paris, excellei 
results are obtaiiied in the small-pox hospital of Brunu, Austria, by batl 
colored with permanganate of potassium. The temperature is reduce 
the general conditinn improved, and the pustules undergo resolution. 

Various antiseptic remedies have been used with the object 
neutralizing the specific cause of the disease. The bcnzoute of sodium, 
it is said, reduces the temperature and modilies the severity of small- 
pox. Petresco commends the action of Van Swieten^s solution. This 
consists of ten grains each of corrosive soblimato and chloride of am- 
monium dissolved in a pint of distilled water, the dose being from half 
a drachm repeated at proper intervals, the effect being carefully 
watched. Sulpluirons acid lias also its advocates. ^M 

Pitting can be reduced to a minimum by keeping the patient in ^H 
cool, dark room, and ai)plying tincture of iodine freely to each papule* 
An ointment containing iodol, aristol, or sulphur may likewise be 
employed for the same purpose. Each pustule should also be punct- 
ured early, and the interior touched with nitrate of silver after the 
pus has been evacuated- This, liowever, is a tedious and painful pro- 
cess. The late Dr. Addinell Hewson, of Philadelphia, insisted that 
better results wera obtained with less pain by covering t!ie affected 
surface with a thick piisto composed of fine clay and water. Weak 
mercurial plasters are frequently employed for a like effect. In order 
to lessen suppuration, Talamon nuikes use of an ethereal solution of 
corrosive sublimate applied in the form of a spi'ay. The formula 
recommended is as follows : 

j^ Acid, citrici gr, xv, 

Ilydrarg. chlor. corrog gr. xv. 

Sp. viTii rcct (DO*") m Ixxv. 

Ether q, s. ad. f 3 xi jss. 

M. 

For the first or second day of the eruption the face is first wash( 
with soap and water, rinsed with borated water, and dried with absorb- 
ent cotton, after which the spray is used, the eyes being protected by 
borated cotton. The spray is directed upon the face for barely a min- 





EXUDATIONS. 



18T 



ute* Tlie slcin assumes a slight frosty appearaTice. Fifteen minutes 
aft^r the use of the spray the face is rubbed with a pledget of cotton 
dipped in a glycerine solution of sublimate, liidf a drachm to the ounce. 
During tiie tirst three days this treatment is carried out three or four 
times in the twenty-four hours, but the spray may he discontinued 
after the sixth or seventh day, the glycerine solution being applied until 
the scabs begin to loosen. The results of this method are said to be 
very good when the eruption is discrete, the pustules generally abort- 
ing, but in conflnenfc or malignant cases no benefit was obtained- 

Schiermmei reports favorably of the use of a paste composed of five 
part* of carbolic auid, forty of olive-oil, and sixty of precipitated chalk. 
ThiJ* ini:xt.ure is spread upon a mask, apertures being left for tlie mouth, 
rLose, and eyes Colleville prefers an ointment consisting of one part of 
icjdoform to twenty parts of vaseline. A phin of local antisepsis de-. 
by Bianchi was attended by considerable stiecess in ninety-six 
twenty-two of which were slight, thirty-nine grave, and tifteen very 
geyere. The patient is first placed in a tepid bath containing one part 
in twenty of boric acid. During the batli he is covered with an anti- 
•eplic soap. This bath, or one of a 1 : 1,000 solution of corrosive sub- 
limate, is repeated every fourth hour. After each bath an ointment of 
iodoform and vaseline of one to five per cent, strength is applied. All 
th«pQstvde3 are opened with an aseptic needle. The linen of the pa- 
Unnt and the bed must be f rerpiently changed ; the floor, walls, and 
fiitniture of the apartment wajshed every second day with a 1 : 200 solu- 
tion of corrosive sublimate. This method of therapy is 8ai«i to have 
•Jimitiiahed fever, abridged tlie course, and moderated the severity of 
tb eruption. It is thought also to be of great prophylactic value. 
Wonsof carbolic acid or of mercuric bichloride relieve the tension of 
tlie skin and lessen the fetor of the discharge. 

In a case of confluent small-pox Baudon obtained a satisfactory re- 

^it by covering three times a day the face, limbs, und chest with a 

ponuulo of one part of salicylic acid to twenty-five parts of vai*eline, 

i powder of talc, one part, and salicylic acid, twenty- five parts, was 

Ihea dnsted upon the surface. When, at the end of eight days, he re* 

iDored the coating which had accumulated upon the parts, the skin 

Wi8 smooth, free from scabs or scara. Internal treatment had consisted 

of four grains of quinine three times a day. The body exhaled no odor 

during the course ol the disease. Lewentaner, of Constinitino[de, used 

trpon the scalp, face, and neck in six cases of severe confluent small-pox 

a paste eomix»sed of three per cent, of carbolic or salicylic acid, made up 

rith atarch or oil of sweet almonds and held in jiosition by means of a 

mAsk. The?e cases recovered without scars or otliei complications. 

Ulcerationa of the cornea sliould be touched at once with the solid 
mtniie-of -silver stick. In variola conSuens, and in the more severe 
cases of variola discreta, when the fever remains high, ice-bags may be 



188 ^^^^^^iSEASES OF THE SKITS'." 

applied to the head and chest, or the patient placed in a cold bath. 
When tlie fever assumes a typliokl type, and the pulse becomes soft 
and feeble and the mind dull and wandering, full doses of etrychuine 
and digitalis are to be given every fonr hours, and from ten to fifteen 
drops of oleum terebinthina^ once in three hours. Camphor, caffeine, 
carbolic acid, and carbonate of ammonia will also be found serviceable. 
Favorable results have been obtained also from the subcutaneous injec- 
tione of fifteen to twenty minims of ether, repeated two or three times 
daring the course of the day. The diarrho'a which sometimes follows 
can readily be controlled by dilute Bulplvuric acid and opium. If 
petechial spots appear on the surface, or hiiemorrhugic extra vasuitiong 
occur, full doses of chloride of iron and strychnine should be given, in 
alternation with olenm terobinthiuaf, every two hours. Alcohol is in- 
dispensable in the treatment of all grave cases. If symptoms of pneu- 
monia, pleuris}^, or pericarditis appear, a blister should be placed over 
the alTected region, and stimulants freely administered. Gastric and 
intestinal haemorrhage can be checked by Monsel's solution, given as 
required, in from five to ten drop doses, well diluted. Variola ma- 
ligna usually defies all medication, but occasionally recovery has been 
effected. The treatment of this variety should begin with free purga- 
tion, after which dilute sulphuric acid, strychnine, camphor, earboHc 
acid, and oleum terebiuthime are indicated in appropriate doses. Dn 
n. Russell, of Superior, Wis., has reported a ease in wliich recovery 
followed the administration of tincture of iodine every three hours, 
Dn N. S. Davis,* of Chicago, has obtained good results in some des- 
perate eases from a combination of carbolic acid and t!ie hy])osiilphite 
of sodium, as in tiie following fornmla : 

IJ Acidi carbolici ^- x. 

Sodii hyposulphitis 3 vj, 

AqujE menth. pip f ? iv. 

M. hJig. : One teaspoon fid in water every one or two hours. 

Cases of varioloid do not require much medic inc. The adminis- 
tration of a laxative and a diaphoretic mixture during the initial stage, 
and a chalybeate toiuc after the disease is well developed will usually 
bo sufficient. 

Tliosc aflflicted with variola should be rigidly isolated, and no one 
j>ermitted to come near tliem who is not protected by vaccination or 
by a previous attack of the disease. The discharges from the patient 
should be disinfected with common salt, carbolic acid, sulphate of iron, 
or mercuric bicldonde. All clothing and articles used are to be disin- 
fected or destroyed. The room should be thoroughly fumigated with 
chlorine, iodine, or sulphurous-acid gas, after the patient has been re- 
moved from it. The scabs should be carefully collected and burned, 

♦ Lectures on the Principlea Mid Practice of Medicine. By N. S. Daria, A. M,, M. D., 
LL. D. Cliicago^ Joosen, McClurg k Co,j 1884. 



EXUDATIONS. 



ISO 



* 



Prognosis.— The prognosis of varioln is largely influenced by the 
age of the patient and the extent of tlio eruption. The greatest fa- 
tality occurs, as a rnle, in young cliiUlren and in old peo])lo. Very 
few who are attacked before the sixth or after the sixtieth yeur 
recover. Young adults are more likely to recover. 

The prognosis is fiiTomble in all uncompUeated coses of variohi 
discreta. It is also so in eases of variola oonfhiens in which only 
a few large patehea are present ; but when tiie tendency to coalesce 
becomes general, the result is doubtful. It has been estimated that, 
while the mortality in Tariola dificreta varies from three to live j)cr 
cent, in variola conlluens it exceeds fifty per cent. Variola maligna 
lias a fatal tendency. Varioloid is a, benign affection, rarely ending in 
dcMitb« 

VAKICEIiXiA. 

Synonth. — Chicken-pox. 

Varicella is a mild, contagious, febrile alTection, characterized by the 
development of a vesicular eruption on the general surface of the body. 

Symptoms. — VariceUu is a ilisease of infancy and early childhood, 
Beldom Been after the tenth year. The incubation period varies 
from eight to seventeen days. The chief symptom, and that which 
usually first attracts attention, is the appearance of a vesicular rash 
after a premonitory fever of twenty-four or tliirty-six hours* duration. 
The fever rarely rises above 101^, and in some eases is so light as to es- 
cape notice altogether. The pulse is usually increased in frequency, 
and there may be 8ome lieadacfie and restlessness. The vesicles ap- 
pear first on the chest and abdomen, and then nijiidly extend to the 
extremities. In some cases they may be observed on the forehead, 
scalp, and neck» and on the conjunctiva and the roof of the month, 
but they seldom ever appear upon the lower part of the face. They 
are circular in shape, and vary in size from a pin's head to a largo 
pea. The first step in their formation consists of the appearance of a 
cumber of rose-colored spots, on which vesicles develop after a few 
hours. They contain a clear, serous or yellowish fluid, neutral or 
alkaline in reliction. They are all out upon the Burfaee and attain 
their full size on the second day. On the following one they begin to 
maturate or dry up, forming small brown or yellowish crusts, which drop 
off iQ two or three days. A small cicatrix is left at the site of each, 
but, as the corium is not involved, it usually disappears after a time. 
The fever subsides when nuUuration commences, and the whole course 
of the disease is terminated within a week. 

Diagnosis.— Varicella might be confounded with varioloid or with 
measie^. In varioloiti, however, the eruption is first papular, then 
feeicular, then pustular. It appears on the third day of the primary 
fever, and may be limited to the face, where it is usually first observed. 



190 



lAfiES OF THE BKIN. 



Ill measles, tlio eruption is seen first on the face ou the fourth day of a 
severe fever, but it is coarsely papiilar in cliaraeter, and aecompanied 
by marked coryza and bronchitis. In Tari€ella, on the otlier hand, it 
appears on the first or second day of a mild fever ; rarely upon the 
face, and is never papular or pustular. 

Pathology. — The rose-colored spots which precede the developnient 
of the vesicles are due to active congestion of the capillary yessels of 
isolated cutaneous papilla. As the morbid process continues, an exu- 
dation of serum occurs which, penetrating between the layers of the 
epidermis, separates them, and results in the formation of a vesicle. 

Etiology. — Varicella may occur si>oradieally or as an epidemic. It 
is propagated by contagion, and is evidently due to a specific poison, 
but neither the nature of the poison nor the exact method of its com- 
munication is known. Efforts to discover a specific micro-organism 
have not as yet been attended by decided success, Tenholdt disco veretl a 
micrococcus in the contents of tlic vesicles, and in thirty cases Pfeiffer 
found a germ which went through successive stages of arawboid, cyst, 
and spore formation. It was impossible to cultivate this parasite upon 
any soil. But these observations are far from conclusive. 

Treatment — If the fever aiul headache become severe, from one 
eighth to one fourth of a minim of the tincture of aconite, or half a 
minim of the tincture of gelseniinm, may be given in sirup and water 
every three hours, and a saline laxative administered. 

The majurity of cases, however, require no other treatment than 
rest and a mild diet. The patient should be kept indoors for & few 
days, and restricted to a diet of bread and milk and fruit. 

Prognosis. — Tlie prognosis is uniformly favorable. Only two or 
three deaths from varicella have ever been recorded, and, being debili- 
tated children, they were probably dying from inanition when the dis- 
ease appeared. In rare iustances haemorrhage, catarrhal pneumonia, or 
nephritis has occurred as a complication of chicken-pox. J)r. Walter 
T. Roberts, of Louisville, Ky., has chronicled the case of a previously 
healthy infant of nine months in whom, on the fourth day of an att-aek 
of varicella, a dermatitis gangrjenosa began to develop and terminateil 
life upon the sixth day. The dermatitis was peculiar in being nnilat- 
era!-* Under the name of varicella gangraenosa Mr. Hutchinson has 
described some cases in which ulceration took place in the varicella 
vesicles. 

VACOmiA. 

SyNONTU. — C0W'[10X. 

Vaccinia is a specific, contagious, eruptive disease, attacking cat- 
tle, and which, when transmitted to man by inoculation, so modifies 
the entire system as to render it insusceptible for a long time to the 
* Medical Progress, February, 1891. 



EXCDATI0X9. 



191 



: 



of 'I'ariola, Confusion and controversy have arisen as to the na- 
txire, relationship, or identity of the afTections loosely denominated 
por, and which occur in several of the domestic animals. An ablo 
sammary of thia vexed subject has been given by Mr. Fleming in a 
paper upon *' Variola in Animals and Men," Sheep-pox and goat-pox 
differ from each otJier and from cow-pox, horse- pox, and variola. 
Both cow-pox and horse-pox, or " grease," when inoculated into the 
human subject prevent the development of variola. Prof- Peueli, of 
Toulon, has demonstrated that vaccine derived from the horse and 
passed through tho calf to tlic child is much more powerful than a 
rariola which has passed for a long time between children and calves. 
Ordinary human lymph piussing from one c:df to another loses its 
power in the third or fourth generation, while the energy of horse-])ox 
Tdccine seems undiminished at the eleventh generation. The process 
of inoculation is termed vaccination. 

All children should be vaccinated during the first six months of 
infantile life, and revaccination performed about the eighth year of 
age, and then again at puberty. If the vaccination takes properly at 
eftch of the^e i>eriods, further repetition will be unnecessary. Statis- 
tics show tliat while varioloid may occur in seven per cent, of those 
who have been vaccinated once, it is rarely seen in those who have 
been vaccinated twice, and never observed in those who have undergone 
it three times. 

Either bovine or humanized virus may be employed, but, in using 
the letter, care must be taken to select only that which has been ob- 
tained from healthy persons, uncontaminated by syphilis or scrofuliv 

In performing tho operation, almost any part of the integument 
jnskj be used. The arm or leg is generally selected and scarified longi- 
tudinally and transversely over an inch of tlie surface. The scarifi- 
caition should be made lightly, so that it will merely bring the blood 
to the surface, and not cause it to ooze out in drops. If the vaccine 
matter is in a liquid condition, it can then be placed on the surface. 
If quills or points are employed, they should be dipped in water and 
then rublKxl freely into the selected spot. If a scab is used, it may be 
di^solvetl in a few drops of water or glycerine, and then ajtplied on the 
wounde<l spot. 

Mr. \\\ R. BuckcU, of Cheltenham^ England, has narrated * the 
hLitory of a i>eculiar case in wliich a vaccine vesicle developed upon the 
tongue. A mother had run a fish-bone into lu^r tongue two days be- 
fore her baby was vaccinated. The tongue remained sore for some 
itine. One week after vaccination the mother kissed the babe upon 
the arm at the site of vaccination. Six days later her tongue began to 
swelL 

In order to avoid the possibility of septic accidents, it is well before 
* Briliflh Medical Journal, June 22, 1889. 




DISEASES OF THE SKIN, 

operating to have tlic arm tliorotiglily cleansed with soap and water 
and to hold the blade of the lancet, if one be iised, for a momcDt in a 
ilanie. More elaborate antiseptic precautions havo been suggested, but 
are likely to destroy the virus and thus defeat the very object of the 
operation. Dr* Alfred Leach lias followed an antiseptic method of 
vaccinatiou for six years, during which period he had but one case of 
inflamed arm. Ilis custom is to wash iiistrunients, lympli tube, and 
patient's arm in a disinfecting sohition, and to make in four places 
small scarifications and valvular punctures with a Graefe'n cataract 
knife charged with lymph. Bismuth is dusted upon the wounds when 
perfectly dry. The rapid destruction of animal lymiih in hot coun- 
tries has been a serious difficulty. In India the lymph seldom retains 
its jiower for more than three days. It can be preserved in boro-glyc- 
eride for about fifteen days, Surgeon-Major W. G. King,* of Madras, 
has succeeded in producing a vaccine paste whicli remains efficacious 
for about a month. Tlie paste consists of the pulp of the vaccine ves- 
icle mi.vcd with pure lanolin in the proportion of one of the former to 
four of the latter material. 

Symptoms.^lf the vaccination has been properly performed, and 
pure vaccine matter employed, a hanl, red papule will appear at the 
site of inoculation on the third or fourth day. This papule will 
increase in size, and become yesicular on the fifth or sixth. The 
vesicle is umbilicated, is surrounded by a rod aureola, which increases 
in nm\ On the eightii or junth day it is converted into a pustule, 
which reaches its full development on the tenth or eleventh. The 
aureola then begins to fade, a dark-brown spot appears in the centre, 
tlie contents dry up, and a dark-brown or mahogany-colored scab is 
formed by the fourteenth or gixtecnth day. Cicatrization continues 
beneath until about the twenty-first or twenty-third. The scab then 
falls oil, leaving a circular, depressed, reddish cicatrix, which usually 
remains tlirongii life, hut gnidually becomes whiter than tlie adjoining 
skin. 

The constitutional symptoms accompanying true vaccination con- 
sist of slight fever, headache, and restlessness during the evolution 
of the eruption. In some ctises the axillary glands become swollen 
and painful. In other cases a dilTuscd acarlatiniform, or papular, or 
papulo- vesicular eruption may appear over the whole body. These, 
however, are only of brief duration, and usually disappear witliin a few 
days. 

A case of generalized vaccinia has been observed by Gaucher. A 
child was vaccinated with calf-lymph. Eiglit ditys later three good 
vaccine pustules were present upon each arm and the fever became 

♦ " Concise Report on Kcsiilts obtained in the ilmJrns Presidency wjtb Lauolfne-Tao- 
dnc dnrinj; the Ex peri in en tii I Itfsue from November, 18S0, to July, ISi^L" Dy Surgvoo- 
l!aj jr W, G. Kin^, M.B., D.P.JI., iti Tbe Iniliau MtHJical RocjonJ, Decemtrer 1, lSi»t 



A 



i:XUDATIONa 



193 



"iittwtre. On the eleventh day a general eruption was scattered over 
iwirlj all the body. Some of the pustules advanced to iimbilication 
while the development of others was iirrestcd. The general condition 
grew woi"s^, and the cliild died with symptoms of aspliyxia. The lunga 
were found congested, the sj>leeu enkirged, kidneys softened, and the 
liver in the early stage of fatty degeneration. 

Vaccination witli impure nuitter may entail the most serious eon- 
seqnences. The eruption jiroduix-d by improper virus docs not pursue 
the typical course of true vaccination. The aureola ap(>ear8 early, and 
is large and irreguhxr in outline. The papules appear earlier, also, and 
change rapidly into vesicles and pustules, which are not umbilicutetl, 
and either dry up early, forming a tliick, black scab, or extend into 
large sappurating ulcers, whicli spread widely and deeply, and mani- 
fest DO dtsi>osition to heal. Erysipelas not infrequently occurs m a 
complication. Boils and abscesses may also form, and run a tedious 
and painful course. 

The subject of vaccination eruptions was discussed in the Section 
of Dermatology at the meeting of the British Medical Association in 
IStfO. Mr* Malcolm Morris divided these rashes into two groups, one 
being duo to pure vaccine inoculation, and a second caused by mixed 
infection — that is, by vaccine togetlier with an additional virus. Cer- 
tain rashes of the first chiss appear within the first three days before 
the development of the vesicles, and are probably originated by reflex 
nervous influences from the jiart operated upon. They assume the 
forms of urticaria, erythema multiforme, vesicular, and bullous erup- 
tions. Those which follow the evolution of vesicles and due to the 
aiisurption of virus may take the form of roseola and resemble measles ; 
of erjthema, resembling scarlatina, or of purpura. Roseola and erythema 
generally appear upon the eighth or tenth day after vaccination, spread 
from the vesicles, and are accompanied by slight constitutional symp- 
toms. Sequelne of vaccination are eczema and urticaria ; psoriasis and 
pemphigus have occasionally occurred. Eruptions due to mixed infec- 
tion introduced at the time of vaccination are impetigo contagiosa and 
dermatitis or erythema. AlTections due to introduction through the 
wound subsequent to vaccination are erysipelas, cellulitis, boils, gan- 
grene, and, in very rare instances, pyaemia. Mr. Hutchinson has re- 
porU^d a case in which a general vaccinia became gangrenous. 

Sfjme individuals appear to be lususceptible to the action of vac- 
cination. It is probable they are alsn at that time insusceptible to the 
poiAon of variola, but, as that peculiarity of the constitution may be 
modified by time or other circumstances, repeated efforts should be 
miide to induce the mild disease in them. I recollect several cases 
in which six or seven vaccinations failed, but a later one proved suc- 
oessfuL When former attempts have failed, vaccination should be 
rtp^tatcd at each new epidemic. 
13 



104" 



DISEASES OF THE SKIN. 



Tlie cntaiicoiis symptoms of other eruptive fevers may bo briefly 
described its folio wg : 

TvpnorD Fever. — In typlioid fever the eruption appctira about 
the seventh diiy, but niuy be delayed until the tenth or twelfth- It 
consists of a few small pule-red or rose-colored spots, whieh are not at 
all or only slightly elevated above the surrounding surface. They are 
circular or oval in shape, and disappear upon pressure, returning as soon 
as it is removed. Tiicse spots are usually developed only on the chest 
and abdomen, but in some cases they muy be observed upon the back. 
They vary in number from one to twenty-five or more. Occasionally 
tlie eruption is more disseminated and abundant Spots may appear 
upon the extremities as well as Tipou the trunk- Murcbison mentions 
one case in which they a])peared upon the face. Each one remains visible 
for three or four days. It then fades, and another is developed near 
the site of the first. Successive spots appear and disappear in this 
manner for a week or more. They then disappear without either pig- 
mentation or desquamationj but return if a relapse occurs. Sudamina 
sometimes occur in the later stages of typhoid fever, but are not char- 
acteristic of the disease. In rare instances also small blue spots, inches 
Meudlresy have been observed. Tlicy are not peculiar to ty]ihoid fever, 
generally precede the rose-colored eruption, arc not elevated, and do not 
disappear on pressure. 

Accidental raslies occasionally appear iti typhoid fever and may 
embarrass the diagnosis. An eruption similar to urticaria or a soarla- 
tiniform erythema has been observed. The erythema generally occurs 
at the end of the first or in the third week of typhoid fever, and may 
be followed by diffuse desquamation. An epidemic of infectious ery- 
thema in the course of typhoid fever has been described by lIutineL* 
Most cases developed during the third week. The access of this com- 
plication suddenly increased the prostration ol the patient. A diller- 
ence in severity Wiis observeil, some cases beiug comparatively benign, 
The nriue is scanty and contains much albumen. If the advent of 
the erythema is preceded by vomiting, change in the features, reduc- 
tion of teinporature, and retardation of pulse, the teroiination is gener- 
ally fatal. In the absence of these syniptonis a very slow^ recovery took 
place. The average duration of an attack was two and a half days. 

Typhus Fkvkh. — In typhus fever the eruption appears from the 
fifth to the seventh day of the disease. It consists of numerous coarse 
dark- red spots or papules, which are elevated above the surrounding 
healthy skin, and are nut influenced by pressure. They are abun- 
dantly developed upon the trunk and the extrotnities, but never appear 
upon the face. In some cases of typhus the spots turn purple or be- 
come surrounded by black petechia?. Dark or purple linear and irregu- 
lar hoemorrhagic extravasations may also occur* 

• ReruQ mcDSuollc dca Maladios dc rEnfamrc, Miircb, 1890. 



EXTTDATIONS. 



195 



The eruption attains its maximum development in twenty-four or 
forty-^ight hours, and remains permanent until tho fourteenth or 
fifteenth day, when it slowly fades as convalescence begins. If the 
disease end8 fatally before that time, the eruption remains after death, 

Cbrebbo-spinal Fever.— hi ccrebro-spimil or spotted fever the 
eruption usually appears, if at all, witliin the first twenty-four hours, 
bat it may not develop until the third day. It consists of purpiiroua 
or cherry-colored spots, which are elevated, and do not diijiippear upon 
preflBore. They are found upon all portions of the body except the 
lace, and vary in number with the severity of the attack. They dis- 
appear with convalescence, but remain on tho surface in cases which 
result fatally. 

Diphtheritic Spots,— Severe cases of diphtheria are sometimes 
complicated by an eruption resembling that of cerebro-spinal fever. 
It may appear at any time after tlio third day. It consists of dark-red 
or cherry-colored spots, wliich are not influenced by pressure. They 
are not elevated, however, and are usually few in number and limited 
to the face and chest. Diphtheria may also be accompanied by an 
erythematous rash similar to that of sciirlatina. It is not as vivid, 
however, as the scarlatinal efflorescence, and never extends beyond the 
neck and breast. 

Influenza. — Although influenza is attended by no characteristic 
eruption, yet in the epidemics from 1889 to 18^)2 ra^^hea were seen in 
qotte a number of cases by ditferent observers. Sometimes t!ie eruption 
assnmed a papular form and again appeared like that of scarlatina 
and was followed by desquamation. Occasionally a purpuric lesion was 
encoantered. Among other cutaneous lesions manifested during its 
cotme were urticaria, ecthyma, erythema nodosum, roseola, erysipelatoid 
dermatitis^ and a morbilliform eruption. A few cases of herpes zoster 
were also reported, some complicating, others ftillowing the influenza. 
Dr. Mapother observed that the great debility due to influenza con- 
verted, when the patients were eczcmatoos, a serous into a pustular 
discharge. It also predisposed to acute attacks of pustular eczema.* 



SR7SIP£LAB. 

8TS0SYMs.^The rose— vSt. Anthony's Ere. 

Erysipelas is an acute speciflc, eruptive, febrile disease, character- 
ized by an intense inflammation of a limited area of the skin or mucous 
membranes, accompanied by various constitutional phenomena, and 
terminating in desquamation of the afTeeted portion of the epidermis. 
It is feebly contagious in character. 

Symptoms. — Krysipelas usually begins abruptly with a slight chill, 
or an attack of nausea and vomiting. This is followed in a few hours 

♦ haacet, Mny 2i, 1890. 



im 



OF 



SKIN. 



by high fever» and raore or less headache and paio iu the buck and 
limbs. The tongue becomes coated with a tliick vvliite or yellowish 
fur, the skin is dry and hot, the urine is scanty and high-colored, and 
the bowels are torpid. Tlie pulse is rapid and forcible, varying from 
100 to 130. Tlio temperature ranges from H}'i° to 104^ There k in- 
tense thirst, but no desire for food. 

The eruption nsnally appears within the first twenty-four or thirty- 
six hours. It consists of a circumscribed deep-red or rose-colored spot 
which generally appears first upon the nose, cheek, ear, or scalp. It 
may, however, develop upon any portion of the cutaneous or mucous 
surfaces. In some cases it is first observed upon the fauces, in others tlie 
vulva. Erysipelas of the larynx is generally an extension from the 
face or nose, though it is sometimes witnessed in connection with or 
consequent upon erysipelas seated in some distant part. In rare in- 
stances it may occur as a primary mainfestation. A case of primary 
erysipelatous broncho-pneumonia has been reported by Dr. M, Mosny.* 
The patient was a servant girl who, after tw^o days* attendance upon 
her master, suffering from erysipelas of the face, was attacked by 
pneumonia. The streptococcus of erysipehi^ was found unmixed with 
any other organism. 

It disappears on pressure, but returns as soon as the prec^sure is re- 
moved. It is preceded or accompanied by a sensation of heat and ten- 
sion, and more or less tingling or pain. There is also intense itching, 
and the surface is glossy and swollen. The eruption and tumefaction 
mpidly spread -in all directions. If the face or scalp is involved, the 
features become distorted to such an extent that they can scarcely he 
recognized. The lips are stiff and tumid, the nose, cheeks, and scalp 
are infiltrated and swollen, and the eyelids can not be separated. In 
severe ca.ses large vesicles or blisters (ilkd with serum are developed 
npou the afTeetcd surface. In grave cases the vesicles become black or 
purple from an extravasation of blood. 

The eruyjtion reaches iLs maximum development in about three 
days. It then ceases to spread, and gnuUmlly loses its vivid-red ap- 
pearance, a.ssuming a yellowish hue. The swelling also subsides, the 
vesicles shrivel up, and the febrile and other symptoms disappear. 
Convalescence is established about the eighth or ninth da}*. Moderate 
desquamation of the epidermis then takes place, and in some cases the 
hair falls out, but a new growth is soon develo])ed. 

Various eompHeations are observed during an utttiek of erysipelas. 
The cervical and axillary ghmds are frequently enlarged. Delirium 
may be caused by the height of the temperature, or from embolism 
of the cerebral capillaries. The urine nuiy become loaded with al- 
bumen, or it may be completely suppressed, and ursemic poisoning 
ensue. Endocarditis, pneumoiua, and pleurisy have also been noticed. 
* Lc Progrfefl M6dicail, February 15, 18»0. Uedlcal Biilletm, Jane, 1890, p. 218. 



mm 



i 



EXUDATIONS. 



1^' 




In the phlegmonous variety nf erysipeliis the areolar tissue is ex- 
tensively intUtrateJ with serum ; aiippiiration occurs, and nmch do- 
truction of tissae results. In gangrenous erysipelas the surface 
urns black, large sloughs are formed, atul the patient dies from 
ysemia. In erysipelas of the fauces the tongue, pliarynx, and larynx 
re swollen, and death may suddenly ensue from cedema of the air- 
ges. 
Erysipelas ambnlans is a semi-chronic variety of the disease in 
"which the eruption recurs from time to time, but always upon a diSer- 
^_ eut region of the body from that which was previously attacked, 
^B Diagnosis* — The diagnosis of erysipelas is easy. The only affec- 
^Vlioud which present any resemblance to it are erythenia and eczema. 
^Hjn erythema, however, there is neither fever nor paiu, and little or no 
^Bswelling. The eruption usually appears upon the trunk or extremi- 
^^ties, and cousist-s of several large spots or blotches, which arc not cir- 
cumscribed, but fade imperceptibly into the surrounding normal skin, 
lu eczema the surface is fiery red and burning, and covered either with 
inute vesicles or fine scales; but there are no constitutional symp- 
toms. Erysipelas of the fauces * or pharynx might be mistaken for an 
ordinary irritative inflammation of those structures. The diagnosis 
can readily be matie, however, by contrasting the dusky-red color, the 
rapid development, the migratory tendency, and the constitutional 
symptoms of erysipelas, with the bright-redness, the restricted devel- 
opment, and the comparatively mild nature of ordinary lutlanimations 
of the pharyngeal or buccal cavity. 

Pathology. — The first step in the morbid process consists of active 
hvperipmia of the blood-vessels of the atTectcd surface. Exudation of 
aeram and migration of the white corpuscles then occur. All the 
lAjT^rB of the skin become (Edematous and infiltrated with serum and 
masses of leucocytes. Vesicles are formed by an accumulation of fluid 
^K between the layers of tlic epidermis and between the epidermis and 
^Pthe corium. In severe cases rupture of isolated capillaries may follow. 
I The blood is thinner and darker than normaL The heart, kidneys, 
^■hver, and spleen undergo more or less granular degeneration. Em- 
^|Wism of the cerebral vessels sometimes happens, 

f Etiology. — Erysipelas may develop at any age, Itut it is most fre- 

qnentlj met with from the twentieth to the fiftieth year. It is not 
Umited to any season, but is most prevalent during the spring and 
I autumn months. One attack predisposes tlie individual to others. 

It has been held that there are two forms of erysipelas — contagious 
tnd non-contagious. The former is produced by a specific poison, and 
is propagated by individual contact as well as by atmospheric diffusion. 
It usually prevails in epidemics of varying extent and severity, but 

* " Errripeliis of the Upper AirTaaaages." By William Port«r, M.D. New Enfjland 
MediMi Montblj, Ikocmlxfr, ISSa. 




1U8 



DISEASES OF THE SKINT 



isolated cases are not uncommon. The iion-contagioua variety of ery- 
sipelas may be produced by a blow, or by exposure to cold or damp 
M'oatlier, or by reflex irritation from idcoholic indidgencc or other cauaee^ 
and may be regarded as a difTused dermatitis. 

Facial erysipelas may depend upon intra-nasal lesions, such as ex- 
treme turgescencG of the mucous membrane or occlusion of the nares 
by enlarged iurljiiiated bones. Of seven ly-f our cases of facial erysipelas, 
Lehrnbecher found in forty-seven some chronic intiammation of the 
nasal mucous membrane or cracks, crusts, and ulcers. 

A speeitic microbe of erysipelas has been isolated and cultivated. 
It does not, however, lend itself readily to artilicial cultivation. Crown 
in gelatine, it soon atrophies. The streptococcus of Fehk-isen devel- 
ops well at 70^ F., flourishes abundantly at 95° to 100% ceases to bo 
prolific at 107°, and is destroyed above 120^. It survives at aa low a 
temperature as 20° F. Below this point it probably can not live. An 
interesting conimuiiication made to the Biological Society of Paris by 
M. Leroy, of Lille, may throw light upon the obscure origin of certain 
cases of ervsijiehis. In December, 1887, M. Leroy prepared a gelatine 
tube witli a pure culture of this organism. As usual, it did not thrive 
well, and at the end of four or five wc^^ks appeared to be entirely 
atrophied. But to his surprise, in the latter part of Januar}-, 188*j — 
that is to say, after an interval of more than a year — the microbe 
which had been considered dead resumed growth and gave rise to 
active new colonies. The tube had remained during the year at a 
distance from the stove, exposed only to the ordinary temperature of 
the room. Animals inoculated with the revived culture demonstrated 
its activity and virulence.* 

According to the investigations of Fchleisen, the streptococci erysip- 
elatis enter, through some lesion, the skin, its lymph-spaces, and ves- 
sels, where they develop rapidly until the vessels are more or less oc- 
cluded. An active hypera?mia is excited, together with an exudation 
of plastic, cellular material By the time the inflammatory action has 
reached its height the colonies of micro-organisma iiave disappeared* 
Infection extends by way of the lymphatic vessels. As a rule, micro- 
organiams do not seem to enter the blood, and those which do so are 
speedily destroyed. These germs arc capable of development outside 
the human organism, wliich fact serves to explain the occurrence of 
epidemics of facial erysipelas and the increased number of cases at cer* 
tain seasons of the year. They have been detected l)y v. Eisolsberg 
and Emmerich in the air of a dissecting-room. They are disseminated 
hy particles of desquamated skin, to which they adhere. When brought 
into contact with favorable organic media, they develop and are sub- 
sequently dispersed through the atmosphere. It is probable that they 
are frequently present in decomposing organic matter. This view is 

• Modical Bulletm, May, ISW), p. ItO. 



ESUDATIONS, 



109 



supported by the fact that decomposing secretions of wounds, espe- 
cially when mixed with blood, cause erysipelas.* 

The streptococcus discovered by Fehleisen and believed to be the 
exciting cause of erysipelas bears a marked resemblance to the strepto- 
coccus pyogenes* On the grounds of the ditiereot results of inocula- 
tion oxperinients, however, Fehleisen disbelieves that the erysipelas 
germ is a pyogenic microbe. Pure erysipelas can not, according to 
this conception, be attended by suppuration. Pidegmouous erysipelas 
is regarded as due to mixed or secondary infection. From the evi- 
dence furnished by inoculation it appears that the etage of incubation 
is of three or four days* duration. The erysipelas microbe has been de- 
tected by MM* Verneuil and Clado in ^irodiicts taken from cases of 
IjmpKaogitis. These observers, therefore, hold that erysipelas and 
lymphangitis are simply different forms of the same disease. C'Ult- 
ures derived from patients suffering from acute lymphangitis pro- 
daced erysipelas in rabbits. 

TreatmeDt. — The most effective treatment of idiopathic erysipelas 
in young and robust adults consists in the hypodermatic administra- 
tion of from one sixth to one fourth of a grain of pilocarpine hydro- 
chlorate. It produces profuse diaphoresis, during which tlie jiulse and 
temperature full to almost norma!, the eruption becomes pale, the 
tumefaction diminishes, and the further progress of the disease is 
checked. This method is of striking benefit wlien erysipelas has at- 
tacked the larynx. In cases where hypodermatic injections are not 
deemed advisable, pilocarpine or jaborandi maybe given by the mouth. 
Neither of the^e remedies should be ordered, however, to anipmic or 
debilitated subjects, as serious cardiac depression might result. In 
BQch cases some other plan of treatment is preferable. Tlie adminis- 
tration four times daily of a pill containing three grains of the sulphate 
of quinine and one twelfth of a grain of the extract of belladonna 
ha& been recommended, and is often followed by good effect. A com- 
bination of aconite, niij, and carbolic acid, niss, every four hours, has 
also prodaced excellent results, but is not suitable for asthenic cases. 
M. Tison speaks highly of the use of aconitine in facial erysipehu?. He 
_ administers every sixth hour j^^ grain of BuquesneFs crystallized 

^B aconitine, and has seldom found it necessary to continue the treat- 
^^ moot beyond the tliird day. irsually it could be discontinued within 
I forty-eight hoars. 

^H Some patients require to be stimulated from the beginning, and 

^B irill not tolerate the employment of aconite, pilocarpine, or any other 
I cardiac depressant* The pulse should be the guide, and aconite or 

^K belladonna employed in accordance with its indications. These agents, 
^H bowerer, have no direct influence on the course of the contagious 

^^ ton 



• Lehrbnch der Pathol ogiacheo Gjaaecologic^ Vorloatmgen fur Aerzte und Stadlrende 
Dr. P. Bumigftrten, Braunschweig, 1888. 



DISEASES OF THE SKIN. 



variety of tlie disease, ami can only be regardod as adjuvants in its 
treatment. Tlie tincture of the chloride of iron, however, is almost a 
specific in both varietiea of the disease- It acts equally well in the 
sthenic and in the ai^thenic forms. It should be taken in large doses, 
one half to one or two drachm?, every three liours, until convalescence 
is esttiblisbed. The bowels shonld also be freely opened by a calomel 
or calomel-and- jalap purge, followed by a saline, lle&t in bed in a 
dark room is also essential. 

According to a fragment found among his papers and published 
since bis death, camphor was the favorite remedy of Pirogoff. He 
gave it in half-grain doses six times during the first day, afterward in- 
creasing the doseg to one grain. When camphor failed lie administered 
calomel or tartar emetic. The former wsis preferred when the tongue 
was heavily coated, and was given in the dose of six grains once a day. 
The tartar emetic was employed when the patient had eaten too he^irtilj 
twenty- four hours previously to the development of erysipehis. Various 
antiseptic substances have been administered internally with more or 
less success. Among these may be mentioned creasote, permanganate 
of potassium, and ^-naphtbol, the hrst and last named being the most 
efficient. Rhus tosicodendron lias been found of avail by Phillips. 

Ill severe cases, characterized by high fever, bounding pulse, and 
throbbing carotids, ice-bags should be applied to the head and face, 
and full doses of aconite or veratrum viride administered every hour 
until some relief i.s obtained. If there be fierce delirium and high 
fever, the same measures maybe resorted to; but if the delirium is 
low and muttering, and evidently due to suppression of urine, one or 
two drops of crotou oil or an eighth of a grain of elaterium should be 
placed on the back of the tongue, or sufficient pilocarpine injected 
hypoderniatically to produce profuse diaphoresis. In an unusually 
severe case which spread from the face to the trunk and upper extremi- 
ties, Dr. Favre, of Fribonrg, obtained a strikingly good result from the 
use of antipyriu. If symptoms of embolism supervene, I advise the 
free nse of carbonate of ammonium and the alkalies. In jihlegmonous 
erysipehis, quinine, iron, belladonna, and stimulants are the remedies 
to bo relied upon. In the gangrenous variety, camphor, strychnine, the 
mineral acids, and oil of turpentine may be resorted to. In malarial 
erysipelas large doses of quinine are necessary. 

In erysipelaa of the larynx the constitutional treatment should be 
conducted upon the general principles already stated, and ice should 
be applied to the neck, and the patient directed to swallow pieces of 
cracked ice. Morphine or cocaine may be used locally in order to 
abate pain. If swallowing is difficult, alimentation by the o^sophage^ 
tube or by rectal injection maybe resorted to; if dyspnoea is urgent, 
scaritication of the swollen mucous membrane or tracheotomy may 
become necessjiry. If the nasal cavity be the seat of the disease, tam- 



^ 



ii 



1 



EXUDATIONS. 



201 



pons of corrosive-sublimate cotton should be introduced ; and if there 
ia mnch suppuration the nams should bo washed out with a weak sohi- 
tion of the same substance (1 : 4,000 or 5,000). 

It has been said that external applications in erysipehis are useless, 
and, when ordered, are only of the nature of placebos. This is a 
grievous mistake. The itching and burning demand relief, and if it 
is not obtained, the patient teara his skin with hi* fingers, and at times 
becomes almost frantic. Various preparations have been recommended 
for external n&e in erysipelas, but the majority are useless and many 
are injurious. Tincture of iodine^ mercurial ointment, and solutions of 
nitrate of silver and carbolic acid can be emjjloyed, but they are all 
more or less painful and often inefficient. The ointment of the oleate 
of bismuth, on the other hand, is an elegant and effective application, 
which can be depended upon to allay the itching and burning, and 
lessen the pain and nervous irritability. 

M. Marc See is accustomed to use a permanent antiseptic dressing 
chiefly composed of the subniti-ate of bismuth, either as a prophylactic 
in the case of unliealthy wounds or as a remedy in actually developed 
erysipelas. Pirogoff's method was to cover the diseased surface with 
slices of common lard* covered by a layer of cotton-wool and held in 
place by a bandage. As a iocid dressing, he also recommended a piece 
of linen cut into a mask when the face was aflfectod, and thoroughly 
saturated with camphorated olive-oil. As a local application^ M. Tison 
recommends a solution of camphor in ether. In erysipelas of the 
trank and limbs. Dr. A. Rose, of New York, has seen great advantage 
from immersion of the affected part in a bath of a temiierature of dO" 
to 95°. The inflammation and pain are rapidly relieved and the fever 
red peed.* The ointments of carbonate of lead and boric acid are iiho 
valaable. Another useful but not so elegant an application is the 
earth-dressing of Dr. Addinell Ilewson. This dressing consists of a 
thick pjLste of clay and water. It relieves the piiin and biirnitig almost 
inst-antly, lessens the fever and swelling, and in many cases exercises 
an abortive effect upon the disease. Sir Dyce Duckworth recommends 
a thick ehalk-ointment.f 

Dr. George C. Kingsbury advocates the local use of ergotin in the 
form of a fifty- per- cent, solution in distilled water, frequently applied 
with a camel Vhair brush to and around the affected area. A few ap- 
plications suflice to reduce swelling and relieve pain. J; \ arious anti- 
aejitics have of late years been widely em|doyed as Igral applications, 
Uuna considers that ichthyol and resorcin exercise alnio.st specific in- 
flaence. Concentrated solutions of the latter are capable of producing 
cedema and blebs. It is therefore prudent either to begin with a weak 
■olation and increase the strength to the point of tolerance, or the 

♦ Thcimpeatic Gaiette, January 16, 18(H). f Practkioncr, January, 1887. 

X Britisb Med teal Journal, Murch IS, 18D0. 



202 IHSBASBS OF THE SKIK. 

remedy may be conjoined with some substance wlucli slial! mitigalft ilg 
action, and among tlio best of tlicso are oxi(Je*of*zine ointment and 
linseed or olive oil. Upon hairy parts, especially the soalp, it is better 
to use an oil As a rule, equal parta of resorcin or ichthyol and zinc 
ointment forms a serviceable application. In a number of cases of ery- 
sipelas in recently vaccinated infants, Dr. Himmelfarb nsed one half 
draclim of purified resorcin to one ounce of glycerine. This solution 
wa^ painted every hour by means of a camelVhair pencil upon the dia- 
eaaed area and a surrounding healthy zone, and complete recovery took 
place within twenty-four hours, 

Dr, Fessler, first a^istant of Prof. Nussbaum, of Munich, has pub- 
lished in a monogram* the ivsults of numerous ba<:*tenological experi- 
menta and clinical observations relating to tlie influence of ichthyol 
upon cultures of the specific streptococcus of erysipelas. Weak solu- 
tions were found very destructive to this micro-organism, and the au- 
thor conckides that ichthyol, employed early and energetically, will 
cure the disease by destroying its germ. The method of treatment con- 
sisted in rubbing vigorously, for ten minutes at a time, a strong ichthyol- 
ointmcnt into the affected surface and its vicinity. Any wound must 
be carefully disinfected and antiseptically dressed. From the author's 
tables it appears that while from 1880 to 1888 the mean duration of 
the cases treated by other methods was about twelve days, and in no 
single year less than nine days, the ichthyol treatment reduced the 
length from 188G to 1888 to an average of less than seven days, and in 
the first half of 1889 the duration had fallen to 5*G days. CavelH claims 
good results from the use of picric acid. He states that the swelling 
and pain are markedly decreased in from twelve to twenty-four hours. 
lie employs an af(ueou8 solution, one and a half parts of picric acid to 
two hundred and fifty part^ of distilled water, applied externally five 
or ten times a day.f He conceives that the drug penetnites the homy 
layer, acts as a protective to the stratum ^lalpighii and restrains in- 
flammation by its astringent properties. He suspects, moreover, that 
it is able to gain the interior of lymphatic conduits and destroy the 
micro-organisnis on which the disease depends. Excellent results have 
been reported from RosenbacirB treatment, which consists in washing 
the erysipelatous patch and the surrounding skin with soap and after- 
ward applying continually a five-per-cent. solution of carbolic acid 
in absolute' alcohoh For an alcoholic solution Prof, Ebstein substi- 
tutes a five-per-cent. carbolized vaseline with, it is said, equally good 
results. 

Since the erysipelas cocci are destroyed by ninety-per-cent alcohol, 
Behrend has employed this agent as a local bath to a part attacked by 

* " KtlniKchExperimentclle Studicn iiber CMrurgiscUe Infectionskratjkhciten, ron 
Dr. Julius Fesaler." 

f tiazzetla degU OBpitati, 1689. 



EXUDATIONS, 



203 



erysipelas. The application repealed thrice daily was made to extend 
one half inch beyond the border of the diseased patch. He found that 
the disease was quickly arrested and completely curud within three to 
15ve days, Creolin, likewise, has been found efficacious. It has been 
used ia the strength of three parts to twenty- five parts of lanolin, or 
one part of creolin and four parts of iodoform to ten parts of lanolin. 
The hypodermic injection of three or four svringefuls of a three-per- 
cent carbolic-acid solution it? advocated by Hneter. The injection 
should \ye made along the border of the erysipelatous patch and into 
the tifisues which the disease is about to invade. 

Dr. M. Strizover, of Soroki, Bessarabia, makes use of hypodermic 
injections of corrosive sublimate one grain^ and carbolic acid ten 
grains* dissolved in two ounces of distilled water. His method is to 
inject a Pravaz syringeful of the solution at several points, a few drops 
at each. The same fluid is then rubbed into the parts for several 
seconds by means of cotton- wool ; a layer of wadding satunitcd in the 
eolation is then laid upon the surface and held in position by a gauze 
bandage. The dressing is changed in six or eight hours, and not more 
than one injection is generally needed. An ointment of corrosive sub- 
limate made with lanolin has also proved of benefit Wolfler asserts 
that the gentle and equable pressure of strips of sticking-plaster is 
guccessfnl in limiting tiie disease to the area covered by the dressing. 
Ue reported* twenty-four castas, in twenty-one of which this method 
had proved efficacious. A plan devised by Kra,"*ke, and slightly modi- 
fied by Biedel and others, consists in surrounding the patch by a line 
of incision which is to be intersected throughout its length by short 
cuts crossing it at right angles. Ordinarily the iiu-isioua need to bo 
bat little deeper than those made in vaccination. The scarified sur- 
face ia then washed with a five-pcr-cent. solution of carbolic acid, and 
kept constantly wet with compresses soaked in a two-aud-a-lmlf-per- 
oent. solution. Some prefer using a sublimate solution (1 r l/JOO) in- 
stead of the carbolic acid. Dr. A. Seibert, of New York, has designed 
two small-toothed instniments by which the operation may be conven- 
iently performed. If done npon the face, great caution will he re- 
quired lest the incisions be made too deep and an unsightly scar be 
produced. 

Carbolic acid or corrosive sublimate may be used, as by De Amicis, 
without frcarifjcation. This writer generally emi)loys equal parts of 
carbolic acid and glycerine, applied every second hour to the affected 
patch and a surrounding zone. In phlegmonous erysipelas he follows 
Hueter's method of hypodermic injections. If the odor of carbolic 
acid is intolerable to the patient, a one-per-cent. solution of corrosive 
sublimate in glycerine is substituted. Nolte applies mucilage of acacia 
oootaining three to five per cent of carbolic acid. Inunctions of tur- 
• Zeitschrift fur Thcrapie, Julj IB, 1880. 



204 DISEASES OP THE SKIN. 

peutine have likewise proved beneficial. The following mixture is 
reeo mm ended as a topical remedy by Dr. Eothe : 

H Acich curbolici gr. ixj. 

Sp. villi rectificat, 

Tr. iodi aa fit sxx. 

01. terebinth f | j. 

Glycerini f 3 iij. M, 

Salicylate of sodium dissolved in glycerine is highly recommended 
by Inglessis. An oiutmeut containing creasote or salol has been found 
beneficial Dr. Dewar praises the action of a dressing composed of equal 
parts of 8nli>liiiroiis acid and waten A. H. Neiith has observed good 
results from the topical employment of aeetanilid nuide into an ointment 
with lard, lanolin, or other suitable excipient in tiie iiroportiou of 
twenty grains to the ounce* As erysipelas may originate from a point of 
infection within the nose, it is well to cleanse the nares at intervals with 
a three-per-cent. solution of boric acid, as advised by Lehrnbeeher. 

Prognosis.— Uncomjilicated idiopathic cases of erysipehis invariably 
terminate favorably. The occurrence of delirium indicates a grave 
case, but not necessarily a fatal one. (Edema of tlie air-|iasi?age5 and 
embolism of the cerebral vessels are seldom followed by recovery. 
Pneumonia, pleurisy, and endocarditis are nnfavorabk* complications. 
Pya^mic and ura3mic cases usually die. Phlegmonous cases pursue a 
tedious course, and present a high death-rate. Uangrenons erysipelas 
is generally fatal. Alcoholic subjects are unfavorable cases, 

OHAKOEOID. 

Stnostms.— -Soft chancre, non-jiifecting chttncrc^Chancroi'de^ — Scbankcr. 

Chancroid is a localized virulent, contagious, specitic venereal dis- 
ease, ciniracterized by the formation of one or more peculiar ulcers 
npou the cutaneous or mucous surfaces, accompanied by inflammation 
of the adjacent lymphatic glands, but not followed by any other symp- 
toms of eonstitiitional infection. 

Symptoms,— The lesions of chancroid mfiy occur upon any portion 
of the body, but they are most frequently observed on the genital 
organs. The glans and )>re])uce in the male, and the fuurcliette, labia 
majora, labia minora, and the lower part of the vagina in the female, 
are especially liable to be involved. The body of the penis and the 
urotlira and scrotum in tlie male, and the uterus^ urethra, perinseum, 
and anus of the female, may alsu be affected. Chancroid of the fingers 
has occurred in gynaecologists and accoucheurs as a restilt of infection 
through a cut or an abrasion while making a vaginal examination. 

Chancroid has no period of incubation. The morbid process be- 
gins as eoon as its essential virus is absorbed* If a droi> of chancroidal 
pus be inserted beneath the epidermis, the point of insertion will be 



"EXITDATIONa 



m5 



surrounded in a few hoars by a faint reddish blush, Tvhich gradually 
increases in size and distinctnf^ss until the second day, when it api»car8 
as a well-marked inflammatory aureola. A vesicle is then developed at 
the |x>int of inoculation, and becomes converted into a pustule.^ whieli 
usually breaks spontaneoui^ly in a few days. The resulting uleer is a 
tjpicd chancroid, which does not differ in appearance or course from 
those which result from impure sexual intercourse. 

The interval of several days which sometimes elapses between ex- 
posure to conta^non and the appearance of the lesion, is due to the 
fact that no abrasion of the surface occurred, and that absorjition con- 
sequently could not take place until the acrid virus had corroded 
away the outer laj^ors of tlio epidermis or insinuated itself throuorh 
the foUicles into tlie interstitial spaces of the retc mucosum. Ab- 
sorption ia rarely delayed longer than a week, however ; and, if an 
abrasion exists, well-marked symptoms may develop within a few 
honrs. It has been estimated that in twenty-tive per cent, of cases 
the lesions appear within two days ; in twenty-live per cent, more, 
within four days ; in thirty per cent, more, within six days ; and in 
the remaining twenty jier cent at various times^ from a week to 
twelve days. 

Usually, within two or three days after infection, the characteris- 
tio lesion of chancroid becomes manifest. It consigts of a sharply- 
deOned round, ovuL or irregular ulcer, with abrupt, perpendicular, or 
sloping edges. Its base at first is red and smooth, but soou becomes 
irregular and granulated, and covered with a gray or yello wish-white 
pultaceous material, consisting principally of pus. It is surrounded by 
an inflammatory non-indurated aureola, and is continually secreting 
more or leas thick white or yellowish pus, which may or may not be 
tinged with blood. If no treatment be instituted, tlie ulcer gradually 
increases in size for one or two weeks, frequently attaining a diameter 
of half an inch. In mild cases, a process of spontaneous repair may 
then begin. The inflammatory aureola disappears ; the secretion be- 
comes altered in character, and finally ceases ; healthy granulations 
spring up, and, if the destruction of tissue has not been too great, 
the healing process will be completed without the formation of a per- 
manent cicatrice. 

In severe ca^s, the ulceration continues to extend in all directions 
until a large area of the surface is involved. It then tends to assume 

1~ a chronic character, and is subject to various modifications. In ma- 

lignant or phagedenic chancroid the ulceration spreads deejily and 
widely, producing intense pain and great destruction of tissue. In 
Bome ca^s the rapidity and severity of this process are so excessive 
M to result in tlie sloughing of the glans penis, and destruction of the 
Bcrotom in a few days. In the female it is frequently productive of 
frightfuJ and loathsome deformities. 



DISEASES OF THE SKIN," 



Oliancraidal ulcers may be siTjgle, but, as a rulo, they are miiltiplo. 
Owing to the auto-iiioeulability of their secretions, as well as to the 
fact that seTeral abraded points may be iufected at the game time, 
there is no limit to the iiuniber wliich may be j>reseiit. I have seen a 
patient who had thirty -seven distinct clmncruids?, and instances are 
recorded iu which a gtill greater number were observed. 

All chancroidal nlcers are accom|»anied by more or less inflam- 
matiun and infiltration of the snrrounding tissues. In some cases 
the entire penis is enormously swollen ; in others the infiltration ia 
limited to the prepuce or the glans penis, producing phimosis or 
paraph imoBis. 

The most fref[uent complication of chancroid is bubo, or inflam- 
mation of the neighboring lymphatic glands. At times the lymphatic 
vessels leading to the glands also become red, inflamed, and hardened, 
and can be felt like hard cords beneath the skin. When it assumes 
this phase it is a genuine lymphangitis, which may eventuate in sup- 
puration and the formation of small abscesses along the course of the 
inflamed lymphatics. It usually, however, terminates in resolution in 
a few days, 

A bubo pursues a more prolonged course. Its presence is an- 
nounced by swelling of the affected gland, and a sense of tenderness or 
pain upon motion. Buboes may occur upon any region of the body, 
but, as their exciting cause generally exists upon the genital organs, 
they are usually found in the groin. They develop during the first 
few days of the existence of the chancroid. They vary in size from 
a hassel-nut to a small coeoanut, in accordance with the number of 
glands involved, the intensity of the morbid process, and the state 
of the patient's constitution. They also vary in duration and termi- 
natioTi, In mild cases there is no pain, but merely a sensjition of dis- 
comfort, which passes away in a few days, and the swelling wliich is 
only moderate disappears in two or three weeks without suppuration. 
In severe cases the glands increase largely in size, and become in- 
tensely painful. The overlying integument is red and tender, and 
suppuration progresses so rapidly that fluctuation can be jicrceived in 
Ave or six days from the commencement of the swelling. The pain 
increases with the formation of pus until the bubo is opened or epon- 
taneous evacuation of it^ contents occurs. The cavity of the ulcer 
which is exjiosed is similar to the chancroidal ulcer from which it 
originates. It secretes tlie same virulent pus, and is subject to the 
phagedaenic and other complications of chancroid. If left untreated 
it may become chronic in character, and involve a large area of 
Burface. Usually, however, the character of its secretion gradually 
changes, healthy granulations spring up, and a cure ia finally effected 
by cicatrisation. 

Diagnosis. —The diagnosis of chancroid is frequently diflBcult. The 



^^^^^^^^^^^^^ EXUDATIONS. \iin 

principal affections with which it may be confounded are chancre, 
herpes, eczema, epitheliama, and iuuocont erosions or abrasions oc- 
casioDed by sexual intercourse. Chancroidal ulcera are painful to the 
boucb, rapid in develujiment, and have no marked |K^riod of incu- 
batiou^ They are usually mtdtiple, their secretion is copicms, puru- 
lent, and anto-inocalable ; their base is not indurated, and they rarely 
involve more than one lymphatic gland at a time. Chancre, on the 
contrary, is glow in development, painless to the touch, and has a 
well-marked period of incubation. It is usually single^ its secretion 
is thin, sanioiis, and not auto-inoculable. Its base is indurated, and 
it involves a chain of lymphatic glands, which rarely suppurate. The 
gubsequent history of the case is also different. It must not bo for- 
gotten, bowever. that it is possible for the same lesiou to contain the 
poison of both chancroid and chancre, and that while the rapid de- 
Telopment of the symfitoma of the former may obscure those of the 
latter for a time they will not prevent their tjiial a]>peanuice. Con- 
fleqneQtly, a patient who is suffering from ehaucn^id sliould not be 
aeeared that he has not contracted 8yi)hili3 until the ordinary incuba- 
tive period of that disease has elapsed without the development of its 
characteristic symptoms. 

Herpes may usually be distinguished from chancroid by the pres- 
ence of the minute vesicles of the former disease, the severity of the 
local irritation, the history of former similar eruptions, and the ah, 
8eace of prog^reasive ulceration and glandular involvement. Eczema 
is attended by excessive itching and irritation, but is devoid of ulcera- 
tion. In epithelioma the secretion is either absent, as in the early 
stttges, or thin, sanious, and fetid^ as in the later stages. The knobbed, 
wart-like, or cauliflower appearance, and painful character of the 
growth ifl aUo significant. 

Simple erosions or abrasions of the glans, or of the prepuce, or of 
the body of the penis are of frequent occurrence, and may be mistaken 
for commencing chancroids. They are bright-red in color, and often 
cover a large area, and are at times the seat of a serous discharge. 
They do not extend in depth, however, and, if not irritated, will jn- 
Tari&bly disappear in a few days* 

Balanitis has been mistaken for chancroid, but that error can 
readily be avoided. In balanitis the greater portion of the glans 
is involved, and the discharge is thick and purulent, but there is no 
iDgainal involvement, tio destruction of tissue, and all the symptoms 
impidly disappear under appropriate treatment. The ulcerations of 
tertiary syphilis present a striking resemblance to those of chancroid. 
Their edges, however, are more indurated, their history is different, 
their course is slower, their secretion is not auto-inoculable, and thej 
are not accompanied by the fortnatiou of buboes, 

Patliology. — The pathological conditions which are present in 



flMM 



DISEASES OF THE SKIN. 



fhiincroid do not appear to differ in any respect from those which oc- 
cur in ordinary ulcerative processes. Tlie floor of the ulcer^ which ig 
formed by the coriiim, is destitute of papillae, and is uneven and cov- 
crctl with pUH-ceUa* The retc miicosum and the papillary layer of the 
margins of the ulcer are anlematous, and infiltrated with cells. The 
underlying corium is also thickened and infiltrated. The vessels of 
the corium are dilated and tortuous, and their walls are swollen and 
surrounded by a network of new fibrous tissue. 

Etiology-— Cb aneroid is due to the absorption of the peculiar vims 
of another chancroid. The poisonous principle resides eliiefiy in the 
pus-corpusclea of the chancroidal secretion, and we are warranted in 
supposiug that it consists in a hitherto undiscovered specific micro- 
organism. It is conveyed exclusiveiy by contagion, which may, how- 
ever, be mediate or immediate. There have been instances, as before 
remarked, where it has been contracted by accoucheurs or gynaecolo- 
gists while making a vaginal examination, but in the main it is duo 
entirely to impure sexual intercourse. 

Treatment. — The prophylactic treatment of ch aneroid is of the first 
importance. The parts should be thoroughly cleansed with soap and 
water immediately after a suspicious intercourse, in order to remove 
any poisonous material that may bo liidden in the folds or furrows of 
the skin. If any abrasions be noticed, a physician should be consulted 
at once. 

After a chancroid has developed^ the most effective treatment con- 
sists in cauterizing the entire affected surface. By this means all dan- 
ger of farther contagion is averted, and the specific ulcer is changed 
into an ordinary simple sore. Any active caustic may bo used fur this 
purpose, but those which are most frequently employed are the gtd- 
vano-cautcry, tlic actual cautery, nitric acid, and sulphuric acid* The 
galvano and the actual cauteries possess the advantage of being only 
momentarily painful; their action can also be easily restricted to the 
affected spot Acids will sometimes diffuse over a portion of healthy 
tissue in spite of every precaution* The caustic alkalies are still more 
diffusive and very painful. 

Fournier advises tlie use of a three-per-cent. solution of nitrate of 
silver, applied thrice daily upon a pledget of absorbent cotton. Solu- 
tions of peroxide of hydrogeti or chloral or Labarnique's fluid are like- 
wise of service. Liquid carbolic acid is also a good cauterant. 

No matter what agent may be employed, care must be taken to 
thoroughly cauterize every portion of the sores, for if any of the virus 
be left undestroyed it will speedily multiply and invatle fresh areas of 
the surface. The patieirt sliotdd avoid as far aa possible severe labor 
or exercise. Alcoholic tlriuka should be prohibited. 

After the cluiueroid has been thus effectually treated it should be 
covered with powdered bismuth, subiodide of bismuth, or zinc-oint- 



EXUBATIONa 



S09 



ment, or any non-irritating application, and permitted to heal by gran- 
ulation. The use of pyokt^inin in weak solution or as a diluted powder 
promotes the healing process. 

If nitric or sulphuric acid be used, a solution of cocaine, crcasote, 
or dilute carbolic acid may be first applied to the surface in order to 
lessen the pain produced by the cauteriziug acid. Lctzel has fouud 
the solutioTi of llie chloride of iron au efficacious application. In the 
course i>f four days a bright graoulatiug surface results. C'alomcl 
may then be used as a dusting-powder, and in about five days more 
the acre will generally be healed. Iodoform is an excellent dressing, 
but its penetrating odor is often an objection. In such cases iodol, 
aristol, or europhon may bo employed as a gubstitiUe, either in the form 
of a powder or a five-per-cent, ethereal soKition. If deemed advisable, 
iodol may be combined with alum or subnitrate of bis^inntb. It is not, 
however, according to the comparative studies of Dr. Sziidek, of Kiev, 
as efficient as iodoform. Prior to applying the iodol the surface of the 
nicer should bo carefully cleansed by means of a corrosive-sublimate 
solution and be cauterized. The powder should not be applied in a 
thick layer, which causes relenti<.ta of the discharge. Prof. Stiiko- 
Tonkoff, of Kiev, praises the action of benzoate of mercury, which may 
be Med either as a powder or in watery solution (1 to 3 parts to 500)- 
As it gives rise to considerable burning, it is advisable to add cocaine 
to the lotion. The sub-benzoate of bismuth is a remedy which 
is atlvoeated by Dr. Finger. Dusted over the sore it gives rise to a 
flight burning sensation, which, however, soon passes of! without any 
local irritation. In from three to six days t!ie sure begins rapidly 
to cicatrize. Other efficient applications are : Bromine, % x to tho 
oonce of olive-oil; a weak solution of sulphate of co}>per; a diluted 
fluid extract of bamamelis or hydrastis; an ointment of resorcin, naph- 
thaline, ichthyol, or nitrate of mercury. »SalicyUe and pyrogallic acids 
bare also been recommended. Ilie former is used as a powder, tho 
bitter as a pure powder, or mixed with starch or bismuth, us a ten- or 
twenty-per-cent ointment, or dissolved in collodion or traumaticin. 

Dr. Osc^r V. Peterson advocates scra]>iug out the chancroid with a 
sharp spoon, as is done in the ease of lupous ulcers, lie previously 
deanaea the sore and surrounding skin with a solution of corrosive 
mblimate or carbolic acid, afterward wiping the parts with n piece of 
cotton- wool soaked in ether. In order to render the operation pain- 
leee, a two-per-cent solution of hydrochlonite of cocaine is injected be- 
neath the skim After the operation a dressing of iodoform powder 
and gauze is applied. He states that by this method tlie duration of a 
€We is materially shortened. The same writer speaks favorably of 
painting the surface of the sore with pure tincture of iodine, and ex- 
cision of the sore and adjacent skin with subsequent application of 
sutorea. The wound heals in three days by first intention. Besides 
u 



210 



DISEASES OF THE SKIN. 



being painful, excision is imsuitcd to ulcers situated on the glang,* 
For the purpose of absorbing the discharge from the sore, keeping the 
surface dry, promoting cure, and preventing auto-inoculution, absorbent 
cotton has been usefully employed in the wards of Belloviie Hospital. 
The method of application is to surround the penis just behind the 
corona with a small roll of cotton kept in place by a rubber thread 
band. The dressing is light, and can be easily renewed as often as 
necessary. The more dry the surface of a chancroid ciin be kept the 
more rapidly will it heal. 

Rcsorcin and acetanilid are other substauces which have been em- 
ployed with advantage. If severe or erysipelatous inflammation de- 
velop, the afTuctud part sliould be elevated aud kept moist and cool by 
the application of cold water or lead- water and hiudanum. 

If phagedienic ulceration occurs, all sinuses and tistuhe must be laid 
opeu^ all sloughs cut away, all pus removed from the surface, and tjn- 
spariug cauterization promptly resorted to. Prolonged immersion in hot 
water has an excelleut effect. If the pain be severe and the constitutional 
excitement high, morphine and aconite are to be administered, in suffi- 
cient quantity to allay pain and to moderate nervous and arterial ten- 
sion. After these symptoms have abated, constitutional tonics, such as 
iron and quinine, with generous aliineutation, are required. 

The formation of a bubo can not be prevented, but judicions treat- 
ment will frequently promote its resolution or prevent suppuration. 
As soon as the inguinal glands become enlarged or tender, the patient 
should be sent to bed, a stdine cathartic administered, and tincture of 
iodine painted freely over the skin of the affected region. If the gland 
continues to enlarge and tlie pain to increase after this treatment has 
been persevered in for twenty-four hours, another saline catliartic may 
he administered^ and a bag of ice applied at short intervals to the swol- 
len gland. If there be no pain or inllammatory symptoms, hut merely 
a progressive increase in the size of the bubo^ constiint pressure, as 
from a bag of shot or a disk of metid, held in place by a spica baud- 
age, will be tlie most effective remedial measure. 

If suppuration ensues, the bubo must be opened as soon as fluctua- 
tion is perceived, and its contents thoroughly evacuated. Its interior 
stirface should then be thoroughly cauterized, and afterward dreseed 
with an emollient ointment, and permitted to heal by granulation- 
Tonics and stimulants must he given whenever indicated. 

In yilaco of a large incision which will leave an indelible and un- 
sightly scar of proportionate size, it will usually be found better to 
evacuate the pus either by a small opening made with a narrow-bladetl 
bistoury or by aspiration. The cavity should then be irrigated by a 
weak solution of corrosive sublimate, and slight pressure be maintained 
by means of a compress and bandage. A small quantity of nitrate-of- 

• Janroal of Cutnneous and Geoito-Uiinary Diseases, September, 1889, p, 360. 



EXUDATIONS. 211 

nlver eolation may be used instead of the bichloride. Welander has 
used benzoate of mercury by injection in one hundred cases of 
buboes. He finds that if the injection is murlo before fluctuation has 
scarred, it will in most cases prevent or greatly limit the produc- 
tion of pus; and that ercn when fluctuation is decided, if the skin 
be thick and well nourished, in about half tlie ciiiies the necessity of 
eracuation will bo obviated. A bubo may be Tery advantageously 
opened by the galvanic knife, and proper drainage is thereby favored, 
since the opening does not close so readily as tliat made by the ordinary 

K bistoury. 

H Phimosis and paraphimosis may be relieved in accordance with the 
methods appropriate to each individual caee. 

PtOgnosis. — The prognosis of chancroid is always favorable so far 

I as danger to life is concerned, but it occasionally pursues a tedious 

H coarse, and may result in the production of permanent cicatrices or 

^Bother deformities. 



SYPHILIS. 



Syphilis is a virulent, chronic, contagious, systemic disease produced 
by the absorption or inoculation of a specific vims, and manifesting 
itself primarily by the development of an infectious lesion at the point of 
inoculation or absorption, accompanied by iin involvement of the ad- 
jacent lymphatic glands, and fallowed by a series of morbid manifesta- 
tions which first involve the skiu and mucous membranes, and finally 
extend to all the organs and tissues of the body. As a general thougli 
not invariable rule, one attack renders the patient insusceptible to a 
second infection. 

Symptoms. — There are four more or less well-marked stages of 
fvydiilis: the primary, in which the force of the disease appears to be 
concentrated at the point of infection and in the contiguous lymphatic 
?lan*ls; the secondary, in which the cutaneous and mucous surfjices 
are mainly involved ; the tertiary, in which the osseous, cartilaginous, 
kjnuscular, and fibrous tissues are invaded ; and the quaternary, in which 
the nervous system and the viscera are profoundly atfeeted. 

Primary Syphilis. — After a period of incubation, which varies 
from ten days to several weeks, the presence of the virus of syphilis in 
the circulation is annouufed by the development at the point of infec- 
tion of the characteristic initial lesion of the disease. This lesion, 
which is ordinarily known as "a chancre," is genendly situated upon 
rhe genital organs, but may appear upon any portion of the body which 
has been exposed to contagion. It sometimes forms at the meatus 
irinarius, or even within the urethral canal in the region of the fossa 
lavicularis. In these situations, and especially the latter, it may lead a 
careless or inexperienced observer to a mistaken diagnosis of gonor- 
rhoea. The discharge, however, is more scanty than that of gonorrhroa, 




I 



212 



DISEASES OF THE SKIN, 



the pain more localized, and an induruted spot is suggestive of chancre. 
The lesion rarely ooeiirs in the deeper urethra, but Fitzgibbon has re- 
ported Ji ciise, under the title of " svphilitic goiiorrliceii,^* in which an 
induration about hiilf an inch in diameter could be felt at and Just an- 
terior to the membranons urethra. Urination wim impeded, a thin 
semi-purulent discharge existed, and the inguinal glands were en- 
larged. A papuhir svphiloderm subserjuontly made its appearance. 

Accidents, careless or uncleanly habits, or unnatural connection, 
may lead to the development of a chancre in many unusual situations, 
upon the lip, tongue, tonsil, nipple, eyelid, nose, chin, anus, extremi- 
ties, etc. During the ten years from 1878 to 1887 inclusive, Prof. A. 
Posjielow, of Moscow, saw 198 cases of extra-genital chancres among 
patients belonging to the ^vorking classes. Of this number the lesion 
occurred upon the lip in 49 cases (in 20 men and 39 women) ; upon 
the gums in 1 (a man) ; the tongue in 3 (1 man, 2 women) ; the thnuit 
in 4l> (14 men, IVZ women); the breast, 09 (all women); the chin in 1 
(a woman) ; the eyelids in 3 (men) ; the nose in 1 (man) ; the trunk in 
10 {5 men, 5 women); the upper extremities in (3 men, 3 WM>men); 
tlie lower extremities— thigh, nates, 4 (women) * Statistics upon the 
same subject have been collected' by Nivct, Morol^ Lavallee, Veslin, and 
Foulard, from the service of Prof. Fournier. 

Chancre of the tonsil is, in fact, of more frequent occurrence than 
is genendly supposed. This circumstance should be borne in mind, and 
lead us, in castts where an eruption is of doubtful origin and the initial 
lesion can not he elsewhere found, to carefully ins|>ect the mouth. 
Chancre of the tonsil is limited to one side, and is accompanied with 
difliculty in swallowing and enlargement of the glands in front of the 
ear and below the jaw. The conjunctiva is the seat of the initial 
lesion in occasional instances. The sclerosis is usually situated upon the 
free margin of the lid, but has been seen ujion more remote portions of 
the palpebral membrane, ancl in six cases upon the ocular conjunctiva, 
A chancre usually consists at first of a small rourul or oval abrasion of 
the skin or mucous membrane, which varies in size from a pin's head 
to a three-cent piece. It is ahnost invariably single. Its base is 
slightly depressed, dark red in color, and indurated, especially in men. 
The induration is sometimes less in women, f and in some cases en- 
tirely absent. This primary lesion is not surrounded hy an aureoJa, and 
rarely suppurates unless irritated. Its secretion, which is thin, serous, 
and scanty, is highly contagious, but not auto-inoculable. If ulceration 
occurs, the secretion becomes sero-purulent in character, and the base of 
the ulcer is covered with a layer of gray or dirty-white aphistic lymph. 
At times deep and extensive ulceration occurs, especially when the 

* Metlical Bulletin, January, 1890, p. 17. 

f W. E. Cant, F. R, C. S,, in a report on cUnicttl obaservatbns on " Induration, In the 
Primary Lesions of Syphilis in Women." British Medical Jauraal, Febrimry 12, 1887. 



EXUDATIONS. 



213 



» 



general condition of the patient is bad. Perforation of tho urethra, 
with establishment of a iirinsiry fistula, hm been known to occur. 
Chancres situated in the groove behind tlie glnns are particuhirly apt 
to ulcerate deeply, and those located in the pubic region often take on 
nn ectUyniatons appearance. 

In the Ilnnteriau variety of chancre the ulcer is deep and fnnnel- 
ghapod, its edges are sloping and indurated, its base is hard and cov- 
ered with lymph, and the lesion in its entirety feels to the touch like 
a split pea set into the skin. Another variety of chancre is that which 
appears as an elevated indurated papule, which mayor may not become 
excoriated or nlceratetl. 

The initial lesion occasionally varies considerably in appearance 
from the preceding deficrijJtiori. Dubuc has described a manifestation 
which he terms ** herpetiform multiple syphilitic chancre," in which 
from five to fourteen small, round excoriations occur on the prepuce 
and glans» Induration is but slightly marked, Braquehaye haa re- 
ported, from the Bordeaux Polyclinic the case of a woman, aged twenty- 
four yeara, in whom three chancres developed upon ditferent parts of 
I the face.* However atypical the form, in fact, the presence of iodu ra- 
tion is the most constjtnt and characteristic feature of the chancre. 
Nevertheless, there are exceptions even to this diagnostic sign. In 
women it is often extremely difficult to demonstrate any hardness of 
tttae. Even in men, cases are sometimes met with in which no hurd- 
11688 can be detected by the moat careful examination. On the other 
hand., a case may be occasionally seen, as has been described by^aposi 
»Dd Dr, Edwin C. Burnett, of 8t. Louis,f in which sores with every 
mark of the lluutertan chancre, including the hardened base, are not 
followed by any secondary outbreak. Dr. Burnett offers the suggestion 
that in gnch cases the virus of the disejise may be renilered inert in the 
first stage through some influence which we do not understand. Finally, 
the fact should never bo forgotten that chancroids or non-venereal le- 
sions may acquire an inflammatory hardness from cauterizing agents 
which patients havo often used before seeking the surgeon. In some 
instances hardness due to inflammatory exudation very closely simu- 
lateg the induration caused by cell proliferation. 

Ulceration, though usual, is not invariable, and the chancre occa- 
Bionally appears in the form first described by Lanceraux as papule 
^fche, or dry papule, the induration feeling like a pea buried beneath 
e akin, the epithelium remaining absolutely intact. Very often it 
appears as what Bassereau has called the superficial erosion, the sore 
bein^ small, oval or circular in outline, with a reddish floor, scanty 
f" ' L and resting upon a thin, hardened base known as parchment- 
i! '>n. Mauriac has called attention to a rare form of the initial 

* Medical Bulletin, November, 1889, p. SM, 

f JotinuU of CutAocous and Genito-Urlnar; Dlfeasea, SepteiTibcr, 1889, p. S25. 



^tT^^^^^^^ DISEASES OF THE SKIN. ^^^^^^^^ 

lesion ivliich he liaa ealletl " iufectiiig bulano-postliitis," wliich miglit 
eiisily be niisUikeii for simple biikno-posthitis. Tho mucous mem- 
brane of the prepuce is of a deep red color and tliickened, and is usuaDy 
slightly cro^lcd. The glans may also be guperficially thickened, and is 
generally e rot led. 

Chancre, as a rnle» is not accomijanicd by pain or any other sub- 
jective symptoms, and usually disappears in u few weeks without either 
eiciitrizalion or pigmentation. In some cases the lesion becomes aU 
tacked by phageda?nic ulceration or by gaugrene, but these complica* 
tious are estrwrnely rare. 

When a chancre is of large size and accompanied by a great deal of 
oedema and nleenition it is ajit to be followed by unusually severe con- 
stitutional symptoms. 

Syphilitic bubo, or enlargement of the adjacent lymphatic glands, 
is a constant accompaniment of chancre, and usually occurs contem- 
poraneously witli the developnu^nt of that lesion. It may exhibit it- 
self upon any portion of the body where lymphatic glands exist, but 
is usually observed in the inguinal regions. It involves a group or 
cluster of glands^ which become indurated and swollen, and rarely sup- 
purate. They vary in size from a small marble to a walmtt. They are 
freely movable under the skin, and are not painful to the touch. They 
reach their maximum development in from two to four weeks, and 
after remaining statiotiary for several months gradually return to their 
normal size and condition. Suppuration is not usual, but may occur, 
probably from adventitious causes, 

Diagnosis.^Thc diagnosis of primary syphilis is not usually at- 
tended with much ditticulty. The principal affections with which it is 
liable to be confounded are cliancroid, herpes, and simple erosions of 
the cutaneous or mucous surfaces. Chancroid, however, usually begins 
as an angry-looking ulcer, which has no period of incubation, and is 
rapid in progress and attended by a high degree of inflamnnition* Its 
e<lges are abrupt and n on- indurated, and it^ secretion is copious, puru- 
lent, and auto-inoculable. It is usually multiple^ and more or less 
painful. Finally, its accom|^uying bubo is extremely painful and 
liighly iiifiammatory in character, tending to suppuration, and, with 
rare exceptions, is limited to a single gland. Chancre has a well-marked 
period of incubation, aiid usually begins as an apparently insignificant 
erosion, which is slow in progress and attended by a low degree of in- 
flammation, lis edges are sloping and inil united, and ita secretion is 
thin, scanty, and not auto-inoculable. As a rule, it is single and pain- 
less, and finally its accompanying bubo is composed of a number of 
glands w^ich become hard and swollen, but are not painful and rarely 
suppurate. In herpes there is generally a history of previous similar 
eruptions, and the lesions disappear in a few tlays without producing 
any glandular iiivolvcment. Accidental simple abrasions frequently 



flHA 



EXUDATIONS. 



^^^^^^^■ktiiigiiished in appearance from the erosive form of chan- 
^^^^^K^^nvLj be observed imraediately after intercourse, however, 
and hetil kindly iu two or three days under the protective covering of 
a layer of bismuth subniLrate, zinu oxide, or some similar non-irritating 
application. II the intercourse liaa been of a suspicious nature, how- 
eTer, it must be remembered that there is a possibility of inoculation 

• having occurred at the jmint of ercjsiun, and consequently a decided 
opinion should not be given until sufficient time has elapsed without 
the appeiirance of any other symptoms. 

Later Syphilis. — In secondary syijliilis the cutaneous and mucous 
[membranes are principally affected, but iritiy, orchitis, and other com- 
plieaiiona may develop. In tertiary Hvphilis the deeper tissues of the 
ibodj are involved, but lesions of t!ie skiti and mucous membranes may 
be present In quaternary syphilis the cerebro- spinal system and 
ilhe internal organs are the subject of the disease. The line l)etween 
these varieties is not always well marked, however. 8ome of the enijv 
itive symptoms belonging to the secondary group may be delayed until 
the terfiary stage, while occasionally grave nervous symptoms a])j>ear 
early in the course of the disease. 

The development of the symptoms of secondary syphilis is usually 
^ preceded by marked constitutional derfiugemcnt The appetite is im- 
mk paired, the bowels are constipated, the uriue is scanty and high-colored 
" and there is a sensation of general jnfilnisf. The patient is irritable 
and despondent, as if from a foreknowledge of imperuHng illness. 
There is pain in the hones and around the Joints, especially at night, 
and glandular swellings occur in various portions of the body. Muscular 
pains may also be present. Headache and vertigo are not uncommon. 
Insomnia not due to pain may occur, aud in rare itistanees, especially 
aoiODg women, considerable mental disturbance may attend the out- 
break of the secondary period. More or less fevcrishness may be pres- 
ent* In some cases the fever is periodical in character, and erroneously 
Assumed to be of mahirial origin. Iu others it may assume a continued 
B type, may last for several weeks, during which the temperature may 
at timed reach 104** F., and in rare instances may closely simulate 
tj.'pboid fever. The absence of epistaxis, tympanitis, gurgling in the 
iliac fossa, should, however, be sutticient to establish the diagnosis. In- 
stead of the scanty eruption that belongs to typhoid fever, the sym- 
metrical roseolar or papular rash of secondary syphilis makes its ap- 
nee. As a rule, the spleen is not emlarged in syphilitic fever, 
onged syphilitic fever leads to emaciation, anaemia, and serioua 
lebility. 

During the febrile stage a decided loss of red blood-corpuscles oc- 

varyiug from eleven to sixty-five per cent. At the same time the 

! blood -corpuscles are increased. This alteration in the composi- 

ftion of the blood leads in some instances to shortness of breath, palpi- 



I 



21G 



DISEASES OF THE SKIN. 



tation of the heart and basal murmurs, oxlonia, auJ epistaxis, Vajda 
determined tliat with the fiiv«* aiul lit^volopment of the eruption an 
increased excretion of urc4i, creatinine^ phosphates, and sulphates takes 
place More recently the blood of syphilitic patients has been made 
the subject of study by Dr. J, V, Iljelinman, of Ilelsingfors, in the 
clinic of Prof 8mimoff. His conclusions are that a nnmifest ansemia 
is produced and is at its height during the period of eruption. As the 
general symptoms subside the blood tends to regain its normal com- 
position. In these researches the proportion of red corpuscles and 
h^matine were accurately determined. Syphilitic fever occurs most 
frequently in those of delicate nervous organization, and especially in 
anaemic women, 

l>r, Oscar V. Petersen, of St. Petersburg, has lately published the 
results of some valuable researches concerning the occurrence of albu- 
minuria in syphilis. According to these, albumen appears in the urine 
in 3*8 percent, of patients with recent syphilis, in 38 per cent, of those 
having secondary symptoms, and 5-8 per cent, of those with late mani- 
festations. Of eighty-eight autopsies of syphilitic bodies, in thirty-four 
he found renal lesions present. 

After these preraonitorj sym])tom3 have existed in varying inten- 
sity for several days, any doubt that may have been entertained as to 
their nature is dispelled by the appearance of one or more of the char- 
acteristic syphilitic eruiitions, or syphilides. Secondary syphilis usu- 
ally manifests itself about six weeks after the appearance of the chan- 
cre, though exeeptioiudly the period may be prolonged to eight or ten 
weeks. During the course of secondary syphilid a diminution or loss 
of the different forms of sensibility in certain regions has occasionally 
been obserTed. 

All the syphilides possess certain general features which are pecul- 
iar to them as a class, and serve to distinguish them from the ordinary 
non- venereal cutaneous eruptions. The most important of these char- 
acteristics are the color and course of the eruption, the polymorphism 
of the lesions, the character of the ulceration, the color of the crusts 
and scales, and the absence or in significance of the subjective symp- 
toms. 

Color. — Their color varies with the size and situation of the le- 
sions. The small macules and pnpules are usually bright red at tirst* 
but gradually acquire a dark-red or coppery hue. The large papules 
and tubercles present the characteristic raw^-ham or copper-colored apv- 
pearance from the beginning. As the lesions disappear this hue fades 
and changes into brown, yellow, or dark-gray. In some cases the 
normal pigment of the skin is destroyed or absorbeil, and large white 
patches, resembling those of vitiligo, are formed- All the sy]>hilidea 
develop slowly, pursue a tedious course, and manifest a marked tend- 
ency to recur. 



^^^ EXUDATIOXa ^^^^^^« "^^ 

1. — Polyraorphism, or the tendency of seroral forms 
of lesions to appear at the same time, is especklly clmracteriatic of the 
earlier sypbilides, but it is also a feature of the later eruptions. A 
macular eruption is occasionally complicated by the development of 
papules. Papules, vesicles, and veaico-puBtulea may frequently be ob- 
eerred to be commingled, while in other casea tubercles, pustules, and 
ulcers are often present at the same time. 

Satles.—The scales are usually few in number, and white or trans- 
parent in color. They are thiti, friable, and easily detached. They 
are developed over the centre of the lesion, and rarely extend to the 
periphery, 

Cru.%ts. — The crusts or scabs are brown, dark-green, or black in 
color, and are firmly adherent at the ]>eriphery to the subjacent tissues. 
They are thickest in the centre, and frequently present a conical, 
vaulted, or laminated appearance. 

Ulcerations, — The ulcerations of lat« syphilis are apparently cause- 
kfis in origin, and usually painless in character and protracted in 
dturatiou. 

Subjective Symptoms, — The gypliilides, as a rule, are not accom- 
panied by any subjective symptoms. In some cases there is an itching 
sensation, but examination may ^bow that it is not due to the develop- 
ment of the syphilide, but to pressure of the clothing or some other 
external irritation. In exceptional instances decided itrhing may occur. 
The lesions are seldom painful. 

The sypbilides may ajqicar upon any portion of the cutaneous sur- 
face, but certain forms manifest a predilection for different regions of 
the body. The macular variety usually develops first upon the abdo- 
men and thorax, and tben extends to the back and extremities, but it 
rarely appears upon the face. The papular eruptions sometimes in- 
volve the forehead and cheeks, bnt are generally limited to the body. 
The pustular sypbilides attack the entire surface, but are most marked 
on the scalp, the face, and the extremities. The st|uamous variety is 
most frequently observed on the elbows and knees, and the palmar and 
plantar surfaces. 

The sypbilides may be divided into two principal groups — those 
which occur in the secondary^ and those which occur in the tertiary 
stage. The first group comprises the macular, the pigmentary, the 
papular, the papulo-squamous, the vesicular, and the small pustular 
varieties ; the second consists of the large pustular, the tubercular, the 
bullous, and the gummatous. 

The lesions of the secondary group arc superficial, generalized, 
numerous, and symmetrical ; those of the tertiary are deeper- seated, 
localized, few in number, and asymmetrical. 

Rebellions sypbilides have occasionally been known to disappear 
imder the influence of an attack of erysipelas or variola. 



L 



■i 



DISEASES OF THE SKIX. 



Macular Syphilide. 

Stkostiis.— Roseola ByphlliticA— Erythematous syphilide — Hacalar 8yphiIodeniL# 

Tbia eruption is usually the first symptom of secondary sypbilis, 
and is geuerjilly Uevelopeti about eix weeks tdter ilie appearance of the 
initial lesion. It may appear at the end of the fourth week, however, 
or may be delayed for two or three montlis. It consists of a nuoiber 
of small round or oval spots, which are indistinct in appearance at 
tirst, but soon become bright- red in color, and then gradually change 
to dark-red or brown. They are generally on a level with the sur« 
rounding surface, but occasionally they are slightly elevated or semi- 
pupular in character. They usually appear first npuii the abdomen, 
and then extend over the thorax and the extremities, but tliey rarely 
involve the face or the hands. The eruption attains its maximum 
development in three or four days, and then remains nncbanged for sev- 
eral weeks or months, after whicli it slowly changes in color to dark- 
yellow or yellowish-brown, and then fiuwlly disappears witiiout pigmen- 
tation or de8f[uamation. The epot^ often pass unnoticed by the pa- 
tient, but probably occur in all eases. 

The macular syphilide sometimes recurs, not, however^ as a rule, 
soon after its subsidence, but after tlie lapse of several months. The 
relapsed eruption is apt to be limited to certain parts of the body. 
It is not attended by any subjective cutaneous symptoms, but is fre- 
quently preceded and accompanied by marked sore-tliroat and severe 
osteocopic pains. Alopecia is also of frequent occurrence. Ilelapse^ 
are common. 

The earliest form of sore-throat is that known as erythema, injec- 
tion with or without swelling of the roof of the month, soft palate, or 
fauces. Sou^ewhat later, in the same situations and upon the tonsils 
or in the pharynx, the mncous membrane may be seen studded with 
opaline patches. These present a milky appearance, and resemble 
Bpots to which a solution of nitratt^ of silver or carbolic acid lias been 
applied* Synovitis sometimes coincides with the development of rose- 
ola, Occasionally a dry pleurisy is met with at this stage. 

Dia^osis. — The diagnosis of the macular syphilide is compara- 
tively easy. The only eruptions resembling it are tliose of rotheln, 
roseola, tinea versicolor, and those due to the administration of cer- 
tain medicinal substances. The eruption of rotheln, however, con- 
sists of irregular blotches, and is accompanied by more or less catarrhal 
gymptoms, and rarely occurs after childhood. The spots of roseola 
are irregular in size and ephemeral in character, and are caused by 
some gastro-intestinal disturbance. The patches of tinea versicolor are 
yellowish or brown in color, furfuraceous in a]>pearance, irregular in 
outline, and increase in size by peripheral extension. Medicinal erup- 
tions are sudden in development and are accompanied by more or less 



EXUDATIONS. 



2ia 



^^ and 
Hvid 



itching, and nsually disappDiir as soon as the exciting cause is bus- 
jM?nded or removed. 

Pigmentary SvpniLiDE.— This rare affection is characterised by 
the development of round, oval, or irregular patches of iHginentiition 
in the skin. Sometimes there seems to ho rather a disarrangement 
than an actual excess of pigmentation. Spots of variable sizo and 
shape develop, exhibiting a bhmclied centre surrounded by a dark 
margin. This form is most frequent upon the sides of the neck. 
They vary in color from dark-gniy to jeHo wish-brown, and in size 
from that of a pea to an inch or more in extent. They have even been 
seen as large as the palm. Neighboring spots may coalesce a^ they en- 
large. They are smooth to the touchy and are not ck^vated above the 
surrounding normal skin. The coloration is in some cases so faint 
that they are with difRoulty perceived unless viewed in a strong light 
and in an oblique direction. They arc most frequently met with upon 
face and neck, but they also occur upon the thorax, the abdomen, 
d the extremities. They arc not accompanied by any subjective 
mptoms. They appear more abundantly on womeu than on men, 
and do not appear to differ in any essential respect from the lesions of 
chloasma. They run a protracted course, remaining for sevend months 
or years, and are not ameuable to anti -syphilitic treatment. These 
patches may eventually disapj^ear, leaving no trace behind them, or the 
pigment may be entirely absorbed and a spot resembling vitiligo re- 
main. They are usually met with during the first year of the syphilitic 
inanifestations, and are probably produced by the disturbing elTect of 
the syphilitic poison upon the terminal iilaments of the cutaneous 
Benres. ' 

Audry has had the opportunity of examining sections taken from a 
of genemlized pigmetary syphilide. Tlie pigmented spots were 

ormed by a pigmentary intiltmtion composed of small, yellowish 

locks, themselves formed by finely aggregated granulations. They 
are also found here and there in the papilla?, and were seen in the su- 
perficial layers of the derma. But their chief deposition is in the gen- 
erative layer and the adjacent stratum nmcosum. The arterioles and 
capillaries were intact, and no evidence of recent or remote haemor- 
rhage was detected. Audry believes that the pigment is brought 

rora the derma by the pigmentiferous corpuscles, lie found no 

igiis of chronic inflammation.* 



Papulae Syphilide. 

The papular eruptions of syi>hilia consist of two principal groups 
H» elasaee — the small acuminated, or miliary papules, and the large, 
flat^ or lenticular papules. The papulo-squamous syphilide and the 

• Joomal of CutaaeoiiB tad Genito-Uriiiary Diseases, Julj, 1690^ p. 281. 



IME t/BRARy. STAHFORG mWIK 



220 



OF THE SKIN, 



broad condylomata or mucous patches may be regarded as modifica- 
tions of tho lenticoliir variety. 

Small Papular Syphilibe {Sf/nofii/ms : Miliary papular sypbi- 
lide; lichpn Byphiliticu8),^Thi8 eruption consists of a number of 
minute, round, acuuiiniited papules, wbicb vary in size from a mustard- 
seed to a sniiill shot- Tbey are bright-red in color at first, but become 
dark- red or reddish-brown in a few days. They arc firm to the touch, 
and are slightly elevated above the surrounding integument and eov- 
ered with minute scales. Some, espeeiully those which are formed 
around tlic hair- follicles, may become transformed into vesicles, and 
then into pustuh^s, but the majority reniaiu papidur, and finally disap- 
pear by resolution or by fatty degeneration and absorption. This erup- 
tion is one of the earliest manifestations of secondary syphilis, gencnilly 
appearing within three months after the development of the primary 
lesion. It is symmetrical in character, and diffused more or less over 
the entire surface. The papules manifest a tendency to develop in 
groups or clusters of a dozen or more. This grouping ia especially well 
marked upon the face, shoulders, and arms. The eruption is chronic 
in character, and liable to recur, but is not accompanied by pain or 
itching. In severe cases it is followed by the forniation of minute per- 
manent cicatrices, indicative of atrophy of the eorium. Slight pig- 
mentation may also remain. 

Diagnosis, — The small papular syphilirle might be mistaken for 
papular eczema, lichen ruber, or lichun scrofulosua. The lesions of 
papular eczema, however, are usually localized, and accompanied by 
marked itching and burning sensations. They soon become vesicular 
in character, but do not develop in clusters. Tlie miliary papules of 
syphilis, on the contrary, are generalized, and are not usually accom- 
panied by any subjective symptoms. They only occasionally become 
vesicular, and almost always develop in clusters. Very often there is 
a history of an antecedent specific lesion. In lichen ruber the erup- 
tion is accompanied by severe itching and burning, but it never appears 
upon the face, and pursues a different course. In lichen scrofulosuB 
tlie papules are situated upon the trunk, and are accompanied bj other 
evidences of the scrofulous diathesis. 

LAttdK, Flat pAin'LAR ^wkilid-e {St/nonf/m * Lenticular syphi- 
Hde).^ — This eruption appears later, as a rule* than the miliary syjihi- 
lide, and is significant of a more obstinate form of the disease. It con- 
sists of a number of large, fiat papules, which vary in shv from a small 
shot to a hcan. They are round or oval in shape, firm and smooth to 
the touch, and are elevated above the surrounding surface. They are 
light- red in color at first, but soon assume the characteristic raw- ham 
or copper color. They are devoid of scales, and present a dull, glaze<l 
appearance. Tbey are usually developed in large numbers, but not as 
abundantly as the miliary lesions. They run a protracted course, and 



EXUDATIONS. 



221 



r 



frequently recur. They may appear upon any portion of the body, 
bat are especially observed upon the neck, back, shoulders, and the ex- 
tremities, and around the genital organs. They are also found upon 
the scalp, and f»n the foreliead, wliere tliey form the chiiractoristie 
** corona veneris.'* They slowjy increase m size by peripheral growtli 
daring the first few weeks of their existence. They then remain sta- 
tionary for several months, usually difiappearing by disintegriition and 
nbsorption, leaving more or lesa piguieutatiou and atrophy to murk 
eir location. 
Occasionally^ while the centre undergoes retrogrci^sion, the periph- 
has invaded the surrounding iutegument, blending iierhaps with 
her lesions of the same kind, forming auuular, oval, or tircinate tig- 
res. Usually the border exhibits a fine scaling. In favorable situ* 
tions tlie lesion may be converted into a mucous patch. This mani- 
tation of the dise^ise is much more eommon in negroes tlian in 
hitcii, AS has been pointed out by Dr. Atkinson, of Baltimore, and Dr. 
ardaway^ of St. Louis. In some cases excoriation and ulceration take 
ace ; in other cases they become converted into papules. In depressed 
nditions of the system or when the disease is unusually violent the 
large, flat papules may, after gnperdeial neerupis has occurred, become 
covered with a thin diphtheroidal membrane of a dirty-gray color. 

In exceptional cases the large papule occurs as the first cutaneous 
manifestation of the disease. In others a few large puj>ulea may be 
present at the same time with a macular syphilide. Usnally, however, 
this form of emption is developed in the later periods of the secondary 
stage and may be encountered as late as the second or even the third 
year after the original infection. It is generally more abundant the 
earlier it appears. Thin, yellow, and easily detached scales sometimes 
form upon the surface of the lesions when they are situated upon parts 
which abound in sebaceous glands. In rare cases the papules, growing 
Qnasnally large, project above the surface so as to bear some resem- 
blance to a cauliflower or raspberry. The rounded prominences arc 
smooth, red, of different size, and between them slight ulceration gives 
rise to some pus. This pus may become dry aud form a crust. IV hen 
abundant it gives rise to a very offensive odor. This unusual transfor- 
mation has been most often seen upon scalp, face, shoulders, and geni- 
talia. It has been termed the frambtesoid, vegetating, or verrucous 
syphilide. A very similar appearance is sometiuiea jiresented by the 
uloenited tubercular syphiloderm; and De Amicis, of Xaples, has seen 
macules of the forehead become converted into a berry-shaped mass. 
The most common forms of transformation which they undergo, 
wever, are into moist and squamous pustules. 

Moist Papules {StfHonf/ms : Mucous papules; mucous patches; 
condylomata). — Moist papules, or mucous patches occur only in syph- 
iUai. They consist of large, flat papules, which have been modilied 



m 



222 



DISEASES OF THE SKIN. 



by the combined influence of heat and moisture. They are seen on 
the tongue, !ips, anus, vulva, and other mucous surfaces. They are als^o 
found oil tlie perina?am and the serotum, in the axilloe, beneath the 
mammoe, between the tocsi, in the groins, around the umbilicus, and on 
any other portion of the body where apposing surfaces come in contact 
witli each other. They vary considerably in size. Some of the hirge 
condylomata frequently niciisure one or two inches iu diameter. They 
are usually slightly elevated above the adjoining surface, but may ite 
depressed beneath it. They are soft and smooth to the touch, and 
vary in color from dark-red to gray. Their surface is usually moist, 
and covered with epithelial debris. Adjacent lesions frequently coa- 
lesce, forming large patches. Excoriation and ulceration may also 
occur, or hypertrophic granulation take place, resulting in the forma- 
tion of large warty or vegetative excreaceucep. 

Mucous patches of the tongue and lips are irregular in shape, and 
usually deeply fissured, and more or less painful, but they rarely ulcer- 
ate, or become the scat of vegetative growths. 

PAPrLo-SQUAMora SvpniuDE, — This eniption usually appears 
late in the course of the disease. It is symmetrical in character, and 
may involve any portion of the integument, but its favorite seat^ are 
the palmar and plantar surfaces. It consists of a few large, round, 
oval, or oblong* flat psqjules, which are slightly elevated above the 
snrrounrling surface, and are covered by a lliick, dry, white or grayish 
non-imbricated scale. These papules increase in size by peripheral 
growth, and frequently coalesce, forming large irregular patches. The 
scales are only slightly adherent, and can easily bo detached, exj>os- 
ing the dark-red surface of tlie papules beneath. When the scales 
are removed they are slowly replaced. Tiiis form of sypbilide ia 
chronic in character, and may remain for years. It finally disappears 
by cessation of the scaling process, and absorption of the iidiltmtton. 

In severe cases, attecting the palmar and plantar surfaces, the so- 
called syjihilitic psoriasis, the patches attain a large size, and are 
deeply fissured and painful. The nails occasionally become involved. 

Diagnosis,— The diagnosis of the large ])apular syjdiilide is usu- 
ally easy. The only affections resembling it are lichen planus, acne, 
and psoriasis. The papules of lichen planus, however, are anga- 
lar in outline, depressed in the centre, and are limited to the fore- 
arms and legs, never appearing upon the face or neck. They are 
also covered by a large, waxy, transparent scnle. The lesions of the 
syphilitic eruption are round or oval in outline, not umbilicated or 
depressed in the centre, not covered with a waxy scale, and they are 
diffused over several regions of the surface. The papules of acne are 
acuminated in form, bright- red in color, and are confined to certain 
regions of the body, as the face and neck. They are also mostly brief 
in duration, frequently becoming pustular, and disappearing by ab- 



EXUDATIONS. 



223 



sorption. The eruption of psoriasis may at first resemble the lesioug 
of the papular 6y]>hilide, but the development of the characteristic 
mother-of-pearl scales of the former disease will effectually settle the 
question of diagnosis. 

Lesions resembling moist papules or mucous patches are sim- 
ple acuminated or non-syphilitic papillary new formations. They 
are due to local irritation of the cutaneous or mucous surfaces by 
acrid discharges, and spring from apparently normal tisifues. The 
syphilitic lesions, on the other hand, are surroauded by more or less 
infiltration* 

The papulo-squamous syphilide might be mistaken for one of the 
forms of psoriasis, or for squamous eczema. The lesions of psoriasis, 
however, are numerous and diffused, while those of the syphilide are 
few and localized. Psoriasis rarely affects the palmar or plantar sur- 
faces, and never appears there without involving some other portion 
of the integument at the same time. Superficial desquamation is pro- 
fuse in psoriasis, and scanty in syphilis. When the scales are removed 
in psoriiisis, a bleeding or bright-red surface is exposed ; when they 
are detached in syphtlis, a dark-red pa]>ale is discovered. The lesions 
of psoriasis develop rajtidly, nml are accompanied by more or less itch- 
ing ; those of syphilis develop slowly, and are not attended, as a rule, 
by any subjective symptoms. Finally, the lesious of ]isoriasis are uni- 
form in character, manifest a predilection for the extensor i^urfaces, 
and are covered by the characteristic waxy or mothe]*-of-pearl scales ; 
while those of syphilis are poly^morphona, and are found on the flexor 
rather than on the extensor surface, and are covered by a grayish or 
dirty- white scale. 

The patches of squamous eczema arc irregular in Bhape* and are 
accompanied by itching and burning. They pass imperceptibly into 
the surrounding healthy skin, and are not surrounded by iuOltration. 



Vesicular Syphilide. 

This is a rare manifestation of secondary syphilis. It usually ap- 
pears within six mouths after the development of the primary lesion, 
bat in some instances nut for a year or more. The vesicles vary con- 
giderably in size, shape, and distribntion* In some cases they are 
gmall and clustered together, as in eczema ; in others, they are large 
and ij^latcd, as in varicelhi. In the former they are minute in size, 
conical in shape, and arninged in groui)s or patches, and are generally 
observed on the trnuks and extremities, rarely or never appearing on 
the face. They are seated upon a dark-red base, and are usually situ- 
ated around the hair-follicles. Tliey terminate either by absorption, 
or by transformation into pustules which break and discharge, leaving 
a small nicer, which heals without the formation of a scar. They aie 
not accompanied by any subjective symptoms. 



is OF TDB SKIN. 



The large, varicella-ljke vet:iclcs are develojied upon a reddened, 
ioliltrated base, and frequently attain the !?izo of a large beau. They 
arc few in number, and are BL-attered over the face, trunk, and ex- 
tremities. They contain at flr^t a clear, serous fluid, which becomes 
purulent in a few days. They finally either dry up. or rupture spon- 
taneously and discharge their contents. A gi'eenish-brown crust is 
then formed, which is ca^st off in a forttiiglit. leaving a slight pur- 
plish discoloration, which gmdually dii^appears. Again, Buccesslve 
crops of vchsiclea may appear and protract the eruption for months. 
Itching and burning are absent during the wliolo course of the 
disease. 

Diagnosis, — The email veaicnlar syphilide resembles eczema in 
many particulars, but the distinction can always be made by remem- 
bering that the vesicles of eczema are of brief duration, accompanied 
by intense itching and burning sensations, and are not sitnuted upon 
a reddened, intiltrated base. The lesions of tlie large yesicuhir i^yphi- 
lido might be mistaken for varicella or varioloid, but a consideration 
of the dark-red, infiltrated base, the history of the case, and the course 
of the eruption, will lead to a correct conclusion. 

PusTULAE Syphilide. 

Pustular manifestations of syphilis, as a rule, are indicative either 
of a more severe form of the disease or of a depraved or impoverished 
condition of the patient's tissuej?. The individual pustules diller in size 
and shape, as they also do in number. They are usually surrounded by 
a reddish aureola, and are situated around the hair-follieles and seba- 
ceous glands. Sometimes they are diffused over all portions of tlie 
surface, but are most frequently met with upon the trunk and the ex- 
tremities. They generally begin as papules or vesicles, which are 
rapidly transferred into pustules ; indeed, so quickly, in some, that 
the papular or vesicular stage nf the eruption escapes observation ; in 
others, the pustules are slowly developed upon lesions which have been 
in existence for weeks or months. 

The pustular eruptions of syphilis are sometimes termed *'pu8tulo- 
crustaceous eruptions," from their tendency to terminate in crusts. 
This tendency is especially manifested by the larger pustules. The 
crusts generally correspond in size and sha|>e with their pre-existing 
lesions. They may be soft and friable, but are usually firm and hard ; 
and in color range from yellow or brown to dark-green and black, 
Each crust is situated over an ulcer, which may be superficial or deep, 
in accordance with the character of the primary pustule. The ulcer 
presents a clean-cut or ]ninciied-out appearance. It^s edges are sharply 
defined, and surrounded by a slight area of infiltration. Its base is 
uueven, and covered with a profuse gray, yellow, or greenis!j purulent 
secretion, liepair is protractedj but finally takes place by granulation, 



J 



1:XITDATI0KS. 



225 






ling in the formation of a perhaps permanent cicatrix. More or 
s pigmentation also results. 

The pustular gyphilides may be conveniently regarded as consisting 
if four principal groups : the small aeuminatud, the large acuminated, 
le small flat» and the large flat vai-ieties. 
Small Acuminated Pustular SYruiLtDE (Si/tfom/m: Miliary 
istulur Sypbilide). — This variety of tlie pustular syphilitic eruptions 
is the first of the manifestations of secondary gyijhilis. It, with a 
few exceptions, appears in from six weeks to three months after the 
ievelopment of the luitial letiioo, and is usually accompanied by syphi- 
litic fever, erythema and soreness of the fauces, and more or leas fall- 
of the hair. It may not appear, however, until later in tlie prog- 
of the disease. It consists of a numlier of minute pustules, which 
develoijed around theoritiees of the hair-follicles, and are generally 
metrated by a hair. They are rarely larger in size than a grain of 
-ley. They are situatf^d upon a miuute, reddish, elevated or papular 
They are spherical or acuminated in form, and contain a drop 
«ero-purulent matter, which soon becomes converted into a yellow, 
friable crust This cmst drops off in a few days, leaving a slight de- 
pression in the epidermis, which is likely to become the seat of sub- 
i sequent pigmentation or desquamation. 

^m The pustules sometimes are isolat^-d^ but they are nsnally arranged 

^■ici irregular groups, and widely diffused, occasionally covering the 

^Pentire surface. The thorax and back and the extremities are most 

frequently involved, however. The eriqition is often complicated by 

the presence of papules, vesicles, and papulo-pustules. 

Labge Acuminated Pustulau Syphilidb {S7/no?ijfnni: Acne 
<vphilitica ; Variola*form Syphiloderm).— This variety of the M'phi- 
hdes is seen early, hut not us eoon m the miliary form. It uj^uully 
^■npjiears from the fourth to the sixth mouth after infection, but may 
^^be delayed for a year. It consist? of a number of pustules, which 
are round and acuminated \n form, and vary in size from a split 
pea to a small bean. They are situated around the hair-follicles, and 
are developed upon a dark-red or copper-colored base. They are ele- 
vated above the surface^ and surrouudod by a coppery aureola. Tliey 
I develop first as small red spots, whieh rapidly become papular and 
|faen pustular. They contain a }elIow, purulent fluid, which sooner 
Iprlfttcr becomes dried up and converted into a thick, yellowish or 
brownish crust, beneath which a superficial ulcer exists. The crust 
finally drops off, and tlie ulcer heuls by granulation followed by a 
mi D ate cicatrix. The pustules may be disseminated, but are usually 
mped. They are few iu number, and limited to the face and 
liouJderB, They may, however, extend to the :^ealp and trunk, and 
cases involve the entire surface. They develop either rap- 
'elowly. They are not often attended by pain or itching, or 
15 




22(5 



DISEASES OP THE 



any other subjective symptoms. The individual pustules generally 
dii^appear spoil taueously within two or three weeks after their first 
ajipcaraiice, bnt new le^^ions appear from time to time for sevem) 
montlis. 

Small B'lat Pl'STULar 8yphilide {iSi/nont/m: Impetigo jsyphi- 
litiea). — There are two vaneUes of this form of eruption — the super- 
ficial or disseminated, and tlie deep-seated or discrete. The superficial 
variety is charucterized by the formation of a num!x^r of small, flat 
puKtules, which are seated upon a dark-red, infi United base. They 
begin us circumscribed, reddish elevations of the surface, whfch speedily 
become papular and then pustular. They are developed in groups^ 
and frequently coaleyee to form large irregular jmtches. They are 
surrounded by a dark*red aureola, and 8oon become covered by dry^ 
yellowish, greenish, or brownish cmsts, beneath which more or less 
sufjerfieial ulceration exists. They rarely appear before the second 
year of the disease. They may a]>pear upon any portioti of the body, 
but are most frcrpiently ob?erved upon the face and scalp and around 
the genital organs. They are also met with upon the legs and fore- 
arms. They run a comparatively mild course, and heal without much 
permanent cicatrization. 

The deep-seat<,^d pustules are isolated and few in number. They 
usually occur upon the scalp or on the extremities, and rarely involve 
the face. They belong to the tertiary rather than to tlie secondary 
8tiige, Mud may not apj>ear until the third or fourth year of the dis- 
ease. They begin as papules, and become transformed into pustules, 
which pursue a protracted course. They are surrounded by a coppery 
aureola, and covered l>y a thick, black i.sh-green crust. The underlying 
ulcer is deep and indolent, and covered with a grayish or greenish 
purulent secretion. Repair gradually occurs by granulation and cica- 
trization, but it may be delayed for monthfs, and is always followed by 
permanent disfigurement. 

Large Flat FrsTULAR Syphilide (Stfnoni/m: Ecthyma syphi- 
liticum). — This eruption consists of large, flat, isolated pustules, which 
are situated ui>on a reddened, infiltrated base, and surrounded by a 
coppery aureola. They are irregular in shape* and are from a sixteenth 
to a half or an inch in area. They belong to the tertiary stage, sel- 
dom appearing before the third year of the disease. They evince a 
marked tendency to break down early, and become covered with their 
chanictenstic crusts. Any portion of the Ixidy may be afTocted, but 
they are usually confined to the back, shoulders, and extremities. 
There are two varieties of this form of eruption — the sujierficial and 
the deep. In the former the pustules are numerous and disseminated, 
and nin a comparatively brief course. The cnist*! which are formed 
by the breaking down of the pustules are fliit and firmly adherent, 
and yellow or dark-brown in color. The underlying ulcer i^ super- 



BXrBATIONa 



^ 



^ 



Bctal, and beals with slight eicatri nation. The pnstnles of the latter 
Bre few and isolated, and generally limited to one refrioii or one side of 
the body. The crusts which are formed by the breakiu^ down of the 
pustules are conical ia t^hape and dark-green or blackisli in color, and 
•e^ted upon large, deep, unhealthy ulcers. The edges of the ulcers 
are infiltrated, and their surfaee is covered with a fool, greenish-yel- 
low secretion. In sonfie ca.<es tlie uleeralive process remains station- 
ary, in others it extend.^ periplierally. As a resiult of this exteni?ion, 
and the continual drying up of the matter which is poured out, the 
crust i5 elevated still higher in the centre, and gradually assumes a 
stratified or oyster-shell a]»pearance- This form of crust ia known aa 
mpia. but is not ]>eculiar to the pu:^tular sy]ihilides. It is frctiucntly 
observed in the bullous grou]), and is symptomatic of the malignancy 
of the disease. It is invariably followed hy mai'kcd cicatrization. 

Dia^OSis. — The pustular syphiiides are not difl'K'ult of diagnosis. 
The lesions of the acuminated variety might be mistaken for the pust^ 
ulea of acne or of variola. In acne, however, the pustules are usually 
limited to the face and shoulders. They are not sinTounded by the 
coppery aureola of the syphilidcs, and are not arranged in groups. 
They run a rapid coui-se, appearing and disappearing quickly, but are 
followed by successive crops, which protract the course of the eruption. 
iloreovor, there is no history of a specific infection, nor are there any 

r symptoms of syphilis present. Hare cases of univcrifal pustular 
jlis may present a striking resemblance to variola, but the slightest 
examination of the pulse, temperature, and history of the patient will 
saffice to show the true nature of the disease. 

The small, flat pustular syphilides can be distinguished from sim- 
ple impetigo and pustular eczema by their infiltrated base, their cop- 
pery aureola, their chronic cluiracter, and the absence of subjective 
symptoms. Moreover, the crusts of the syphilitic lesions are situated 
upon an ulcerated base, while those of eczema and impetigo are seated 
upon a simple reddened or oozing non-ulcerated surface. 

The large, flat pustules can be recognized from those of ordinary 
ecthvma by the history of the case, the presence of a coppery aureola, 
the appearance of the crust, and the obstinate eliaracter of ulceration. 
In a certain class of cases, fortunately rare, lesions that usually occur 
only in the later secondary stage develop rapidly at an early period of 
constitutional involvement. This variety is appropriately termed ma- 
lignant precocious syphilis. The outbreak is often preceded by a severe 
fever, which may assume either a periodical or continued typo. The 
eruption is generally of pustulo-crustaceoua form, and exhibits the 
appearance of syphilitic ecthyma. Iritis, periostitis, and visceral iu- 
Wvementa may be simultaneously manifeated. Nutrition is seriously 
impaired, and death not infrequently results within a few months of 
infection. 




228 



DISEASES OF THE SKLV. 



T0BEBCULAR SyPHILIDE. 

Tliis eruption belongs to the tertiary stage of sjpliilis. It 
appears beforcs the second year of tlie disease, but most frequently dur- 
ing the third and fourth years. It may be delayed, however, for five 
or ten years, or even longer. On the other hand, in exceptional cases 
it may appear during the secondary stage, when it is generally dis- 
tributed over tlie entire body. It consists of a number of tubercles, or 
solid elevations of the skin, which vary in size from a split pea to a 
chestnut. The spots are rouiid or oval in shape, dark-red or roddish- 
brown in color; are firm and smooth to the touch, and present a glis- 
tening apiiearance. Tliey are usually seated in tlic coriom, but may 
extend iulothe subcutiineous connective tissue. The tubercles are gen- 
erally multiple, but are not often present in large numbers. They may 
be widely disseminated, but are usually limited to one or two regions of 
the body. The face, neck, and shoulders appear to be favorite locali- 
ties for their development. They are seldurn observed upon the ex- 
tremities. When a number of tubercles appear upon any portion of 
the body they manifest a tendency to form clusters or groups, or seg- 
ments of circles, and tinally coalesce and form irregular or serpiginous 
patches. In some cases these patches are kidney-shaped, in others 
they resemble a horseshoe. The development of the tubercleB is slow 
ami unaccompanied by any subjective symptoms. 

After attaining their maximum growth tliey remain stationary 
for several months, and then disappear, either by fatty degeneration, 
absorption, or by idceration. When they disiippear by absorjytion, 
more or less pigmentation and depression of the epidermis are ob- 
served at their site for a long time. Finally, however, the skin regains 
its normal color and appearance. 

The ulcerative process may begin either upon the surface, or in the 
interior of the tubercles; but, no matter where it commences, it does 
not cease until all of the material composing tlie tubercle hm been 
destroyed. The resulting ulcer will be either superficial or deep, in 
accordance with the depth to which the syphilitic new formation hiis 
been imbedded in the skin. Its edges arc dark-red and intlltrated, 
and its base is covered by a grayish, yellowislu or greenish secretion. 
It is round, oval, or irregular in shape, and not iufrcquently crowned 
with a thick, pigmented crust. When a group of tubercles become 
attacked by the ulcerative process, an extensive irregular or serpiginous 
excavation is produced, involving the whole ailected surface. Kepair 
gradually occurs by giunulation, leaving large permanent glistening 
cicatrices, which are usually depressed beneath the level of the adju- 
ceut skin. 

The ulceration is sometimes complicated by exuhenint papillary or 
wart-likc excrescences, wdiich spring up from the base of the ulcers. 



EXUDATIONSw 



220 



are coyered by an offensive, yellowish, semi-porulent gecretion^ 
ind vary in size. They aru met with most frequently upon the scalj> 
id around the genitalia, fonnitig the so-ailled syphilia cutanea pupil- 
[lomata. 

Diagnosis. — The tnbercukr form of syphilU is iisufdiy not dillicult 
>f diagnosis. The only affections which resemble it are lepra, lupos 
Tulg&ris, epithelioma, and ordinary varicose ulcei-s. The tubercles of 
fpra, however, are slower in growtb, larger in size, and more chronic 
character. They are accompanied by more or less anffiethesia, and 
"are productive of extensive deformity, Lnpu« vulgaris usually muni- 
■iests itself early in life, while tubercular syphilis rarely appears before 
liddle age. The tubercles of lupus are smaller, moreover, and softer 
than those of syphilis, and pursue a more chronic coarse. The nlcera- 
tion in lupus is superficiiil, the tlieeliarge is scanty and serous, and the 
crusts are thin and reddish. In syphilis the ulceration is deep-seated, 
the discharge is copious and purulent, and the crusts are thick, and 
present a greenish, yellowish, or dark-brown appearance. The cica- 
trices also diifer, being hard in lupus and soft in syphilis. In sypliilis 
there is also a history of previous infection, and other symptoms of 
the disease are apparent. 

In epithelioma there is? ordinarily only one lesion, which is slow in 
growth, obstinate and painful in character. Its base, which bleeds 
at the slightest touch, is fungiform, or rod and granular, and covered 
^with a thin, sanguineous, or sero-puruleut secretion. The age of the 
H l>atient is also significant. Ordinary varicose ulcers may be confounded 
H irith those which are due to the degeneration of syphilitic tubercles, 
■ The situation of the former, however, and their occurrence in persons 
Hirho are compelled to stand for hours at a time, and the varicose con- 
" dition of the surrounding veins, will point to a correct diagnosis. 

^M This eruption occurs only in debilitated individuals, in the ad- 
^Vanced stages of the disease, and in infants who arc the subjects of he- 
reditary syphilia. It consists of a number of bullfe, or blebs, which vary 
in size from a small bean to a walnut. They are situated upon a red- 
dened, infiltmted base, and are surrounded by a dark-red or coppery 
•areola. They are firm to the touch at first, and filled with a clear, 
ms fluid, which becomes oparpie in a few dayjt. In some individuals 
contents of the bullie are ptindent or bloody in character. In 
Mothers the eruption is of a mixed nature, consisting of both bulhe and 
ialea. The eruption may appear upon any portion of the body, but 
lallj limited to the trunk and the extremities. After a variable 
Kme the bullae rupture spontaneously, and the watery portion of their 



BlTLLOUS SyPHILIDE. 
Stjiomtm, — Pemphiguii Bypliilitiea. 




230 



DISEASES OF 






contents escupes. The remainder dries up into thick, yellowisli, 
greenish, or brownish crusts, which vary in shape ami size in accord- 
ance with the character of the ulcer upon which they are seated. The 
crusts of snperficial, indolent ulcers are flat and easily detached, while 
those of the deep-seated, spreading variety are conicaU stratified, and 

(irmly adherent, forming 
the condition known as 
rupia. Fig. 11 represents 
an unusually severe case 
of rupia, to which my 
tention was called by 
Albert Fricke, of this city 
Rupial gores pursue a tedi- 
ous course, and are always 
followed by the formation 
of permanent, depressed, 
round, oval, or kidney- 
shaped cicatrices. 

Diagnosis. — The lesions 
\-«*--__ of this form of 6\^hilide 
present a superficial resem- 
blance to those of pempbi- 
/ gus vulgaris. The latter, 
however, occur in succes- 
sive crops, and are not fol- 
lowed by ulceration or cic- 
atrices, and the crusts are 
thin and yellowish. Tlie bullie of syphilis are characterized by thu 
rapid production of large, thick, pigmented crusts, and end in p 
tracted ulceration and permanent cicatrization. 

An unusual cutaneous alteration effected by syphilis has been de^ 
scribed by l)r. Coulhon under the title of wasting secondary syphilidc 
or abdominal streaks. The lesion begins in the form of small, linear, 
violaceous patches in cortaiu situations. These patches disappear after 
awhile, leaving behind them white lines similar to those observed upon 
the abdomen of pregnant women, but differing from the latter in be- 
ginning as violaceous spots and in their symmetrical arrangement. 
They are not regarded as characteristic of syphilis, but as evidence of 
profoundly disturbed nutrition of the integument.* 




V 



\ 



Fig. I L — Rupia. 



a^ 



GuMMATors Syphilide. 

It consists in the formation of one or more circumscribed tumors or 
nodes in the subcutaneous connective tissue. They commence as small, 
round, firm nodules^ which can be slightly moved beneath the epi- 
» New York Mcdkul Journal, March 8, 1890. 



Plate IL 





GumniatoiiH Syphilide, with ulceration titid necrosis of 
fn^ntal boue (from NatuiT). 




EXUDATIONS. 



IN 



to 



dermis. They are painless to the touch, but are usually accompiiiiit^i 
by nocturnal osteocopic pains. When first observed they are about the 
size of a split pea. They slowly increase in diameter, by the deposition 
of add itional material, until they attain the diineosions of a chestnut 
or a walnut. There are two varieties, tlie superficial and the deep- 
seated. The aoperficial form visible tumors, whieli project above the 
snrrouDdi ng surface. The overlying epidermis is normal in color at 
first, but finally becomes pinkish or reddish in hue. The deep-seated 
are situated in the loose fascia, between the skin and the mnseles, and 
rarely project above the surface. They can be plainly felt, however, 
and outlined by the fingers as firm oval or oblong tumors. They 
are rarely seen before tlie second or third year of the disejuse, and may 
not occur until a much later period- Guniuiata are liable to api>car 
upon any portion of the body, but are more often met with in those 
regions where the subcutaneous connective tissue is abundant, as on 
the butt4:>cks, the abdomen, the sides of the neck anil thorax, and on 
the flexor surfaces of the extremities. They are seldom observed upon 
the palms or soles; are usually single, but may be multiple. The 
number present at one time, however, is scarcely ever more than three 
or four. Gummata attain their muximnni in almut two months. 
They then remain stationary for a perio*], after wliich they become soft 
and tioctuating, and disappear by absorption or ulceration. When 
the latter is about to take place, the gumma becomes slightly painful 
or tender, the skin borsts near the centre of the lesion, and a small 
quantity of semi-purulent or blood-streaked material oozes out The 
morbid process continues until an excavated ulcer as large as or larger 
than the original lesion is formed. Its kisc is uneven and covered 
with a yellowish or reddish aplastic deposit. Its sides are usually steep, 
but may be undermined or sloping. The ulcer jiursues a protracted 
coarse, and may extend to tlie underlying structures, producing great 
destruction of tissue. Healing finally occurs by granulation, with a 
white depressed cicatrix. 

Diagnosis. — The diagnosis of gummata is usually self-evident. 
They might be mistaken for small fibrous or fatty tumors, but the 
history of the case, the situation of the lesions, the nocturnal osteo- 
copic paina, and other symptoms of the disease, will prevent an error 
from being made. Gummatous ulcera can readily be distinguished 
from Taricose ulcers by the history of the case, the character of the 
secretion, absence of pain, and existence of other syphilitic lesions. 

Syphilitic paronychia, onychia, and alopecia are described under 
the affections of the nails and hair, in another part of this book. The 
syphilitic affections of the viscera, and of the osseous, muscular, fibrous, 
and nervous Bysteras, cannot be even briefly mentioned in this article 
without expanding it far beyond the space to which it is limited. 
Their consideration, moreover, properly belongs to a work on syphilis 



k 



DISEASES OF THE SKIN. 



alone. It 19 sufficient to say tliat tlierc is not a tissuo or a portion of 
the body which may not be invaded bj tliis omnipresent disejise, and 
that many baffling or obsciiro cases may freqnently be relieved by ap- 
propriate methods when the possibility of their being of a eyphilitic 
origin is recognized. 

It should not be forgotten, however, that visceral ayphilis may exist 
at an early period of the secondary stage; and, indeed, I believe that 
til is happens more often than is com^monly supposed. JuUien has 
lately described* a unique complication which was observed four 
months after the appearance of a chancre. A painless, smooth, indis- 
tinctly lobulated swelling occupied the helix, antihelix, and fossa of the 
antihelix. The reporter denominates it a " Ivmphochondric syphi- 
loma.'' 

Pathology of Syphilis.— The pathology of syphilis has been thor- 
oughly investigated by Auspitz, Biesiadecki, Kaposi, Neumann, Otis, 
and others, and may he said, in brief, to consist of local cell -prolifera- 
tion, and an accumulation or infiltration of small, round cells. The 
induration of the initial lesion is pnxluced by intlltration of the papilla 
of the corium and the subcutaneous connective tissue with small round, 
nucleated cells composed of finely granular protoplasm. Tliey not 
only fill up the interstices of the corium and subcutaneous connective 
tissue, but penetrate into and through the walls of the cutaneous 
vessels, increasing their size but lessening their calibre. The ulcera- 
tion which finally occurs is due to the interference in nutrition pro- 
duced by the increased pressure upon the minute arterioles. The 
glandular complications of syphilis are produced by the same cellular 
multiplication. 

The macular syphilide is characterized by similar round-cell infil- 
tration in the papillre of the corium, and around and within the walls 
of the papillary vessels. 

The papular lesions are due to a circumscribed, dense, round-cell 
infiltration in the papillary and sub-papillary layers of the corium, 
and in the upper portion of the subcutaneous connective tissue. The 
depth and extent of the infiltration correspond with the size of the 
papules. The mucous patches or moist papules are preceded by a 
similar process in the superficial portion of the corium. The papilhv 
are enlarged and branched or club-shaped, and the jjapillary vessels 
are Bwollen and tortuous. The tubercles and gummata consist of 
masses of closely packed round cells, which surround and penetrate all 
the cutaneous structures, and finally, by their increiieing pressure, oh- 
literate the capillaries, and produce atrophy and ulceration of the 
affected structures. 

The jvustular lesions are preceded by round-cell infiltration of the 
corium and its vessels, but more or less exudation and migration of 
* Annalea de Dennatol. ct Syph., Fcbmary, 1889. 



EXUDATIONS. 



'"233 






leucocytes also take place. When absorption occurs, the exudation is 
dirried away through the lymph-spaces. In the vesicular and bullous 
lesions the cxudiition of serum is large, prodiieiut^ (pdeina of the luljii- 
nt tissues. The eharacteristic routid-cell infiltration is also present, 
liowever. The various lesions of the muscular, fibrous, osseous^ and 
nervous systems, and of the internal organs, are also due to cellular 
proliferation and infiltration. 

The gumma consists of an accumulation of embryonic cells. It 
grows at its peripheral while its central portion undergoes retrograde 
metamorphosis. According to the recent histologicsd researclies of 
ilarfan and Toupet, the gumma originates around small blood-vessels, 
which become gurroundt:d by a mass of round cells intermixed with 
fibrillated tissue forming a coarse reticulum. Thus arises a nodule or 
sclerosed area. The larger vessel which supplies this area likewise 
suffers alterations of its outer and inner tunics. The calibre of the 
Tesset is progressively narrowed. Obliteration of the vessel is followed 
by degeneration of the central portion of the nodule. 

Etiology of Syphilis. — Syphilis is due to the entrance into the sys- 
tem of the s])ecific virus which is contained in the blood of syphilitic 
subjects, and in the secretions of syphilitic lesions, and is known as 
the virus of syphilis. The exact nature of this virus has not been de- 
termined. 

Many attempts have been made of late years to demonstrate that 
syphilitic infection is due to a specific micro-organiriui, and Ijustgar- 
ten, of Vienna, believed tluit he had succeeded in isolating tlie jjatho- 
genetic microbe of the disease. The subject cannot yet, however, be 
regarded! as settled. Dr. Smirnoff, of Kazan, examining one hundred 
cases of syphilis, failed to find a characteristic niicrn-orgauism con- 
staotly present in secretions taken from syphilitic sores or in indurated 
eyphilides. In many cases but few microbes could be detected; in 
oihers they were identical with those normally present in healthy tie- 
fiiKrs and in the normal secretions of the genital organs, or so many 
different germs were present as to render it difficult or impossible to 
identify anj* one as charactcristie and the exciting cause of syphilis.* 

That the virus may infect the system tlirougli an unbroken surface 
by absorption after long contact, is probable, but an al>rasion or some 
other breach of continuity of the surface is generally necessary. The 
virus enters the circulation through the medium of the lymphatic sys- 
tem. It first produces a low grade of inflammation anil cell-prolifera- 
tion in the walls of the lymphatic vessels at the point of contagion. 
These cells become infected and are detached from the vessel -walls 
and conveyed to the lymphatic glands. They then enter the thoTacic 
duct, and, after mingling with the general blood-current, are carried 
to the yarioQB tissues of the body. 

Bpixiklyn Sledical Joanial, September, 1888. 




234 



DISEASES OF TIJE SKIN. 



Risking snperfluoua mention, I nmj remark tliat syphilis can be 
communicated hy direct or indirect contact, or by hereditary tnms- 
mission. The most ordinary method is by sexual intercourse with one 
diseased. It may be contracted, however, in a variety of other ways. 
Gyna?cologista and accoucheurs have been infected through an abrasion 
of the lingers while making a vaginal examination. The disease has 
not infrequently been communicated by infected instruments in cathe- 
terization of the Eustachian tubes. The dentist is in danger of ac- 
quiring syphilis from contact with lesions or secretioiia of the moiuli. 
On the other hand, dental instruments may serve to convey the virus 
from one patient to another, as Br. L. D. Bulkley has suggested ; 
smokers likewise may become infected by using the pipe or cigar of a 
Bvpiiilitic friend. Surgical instruments have also been the medium of 
spreading tlio disease. Reports are made from time to time of the out- 
break of syirhilis in consequence of tattooing, the operator suffering 
from mucous patches and moistening the neetlle or colors witli hh 
saliva. A number of cases of tlii?i nature were under the care of the 
)atc Dr. F. ¥. Maury in the Piiiladclphia Ilospital in 187 7. A similar 
observation was made in 187G by Albert Josias.* In 1885 a man waa 
arrested in the neighborhood of this city for the same offence. In the 
" British Medical Journal " of May 4, 1880, Surgeon R 11. liarker, of 
the British Army, communieateB the histories of twelve soldiers who 
had been infected in the same manner; while in the issue of Septem- 
ber 14, 1889, of the same journal, Surgeon Whitehead alludes briefly 
to five soldiers t^yphilized by tattooing at Landour, India, Syphilis 
may be contracted by kissing a person wliosc mouth is the subject of 
mucous patches, or by suckling a syphilitic child, or by using the tow- 
els, sponges, cups, knives, forks, spoons, or other utensils which have 
been used by diseased persona. 

Cases are on record in which it has been transmitted by a bite. A 
patient recently brought before the Berlin Medical Society had been 
bitten by a man upon the lip. Thougli tlio wound healed in two or 
three days, in six weeks it reopened and the lip became greatly swollen. 
Five weeks later t!ie inner surface of the lip was the site of an ulcer 
which was surrounded hy great swelling and induratioiL The sub- 
maxillary and cervical gluiids were much enlarged and in time a typi- 
cat syphilitic eruption developed. f A similar case is reported by Dr. 
Tchagin,J while others have been rei>ortcd by Dr. Sturgis and Mr. 
Bryant. In fact, tliis method of transmission was noticed by Sir 
Everard Home, in his addition to John Ilunter's Treatise on Venereal 
Disease. Syphilis may be conveyed through vaccination, by employ- 
ing the lymph or scabs taken from syphilitic subjects. Washer-women 

* Lc Proi;r^9 Medical, 187X p. 205. 

f Driii5h Mt'ilienl Juunial, September 27, 1^90. 

i rroviQciul Medical JoutiulI, March 2, 1891. 



►ATIONS. 



235 






ay become infected tliroogh abrasions of the fingers wliile washing 
clothing stained with gyphilitic- discharges. According to a careful 
computation, Prof. Foiiraier concludes that out of 887 women treated 
bj him for syphilis in private practice, no less than twenty-four per 
cent, had acquired the disease in some innocent — i. e., nou- venereal — 
manner. 

The possibility of its trausmissiun through the seminal fluid alone 
is denied by the most eminent authorities. Otis states as a maxim, 
that to make the infection of an embryo possible, the organism of the 
mother must first be involved. This doctrine is, nevertheless, strenu- 
ously opposed by Prof. Fournier, who cites a number of arguments to 
fiopport tlie view that syphilis may be communicated directly from 
either parent. Syphilitic children are fretjueutly born of syphilitic 
fathers and mothers healthy at leiist in appearance. Of 103 preg- 
nancies in perfectly healthy women, but whose husbands were syplii- 
htic, forty-one, or thirty per cent., were known to have terniinated in 
abortion or premature labor. A father who, prior to treatment, hae 
transmitted the disease to his child, becomes capable after ircatuient 
of begetting healthy olTspring. In " conceptional syphilis," to use the 
phrase of Prof. Fournier, a woman previously healthy, imiu*egnated by 
ft syphilitic father, develops syphilis during her pregnancy, although 
the father presents no actual lesion capable of directly communicating 

tagion. Disease inherited from the mother, however, is more dis- 
us to the offspring tlian vvlien couimunicated by the father. Dr. 

Tarnowsky estimates that seventy-one per cent, of syi)lnlitic nioHiers 
give birth to infants who are either still-born or tlie within a year. He 
particularizes as an illustration the histories of three sy|>liilitic families, 
iu which, out of twenty-two children, only one grew up to be a healthy 
man* Of the remainder, some dictl early, some suJTercd from idiocy, 
hydrocephalus, epilepsy, and other evidences of defective development. 
According to Fournier, twenty per cent, of ihe children die when the 
father is syphilitic, sixty per cent, when the mother is discitsed, and 
sixty-eight per cent, when both sutler. 

Treatment of Syphilis. — ^Tbe plan of treatment most effective in 
syphilis is that which is flirceted to secure the elimination of the 
virus from the system, to prevent the development of complioationsj 
and to preserve the general health of the patient. It consists in 
ihe adoption of suitable hygienic measures, the internal administra- 
tirm of tonics, eliminative and specilic medicines, and the external 
•pplication of protective, stimulating, or specific remedies; but buc- 
can be obtained only by perseverance in the effort to eradicate the 
n for a period varying from eigliteen months to four years, 
here is no abortive treatment for sypbili!^. It may sometimes be 
drisable to excise or cauterize the initial loxsion in order to allay the 
lienl*s anxiety, or to hasten the diaappearauce of the lesion i but the 




236 



IA8BS OF THE SEIN. 



germs of the disease are in the syatem, and secondary symptoms will 
appear sooner or later. The initial sclerosis may be very effectually 
destroyed by the use of the galvano-caiitery. 

A new plan designed to avert the evolution of the secondary stage 
has been proposed by Dr. Bronson, of Now York. This method rests 
npon the belief that daring the primary period syphilis is only a loL-al 
disease, and its author tliinks it possible to prevent exten*;ion of the 
virus beyond the primarily aifected gfingba. Prophylaxis is to consist 
in B series of hypodermic injections of corrosive sublimate beneath the 
initial k'sion a.nd into the mass of the indurated glands, or, indeed* into 
the entire district whose lymphatie vessels tend toward the diseased 
glands.* In objection to this scheme it may be urged that the most 
powerful considerations warrant the conviction that in primary syphilis 
the system is already, in fact, contaminated ; that the initial lesion with 
its connected glandular involvement is but the tirst manifestation of 
one indivisible process. Again, the hope of being able to destroy in 
silu or in its course of transit the infectious virus by a series, how- 
soever multiplied, of injections, is, in view of the rich abundance oij^ 
lymj>h-condiiits, nothing less than cliimerical. ^H 

Jullien thinks that if the primary lesion be excised at a very early 
period* before involvement of the lymphatic vessels and glands, the 
development of constitutional symptoms may be checked. Ordina- 
rily, however, it will be sufficient to direct the patient to apply a 
small quantity of mercurial ointment to the sore two or three times a 
day, or to use the officinal black-wash or yellow-wash night and morn- 
ing. If the chancre assumes a sluggish, ulcerative character, it may 
be induced to heal rajyidly by dusting its surface twice a day with a 
powder composed of one part of calomel and seven parts of bismuth 
subnitrate. Another effective application consists of equal parts of 
bismuth subnitrate and powdered cinchona-bark. The subiodide of 
bismuth and aristol are likewise excellent dusting-powders. Iodo- 
form is invaluable, but its odor is offensive, and precludes its use ei- 
cept in hospital practice. The odor may be modified or partially sup- 
pressed by mixture with balsam of Pern, Tonka bean, naphthalin, ' 
creolin* recently ground coffee, and other substances f which may be 
used for this purpose if the condition of the sore furnishes no contra- 
indication, lodol is an excellent substitute for the latter drug, and 
can be ap]>lied alone or combined with another powder, or in the form 
of an ointment. Europheu is also reported to be of service. A one- 
per-cent solution of osmic acid has sometimes proved a useful topical 
remedy in the case of tubercnlar syphilide, Salol is of service in 
chancres attended with ulceration. It may be need as a powder we^k- 

* tToumal of Cutaneous and Genito-rnnary Difteof^p, Jimc. 1888, p. 231. 
f See Malt^Ha Medica m\d ThcrapcutJcs^ with Espt'ciii! Keference to the Clinical Ap- 
plicatioQ of Dnigs, By John V. Shoemaker, A. M,, M. D., pp, 68!> aoJ GV2, 



i^rf^dik 



! 

J 



Exudations, 



237 






fcned by a mixture with starcb or some other inert substanccj or it may 

[be incorpunited into an ointment. Other substances which may be 

rbeneficially applied to open chancres are: resorcin, one or two drachms 

to the ounce of lard, simple ointment or other Buitable excipient; 

ichihyol ointment of about the same strength. Ciiancres indisposed 
to heal may be stimulated by the ointment of nitrate of mercury, red 
oiide of mercnry, or by naphthalin, one half drachm or more to the 
ounce. The officinal mercurial ointment or plaster proved very etVi- 
cacions in removing the cliaraeteristic sclerosis. Powdered bcnzcmte of 

[ bUmutb is an excellent dressing to ulcerated chancres. /?-nuphthol in 
powder, either alone or mixed with snbnitrate of bismuth, or made 

[into an ointment, is likewise serviceable. 

I Good results are obtained from tlie use of stimulating or astriiigent 

[ lotions. The following are especially valuable : 

I 5 Hydrarg. chlor. corrosiv, ........... gr. ij. 

t Chloral, hydratis gr. v. 

^H Aqu* f 3 ij- 

^H M. Sig. : Ap{»ly externally, 

^K 9 Zinci cblori^li gr. j. 

^^^^K Acidi hydrochlorici dtlut ^ 3 J* 

^^^^V A([na) f 3 j. 

I M. Sig.: Apply externally. 

The sulphate of copper in the strength of Jive grains to the ounce 
of water, with or without the addition of a small quantity of Sydea- 
Imm's laudanum, is a useful lotion. 

If the idceration extends widely and deeply, and becomes phaga?- 
tlenic in character, its entire surface should be promptly and thor- 
oughly cAuterized with fuming nitric aciil, or with the actual cautery. 
When caaterization is performed for moral effect only, or for pru- 
deotial reasons, any form of caustic may be employed, but the gaWano- 
cantery is preferable. Its action is instantaneous, and limited to the 
spot which is the seat of the lesion ; the pain which it produces is only 
momentary, and the resulting cicatrix is usually slight. As a rule, the 
lesa irritiition to which a chancre is subjected the sooner will it disap- 
pear, and the smaller will be the cicatrix by which it is followed. 
The internal treatment of chancre is that of the disease of which it is 
the first manifestation, and should be commenced as soon as the diag- 
nosis is oiade. 

Hyoiesic Treatmext. — As syphilis is pre-cnunenily a disease of 
degenenition, the patient should be placed under the best possible 
iuHnenees to resist its debilitating tendencies. He should be warmly 
clothed, and live as much as possible in the fresh air and sunlight, his 
diet nourishing and easily digested, consisting largely of meat, milk, 
and vegetables; tobacco and alcoholic drinks should be prohibited al- 
together, and excesses of all kinds avoided. The functions of the skin, 



tSBASES OF 



kidneys, and bowels should not be permitted to become disordered, and 
at leiist eight hours out of the twimty-four are to he given to sleep. 
Bathing in lukewarm water two or three times a week is essential. The 
addition of sulphide of potassium to the bath enhances its effect. 
The patient must be eatitioncd against thinking about hia disease, 
and be urged to cultivate an even, cheerful frame of mind. There 
is no malady mure distressing or more difficult to cure than 6j}ihiio- 
phobia. 

Tonk; Treatment. — Tonic remedies are always useful, and fi-c- 
quently indispensable, in enabling the system to withstand the ravages 
of syphilis. In some cases their employment is of even more service 
than the admiuistnition of specifics. Iron, especially in the form of 
the chloride and the sulphate, will almost always be found beneficial. Its 
value is due to the fact that its presence in the s^^stem increases the 
number of red corpuscles in the blood, thus counteracting in part the 
destructive influence exerted by the disease. Cod-liver oil^ arsenic, 
quinine, strychnine, the mineral acids, and tlie hitter tonics, may also 
be given with decided advantage. 

lloang-nau is another remedy of service, especially in those whose 
constitutional powers are notably depressed. Under the same circum- 
stances the chlorate of potassium will be found of decided utility. 

Eliminative Treatment. — The elimination from the system of 
the products of degeneration is secured in part by attention to the 
functions and hygiene of the patient, and in part by the ai'tion of the 
specific remedies. Marked benefit can be obtained in addition, how- 
ever, by the use as adjuvants of agents that promote destructive meta- 
morphosis, and increase the action of the various secretory organs of 
the body. Antimony, Barmparilla, guaiac, stillingia, and sanguinaria 
are the most important of this class. The reputed efficacy of ephedra, 
or Mormon tea, has been investigated Dr. H. H. Rusby, who concludes 
that its depurative action is second only to that of iodide of potassium, 
with which it may tberefore be advant^igeously alternated or com- 
bined.* 

SpECiFro Treatment. — The specific treatment of S3'philis consists 
in the administration of mercury during the early stages of the disease, 
and iodide of potassiiim, cither alone or combined with mercury, during 
the later stages. This is the treatment par excelience of syphilis, and 
the only one which can be relied upon to eradicate the virus from the 
system and prevent a return of the disease. It can be assisted by the 
simultaneous employment of hygienic, tonic, and eliminative measures, 
but without it for a basis they are of comparatively little value. The 
manner in which the curative influence of mercury and potassium 
iodide is exerted in syphilis is not known. It is probable, however, 
that they act in part as eliminative agents, and in part as direct an- 
• Draggista* Bulletin, 1888, p. 220. 



EXUDATIONS. 



239 



» 



.goniats of the process of cell proliferation and degeneration. Whether 
they net directly upon the protoplasmic mutter which contains the 
?ims of the disease, or indirectly by profoundly altering the constitu- 
tion of the blcKid, is still an undecided quention. 

This course-, however, should never be followed as a mere matter of 
€, but be from time to time intermitted and rephieed by a tonic 
regimen. Leloir has pointed ont that a too rigid reliance upon specific 
treatment induces a condition of neurasthenia witli dilatation of the 
fltomach simulating severe cerebral syphilis. In such cases it is a 
serious mistake to continue or increase the doses of specific drugs, as 
thi^ serves only to aggravate the manifestations. 

General MEiucrNAL TltKAT^EE^'T of Early SypiciLts.— The 
general medicinal treatment of syphilis may be appropriately divided 
into that of the early and the late manifestations of the disciise. The 
primary and secondary lesion.-^ are included in the former chtss, and 
the tertiary and qnaternary in the latter. Mercury is by far the best 
remedy in both the primary and secondary stages, and it should be 
em[)loye<l as soon as tlie diagnosis is made. Nothing can be gained, 
and much may be lost, by deferring its use until secondary symptoms 
have appeared. The advocates of delay admit that the early adminis- 
tration of mercury will postpone or modify the development of the 
cutaneous manifestations, but they urge that this delay or niodiiieation 
prevents the formation of an accurate prognosis, and is of no ultimate 
benefit to the patient This dmm is wholly erroneous, however ; 
but even admitting it were partly true, the welfjire of the patient is 
Dot to be endangered in the endeavor to make tlie physician a true 
prophet. 

At a meeting of the Medical Society of London, February 20^ 1888, 
Mr. Jonathan Hutchinson read a jmper on what he styles the "abor- 
tive treatment" of syphilid. Without insisting too strongly upon the 
litend accuracy of the term as indicating absolute annihilation of the 
disease, he believes that it may be fairly useil as a treatment which is 
planned to prevent the secondary phenomena and which usually suc- 
ceeds. If a patient with indurated chancre and no other symptom he 
Rt onc^ placed upon a mercurial course imd continued fur at Icitst six 
months, the experience of Mr. Hutchinson has been that secondary 
mptoms will not make their appearance. ITis choice as a remedy is 
-the gray powder administered in one-grain doses three times a day at 
least- The induration will generally soften rapidly within a week. If 
the treatment be given up at the end of six months, a general erythe- 
matons rai»h often develops within a few weeks. This eruption never 
becomes papular or scaly, and disappears after a few days* return to the 
mercurial treatment. For this reason he regards it ii.s judicious to con- 
tinue the treatment for nine or twelve months. He does not affirm 
that this method will prevent the occurrence of tertiary symptoms. 




^iO DISEASES OF THE SKIN. ^^^^^^^^^^ 

Though I do not feel justified in going so fur as to assert that the 
skin and tliroat symptoma of syphilis can be suppressed by tlie ad- 
ministration of mercury in the primary stage, I am positive that these 
syniploms are so remarkably ameliorakd ns to relieve tlie sufferer from 
much annoyance and alarm. Furthermore, though the virulence of 
the disease in the early period of constitutional involvement usaally 
expends itself upon skin and mucous membrane, the important fact 
should never be forgotten tluit lesions of tin; brain, spinal 4'ord, liver, 
gpleeUj bone, and other structures not infrequently occur during the 
so-called secondary stage. I am, indeed, of the opinion that visceral 
syphilis is juoch more common in the secondary stage than is usually 
supposed. On the other hand, Kaposi, of Vienna, believes that when 
constitutional treatment is begun before the outbreak of secondary 
Bymptoms, a predisposition to future involvement of the nervous sys- 
tem is created. 

3Iercury can be introduced into the system by internal adminis- 
tration, inunction, fumigation, or hypodermic injection. The former 
method is usually adopted in the early stages of syphilis, as it is the 
most convenient, and possesses the fewest disadvantages. 

Any of the preparations of niei'cury arc useful, given alone or ia 
combination with any other remedies which may be iudicateil. The 
preparations which I most frequently employ are the green iodide and 
the corrosive chloride of mercury; but cases sometimes occur in which 
the red iodide, tlie mild chloride, blue-mass, or hydrargyrum cum 
cretii can be used with more advantage, Xo matter what form of 
mercury is adopted, it should be given in small doses at Urst, in order 
to avoid the danger of producing salivation at the beginning of treat- 
ment. The susceptihility of individuals varies so nniclj, that too great 
care can not be taken in this respect. 

Dr, Petersen hiia ascertained that the gums are peculiarly sensitive 
in those patients whose kidneys are involved. A practical deduction 
from tliis fact is that whenever ptyalism occurs in a syjdalitic patieut 
the urine should immediately be examined. 

If the patient's general condition is fair, I usually begin by direct- 
ing him to take one of the following pills, half uu hour after each meal 
and at bedtime: 

3 Antimonii et potiissii tart gr, ss, 

Hydrarg. iodidi vir gr. iij. 

M. Ft. piluhe no. xxiv. 
If they do not produce any intestinal irritation or soreness of tlie 
gums, I increase the amount of the green iodide until a fourth or a 
third of a grain is taken four times daily. At the end of the third 
week the tartar emetic may he discontinued, but the green iodide con- 
tinued in increased quantity without intermission for three or four 
months. I then either stop it for one or two weeks, or redutre it to 




EXirbATioNa 241 

le one slxtoentli of a grain twice a day. During the intermission I 
merally place the patient upon one of the following formulai ; 

IJ Strychninse sulphatis gr, sa. 

Potasaii ijMoratis 3 ij. 

Acitli bydrochlorici dilut f 3 j. 

Aquae f 3 iij. 

M- Sig. : One teiispoonf ul iu water iiftcr meals. 

5 Tinct. belludonnie f 3 jss. 

Tinct ferri chlor £3 jsa. 

Aquje f § ijsa, 

M. Sig. : One teaspoonf ul iu water after meals. 

9 Tinct. ignatiffi f 3 jss. 

Tinct. serpentariie f | ss. 

Tinct. coptis trifolisB f 5 ijsa. 

M. Sig. : One teaspoonful iu water before meals. 
Erythroxylon coca is highly esteemed fia a tonic adjuvant by Dr. R. 
W. Taylor, who administera it in the form of a reliable fluid extract, 
and frequently combines it with the compoimd tinctures of cinchona 
and gentian. 

After one or two weeks of this simple tonic treatment I renew the 

tjnaximum doses of the mercurial for three or four months more. An- 
other week of intermission then ensues, after which the mercurial is 
given for another protracted period, but in somewhat smaller doses. 
After this plan of treatment has been faithfull}^ carried out for a year, 
the intermission may be lengthened to a month, and the periods dur- 
ing which the mercurial is coutinuonsly given reduced to sis or eight 
weeks. If no lesions are manifest at the expiration of six months of 

Eis interrupted treatment, or a year and a half from the beginning of 
e disease, the mercurial is discontinued for two or three months, 
en administered in small doses for a week or two, and then dropped 
for two months more. If any lesions occur in the mean time, the 
tr^jatment is resumed at once. If none appear, however, the patient 
may be considered to be practically cured, but should be advised not 
^^bo marry for at least one year after all symptoms of the disease have 
^Misappeared. By pursuing such a prolonged course of administration, 
^ferof. Fournier estimates that tertiary manifestations will be prevented 
^■b from ninety to ninety-five per cent, of the cases. 

If the person is anaemic or debilitated, a small quantity of iron or 
I of quinine may be added to each pill, or given separately, as in either 
fii the following formulie : 

5 Strychninae sulphatis f r. j. 

Quininae sulphatis. 3 ss. 

Aeidi phosphorici dilut f 3 ij* 

Aquffl f 1 iv. 

M. Sig» : One teaspoonful before meals. 
16 



242 



WBEB OF THE BKIN. 



B Liq, potassii arsenitis f 3 J*. 

Elix. gentianse ferrat. f | iij. 

M, Sig. : One teuspoonful after meula. 
If the movements of the bowels exceed three a day, or griping, 
colicky pains occur, from a twelfth to a fourth of a grain of opium 
should be added to each pill. In some cases it may be necessary to 
discontinue the itse of the mercnrial for a few days. 

If salivation occur, or the gums become spongy, the raercurial 
must be stopped at once, and belladonna, chlorate of pota^^ium, and 
the mineral acids, given in full doses. 

I^ Acidi hydrochlorici dikit f | ss. 

AqujB f 3 iv. 

M. Sig. : Dessertspoonful in water before meals and at bedtime, 

^ Tinct. belladonna* f 3 j. 

Potas.sii chloratis 3 ij* 

Afpia* ... f § iv. 

M. Sig. : Two tcaspoonfuls in water one honr after meals. 
In addition, the month shtaild be thoroughly rinsed ont every two 
or three hours with a weak suhition of common salt, or of chlorate of 
potassium, or with a lotion composed of half an ounce of compound 
tincture of cinchona and six ounces of rose-water 

The tincture of hydrastis diluted with water is also useful as a 
corrective mouth- wash. 

The corrosive chloride of mercury is an effective and easily admin- 
istered remedy. It may be given in pill-form, but is less irritating 
when given in solution. The doses should vary in the beginning from 
the one thirtieth to the one twenty-fourth of a grain, and be gradually 
increased until the one sixteenth or the one tenth of a grain is taken 
four times a day. In exceptional cases no impression is produced 
upon the disease until the dose has been increased to the one eighth 
of a grain. It may be given in wiiter, or in one of the bitter tonics. 
The permanence of the solution may be insured by the addition of 
a small quantity of the chloride of sodium, as in the following for- 
mula? : 

3 Hydrarg. chlor, corrosiv , gr, j. 

8udii chloridi 3 J- 

Aqua? . . , f 3 ijss. 

M* Sig. : One teaspoonful after meals and at bedtime. 

IJ Hydrarg. chlor. corrosiv g*"* J- 

Sodii chloridi 3 j. 

Tinct. einchonse comp ....,,,.. f 3 ijss* 

M. Sig. : One teaspoonful four times a day. 
In case the corrosive sublimate is not well borne, the substitution 
for a certain period of the chloride of gold and sodium has lieen found 
of advantage. The dose of this double salt is from one fiftieth to one 



►ATIONa 



243 



I 

I 



t-euth of a grain three times a day. It is freely soluble in water, but is 
beat administered in the form of a pill or tablet triturate. 

In anaemic or debilitated subjecta the best results can be obtained 
rom the combined administration of the corrosive chloride of mercury 
and the chloride of iron — 

9 Hydrarg. chlor. corrosiv gr- ]• 

Tinct. ferri cblor f J aa. 

Aqnaa f ^ iijsa. 

M. Sig. : Dessertspoonful in water after meals* and at bedtime. 

The biniodide of mercury is highly esteemed by many practitioners. 
It may be given alone or combined with potassium iodide, The dose 
raries from the one thirtieth to the one twelfth of a griun. 

Exceptional instances are met with in which mercury has no power 
to alleviate violent headache. In these cases the substitution of the 
iwlide, alone or in combination with the bromide of potassium, may 
be subatitnted with advantage. In the headache of the secondary 
period not dependent upon serious cerebral lesion, Leroy has found 
aconitine serviceable* lie administers the drug in minute doses. It 
can be given in from ^i^ to -^ grain during the course of the twenty- 
four hours. 

The mild chloride is one of the best preparations of mercury that 
can be used in syphilis, but it must be administered with caution. Its 
action is so prompt that salivation is sometimes produced by it with 
itartling rapidity. It is especially valuable where an immediate mer- 
earial impression is desired, as in syphilitic iritis. It may be given 
in grain or half-grain doses four times a «lay, but where prompt mer- 
earialization is required, one eighth of a grain should be given every 
hour or two. 

Bine mafis is also valuable for internal use. It is slow in action 
hot certain in results, and seldom protltices gastric irritation. The 
dose varies from half a grain to two grainfj, four times daily. It is 
usually given in pill-form, and may be combined with iron, quinine, 
antimony, or opium, when necessary- 

Ilydrarg. cum creta, or gray powder, is an effective and non-irri- 
tating preparation. The dose varies from one ^o three grains, four 
times daily. It may be given as a powder or in pill-form, or combined 
with other remedies. 

Several new mercurial combinations have during the past few years 
been introduced into practice. * These have all in clinical experiments 
proved themselves more or less efficacious in virtue of the mercury 
which they contain, but none has as yet been able to supersede the 
older sttlta. Sufficient evidence has accumulated to demonstrate the 
Dtility of the tannate of mercury. This is considered by Scliwimmer 
to be more active than corrosive sublimate. It is not prone to cause 



k 



244 



51ASES OF 



long time. The dose is one and one half grain, twice or thrice daily 
either in pill or solution. 

The neutriil salicylate of mercury was brouglit to the notice of the 
profession by Dr, Silva Araujo, of Rio Janeiro. Favorable reports 
have been given of its action by various Brazilian physicians j Szadeit, 
of Kiev; Prof. Newmann, of Vienna; Dr. W. C. Caldwell, of Chicago, 
III ; Dr. A» F. Bucliler, and others. The usual dose in which it is 
given is one third to one liulf grain, in pill or tablet, three times a day. 
The last-named writer * treated thirty-two cases of syphilis with this 
compound. II© found it a prompt and efficient remedy, well borne by 
tho gastro-intestinal tract and system at large. It is thought to re- 
Bcmbk the protiodide of mercury more closely tlian any other salt, but 
is said to be better tolerated. Prof. fSchwimmer found this salt of 
value in seventy cases of constitutional syphilis, but states that it ia 
apt to cause stomatitis. This writer administered it either in the form 
of powder or pill. 

Dr. De Lncca treated twenty patients — ten adults and ten children— 
by means of his mercuric alanine. No case of stomatitis was produced, 
and but on© of gaslric intolerance. Ue does not advocate this drug as 
superior to tho tannate and some other forms of mercury, but thinks 
that the ease with which mercuric alanine is tolerated and its excel- 
lent results in infantile syphilis render it an important addition to the 
list of onr resources. Tiie dose is from one tenth to one Bixth of a grain. 

The benzoatc of mercury, chiefly used hyitodermatically, has also 
been tested by Stukovenkoff as an internal medicament in the dose of 
one tenth to one third grain, in pill, twice daily. It was found to be 
slow in action, and in a numlier of cases it gave rise to diarrhoea. 
This salt was also administered internally by Balzer and Thiroloix,f who 
substituted it for tho biniodide in the sirup Gibert, as it readily dis- 
solves in a solution of iodide of potassium. Though tliey confess that 
their experience had been insntiicient for any decided ex])ression of 
opinion, yet they found that the benzoate mixture was well borne by 
seven patients in whom Gibert's preparation excited immediate vom- 
iting. 

The innuence of heat with consequent free diaphoresis is of decided 
benefit as an adjuvant t^ specific medication. Dr. Radestock, of Geit- 
hain, in Saxony, is in the habit of ordering a hot bath, continued for 
about thirty minutes or until tho skin becomes red. The action of the 
skin is promoted by hot decoctions or infusions or by the hypo- 
dermic injection of two cgm, (one third grain) of hydrochlorate of 
pilocarpin daily, A striking exemplification of the effect of heat 
upon cutaneous syphilis is the series of observations made by Dr. 
Kalashnikoff, of St. Petersburg. Partial hot-air baths were admin- 
istered to accessible affected parts for half an hour twice a day. In 

* Jottma! of CutAtieous and OcnitotJilnftry Diseases, Muy, ISftO. f Zof. eit 




EXFDATI0K8. 



245 



I 






e intervals the part was enveloped in hot flannel. The tempera- 
uever exceeded 110^ Fahr. When the hot-air chumber eoiihl 
be nsed, Indiii-rnblxjr hot-water bottles, or tubes through which 
hot water flowed, were em]>loyed. When both arms or lega were 
affected, the hot applications were made to the limb of but one side, 
in order to make comparison. The treatment was generally found 
to have a very favorable effect upon sypbilitic eniptions, even when 
employed alone ; and, in fact, was often benelieial where mercurials or 
iodides had failed.* 

Mercurial IxuxcTiox.^This h a rapid and effective method of 
bringing the system under the influence ol mereury, and ia especially 
useful in all cases where a speedy effect ia desired, as in syphilitic 
iritis, gyphilis of the nervous sy8tA?m, or of the iuterual organs. It is 
also serviceable in many old eases of the disease, and in those in which 
mercury will not be tolerated by the stomach. The difficulties attend- 
ing its use are so great, however^ that it is seldom ordered in private 
practice, except in the urgent cases previously referred to, and in some 
forms of hereditary syphilis. 

The preparations employed in inunction are t!ie ordinary blue oint- 
ment and the ointment of the oleate of mercury. The ointment of 
the mercurous oleate, however, as I have already shown, is far supe- 
rior to the ordinary blue ointment. It is a powerful remedy, which 
ghonld be employed with caution. It po.'J.sesses ilcep penetrating pow- 
ers, and by its quick diffusion frequently produces a rapid constitu- 
tional impression. Its further advantages over the blue ointment are 
its cheapness, and cleanliness of application. A small piece about the 
size of a bean, rnbl>cd in eacli axilla daily, and in the surface of each 
thigh, will be quickly absorbed, without soiling or discoloring the 
clothing; and, while the friction may produce a reddening of the sur- 
face, the eczematous condition, which may follow the use of any mer- 
curial ointment, can be avoided by having the patient take a vapor 
or a hot-air bath two or three times a week. An experience of several 
years has convinced me that frequent opening and cleansing of the 
blliclea of the integument are necessary for the success of the inunc- 
ion treatment; otherwise they will become clogged, an eczematous 
inflammation will be set up, and absorption rendered impossible. 

Dr. O. Dymnicki, of liii^k, has contributed an excellent paper to 
the Polish weekly, '' Gazeta Lckarska," No. 19, 1889, upon the advan- 
tage in certain cases of combining the internal administration of qui- 
ine with mercurial inunction. The quinine was given in the daily 
of one to one and a half grammes (fifteen and a half to twenty- 
ree grains). His conclusions are drawn from the results in 178 con- 
itive cases. The patients in whom the conjoined use of quinine 
proved most beneficial wera those having severe ulcerations, and 
* Journal of Cutnoeoas and Oenito-UriiuLrj Di&eases, July, 1890, p. 284. 





246 TSB&ABE8 OF THE SKm. m 

whose temperature, poise, and body-weight underwent considerahle 
flactuations. These cases were marked by increased metabolism of 
tissue. The viiUie of the quinine appears to depend upon the inhibi- 
tory influence which it exerts n]>on this tissue-change. As a conso- 
fjueuce, the (juinine supports the system and enables it to bear larger 
doses of mercury. On the contrary, quinine proved useless in those 
eases in which tissue-change wiis retarded. 

Merol'RIal Ft MiiiATiON.^This practically consists in placing 
the patient in a mercurial vapor-bath. It is a valuable method of 
treatment, but difficult to employ in private practice. The patient, 
completely stripped, u seated on a chair or stool, beneath which are a 
spirit-lamp, a pan of water, and a tin containing mercury. A large 
blanket or rubber cloak is then thrown around the patient, covering 
him from the neck downward. The lamp is lighted, and profuse per- 
spiration is [jrodnced by tfie generated steam. The mercury becomes 
volatilized, and, deposited upon a thoroughly relaxed skin, is finally 
absorbed. The lamp should be removed in fifteen or twenty minutes, 
and the patient permitted to cool oiT gradually. Any form of mer- 
cury may be used in this method, but the mild chloride is most fre- 
quently employed, as it vaporizes promptly, and its fumes are not irri- 
tating. From twenty to thirty grains are sufficient, and the process 
should bo repeated two or three times a week. 

^lercurial fumiga^on is especially valuable in the treatment of 
obstinate syphilitic eruptions either of the secondary or of the tertiary 
stage. It is also useful in all old cases of syphilis, and where the in- 
ternal administration of mercury is productive of severe gastric dis- 
turbance. Its good effects are due in part to the increased elimination 
of morbid products by the skin, and in part to the rapid absorption of 
the finely divided particles of the remedy. 

MEKcuRrAL Plaster. — M. Quinqnaud,of Paris, has recently pro- 
posed a new method of treatment which consists in the application of 
a mercurial plaster over the spleen. The mass is prepared as follows : 

Diachylon plaster 60 ounces. 

Calom'el.. 20 " 

Castor-oiL 6 « 

Mix, and make into plasters four inches square. After washing the 
skin with soap and water, a plaster is applied and left in position for 
eight days. It is then removed, and the skin is left free for eight days, 
when a second plaster is put on and allowed to remain eight days. 
After the first phister has been in position for four or five davs, mer- 
cury will begin to appear in the urine, and will gradually incrcfisc, 
reaching its maximum on the eighth to the eleventh day. If no second 
plaster be used, mercury will continue present in the urine for a month 
or six weeks. By the plan of discontinuing the use of the pla^iter 
every eighth day for an equal period ptyalism is said to be cull rely 




EXUDATION'S. 



247 



ted. This la certainly a convenient mode of administering the 
ly, and M. Quinquaud cluims that the rcstdts are quite as ulT*3ct- 
ive as its exhibition by the month or liyjiodermie injection. 

Hypouekmic Ix.TECTiON OF MERcritY.--The hvpodormic admin- 
istration of mercury * is the quickest and most effective metliod of com- 
bating the virus and removing the lesions of syphilis, and should be 
?sorted to in all grave cases, and where a prompt removal of the 
'k'sions is of importance. This method of treiitment was introduced to 
tlie profession by Scarenzio, of Pavia, ami improved and popularized 

I by Lewin, of Berlin. f>careuzio employed injections of the mihl chlo- 
ride, suspended in mucilage and distilled wuter, and Lewin an aquo- 
ons solution of corrosive sublimate. The albuminate, the cyanide, the 
green iodide, the forraamide, the peptonate, metallic mercury, tlio 
Sfilieylftte, the succinimide, and other preparations of mercury, have 
also been experimented with since by various physicians, followed by 
good results from each. 

Liebreich, in chemical experiments which I witnessed in C'open- 
hagen in 1884 and in Berlin in 1886, claimed that the formamide of 
mercury was the best preparation to employ liypodermically by reason 
of ita being neutral in reaction, most soluble in water, and not coagu- 
lating albumen. 

The dose of this substance for hypodermic use is one eixlh of a 
grain; and Zeissl, of Vienna, found twenty injections the maximum 
number required to remove severe syphilitic manifestations. Kopp, 
however, after an experience of 3,000 injections, asserts that the forma- 
mide of mercury is valuable only in mild forms of primary and sec- 
ondary disease. Martineau, on the other hand, demonstrated thoroughly 
the utility of the peptonute of mercury in a largo number of syphilitic 
patients I observed at tlie Ilopilal Lourcine, Paris, in the fall of 1884. 

A compound known as gkuine-peptone sublimate, containing 
twenty-five per cent, of bichloride, bus lately been employed by Dr. 
Hiiiler in Striimpeirs clinic at Erlangen. The injections are said to 
be painless, unproductive of local irritation, and prompt in effect The 
dose is two thirds of a grain, equal to one sixth of a grain of mercuric 
chloride. This substance is made by first acting upon gelatine with 
dilate hydrochloric acid, from wliich results hydrochlorate of glutino 
peptonate, containing about twelve per cent, of hydrochloric acid. 
It is soluble in alcohol and forms a double salt with corrosive subli- 
ite. 

Dr. De Lucca, a clinical assistant in the University of Catania, has 

iblished the results of his experience with alaniuate of mercury or mer- 

alanine. This substance is a comhinution of mercury with alanine 

lido-propionic acid. The compound is soluble and easily absorbed. 

• ReniArkj on TreAtment of Syphilis by Hypodermic Injections of Corroilfo Clilonde 
of Hereurj. By the Author. The Lancet, London, September 6, 1684. 




248 ^^^ DISEASES OF THE SKIN, ■ 

It was employed in twenty cases in the daily doso of one thirteenth to 
one sixtli uf a grain. The average quantity of the drug used was three 
and a half grains to each patient, the average duration of treatment 
37'05 days. Suppuration occurred only in one half per cent, of tbo 
total number of iJijeetions. No stomatitis was produced. Tlie cures 
seemed to be permanent.* Wellander, of Stockholm, reconnnenda th© 
hypodermic injection of an acetate of thymol-mercury. It is said to 
ciiWiiG less pain than calomel, to be leas apt to create abscesses, and that 
more mercury can be introduced into the system by its means than by 
the 1180 of corrosive sublimate. The compound is insoluble in wak^r 
and requires to be suspended. It has been used with success by Ta- 
daseohii and Zeissing, whoso formula was as follows: 

T^ Ilydrargyri thyTnolo-aeetici 1 part. 

Paratlini liquidi 10 parts. 

M. Ft. suspension. 

The new i)reparation is likewise endorsed by Dr. Szadek, of Kieff, 
who administers it in a mixture of gum-arabic, of which the formula is — 

5 Ilydmrgyri thymolo-acetici 1'5 part. 

I Mueilag. acacia? 05 part. 

I Aqure destillatfe 20 parts. 

M, Ft. enspension. 

Every three or four days Szadek made an injection of this com- 
bination, lie reports that in ordinary cases six to ten injections are 
suffieieut to suppress the manifestatione. This mode of treatment is 
particularly valuable in the early stages of the disease. 

The benzoate of mercury is preferred by Prof. Stukovenkoff, of 
Kiev. This salt contains forty- three per cent, of metallic mercury, is 
a tasteless and odorless while cry Htal line substance, slightly soluble in 
cold water, but easily soluble in a weak solution of sodium chloride. 
The favorable reports of its action have been endorsed by Balzer and 
Thiroloix.f Benzoate of mercury is not apt to cause pain^ abscesses, 
or indurations, and may bo employed in solution, four grains to the 
ounce of distilled water, together with one grain of cldoride of sodium 
and two grains of hydrochlornte of cocaine, in order to counteract the 
pain. It may likewise be used in the form of a teu-per-eont. emulsion 
with liquefied vaseline. One injection should be given daily, and it 
should be discontinued upon the appearance of stomatitis, 

Th© salicylate of mercury is another sjdt which has of late been 
used for hv^iodcrmie or intramuscular injection. It is a white, amor- 
phous powder, devoid of odor or taste, scarcely soluble in alcohol or 
water. It is therefore prepared in the form of an emulsion, and is 
much less apt to excite local irritation than calomel. It exerts a prompt 
and decided efFect upon the manifestations of syphilis. Sziulek, who 

* Journal of tlio AmericftTi Medicftl Asflociation, April 21, 1888. 

f Annolea de Th^mpcutifiue M^Jico-Cbirurgicales, Jimaary, 18^0» p, 11. 




iXUDATIONi 249 

has employed this salt with eiitisfactory results, recommends tlie follow- 

^H jng formula: 

^B 3 Hydrarg. Balicylat gr. xvj vel xxiv. 

^H Mucilag. aoaciae. gv. viij. 

^V Aq. destiliat f 3 vsa. 

■ M. 

I Fifteen minims of this mixture were inje«^ted into tlie gluteal region 

every fourth day. He thus treated a long series of cases, without ob- 
serving a single local abscesB due to the operation. 

After using most of tlie preparations just referred to, and the vari- 
ous combinations in which they are suspended, I prefer the solution of 
the corrosive chloride in distilled water, as being the moat readily pre- 
pared, and just as effective as any that have been suggested. 

The only valid objection to the h>7iodermic administration of the 

: remedy is that pain is necessarily produced by the puncture of the 
needle. Tliis pain is trilling in character, however, and speedily dis- 

, appears. Another objection frequently ingcd is, tluit abscesses may 
be formed at the seat of the puncture.. This complication will not 
occur, however, if care be taken to t}irust the neetllc of the syringe 
deep into the subcutaneous or muscular tissue, so that the fluid can 
be speedily absorbed. In fleshy persons I usually make use of the sub- 
cutaneous cellular tissue, inserting the injection deep into its meshes, 
preferring the integument of the back or buttock for the operation. 
In thin individuals I always deposit the solution in the muscular tissue 
of any portion of the body, but more particularly the regions just 
alluded to. In 113 cases which I reported to the American Medical 
Association,* 2,132 injections were mlministerod in 20G days, without 
being followed by absoe^es or any other inflammatory sequeloe. Since 
that time I have employed the same method 3,l(j*j times in 441 cases, 
and in no instance have abscesses resulted. The formula which I use is — 

I. Hydrarg. chlor. corrosiv gr. iv. 
f Aquae f 3 j. 
In Bome cases I begin by administering one hj^podermic injection 
daily, of five minims of this solution, and increase the dose minim by 
minim every second or tiiird day, until the disease begins to abate, or 
until the constitutional effects of the drug are manifested. 1 then 
lessen the dose sufficiently to keep tiie system gently under the influ- 
ence of the remedy until all traces of the affection have disappeared. 
In others, particularly the more robust, it baa been my practice for sev- 
eral years to give hy])oderraically as much as one quarter to one half a 
grain of the corrosive chloride of mercury at intervals of every three 
or four days. 

In a communication to the Medical Society of London, April 23, 
1S88, Mr* J. Astley Bloxam, F. K, C. S., stated that since 1884 he had 
* Tniii«ictioti9 of the Amcric&D Medical Aadociatloa for the Ycftr 1883. 




^5ft DISEASES OF THE SKDT, ^^^^^^ 

used hypodermic injections of tlic same form of mercury 1,924 times 
at the Lock Jlospital He recommeiKls the solution for injection be 
X made fresh for each smue^^ and that one third of a grain of the salt 
just named bo inijcrted once a week deeply into the muscular tissue, 
especially of tlic buttock. Many of the patients in whom I employed 
the above method of treatment had previously been given mercury in- 
ternally without much botielit ; others presented such marked irrita- 
bility of the gastro-intestinal tract that the administration of mercury 
per orem could not be entertained. In such cases the hypodermic 
method enables the physician promptly to neutralize the poison of the 
disease, and at the same time to preserve the tone of the stomach and 
support and invigorate the patient by a nutritious diet and the admiu- 
istratiiiu of tonics. 

The injection of calomel ia not altogether devoid of danger. 
Kraus has reported a case in which one and a half grain led to fatal 
dysentery and peritonitis. Prof, Hinieberg, of llelsiiiglors, has seen 
two eases in which death resultedj in one from two and in the other 
from three injections, a week or more intervening between uach opera- 
tion. In each case there was diphtheritic infiltration of the large in- 
testine, and in one jierforation had occurred at the sigmoid flexnre 
with consequent peritonitis; acute parenchymatous nephritis w^as also 
present. In the other case there was found at the spot of injection an 
abscess which contained unhealthy pus and a considerable quantity of 
mercury. Ilebra, however, has not witnessed abscess or any ill result 
in a single case out of lG,tMJO. Neumann, after 344 injections of calo- 
mel in fifty-two cases, conchides that the method is less effective than 
the treatment by inunction. 

Dr. Watraszewski argues in favor of the yellow oxide of mercury in 
doses of from two thirds to one grain. From experiments upon ani- 
mals he believes that mucilage (gum-arabic one part, water 130 parts) 
is a better vehicle than an oil or glycerine, the oU exciting serious em- 
bolic pneumonia, while the mucilage merely produced small embolic 
foci which were absorbed without important subsequent reaction. 

The following formula is recommended by Besnier: 

I^ llydrarg, oxid. flav , gr. xt. 

Pulv. tragacanth gr- v» 

Aquic destillat f f j. 

M- 

Twenty-four minims, equal to three quarters of a grain of the siilt, 
are injected every ten days until mercury appears in the urine. Dur- 
ing the earlier months of the disease it is said that four grains of the 
yellow oxide suffice to hold the manifestations in abeyance. With the 
development of new lesions, a fresh series of injections is instituted. 
Gray oil hiis also been used as an injection ; but a fatal c^se is reported, 
fcitomatitis and instances of fat embolisms in the lungs have occurred. 




EXITDATIONS. 



251 



■ Eichhoff has lately experimeated with europhen, given lijpodermi- 
llsaUy, in both secondary and tertiary syphiiia. The results seemed to 
•"be very satisfactory. His met!iod was, to give each day an injection of 

■ three fourths to one and a lialf grains of europhen dissolved in olive- 
|DiI, beginning with the smaller dose. 

I Electrical Cataphoresis. — Gaertner and Ehrmann, of Vienna, 

■ have devised a bath by which mercury may be introduced into the 
l«ystera through the action of electricity. The tub is nnide in two com- 
Ipartments, one above the other, separated by a diapiiragm formed of 
I in insulating substance and fitting almost hermetically to the human 

■ body. The body thus acts as the only communication between the 
I two compartments, one of which is in contact with the positive and 

the other with the negative pole. The intensity of the current may 
be measured by means of a galvanometer. Currents of any intensity 
may be used and exactly measured. Either side of the body nu\y bo 
alternately subjected to the aetiori of the positive electrode. Mercury 
appears in the urine within twenty-four hours and may still be de- 
tected on the fourth day after the bath. 

General Medicinal Tkeatment of Late Syphilis. — Ab the 
boundary between tlie secondary and tertiary stages of syphilis is not 
always well defined, the term late sifphilis is frequently employed to 
include the obstinate secondary manifestations as well as tlie lesions of 
the tertiary and quaternary stiiges. The treatment of the disease in 
this jHiriod is varied and difhcult. The remedies whicii are of especial 
service are the iodides of potassium and sodium. Some physicians 
prefer the former and others the latter. According to my experience, 
they are of equal vahie in dissipating the lesions of syphilis; but I do 
not prescribe the sodium salt to patients of the uric-acid diathesis, as 
it may result in the formation and deposition in the system of crystals 
of the insoluble urate of soda. The initial dose uf the iodides should 
not exceed ten to fifteen grains four times a day, In cose the potas- 
sium or sodium salt prove depressant the iodide of ammonium may be 
substitute^ with benefit. If no appreciable effect is produced, or if 
symptoms of iodism do not appear, it should be rafudly increased, 
until one or two drachms have been given three or tour times a day 
for several weeks. Still larger doses, as high as an ounce and a half 
daily, for instance, have been adnnnistered in eases of cerebral syphiiia 
with safety and advantage, Wolff reoommemls that when given in 
Buch quantities the salt should be dissolved in decoction of rice in 
order to prevent iodism. 

The iodides can be given in water or in the simple sirup, or in any 
of the bitter tonics. The good effect is enhanced by giving mercury 
in addition, either in the same prescription or separately, at the same 
or different hours through the day. I usually administer them sepa- 
rately, directing the patient to take one sixth of a grain of the green 



252 



[SEASES OF THE SKIN. 



iodide in pi!l-form, or one sixteenth of a grain of the corrosive ehloHde 
in a bitter tonic before meals, and ten to Ulteen grains of the iodide of 
j)otassiuni in water about an hour after meals. Where nec428sary, I 
give the corrosive chloride hypodermically, and the iodides per orem. 
Again, I have employed in some cases iodides,* preferably the potas- 
Bium iodide, from three to five grains injected deeply into the muscular 
tissue every two or three days, with most decided effect in eradicating 
the disease. Occasionally 1 have given one of the mercurials by the 
mouth and used the iodide f hypodermically, and at times the former 
has been injected and the latter given by the mouth. Obstinate cases 
yield rapidly to this treatment. The iodide may also be administered 
by rectal injection when the stomach is disordered. For this purpose 
the following formula has been recommended : 

IJ Potaga. iodid gr. xv. 

Extr. belladonna g^- i* 

AquEe f I iv. M 

When it is desired to give both drugs in combination, by the ali- 
mentary canal, the following may be employed ; 

Ij^ llydrarg. chlor. cor. , . , gr. ij. 

Potassii iodidi 3 v. 

Syr. zingiberi , f 3 iv. 

M. Sig. : Teaspoon fill in water after meals. 
The well-known sirup Gibert is also justly esteemed by many prac- 
titioners. Its formula is : 



J 




3 



M. 



llydrarg, iodidi rub gr, j. 

Potassit iodidi. 3 j. 

AfjujE , f 3 j* 

Syr. simp f ? v. 



Sig. : One tablespoonf ul three times a day. 
Van Buren and Keyes recommend the following : 

IJ llydriirg. iodidi rub gr. jss. 

Ammonii iodidi. ,,...,. 3 j. 

Potassii iodidi 3 ij. 

Syr. aurantii cort f ? j* 

Tinct aurantii cort , f 3 j. 

AqujB q. s. ad f 5 iij, 

M. Sig. : Tciispoonfiri in water after meals. 
Hutchinson, in the lesions of late syphilis, is fond of a eombination 
of the iodides of potassium, sodium, and ammonium, together with a 
small quantity of free ammonia. 

Iron, quinine, arsenic, strychnine, and the mineral acids given at 
times are useful. Marked benefit will be derived from the occasional 

* Intm-imuaciilfir Injections of PrcparationB of lodme in Syphilis. Scbadeck, in St. 
Petersburg, mediein. Woclierischiift, No. 2», 1886. 

f Hypodermic Ua^; of Iodide of Sodiuui. Arcari, in Wion. med. Woch., No. 4, ISBfl. 



A 



^^^^F EXUDATIONa ^^^^^^ §53 

administration of stilliugia, g^miaciim, sarBaparilla, sann:uinfiria^ and 
thtj other yegetable altenitives and siidorifics, such as alder-bark, cory- 
dalis, mezereon, Phytolacca, heliaiithemum, lappa, sambucus, aad 
mana<^ The most important of these ]iave been combined with the 
iodide of potassium to form a serviceable mixture known as the com- 
pound sirup of red clover. 

In the course of his clinical experiments with iodol, Szadek 
ascertaineti that, given internally, tbis drug is more beiiedeial in 
late than in early syphilis. It may be substituted for iodide of 
potassium in doses of one-quarter to five grains three or four times 
a day. 

Dr. Haines has witnessed excellent results from tlie internal exhi- 
bition of oascara amarga in the ulcerations of late sv^hilis. In both 
secondary and tertiary syphilis 1 have lately administered with very 
good results the iodo-sulphate of cirichonine in doses of one to five 
grains three or four times a day. Baths, fresh air, and a nutritioas diet 
are of paramount importance. Anodynes must be given when neces- 
sary, to relieve pain or procure sleep. 

Local Treatment.^ — The local treatment of the initial lesion of 
syphilis has been described on a previous page. The macular erup- 
tions are usually uninfluenced by ointments or lotions, but are mate- 
rially modified by the fumigation treatment, or by ordinary vapor- 
baths. The papular manifestations may be improved by baths and 
mercurial fumigation. The following lotion is serviceable, especially 
in the facial papular eruptions : 

IJ Hydrarg. chlor. cor gr, ij. 

Spt. vini rect. f 3 ss. 

Aqufp rosae , f 3 iijss. 

M, Sig, : Use externally every three or four hours. 
Ointments are also of value : 

JJ Hydrarg, chlor. mitis. gr. xx. 

Bismuth subnit. 3 ij. ' 

Ung. aquas rosfe 3 j. 

M. Ft, ung, Sig. : Apply externally night and morning. 

IJ Hydrarg. chlor. cor gr. j. 

Acidi carbolici gr. v. 

Plumbi carb 3 iij. 

Adipis. 3 j. 

M. Ft. unguent 
Sig. : Use externally twice a day. 
The ointments of the nitrate and of the oleate of mercury, diluted 
in the proportion of one part of the ointment to five or six parts of the 
biw, may also be used with benefit. Moist papules sliould be cleansed 
rith soap and water, or salt and water, and then dusted over with a 
powder composed of equal parts of bismuth subnitrate and powdered 




254 DISEASES OF THE SKIN. ^^^^^^™ 

cinchona-bark ; or one part of the mild cbloride of mercury and seven 
piirts of bismuth subnitrnte^ 

Caustic lead is warmly recommended by Bockbardt* as an appli- 
cation to condylomata, Ho made nsn of Gerhardt's forniubi, 3*3-per- 
cent. solotioE of oxide of lead in a thirty-three-per-cent. solution of 
caustic potash. One of the most clHcient methods of treating condy- 
lomata is by the galvano-cautery. The ointment of arsenic oleate is an 
cfFuctive application to this lesion. It is also good practice to touch 
their surface with a solution of chromic acid, ten grains to the drachm 
of water, Aristol, likewise, is an excellent application to ulcerated 
lesions. It may be added here that this lately introduced drug haa 
been found efficacious in the local treatment of syphilitic oza?Da and 
the ukeratioiiis of late syphilis. 

In alopecia local applications are serviceable in addition to the con- 
stitutional treatment. Besnier recommends that the following liniment 
should be well rubbed into the scalp every night with a soft brush : 

IJ Spir. rosjnarin .... f 3 xxv, 

Tinct. cantharid f 3 ijss. 

M, 

In the morning, the scalp having been washed with soap and hot 
water, the following ointment is applied : 

ft Acid, salicylici 3 ss. 

8ulphur-precip 3 iij. 

Lanolini, 

Vaseltni aa 3 xijss.f 

M, 

The papulo-squamons and tubercular lesions are obstinate in char- 
acter, and require the protracted use of Ltimulating mercurial applica- 
tions. Fumigation and vapor-baths in addition will be found bene- 
ficial. 

The pustular, rupial, bullous, and ulcerative lesions run a tedious 
course, and arc more amenable to internal than to external treatnit^nt. 
Their healing may be hastened, however, by detaching the crusts, re- 
moving all discharges from the underlying surface^ and then caiiter- 
hiug it with a strong solution of nitrate of silver, corrosive chloride of 
mercury, or carbolic acid. A protective dressing of bisnnith subni- 
trate or of oxide of zinc may then be applied. Other excellent appli- 
cations in this cliiss of lesions are iodol and ioiloform, but the peculiar 
and diffusive odor of the latter will limit Its emplf>yment to hospitAl 
practice. 

Gumnnifca should not be opened unless the fluctuation becomes 
pronounced. When this takes place, an incision may be made at 
the most dependent part of the swelling, its contents evacuated, and 

* MuTifttshofto fiir pmkt. Permatol., vi, 18S8. 
f Lii Frixacc Mt'dkale, fc>cptember 5, 1889. 




EXUDATIONS. 



^55 



^^Hiritj syringed out witli a strong solution of tincture of iodine or 
VMoeive chloride of mercury, and then permitted to heal bj granu- 
lation. 

ProgTlOSlB. — The prognoBis of syphilis is not unfavorable, as a rule. 
The improvement in personal habits and hygiene, and the adoption of 
a methodical rational plan of treatment, have divested tlie disease of 
many of its former terrors. It would be folly to deny, however, that it 
b a serious affection* and that it does not tax the skill and patience of 
the physician to the utmost extent. Mutdi depends upon the ago of 
the patient and the state of his constitution, but more upon the 
prompt and systematic administration of appropriate remedies. In 
young, robust adults who are properly treat^^d the disease seldom passes 
beyond the secondary stage. Old people, young children, and the 
debilitated of all ages, are unfavorable Bubjects, but frequently recover 
promptly. Intemperate or dissolute persons suffer more than those 
who lead an even life. When the sypliilitic poijion is added to the 
goaty, the rheumatic, or the scrofulous diathesis, it is apt to pursue an 
obstinate course^ 

The prognosis is also influenced by the character of the cutaneous 
manifestations. Macular or papular eruptions usually indicate a mild 
case. Pustular eruptions are symptomatic either of a more severe 
grade of infection, or of a debilitated condition of the patient. Rupia 
is always significant of a malignant form of the disease. Tertiary 
syphilis is always serious, but varies in severity in accordance with the 
organs which are involved. Syphilis of the nervous system is inva- 
riably a grave affection, and frefjuently fatul. Syphilis of the inter- 
nal organs is also to be dretided. The disease is always amenable to 
treatment, however, and even in tlie most hopeless stages can fre- 
q neatly be cured or considerably ameliorated. " How long after syphi- 
lis has been apparently cured should a patient remain single before he 
can marry, without endangering his wife and expectant offspring?" is 
a question often asked. The general consensus of opinion is that if a 
patient has been under observation for three years, and if no manifes- 
tations of the disease have appeared during the last year, he may get 
married without fear of communicating the disease to his wife or en- 
tailing it upon his eliildren. 

In imperfectly cured cases, however, even though the disease ex- 
hibit no notable manifestations, it remains trausmissiblo for a long 
tnd perhaps indofinito period. Barthelemy has lately reported a ease 
in which a child inlierited syphilis from parents, both of whom had 
had the disease fourteen years previously, and though irregularly treat- 
ed, had been free from symplonis for many years. Prof. Fournier 
his in one case seen it inherited after a lapse of twenty years. As a 
rule, hereditary syphilis is acquired during the three years following 
the first manifestation of the diseiise in the parent. After this time, 



256 



DISEASES OF THE SKIN. 



even in the absence of treatment, susceptibilifcy to inheritance is greatly 
and progressively diminished. 

As a rule, one attack of syphilis confers subsequent immunity. 
The victims of hereditary disease are protected against acquired infec- 
tion. To this rulL% however, exceptions doubtless occur. It is usual 
to consider tliiit a second infection is evidence that the first attack was 
completely cured ; and, in fact, this is one of the arguments relied upon 
to prove that the affection is curable. An interesting exceptional case 
had been observed by Bn Augusto Ducroy,* The patient, a woman, 
forty-six years of ago, whose body was much scarred as a result of 
ulcerated syphilides, and who likewise exhibited a gumma of the scalp, 
was reinfected. The new infection manifested itself by an induration 
of the right labium majus, general glandular enlargement, syphilitic 
roseola on the trunk and limbs, mucous patches on the soft palate and 
velum, s>^hilitic fever, and osteocopes. Subseqnently iritis and a pust- 
ular syphilodcrm developed. Coincidently the gumma upon the scalp 
became deeply ulcerated. 

CoxtiENiTAL 8YPiiiLis.*"InfantiIe syphilis is either acquired or 
congeuital. If acquired, it is the result of inoculation with the secre- 
tions of a syphilitic lesion during parturition or after delivery. Nu- 
merous cases are recorded in which the disease has been communicated 
by a mucous patch or tubercle on the nipple of a wet-nurse. The 
large majority of cases are congenital in character, however, and are 
the result of infection in nfero. 

There are many unsettled problems in regard to the transmission of 
syphilis to the embryo, but the weight of nuthority is in favor of the 
opinion that infection can only occur through the medium of the ma- 
ternal circulation. If the mother is suffering from syphilis when im- 
pregnation occurs, or if she become infected then or at any time pre- 
vious to the seventh month of pregnancy, the disease will certainly be 
communicated through the utero- placental circulation. 

One of tlie most frequent results of maternal syphilis is a succession 
of abortions or miscarriages. In post-mortem examinations of the 
bodies of twenty-eight still-born syphilitic infants, M. Barthtdemv 
failed in most cases to discovei any lesion. Gummata were found in 
five cases, while in eight others the liver was gi'anular, and, upon mi- 
croscopic examination, miliary gummata of the li\'er and kidneys were 
observed. The spleen was in most cases somewhat larger than normal, 
but in other respects unaltered. f 

As a rule, the earlier the ovum is infected, the sooner will it be ex- 
pelled. Tlie pregnancy may, however, go on to full term, and termi- 
nate in the birth of a still-born child. One of the most characteristic 
symptoms of syphilis in mothers is a recurrence of apparently cause- 

* Giornale ItuTLiino <lcUc Mulatti Veneree e del la Pellc, December, 1888. 
f Britifth Journal of Dermatology, October, 1890. 




EXTTDATIONS. 



mr 



Jess still-birtha. In some cases the child is horn alive, but covered 
with an eruption, which needs no explanation. Generally, however, 
when the child is born alive it presents an apparently healthy iippear- 
ancc, but evidences of parental vice or misfortune become manifest in 
a short time. In one hundred and fifty-eight cases of hereditary 
syphilis, which were recorded by I)iday» the first symptoms appeared 
in eighty-six daring the first mouth after birth, in forty-five during 
the second month, in fifteen during the third mouth, and iu the re- 
mainder daring the fourth and fifth months. These statistics show 
that the disease appears almost uniformly in from two to twelve weeks 
after birth. If no symptoms occur during the first six months of in- 
fantile life, the probability is that infection did not iiike place. The 
disease, however, may be latent, aud appear imexpectedly at a much 
later period. 

Infants in whom the symptoms of syphilis are evident at birth are 
usually puny and undeveloped, and present a withered or prema- 
turely aged appearance. The skin is dry, loose, and wrinkled, and of 
a tawny or dull-yellow hue. In some eases largo areas of pigmenta- 
tion are obsen'ed. The hair is dry and scanty, and the nails are brit- 
tle, distorted, or stunted* The neck is thin and wrinkled, aud the sub- 
maxillary glands are enlarged. Varioua forms of eru])tion3 are pres- 
ent upon the skin, especially tubercles and bid he. Patches of erythema 
are scattered over different portions of the body, beginning upon the 
lower part of the abdomen, as a rule, and spreading thence to the 
limbs, chest, and fsice. The tubercles are largo and flat, and widely 
disseminated. When situated on the buttocks and around the genital 
regions, and in the flexures of the joints, they become converted into 
maooas patches, but iu other regions of the body frequently break 
down and ulcerate. Tho bnllsB are similar in appearance to those of 
pemphigus. They are round or oval in shape, aud vary in size from a 
small bean to a walnut. When first developed they contain a clear, 
serous fluid, which finally becomes opaque or greouish -yellow iu color 
and pundcnt iu character. They are seated upon a reddened, infil- 
trated base, surrounded by a dark-red or coppery aureola, and are gen- 
erally confined to the palms and soles, but are liable to a])pear upon 
any portion of tho body, and in malignant cases not infrer|ucntly cover 
the entire surface. They burst spontaneously in a few days, forming 
yellowish or greenish crusts, which cover siipcriicial or deep ulcers. 
Sometimes the ulcerations grailiially heal, aud the child slowly im- 
proves in healtli and strength, and finally makes a good but a tedious 
recovery. On the contrary, however, especially when the eruption is 
di.'igeminated or the ulceration severe, the child suffers greatly, cries 
continually, and either refuses to take any nourishment or only a 
small quantity at long intervals. It gradually becomes weaker and 
weaker, and dies in a few days, either from inanition or from an inter- 

n 



D[SEASES OF THE SKIK 



current diarrha?a. Occasionally it recovers from the first eruption, 
but a new crop of bullae appears after a short interval, luitl, from the 
irritiition und exhaustion which it induces, death speedily follows. 

Infants who have been infected with syphilis during uterine life» 
but who do not exhibit any symptoms of tlie disease when born, may 
remain ajiparently well for several weeks or months, and even show 
a progressive gain in weight and color. As a rule, however, they pre- 
sent a peculiar melancholy appearance, and although nursing with 
avidity they do nut get plump. Tbey are feverish and restless, and 
suffer from more or lesa diarrhoea. The countenance is pallid or of a 
sallow hue, and the eyes have a peculiar staring aspect. Finally, they 
begin iieroeptibly to fail in health and strength, becoming weak aud 
eiuaciatt'd, and crying nearly all the time. The subcutaneous fat 
diminishes or disappears, and the skin is dry, harsh, wrinkled, and 
sallow. These changes are especially noticeable about the face, whicli 
assumes a withered-up or wizened appeanmce, like that of a littlo 
old man or woman. Erythematous spots and patches are devel- 
oped upon various portions of the body. They are irregular in shape 
aud in size. They are usually lightered in color, but may be of a yel- 
low or coppery hue. They are first observed u])on the buttocks, or on 
the genital regions, but may be diffused over the entire surface. 
Many of the spots or patches become elevated in a few days, and are 
transformed into papules and mucous patches. Mucous patelies, or 
moist pa|mles, are the characteristic manifestations of hereditary 
syphilis. They are developed, first, at the junction of the skin aud 
mucous nicmbrauc around the mouth, nose, auus, and otlier natural 
orifices of the body ; then in the axillae, between the toes and fingers, 
behind the ears, around the nmhilicus, between the buttocks, and 
wherever heat, moisture, and friction coexist, as in the fleiiu*es of the 
joints J also on the tongue, roof of the mouth, and back of the pharynx 
and in the larynx. 

Syphilis of the larynx is much less common in hereditary than in 
acquired syfihili^, but laryngitis and mucous patches, followed by strict- 
ure or periehnndritis, have been seen by several authors, especiidly j 
Mackenzie, of Baltimore. The voice is hoarse or entirely lost. Several j 
cases of this kind have been reported by Sevestre. In some case? 
superficial desquamation of the epidermis occurs at the site of the i 
eruption; in others, the papules and erythematous patches become I 
fissured or excoriated, and finally become the seat of extensive nlcera- 1 
tion. Pustular erui>tions are seen less frequently ; they are usually 
commingled with vesicles and papules, aud run a rapid course, termi- 
nating in ulceration and the formation of brownish or greenish crusta^^J 
Large bulhe, seated upon a reddened, indurated base, and surrounddl^H 
by a pigmented aureola, are sometimes developed upon portions of the ^^ 
body, or the entire surface. They contain a clear, serous fluid, which 




EXUDATIONS, 



259 



gradually becomes sanguineous or purulent They ruptnre spontane- 
ously, and are followed by superficial ulceration and the formation of 
crusts. A succession of bulhti mtiy occur from time to time, until the 
fant perishes from exhaustion- This form of syi)hilide is usually 
Complicated by tubercles, pustnilcs, and other lesions. In some cases, 
howcTor, the bulla? are the only symptoms present. 

Another marked symptom of hereditary syphilis, and one which 
16 frequently observed before the cutaneous lesions become manifest, 
is " the snuffles.'* This is a peculiar noise heard during inspiration, 
and is due to the obstruction in breathing caused by the sero-puru- 
Icnt discharges of an accompanying syphilitic coryza or syphilitic 
inflammation of the nasal mucous membrane. The discharge is thin 
and watery at first, but soon becomes thick and tenacious, and accu- 
mulatas in the nares to such an extent that breathing is interfered 
with, and the peculiar snuffling sound produced. As the disciu?c pro- 
gresses the obstruction increiise:^, and finally becomes so complete that 
wo air passes through the nostrils. The child is then compelled to 
breathe through its month altogether, and, as it can not do this and 
suck at the same time, nursing is rendered difficult or impossible. 
Necessarily the child suffers from want of nutriment, and also from 
pain. If the morbid process still continue, the nasal discharges assume 
a fetid character ; the mucous membrane becomea the seat of ulcera- 
tion, which may involve the cartilage, and even extend to and destroy 
the small bones of the nose or of tlie palate. The nmcous membrane 
lining the pharynx and larynx is usually more or less intiltrated and 
Bwollen, protlucing the characteristic syphilitic roughness or hoarseness 
of voice. In some cases the swelling is so excessive as to produce com- 
plete aphonia. Conjunctivitis, keratitis, and otitis may also follow. 

In severe cases the child becomes more and more emaciated ; death 
ensues in a few days or weeks from inanition or from an exhausting 
diarrhoea, or from an intercurrent attack of pneumonia or capillary 
bronchitis. In rare cases death has Uiken place in a few hours from 
aniema of the glottis. In less severe cases the coryza and the cutane- 
ous lesions gradually disappear, the child slowly gains in weight a!id 
strength, and recovers with more or less nasal or palatine deformity. 
Corneal opacity, or purulent otitis, with impairment of sight or hear- 
ing, may also result. In mild cases an apparent recovery sometimes 
(takes place without any deformities or sequelae whatever. The poison, 
or its impression, frequently remains in the system, however, and be- 
comes manifest at a later perio<i in the production of various lesions 
of the periosteum, the hones, tlie teeth, the skin, the viscera, and the 
DervoQS system. The consideration of these lesions properly belongs 
tea treatise on general syphilis. 

Furthermore, so profoundly ia nutrition modified by congenital 
^^'philis that many morbid conditions besides the lesions symptomatic 



I 



360 



DISEASES OF THE SKUT. 



of the disease are fairly attributed by Fournier to this fatal ii 
ance. Such are, in addition to those already described, the arrests oJ ae- 
velopment uot infref|iieDlly witnesscd^delayed dentition, slow general 
growth, retarded puberty, etc. He agrees with Lannelongue in believ- 
ing that this taint is very often the remote origin of congenital de- 
formities, as club-foot, spina bilida, harc-lip, cleft palate, etc. Finally, 
it certainly predisposes to the a<_^quisition of ficrofulo-tuberculosis. 
Tarnowsky regards inherited syphilis as a predisposing cause of rachitis. 
Manifestations due to inherited syphilis may continue to recur for many 
yeai*s. A case is related by Dr, Bristowe* of a boy, fifteen years of «ge, 
admitted to St, Thomases liospitiil on account of a tumor of the liver, 
accompanied by a peculiar temperature record, ranging from subnor- 
mal (OS'^*" to 97° F.) in the morning to 100° or 103" F. in the eYcning 
Examination of the eyes gave evidence of past syphilitic keratitis, and 
a history wus obtained of an infection of the eyes when the boy waa 
seven years of age. Anti-syphilitic treatment reduced the febrile tem- 
peniture to normal within a few days, and the swelling of the liver 
gradually disappeared. ^M 

An unusually severe case of congenital syphilis in a girl of thirteel^l 
years of age has recently been described f by M, Saint-Germain. In 
addition to extensive and obstinate ulcers, necrosis of bone, and de- 
formed extremities, fracture of the humerus and femur resulted from 
such slight force that the accident might almost be considered spou- 
taneons. ^_ 

Biai^iiosis. — The diagnosis of hereditary syphilis is generally sell^| 
evident- The senile facies, the snuffling inspiration, and the cutane- 
ous lesions, form a trio of symptoms which are never present in any 
other d isease. Simple coryza occurring in healthy children may pro- 
duce difficulty of breathing, mid will interfere with nursing, but 
disappears with or without treatment in a few days, and is not acco! 
panied by any cutaneous manifestations, or by the syphilitic count 
nance. The papular rash, termed **red gum,^' which occasionally a] 
pears on the second or third day after birth, miglit be regarded as 
specific in character, but it is a trivial atTection, and disappears spon- 
taneously in a few days. Intertrigo and papular eczema sometimes 
present a superficial resemblance to the erythematous and papular 
syphilides, but their course, history, and concomitxint symptoms are 
widely diflereut. Syphilitic bullae may resemble those of pemphigus, 
but they are situated on a reddened, indurated base, surrounded by a 
dark-red or coppery aureola, and are followed by superficial ulceration 
and the formation of thick, brown, or dark-green crusts. Coryza, the 
senile countenance, and other indications of syphilis, are also present 
at the same time. 

* Clm. J^oc. TroM.t lix., 24». 

f Annnles dc Dermatol ogie ei Svphilograpliie, November, 1890. 



iro- 



atk 



Jonathan HutchinsoTi liaa pointed out that sifter the second donti- 
ion the teeth, especially the central upper inciaors, testify to the pres- 
ice of hereditary taint. These teeth are usually short and narrow, 
►resenting a broad vertical notch ut the edges and being rounded off 
it the corners. This appearainxv, if present, is regarded as pathogno- 
Lonic. It is, however, often absent 
Treatment — The treatment of congenital syphilis is both prophy- 
;tic and remedial, and should bo commenced at the earliest possible 
loment. If a pregnant woman is sntlering from a Buspicious erup- 
tion, or presents a hLstory uf a succession of apparently causeless niis- 
^camagea or stiil-births, or manifests any other appearances of syphilitic 
ifection, she should be placed at once upon a mild mercurial course. 
Chalybeate and other tonics may also be given. The plan of treatment 
[irhich I frequently adopt consists in the administration of a teaspoon- 
of the following corabinatiou one hour before meals ; 

3 Hydrarg, chlor corros gJ"* j- 

Tinct. nucia vomicte f 3 j. 

Tinct gentianie comp f $ iij. M. 

and ten drops of tinct. ferri. chlor., or ten grains of potassium chlo- 
rate in water, half an hour after meals. The patient is placed upon 
a generous diet, and directed to stay in the open air three or four 
hours every day. If the mercury derange the stomach, it may be 
omitted from the above prescription, and given by inunction. This, 
however, will seldom be necessary. 

Besnier reports favorable results from the administration of the 
sirup of the iodide of iron with wine of cinchona, a pill containing one 
fiijcth of a grain of bichloride of mercury, one twelfth of a grain of ex- 
tract of opium, and one twelfth of a grain of extract of gentian being 
also given thrice daily. The iodide of potiissium in amounts from 
seven and a half to fifteen grains daily is furthermore advised. 

When the child is born it ehould be nourished by its mother's milk, 

if possible. If the supply is inaderjuate, or if the pareut's condition 

is such that noreing is not advisable, the infant must not be given to 

lA healthy wet-nurse to suckle, hut fed with cow's milk, or some of the 

mny substitutes for its natural food. T!iis is a role to be rigidly 

joforced, or the gravest consequences may follow. Whole families 

lave been infected by nurses who unwittingly contracted the disease 

rom the lips of syphilitic infants while in their charge. 

The suggestion has been offered by Dr. Fredet that in order to 
kvoid such calamities syphilitic infants should, whenever possible, be 
suckled by goats or other animals not subject to this disejise* This 
method has, iu fact, been previously attempted and is no doubt beue- 
ficial^ bat has been found very dii3icult to faithfully carry out in practice. 
If the milk disagrees with the child's stomach, or fails to be prop- 
rly digested, from one to three grains of |iepsin may be given with 




DISEASES OF THE SKIN. 



each feeding. The child should be warmly clothed, well supplied with 
fresh air, and bathed every day in water in which a little common gait 
has been added. IniinctionB of cod-Hver oil are benefieinl. 

The medicinal treatment of infantile syphilis consists in bringing 
the system nnder the intliience of mercury as rapidly as possible. Thia 
can usually be done by giving one sixtieth of a grain of the corrosive 
chloride of mercury and ten drops of Hux ham's tincture in water, four 
times a day. Good results can also be obtained from the administrar 
tion of one twelfth of a grain of mild chloride of mercury or onef: 
quarter of a grain of mercury with chalk three times a day. Again, 
the protiodideof mercury may be beneficially employed and is especially 
valuable when combined with half a grain of the saecliarated carbonate 
of iron. For a child six or seven mouths of age a combination of 
iniodide of mercury with iodide of sodium is useful, according to 
^Eloy. The good elTects of mercury will usually be enhanced, and iU 
disadvantages minimised, by givifig from one to three minims of 
tincture of chloride of iron three times a day. In cases in which the 
stomach will not tolerate mercury in any form, its internal adminis- 
tration must be suspended, and half a drachm of mercurial ointment, 
diluted with three drachma of lard, thoroughly rubbed into the skin 
every day. 

Lanolin forms an excellent excipient for mercurial ointment. 
Wiederhofer, of Vienna, prefers the red precipitate, one part to one 
hundred parts of lanolin, to the mercurial ointment After inunction 
has been practised for a few days it is advisable to administer a warm 
bath. Eloy writes favorably of the effects of corrosive sublimate baths 
in hereditary syphilis. Three grains of corrosive sublimate and fifteen 
gniins of chloride of ammonium are dissolved in a half-pint of dis- 
tilled water and then added to the quantity of warm water which has 
been drawn for the bath. Moncorvo and Ferreira have recently ap- 
plied the hypodermic method of treatment to infants and children. 
They obtained tlie most favorable results from the use of gray oil and 
corrosive sublimate. The injections, made under strict antiseptic pre- 
cautions, occasioned little pain and w^re not followed by subsequent 
reaction. The ages of the children varied from three months to four* 
teen years. The doses of corrosive sublimate employed were one or 
two milUgrammes (^ to ^ grain), and were repeated every tliird, 
fourth, or llfth day, according to indications. 

The local treatment should be of a mild, ]irotective natin-e. The 
nostrils can he kept clean with a camelVhair bnish dipped in gly- 
cerine. Mucous patches are to be dusted with calomel, painful fis- 
sures uuiched with a strong solution of nitnite of silver, and all ulcer- 
ated or excoriated surfaces covered with a powder consisting of one 
part of mild chloride of mercury and five parts of bismuth subnitrate. 

Obstinate cases, or cases in which the symptomB do not become 



4 

4 






EXUDATIONS. 



lanifest at an early period, generally exhibit marked improvement 

%hen half a grain or a grain of potassiitni ioJiJo is added to eacli dose 

of the mercurial. In all cases, however, the treatment should bo con- 

inued for several months, then suspended for a week or two, to bo 

iguin resumed for a prolonged period. Chalybeate and other tonics 

jidvijsable at intervals. Tlie sirup of the iodide of iron, in doses of 

from lialf a minim to three minims, will bo found especiully serviee- 

kble. Quinine, strychniDe, potassium chlorate, and the mineral acida 

also invaluable as adjuvants to the specific treatment. 

Prognosis. — The prognosis of hereditary syphilis varies in aceord- 

ice with the extent and severity of the lesions, the time of their 

laDifestation, and the general condition of the child. As a rule, the 

lore extensive the eruption, and the earlier the time of its appearance, 

the more unfavorable will be the prognosis. Children who are covered 

with papules or bullfe at birth usually die within a few days. Severe 

coryza is aUo a bad symptom, but not necessarily indicative of a fatal 

result. "IN'hen the eruption is pustular or tubercular in character the 

— ^osis is more unfavorable than when it consists solely of macules 

>aptiles. Children who are born apparently healthy, and who re- 

n free from any atfection of the ykin or mucous membranes for 

sral weeks, seldom develop the malignant form of the disease. 



EHYTBISMA MULTIFORME. 



B^f 
»h 



Erythema multiforme is an acute inflammatory cutaneous alTection, 
characterized by reddish or varicolored macules, papules, or tubercles, 
ditlering in size and shape. 

Symptoms. — Erythema niuUi forme is preceded or accompanied by 
headache, gastric disturbance, and pain in the joints. The intensity 
f the pain is variable, sometimes being very slight and again equalling 
severity that of acute rheumatism. Occasionally inHamniation of 
he throat is experienced a few days before the appearance of the erup- 
tion. In some eases a slight rise of temperature is observed. The 
ernptioti is varied in character, and consists of either macules, papules, 
or tnbercles. The name of the affection — ervtiiema midtifonne — is 
gnificant of the protean character of its lesions. The eruption usually 
mraences, however, as small roseolous spots or macules, which rap- 
T increase in size, forming large, erythematous patches. The pe- 
iarities of form which these patches assume have led to the em- 
oyment of the terms annulare, iris, and marginatum, as indicative 
their shape and appearance. When the erythematous area increases 
>y jwripherat extension, but fades in the center, it is termed erythema 
annulare. When a new patch is developed within an existing ring, 
d rapidly undergoes the same process of peripheral extension and 
liul resolution, a series of concentric rings is formed, exhibiting a 



204 



DISEASES OF TOE SKIS, 



variety of colors; tliis is the condition known as erythema iris. When 
two or more circles meet, to form serpentine bantls, the eruption is 
termed erythema gyratum. When an erytlieniatous patch attains a cou* 
sidcnible size, and presents a sharply defined horder, which is slightly 
raised above the adjacent normal surface, it is known us erythema 
marginatum. 

In some cases the eruption commences as small papules, which vary 
in size from a pinVhead to a split pea. They arc round or oval in 
shape, and bright red or violaceous in color. They are firm to the 
touch, and are slightly elevated above the syrronnding surface. They 
pui-sue a variable course, but nsoally disappear spontaneously in five 
or six days. This form of the disease is known m erythenm papulosum. 
When the papules increase to the diraensiona of a small bean oi' hirger, 
the atfection is termed erythema tuhereulosum. In Bonio cases the 
eruption is complicated by the development of vesicles and bulhe. 

The eruption is usually symmetrical in character. It may appear 
upon any portion of the body^ but is met with most frequently ujjon 
the dorsid surfaces of the extremities* The mucous membrane is occa- 
sionally affected. The lesions pursue an acute course, usually disap- 
pearing by resolution in three or four days, leaving more or less pig- 
mentation of the surface. The disease may be protracted for a week 
or more by the appearance of a second or third crop. The accom- 
panying subjective symptoms are usually slight. 

DiagEOSis. — The ordy diseases resembling erythema multiforme 
are papuhir eczema, urticaria, and erythema nodosum. The papules uf 
erythema multiforme are large, irregular in shape, and are not attended 
by much itching or burning. Those of eczema arc small, and are 
accompanied by intense itching and burning. The lesions of urticaria 
are ephemeral in cliaracter, appearing and disappearing in a few min- 
utes; those of erythema multiforme remain for days. The color and 
subjective symptoms are also different. In erythema nodosum tlio 
erui>tion consists of large, firm nodes, and not of elevated jiatches or 
papules. 

Pathology. — Tlie pathological processes concerned in the prciduc- 
tion of the le^^ions of this disease are dilatation of the capillaries of the 
corium, an<l exudation of serum into the surrounding tissue. In some 
cases lui^morrhagic extravasation takes place. 

Etiology.— The etiology of erythema multiforme is still unsettle*!. 
It may occur in either sex and at any period of life. This affection in 
babes frequently occurs upon the nates as a result of irritating diarrhtpal 
discharges. It is said to appear more frequently during the spring and 
autumn, but it may happen at any period of tlio year. In some c, 
it appears to be dependent upon the rheumatic or lithsemic diathes 
in others it is evidently due to disturbances of digestion, ^talarial 
influences are also potent factors in its production. According to 



ii 





EXUDATIONS. 



265 



» 



win, it may at times be reflex in character, from genitourinary 
sordera. 

Eiythema occasionally makes Us appearance during pregnancy or 

ter delivery. It is Bometimes seen after operatkma upon the uterus. 

n other cases it occurs in connection with irritation of the urethra 

or bladder. Polotebnoff * has observed a papular erythema in a case of 

icterus and one of papule- tubercular erjthenut m a case of cirrhosis of 

e liver witli ascites. The same writer states that in some years 

ety per cent, of the cases of erythema which he has met witli have 

en associated with acute catarrh of the stomach. Dr. Paul de Mol^ucs 

as seen erythema occur in a case of gonorrhoea, and suspects that the 

sh attributed to the ingestion of cubebs or copaiba may not infre- 

uently be due to the urethral inflammation, since he has often found 

that upon increasing the dose of the balsam the rash disappeared. 

Erythema multiforme occasionally develops in consequence of violent 

emotional paroxysms. Luzzato has foond isolated and grouped cocci 

in the blood of a patient with erythema multiforme. 

Treatment — The treatment must be symptomatic and somewhat 
empirical in character. If there is any reason to suspect malarial poi- 
ioning, quinine should be administered in full doses. If the patient 
Is of the lithiemic diathesis, colchicum, lithiom, and the alkalies are 
indicated. If there is a rheumatic taint in the constitution, more 
benefit will be obtained from the administration of the salicylates. 
They are also of service in relieving the articular pains that may be 
present. When evidences of giistric disturbance exist, the diet sliould 
be regulated and the digestion assisted by large doses of pepsin, either 
alone or in combination with nux vomica and hydrochloric acid. 
Iron may frequently be given with advantage, especially to anoemic or 
debilitated patients. The functions of the bowels should be carefully 
ted in all ca.ses. Local applications are useless, unless there is 
ed it>ching and burning, and when such is the case, weak lotions 
of carbolic acid or creasote will be found effective. Ointments may be 
used instead of lotions, if advisable. A warm bath containing bicar- 
bonate of sodium is often useful in relieving the subjective symptoms. 

Prognosis. — The prognosis is always favorable. Tlie eruption in- 
variably runs a benign course, and terminates in recovery in from one 
to three weeks, but relapses may take place from time to time. 




ZIHTTHEMA NODOSUM. 

Sti»ostm. — Dermatitis conniatfomiis. 



^ Erythema nodosum is an acute inflammatory cutaneous affection, 
characterized by a number of reddish or purplish nodules, of different 
ih&pes and sizes. 

* Journal of Ctitancous and Gcnito^Urinary DUeases, Maj, 166S| p. ISl. 




200 



DISEASES OF THE SKIX. 



Symptoms,— The development of tlie eruption is usually preceded 
by slight fever, general w<«^a/vve, gastric disturbance, and pain arouud 
the joints. In some cases sore throat occurs. In others the^e premoni- 
tory symptoms are not observed. The eruption consists of a varying 
number of noduleg, which are seated in the corium and subcutaneous 
connective tissue. They range in size from a bean to a large walnut. 
They are round or oval in shape, and firm and slightly painful to the 
touch. Their color changes at first from a light red to purple. Ery- 
thema nodosum may be developed upon any portion of the siirfacc, but 
occurs most frequently upon the lower extremities, especially over the 
anterior surface of the tibias. The nodules are also often observed upon 
the ulnar surface of the forearms. They are frequently developed in 
crops, which may appear in succession upon various regions of the sur- 
face. As a rule, they are accompanied by more or less itching and 
burning sensations. In some cases their growth is attended by marked 
febrile excitement. The nodules nnmber from one to thirty, or more, 
and reach their maximum in about three days, Tliey then remain with- 
out change for a period, after which they become soft and painless, and 
gradually disappear by absorption. During this stage they present a 
brown, green, and yellow appearance, in accordance with the changes 
produced in the ha^mngh^bin of the elTused blood while undergoing ab- 
sorption. The first nodules usually disappeai* in from ten to fifteen days 
after their development, but, as they may be followed by a succession of 
others, tlie disease rarely terminates for two or threo weeks, and in some 
cases it is prolonged for months. Nodules may form on the tongue or on 
the mucous membrane of the mouth and pharynx, producing so much 
pain and difficulty of deglutition as seriously to interfere with nutrition. 

The eruption may be complicated by the simultaneous development 
of vesicles or bulla', or by an inflammation of the adjacent lymphatic 
vessels. Suppuration never occurs, but usually a slight pigmented 
spot remains at the side of each node for an indefinite period. Polo- 
tebnoflf, however, speaks of seeing suppuration take place in one case 
of erythema nodosum. A case has also been recorded by Iloisholt* in 
which papules and tubercles having every characteristic of erythema 
nodosum tt^rminated in pustules; and, in one situation, the coalescence 
of a number of these caused an abscess. 

DiagEOsis. — The diagnosis of erythema nodosum is comparatively 
easy. The only affections which present any similarity to it are urti- 
caria nodosum, the gummatous syphilide, and ordinary contusions of 
the surface. In urticaria nodosum, however, the cutaneous lesions are 
ephemeral in character, appearing and disappcariug in a few minutes 
or hours^ and are not followed by pigmentation. In erythema nodosum 
the lesions remain for days, an<l are always followed by pigmentation. 
The subjective symptnms are also different, 

* Monatshofte fur prakt. Dermatolo^ie, Bd ij. No. 6. 



mammm 



EXUDATIONS. 



267 



^ma 




S5pliilitic nodules, or gummata, are soft and painless -to the toucli, 
ngle or few in number, slow in development, and frequently termi- 
te in. ulceration. The lesiona of erythema nodosum are firm and 
inful to the toucb, rapid in development, usually multiple, and never 
d in ulceration. The gummatous syphiHde in also generally aceom- 
ied by other evidences of syphilis. Ordinary contusions of the sur- 
e may re3emble the lesions of erythema nodosum when first seen, 
ut their number, location, history, and course will prevent any error 
of diagnosis from being made. 

Pathology. — The pathological changes in erythema nodosum con- 
t of dilatation of the blood-vessels of the corium and aubcutiineoua 
nnective tissue, and an enormous exudation of serum and blood into 
e interstices of the corium and the rete mucosiun. The lymph- 
vessels are also swollen, and migration of numerous lymph-cells oecura. 
Etiology. — The cause of erythema nodosum is not known. It la 
met w\th in adults and in children, in females and in males, and in 
pparently robust as well as in debilitated subjects. It has been eon- 
d by Bohn and others to be analogous in origin to purpura rlieu- 
ica, while Lewin considers it to be an aogio-neurosis. In several 
which have come under m}^ observation, lithoemic diathesis was 
apparent cause. 

Quite a large proportion of cases of erythema nodosum occur in 
rheumatic subjects. Garrod states that this association is occasion- 
ally direct; that the presence of chorea or old heart-lesions points, in 
some cases, to a rheumatic origin, and tluit in others, though no artic- 
ular pains are present, the patients have formally sutfered from rheu- 
matism. He concludes that both erythema multiforme and erythema 
nodosum are often, perhaps usually, manifestations of the rheumatic 
process, though we are not justified in concluding that this is always 
their origin. Dr. Stephen Mackenzie has made a study of 108 cases of 
erythema nodosum taken from the records of St. Thomases, Guy's, St, 
Bartholomew's, and the London ITospital, especially with reference to 
this association. In seventeen cases subacute or acute rheunuitiBm co- 
existed, in seventeen other cases tlio subjects w^ere presumably rheu* 
nuitic. In a number of others it seemed probable that the patients 
possessed the rheumatic taint. In ten cases a cardiac murmur was 
present, though there was no history of rheumatism. In five murmurs 
apparently due to endocarditis came on during the attack of erythema. 
He therefore coincides with the opinion of Garrod, and writes that 
** these conclusions justify the inference that erythema nodosum is fre- 
quently, if not generally, an expression of rheumatism, even when no 
definitely rheumatic symptoms are present," Baumlcr, of Freiburg, 
considers erythema multiforme and erythema nodosum to be different 
forms of one disease, which is of infectious origin. Taylor has seen it 
accompany chronic bronchitie and acute pneumonia. 



1 



20S DISEASES OF THE SKIN. 

TreatmOBt. — The patient should be kept in bed until the febrile 
ajniptonis subside, after wliicli he is to be encouraged to take mod- 
erate exercise iu the open air every day. The diet shoold consist prin- 
cipally of milk, bread, fruit, and vegetables. The medicinal treatment 
must be varied in accordance with the rcquiremfnts of each individual 
case. In stout or robust subjects good results may be obtained from 
the administration of lithium, colchicum, and the alkalies. The 
iodide of potaasium or sodium is particularly serviceable in some cas«e?, 
according to Brocq. The joint-pains are nsnally ameliorated by the 
salicylate of sodium. In the amemic and debilitated, more benefit will 
be derived from the employment of quinine and iron. The tincture 
of the chloride of iron is especially valuable, in doses of twenty or 
thirty minims, after meals. Saline laxatives are indicated in all cases 
in which constipation exists. If the digestion is weak, it should be 
assisted by pepsin and hydrochloric acid. The pain and itching may 
be relieved by soothing ointments or lotions, m in the following 
formulae : 

Jj, VeratriRiB gr. v, 

Bismuthi subuitratis 3 ij. 

Adipia. | j. 

M- Ft* ungt, Sig, : Apply externally. 
5 Tinct. aconiti rad f 3 8ft. 

Acidi carboliei gr. x. 

Spts, vini rect ♦-...♦ f 3 ij. 

Aquie nieiiih. jjip f 3 iv. 

M. Ft. lotio. Sig. ; Use externally. 
A lotion of hamamelig and arnica ia recommended by Piffard. 
Cold applications or evaporating lotions relieve pixin in some casee^ while 
in others warm fluids prove more efficacious. In the later stage of the 
affection gentle pressure by means of the roller bandage is of service, 
and the same may be said of the local use of flexible collodion. 

Prognosis. — The prognosis in uncomplicated cases is idways favor- 
able. Recovery ensues, as a rule, without treatment in two or three 
months, and with treatment iu a much shorter period. Relapst'S not 
infrequently take place. 

URTIOARIA. 

Stsoittms. — njves— Nettle-rash-^Fcbrla urlicata — Urticaire — NesaekuflftchTitg. 

Urticaria is a mild inflammatory affection of the skin, characterized 
by the sudden development of a number of wheals, which arc ephem- 
eral in character, and are accompanied by marked stinging, pricking, 
itching, or burning sensations. 

Synaptoms, — Urticaria may appear at any period of life, but it is 
most frequently observed during childhood. Its advent is nsually pre- 
ceded by general lassitude, slight headache, epigastric oppression, and 



EXXTDATIONS. 



209 



^B^ther Bjmptoms of gastro-intestinal disturbaDce. The tongue is usu- 
^Hillj furred, and the temperuture is elevated from half a degree to one 
^Bortwo degrees above the nonnid. Exceptionally very severe symptoms, 
^^^^a3 high fever, cerebral congestion, and delirium, precede the erup- 
^HHK In maiiy cases, however, no evidence of coiiatitutioual disturb- 
^^Bbnce can be observed until after the development of the characteristic 
^Meniption. 

^B The emption appears abruptly, and not infrequently readies its 
■^maximum developnaent iu a few minutes. It consists of a number of 
wheals, in size from a split pea to a silver dollar, or larger. They are 
firm to the touch, and are slightly elevated above the adjacent cutane- 
ous surface. They number from four or five to a hundred or more. 
The lesions are genemlly round or oval in shape, but may assume a 
Tariety of iiTegular forms. They vary in color from white to pink, or 
bright-red, bnt generally present a white elevated spot m the centre, 
and are surrounded by a more or less distinct aureola. The wheals 
are usually isolated, but may coalesce and form large, irregular patches. 
They may be developed upon any portion of the cutaneous surface, but 
are most frequently met with upon the chest and abdomen and upon the 
eitremitios. They have also been found upon the mucous membmnes. 
Kaposi mentions the occurrence of urticaria in the mouth, pharynx, 
and upon the epiglottis, in which situations it is apt to occasion symp- 
toms of asphyxia. Bock has reported a case in wliich tiie tongue was 
the seat of urticaria. The tongue swelled suddenly and filled the cavi- 
ty of the mouth, was of a bluish color, bright and even glistening, hard 
and elastic in consistence. The diagnosis of lingual urticaria reposed 
upon the rapid development of the o?dema, absence of traumatism, the 
pe43uliar appeanince of the tongue, and the knowledge that the patient 
frequently sufTcred from attacks of urticaria.* Similar eases have been 
described by Laveran, Sevestre, and others. Urticaria is accompanied 
by burning, pricking, or stinging sensations shnilar to those whicli are 
occasioned by contact with the stinging nettle. These differ in sever- 
ity ; in some producing only trifling annoyance, and in others entailing 
intense distress. The desire to scratch becomes irresistible in severe 
cases^ and the patient often tears his flesh to obtain relief. The relief, 
however, is only temporary, and the irritation caused by scratching in- 
variably produces an increase iu the number and size of the wheals. 
The eruption is extremely ephemeral in character. In some it attsicks 
several regions of the body in Buccession, but only remaining for a brief 
^—period in each location. Urticaria is ordinarily an acute affection, and 
^Btrely lasts longer than a few hours or a day or two, during which 
^Several outbreaks of the eruption occur. It may continue, however, as 
^Hl chronic affection. The duration of urti<:aria depends entirely upon 
the discovery and removal of its exciting cause, 

♦ Medicftl Bulletin, December, 1889. 



MO 



D1SEJLSE3 OF THE ^SS, 



Acrrs Ubtica&ia. — An attack of acate urticaria is usnallj pire- 
oedad or acconnianicd by a feeling of languor and general depression. 
TIm toi^iie u GOAted, the puke ia qoickened, the t^mperatore k 
aligiiUj elevated, and there are more or less nausea and epiga«tne op- 
|i9«M0ii. The nrine is osuallj high-colored and strongly acid. The 
emptioQ appears abmptly and spreads rapidly, sometimes coTering the 
vhole body in an hoar or two. Generally, however, it is limited to one 
or more r^ons of the gurface. The individual wheals are extremely 
evsnetcent, disappearing and reappearing scTeral times during the at- 
tack. Frictioii and pressure always hasten their reappearance and in- 
crease their number. When they occur on the face they appear, as a 
nda, on the forehead, eyelids, cheeks, noee, and ears, producing more 
or ieas swelling and disfigurement They generally remain isolated, 
however, and, unlike those which are developed on the trunk and 
extremities^ do not coalesce and form large, solid, irregular masses. 
The eruption of acute urticaria b invariably the seat of intense burn- 
ing, pricking, or stinging sensations, which sometimes become almost 
unendurable. Finally, after the lapse of a few hours, or a day or two, 
the symptoms gradually subside, the itching and burning cea^, no 
new whea^ are developed, and those which are present disappear with- 
oat desquamation or pigmentation. There are several varieties of 
acute articaria» which, owing to their peculiar features, require specisl 
description. 

Urticaria Papclosa. — This form of the disease is also known 
as lichen urticatus. It occurs almost always in young children, and 
particularly in those who are improperly fed or poorly nourished. It 
is characterized by the development of a number of small, isolated 
papules, which usually appear suddenly, and after remaining for a day 
or two gradually disappear. The lesions are in size from a pinVhead 
to a split }>ea^ and are developed around the hair-follicle& They are 
generally bright-red in color, except at the centre, which is white or 
paler than the periphery. They may appear upon any portion of the 
body, but are most numerous upon the extremities. Urticaria papulosa 
causes intense itching, and^ as a consequence, the little patient rt^sorts to 
scratching for relief, frequently tearing oft the apices of the papules, 
and covering the surrounding skin with excoriations, which remsin 
after the papules have disappeared. In some cases the papular erup- 
tion is accompanied or followed by the development of a number of 
minute vesicles. 

Urticaria Bcllosa. — This is a rare form of tirticaria. It is 
characteruBed by bulke as well as by large wheals. In some coses the 
eruption consista at first solely of wheals, which are gradually converted 
by exoessive exudation into bnllse. They may become so large as to 
resemble those which are formed in pemphigus. They are accompa- 
nied by severe itching and burning sensations 



EXUDATIONS. 



271 



I 



con 



Urticaria Xodosa. — ^Tbis variety is also known as giant urti- 
caria, and is of rare occnrrence. It ia characterized b\' the develop- 
ment in the skin and subcutaneous connective tissue of large tubercles 
or nodales, in size from a cliestnut to a small egg. They are hard to 
the touch, elevated above tlie adjacent surfiicc, and seldom appear upon 
the face. They are the seat of intense burning and itching, but gener- 
ally disappear in a few hours. 

Urticaria Hemorrhagica. — This form of urticaria is uBually 
seen as a complication of purpura. The latter is, however, the primary 
and more important affection. The wheals are due to the irritation 
produced by the lesions of purpura, and are ephenieriil in character. 
Xeighboring wheals may coaieBoe, forming large hemorrhagic eleva- 
iions. 

Urticaria Ixtbrmittexs. — In this variety the eruption appears 
galarly every two or three days, or on a certain day each week, and 
ter remaining for a short time disappears, to reappear again at the 
end of the same interval, It may or may not be accompanied by feb- 
rile symptoms 

Urticaria may occur in connection with malaria, rbenraatisra, 
Bright's disease, scarlatina, measles, variola, pertussis, asthma, and 
various nervous and gastro-iutestinal disorders. It frequently is a 
complication of scabies and pityriasis. It has also been observed as a 

uela of arsenical poirioniug. 

Chronic URTifAuiA. — In chronic nrtrcaria the eruption recurs 
at regular or irregular intervals for months or years until the source 
of irritjition is discovered and removed. In some cases a fresh crop 
of wheals appears daily. The itching and burning sensatious are 
less severe, however, as a rule, than in the acute variety, and are 
iometimes absent. Constitutional symptoms may or may not be 
present. 

Diagnosis. — The diagnosis of urticaria is easy. The sudden ap- 
pearance of the characteristic wheals, their brief duration, their disap- 
pearance without desquamation, and the accompanying itching and 
burning sensations, form a complexus of symptoms that arc not pres- 
ent in any other disease. The only afFectious that present any resem- 
blance to urticaria are erythema simplex and erythema multiforme. 
In erythema simplex, however, the patches of iiypera^mia are larger 
than those in urticaria. They are uniformly red in color, are not ele- 
vated above the adjacent surface, and are unaccompanied by the sub- 
jective sensations of urticaria. The eruption of erythema multiforme 
sometimes closely resembles that of urticaria. It is more permanent 
in character^ however, usually remaining unchanged fnr several days, 
and is not attended by any marked itching or burning sensations. 
Urticaria nodosum might be mistaken for erythema nodosum, hut the 
nodules of the latter affection are painful to the touch and remain for 



DISEASES OF THE SKIN. 



aeveral days, while those of the former usually disappear in a f( 
hours. Urticaria bullosa can readily be distinguished from pemphigus 
by the presence of one or more wheals and the course of the disea«.'. 
Facial urticaria has been mistaken for erysipelas, but a consideration 
of the history of the caae, the ephemeral character of the eruption, and 
the absence of the constitutional symptoms of erysipelas, would hare 
preveuted tliat error from being made. 

Pathology.— T lie lesions of urticaria are due to a sudden exudation 
of serum into the upper layers of the skin. The vaso-motor system 
and the muscular fibres of the corium are intimately concerned in their 
production. The first step in the pathological process consists of irri- 
tation either direct or reflex of the cutaneous vaso-motor nerves. This 
produces spasmodic contraction of the cutaneous vessels, followed by 
dilatation and exudation of serum. The secondary dilatation of ves- 
sels is denied by ITnna, wlio has excised and examined wheals pro- 
duced on his own person by nettles, lie supposes the existence of 
spasm in the large cutaneous veins which contain muscular tissue. In 
consequence of this spasm a stiisis of the local lymj)hatic circulation 
ensues. The superficial and deep vessels ol the corium are involved. 
iMore or less migration of white corpuscles takes place. The muscular 
fibres of the skin remain in a state of contraction, and by forcing the 
blood toward tho periphery produce the pale centre and hyperaimic 
aureola of the eruption. 

Etiology. — Urticaria is due to direct or reflex irritation of the pe- 
ripheral vaso-motor system, and is produced by either external or in- 
ternal causes. Among the external causes are the bites of mosquitoes, 
bed-bugs, fleas, and other insects, or contact with a star-fish, jelly-fish, or 
with a stinging nettle and other plants. The hairs of the caterpillars 
of sevend species of moths excite urticaria when brouglit in contact 
with the skin. It may also be occasioned by wearing too heavy or too 
tight clothing in warm weather, or by flannel underclothing or article^a 
of apparel which have bem colored with poisonous dyes. It is sometimes 
Been in consequence of applications of the electric current. Persons who 
have a delicate skin and a nervous temperament are peculiarly liable to 
be attacked by urticaria when they become exposed to any source of 
irritation. In some ^jersons of a markedly nervous type the charac- 
teristic wheals of urticaria aro produced by the slightest irritation. 
Lines drawn upon the skin by a bhint-pointed instrument such as a 
pencil are almost immediately followed by the emptiom In this way 
the w4ieals nuiy easily be caused to form the outline of white letters 
with pink borders. To this phenomenon the French liave given the 
name of auiogrftpltism. It usually occurs in the subjects of hysteria. 
Purely hysterical autographism, however, dilTcrs from true urticaria 
in that neither smarting nor itching attends the development of the 
lesions* 



ESTJDATIONS. 273 

Among the intenml tausus, gastric and idtestinal disorders liold 
the most prominent place; in fact, ninety per cent of the cases can be 
traced to gome disturbance of the alimentary canal. Excessive drink- 
ing of wine or beer, or over-iudulgeuce in any rich variety of food, 
may develop a copious eruption at any time. Certain articles of diet, 
8uch as lisb, oysters, lobsteri?, crab^, shrimps, pork, sansage, and mush- 
rooms, are well known as being especially promotive of an outbreak, 
particularly If eaten during Wiirm weather. It is probable that the 
irritation is then due to fermentative changes or to a special poison 
generated by decomposition of the otTendiug substance before diges- 
tion is completed. In other cases the attacks always follow the inges- 
tion of particular varieties of food, such as rice, oatmeal, strawberries, 
raspberries, and buttermilk, and are probably due to an individual 
idiosyncrasy. 

The eruption sometimes develops so soon after ingestion of tlic 
offending substance that it would seem to be due to rellex nervous in- 
fluence. Owing to a similar idiosyncrasy, outbreaks of urticaria some- 
times succeed the administration of quinine, salicylic acid, salicylate of 
goda, kairin, antipyrine, iodide of potiissium, turpentine, chloral, 
cubebs, copaiba, arsenic, and valerian. Intestinal worms are occa- 
sionally a source of the affection. Urticaria may be provoked by 
menstrual and uterine disorders in females. Dr. Mauton, of Detroit, 
has described two cases in which urticaria developed in women who 
were approaching the climacteric period. In a third case an unmarried 
woman was attacked several months after ablation of the ovaries. Dr. 
Frank, of Prague, has reported the case of a woman, twenty-eight 
ye4irs of age, who, at each menstrual period, was attacked by a very 
aoTcre urticaria which, within one and a half or two hours, invaded the 
entire body. The left ovary and tube being found diseased, saI}>ingot- 
omy was performed, since wlucli time the urticaria has disappeared,* 
It may be caused by disturbance of the genito-uriiuiry organs in males; 
and in susceptible subjects by fright, auger, or any intense menial emo- 
tion. It may occur after or during an attack of variola, scarhitina, mea- 
sles, rheumatism, Bright's disease, asthma, purpura, pertussis, neuralgia, 
and other nervous disorders. Nettle-rash sometimes occurs in patients 
suffering from hydatid cysts, f A cubic centimetre of filtered fluid from 
a cyst was injected by Debove under the skin of three individuals who 
bad never had urticaria. In two of these characteristic wlieals were de- 
veloped, whence it may be inferred that the disease is due to auto- 
intoxication from absorption of the liquid* AtTections of the liver, 
chronic gastritis, and dilatation of the stomach may also be productive 
of attacks of articaria. Chronic urticaria is frequently due to malaria ; 

• Ifedlcal Bulletin, Septcmbt^r, 1890, p. 830, 

f See (jrahmn's Work an Hydatid Disease in its Cliuical Aspects, p. t7— the Hydatid 
Edinbargh niid PbilAdelpliIsi, 1891. 
18 




274 



DISEASES OP THE SKIN. 



in other cases it ia dependent upon gastric or intestinal derange 
Litha*inia and other disturbances of the organs of elimination 
also potent causes in its prodtiction. 

Treatment. — The most important consideration in the treatment of 
an attack of urticai'ia is to discover and remove the exciting cause as 
soon as possible. In acute cases, inquiry should be made as to the na- 
ture and amount of the food recently partaken of; and if the indica- 
tions point to it as the disturbing cause, and there is reason to believe 
that it ia still in the stomach, an emetic of apomorjihine, ipecacuanha, 
mustard, or salt and water, should be administered at once. Imme- 
diate relief can often be obtained by free vomiting. If several hours, 
however, have elapsed since the offending substance was swallowed, the 
probability is that it has passed into the intestinal canal, and emetics 
will be of no avail. A full dose of the mild chloride of mercnrv, 
castor-oil, sulphate of sodium, suljihate of magnesium, or Rochelle 
salts, should then be gi\en to secure free purgation, and followed by 
smaller doses once or twice daily until recovery is complete. It is well 
to restrict the diet to bread, milk, and soup for a tew days. Cold water 
and carbonated waters arc not at all objectionable, but wine, beer, and 
other alcoholic licjuors must be rigidly avoided. 

In those in whom the attack can not be traced to any particular 
article of food, relief can usually be obtained by regulating the diet 
and directing the patient to take five grains of bhie-miLSS at bedtime, 
and a mild saline aperient in the morning. In cases in which there 
is marked acidity or irritability of the stomach, and the urine is scanty, 
high-colored, and strongly acid, bicarbonate of potassium in ten-grain 
doses every two hours will be found invaluable. Acetate of potassium, 
liquor potassap, and bicarbonate of sodium are also of service. When 
the irritability of the stomach can not bo traced to any assignable 
cause, I have obtained marked benefit by the administration of oxalate 
of cerium in ten-grain doses, either alone or combined with a sixteenth 
of a grain of morphine. Bismuth, belladonna, dilute hydroeyauic acid, 
ether, chloral, and chloroform will also be found at times beneficial ; 
likewise the mineral acids. In all cases, however, one or two move- 
ments of the bowels should be secured each day. 

According to Lassiir, an attack may often be cut short by salicylate 
of sodium in doses of twenty-four grains, thrice repeated at intervals 
of two hours. 

In the subacute variety the following combination wdll generally 
afford promi>t and often permanent relief : 

^ Magnesti sulphatis 5 bs. 

Ferri sulphatis .......*. gr. xij. 

Acidi sulphuriei dibit. f 3 j* 

Aquaj , . , q. B. ad. f 3 lij. 

M. Sig. : Two teaspoonfuls, well diluted, three times a day. 







EXUDATIONSL 275 

The various alkaline mineral watera may also be administered with 
benefit. 

In chronic nrticaria the source of irritation should be diligently 
mght for and removed. The food should be light and nutritious, 
md the clothing warm and non-irritating. If lithaenuc or gouty 
lymptoms are present, great relief can often bo obtained from— 

IJ Tinet. aconiti rad ^, xvj. 

Vini colchici rad f 3 ijss. 

PotasBii acetatis 3 ss. 

Aquae .... , . . , f 3 iijss. 

M. Sig. : Dessertspoonful in water three times a day. 
If digestion is slow or ioaMuplete, good results may be derived from 

I the administration after meals of a powder containing ten grains of 
l^epsin, one grain of ij>ecacuuidia, and one fortieth of a grain of strych- 
nine, Apollinaris or Vicliy water, unrestricted as to quantity, is bene- 
iicial in these cases, and often aids materially in effecting a cure. 
Quinine in five-grain doses, three times a day, will be found to be inval- 
uable in cases of an intermittent type, as well as in many others liaving 
chronic urticaria, thaugh, according to Qiiinquaud, arsenic iti the form 
if Fowler's solution is generally more efficacious. OuL'ueau do Mussy 
[ministers thrice daily a pill containing one and a half grains each of 
iwdered jaborandi and exti-act of guaiac with three grains of benzoatc 
rf lithium. Brocq recommends* a pill composed of three-fourth grains 
di of quinine and ergotin with one-tiftieth gi^ain extract of belladonna, 
»m eight to sixteen pills being given at two hours' interval during tho 
ity-four hours. If tho patient be decidedly rlieumatic or gouty, he 
Blbines about one-eighth grain extract of colehicnm witli one-quarter 
grain powdered digitalis, and administers from two to eight during the 
course of the day. Halicylate of sodium or the bromide of litiiium will 
sometimes eflFect a cure when quinine has failed. They are especially 
indicated in those attacks which depend upon the rheumatic or gouty 
uHathesis. Arsenic, atroi)ine, chloride of ammonium, sulphur, naphthol, 
id the sulphites and hyposulphites are of value in some cases, Ich- 
lyol may^ occasionally prove useful in chronic urticaria. Tho remedy 
rom which I have obtained tlie beat results, in obstinate cases, how- 
rer, is sulphurous acid. I usually give it in doses of from one half to 
drachm, three times a day, well diluted with water. In those 
which are depeudent upon nervous causes, Dr. Nitot* ascribes 
ftn almost specific virtue to antipyrin. In one case the eruption ap- 
peared periodically each day. Seven and a half grains of antipyrin 
were administered two or three hours before the expected time of 
attack. After four days of this treatment the urticaria permanently 
, disappeared , 

In cases duo to reflex irritation from the genital organs, prompt 

* Journal dc Mtidecinc de Farbi, June 2, 1869. 




270 



DISEASES OF TKE SKIN. 



roliof is effected by draclim-doaes of the fluid extract of salix nigra. 
Bromide of potassium is also serviceable. Cuscs attended with chronic 
constipation which have resisted other treatment ma}^ he benefited and 
often cured by hypodermic injectioDS daily of two to four drachms of 
castor-oil. 

For the relief of the distressing itching^ and soreness, Blaschko, of 
Berlin, has found anti pyrin of value. For infants he prescribes — 

l| Antipyrin 3 ss. 

Syrup, simpl ^ 3 j* 

M, Ft. sol 

8ig. : Half a teaspoonful at night before going to bed. 
Occasionally he has known larger doBCS to he necessary. 

Attention has been called by Dr. RitTat, of Salon ica» to strophan- 
thns as a remedy in acute and chronic urticaria. Uis plan is to give 
the tincture in doses of fifteen to twenty droj)s during the twenty-four 
hours. He stjites that in the acute form a single dose will often be 
followed by the diisappearauce of the wheals as well as the itching. lu 
five cases of subacute, acute, and chronic urticaria, Stein obtained sat- 
isfactory results from administration of the iodide of potassium after 
failure of the salicylate of swJium, atropine, qiiiaine, and atrophanthus,* 
External treatment is of prime importance in both acute and 
chronic urticaria. The itching and burning sensations are usually so 
intense as to demand imnietliate attention. All tight, coarse, or im- 
proper articles of clothing, and other external sources of irritation, 
should be removed, and soothing applications made to the affected 
surface. Various lotions and ointment?? nuiy be used for this purpose. 
In some, cold water, either in the form of a douche or the cold com- 
press, will be sufficient In others a lotion, composed of equal parts 
of vinegar aud Walter, will be found beneficial. Another excellent ap- 
plication is composed of one part of whiskey and two parts of water. 
Sometimes a hot mustard foot-bath gives almost iustanlaneous relief. 

Gratifying results can usually be obtained from the use of alkaline 
lotions er baths, contjiining a drachm of bicarbonate of sodium or a 
drachm and a half of bicarbonate of potas^iiim to the gallon of water. 
Weak carbolic-acid lotions will often be found useful. I sometimes use: 

5 Acidi carbolici f 3 ss. 

Spts. vini rect f 3 iv. 

Aq. campliorip f 5 "^j- 

M. Sig. ; Ap]ily externally. 
The officinal creaaote-w^atcr may also be emj)loyed with advantage. 
Another efficacious application is : 

5 Tinct. aconiti rad f 3 j. 

Aq. month, pip. , , f 1 iv, 

^I. Sig. : Use as a lotion every hour. 

* Mtinclicuet' med, Woclieiiscbrifl, October 7, 1890. 




^ EXUDATIONS, 077 

^f A solution composed uf menthol five grains, and water one ounco, 
HIb a good remedy. A variety of other lotions have been recommended, 
Hthe most valuable of which are : benzoic acid ten grains, alcohol four 
^Hraehms, water six drachms; chloral thirty grains, water one ounce; 
■^chloroform five minims, alcohol one drachm, water four ounces; cor- 
roaire chloride of mercury two grains, water four ounces ; dilute hy- 
drocyanic acid ten minims, water three ounces; dilute sulphuric acid 
©ne drachm, water eight ounces ; citric acid two drachms, water six 
onnces; acetic acid one drachm, water five ounces; carbonate of am- 
monia one drachm, water four ounces. One part of ether to two part^ 
of lukewarm water is recommended by Quinquand. Sweet spirit of 
nitre^ either plain or diluted with water, or spirit of Mindererus and 
nj alcohol in equal parts have sometimes proved efficacious. 
H The following combination will frequently be found useful, espe- 
cially in chronic cases : 

U Hydrarg. chlorid, corros gr, ss. 

^fe Tinct benzoini- f 3 ijss. 

^^^^^H Glycerin! f 3 ij- 

^^^^^y Aq. rosse ^ 3 vj> 

■ M. 

" A lotion containing belladonna may also be recommended. In 
many eases ointments may be employed with advantage. I some- 
times Qse : 

I ^ Acidi carbolic! 3 ss. 

^b Camphorae 3 j. 

^^^H Chloral h jdrat 3 j« 

^^^f Vng, aq. T0S3S | ij. 

^f M. Ft ung. Sig. : For external use. 

H Another excellent combination is: 

H 5 Bismuthi subnitnitis 3 ij. 

^k Vug. veratrinae | j. 

^m M, Ft, ung. Sig. : Apply externally. 

■ The ordinary benzoated oxide of zinc ointment is also a service- 
able application. Kbuth states that an ointment containing twenty 
grains of acetanilid to the ounce eflfeetually relieves the itching and 
dngiing sensations. The distressing itching may be alleviate*! by 
diachylon, menthol, cocaine, naphthol, belladonna^ or ichthyol oint- 
ment In chronic cases great benefit can be obtained from the em- 
ployment of baths containing half an ounce of dilute nitro*muriatic 
acid to the gallon of water. Ordinary salt-water baths are of value. 
Warm baths containing sulphurated potassa, as recommended by Jaraie- 

■ Bon, are likewise beneficial Two ounces of the salt are added to 
thirty gallons of water. Quinquaud, on the contrary, asserts that 
chronic urticaria is aggravated by the use of baths, and recommends 
etkvelopment of the affected parts, whenever practicable, in cotton-wool. 





278 



DISEASES OF THE SKIN. 



Prognosis. — The prognosis of urticaria is always favorable. Acute 
casea can be promptly relieTeil by appropriate treatment, and fre- 
quently subside spontaneously witliout any meilication. Ilelapses may 
occur from time to time, but tliey are as amenable to treatment as the 
primary attack. 

Chronic urticaria is a more stubborn affection, and sometimes 
baffles all treatment for months, but it disappears when the irritation 
which produces it is discovered and removed. 

Urticaria Pigmentosa.— A brief description may be given here 
of a mre aifection which has been termed urticaria pigmentosa by 
some writers, and xanthelasmoidea by others. It manifests itself dnr* 
iu*^ infancy or early childhood. It is characterized by the sudden ap- 
pearance of wheals, tubercles, or large pajvules, whicli are elevated 
above the surface* and vary in color from pink to yellow or dark- 
brown. They remain prom incut for several days or weeks, and then 
slowly subside, leaving large, green, brown, or yellow pigmented and 
indurated spots to mark tlieir location. In some cases the wheals do 
not disappear, but remain as permanent new formations in the skin 
and subcutaneous connective tissue. The eruption is accompanied by 
intense itching and biiruiug^ and more or less constitutional disturb- 
ance. The pathology of this affection is unknown. Some observera 
regard it as a distinct disease, while others believe it to be only a vari- 
ety of urticaria. The treatment should be palliiitive and symptomaUe. 

Aft TE CiRciTMsriUBEi) (Edema of the Skin. — This condition 
bears a certain resemblance and perhaps relationship to urticaria, with 
which it has probably often been confounded. It wiis first particularly 
described in 1870 by Milton,* who unfortunately bestowed upon it the 
name of giant urticaria, a name also applied to urticaria nodosa. Sub- 
sequently cases were reported by Quincke, Striibing, and others under 
the title which heads this paragraph, and Dr. M. B. Hartzell hiis pub- 
lished f an account of a case which came under his care. The affec- 
tion usually develops upon the face, though other portions of the 
body may be attacked. The cedematous swelling is generaUy soft, 
pitting upon pressure, but exceptionally it is hard and no indentation 
can bo made upon it. The tumors vary considerably in size, eonie- 
times being as large as a fist. The skin which covers them is usually 
unchanged in color, occasionally it is retldencd. As a rule, itching 
and pain are absent, and the only sensation experienced is that of ten- 
sion. The trouble is apt to make its first appearance during the night, 
twenty-four hoars often sut!icing for its development and retrocession. 
The lesion develops rapidity, and is of comparatively brief duration. Most 
often it is rapid also in its disappearance. Frerpiently but one tumor 
is produced at a time; sometimes two or three may coexist, but the 
number wliich simultaneously appear is never large. As a result of 
• Edinburgh Medii^J Journal, 1876. f Univereitir Medical Magazine. May, 18^. 



EXUDATIONS. 

recnrrent attacks the skin may lose its elasticifcy and hang downward 
ia a fold. The disease may attack the mucous membrane of the mouth, 
tongue, or larynx, and give rise to difficult respiration or dDglutitton. 
Alarming dyspuu^a lias, iu fact, been produced, and in one cane iloath 
occurred from a*dema of the larynx. In some instanceti the dysprnjoa 
has preceded the evolution of the cutaneous lesion. 

Most of the cases repoiled have been accompanied by symptoms of 
gastro- intestinal disturbance. In a minority the patients were subject 
to attacks of urticaria. In some the lesions of urticaria and of wdema 
were both present at the same time. Generally, however, the two did 
not coexist A number of cases have arisen from prolonged anxiety or 
severe grief, but in others no cause could be detected. There seems to 
be a strong tendency to heredity, and Osier alliulcs to a family in which 
cutaneous cedema could be traced through Ave generations. The disease 
once established is liable to recur frequently for an indefinite period. 

Tonics and laxatives are employed, but the treatment is unsatisfac- 
tory, Iu riartzeira case small doses of the salicylate of sodium together 
with a saline laxative appeared to diminish the frequency and seventy 
of the attacks. 



lilOHEN PLANUS. 

Lichen planus is a chronic inflamnuitory cutaneous affection^ char- 
acterized by the formation of small, flat, circular or quadrilateral, red- 
dbb, umbilicated papules, which pursue a chronic course, but finally 
terminate in resolution, and ai*e followed by more or less pigmentation 
of the surface. 

Symptoms.— The eruption usually develops without any premoni- 
tory symptoms. It is symmetrical in character, and consists at first 
I a variable number of minute red papules, which are of about the 
of a mustard-aeed, and are accompanied by more or less itching, 
hich is apt to be worse at night. They may appear upon any por- 
n of the surface, but are most frequent upon the anterior surfaces of 
e foreanns and the tibial surface of the legs, and seldom occur upon 
he palms or soles. They rarely, if ever, develop upon the face, but have 
been observed upon the tongue and the mucous mcmlirane of the mouth 
and fauces. In two cases Bulkley has seen them appear primarily on 
the glans penis. The lesions attain their full development in a few 
days^ and are in size from a pin's-head to a split pea. They are then 
oadrilateral or irregularly rounded in shape, and sliglitly elevated 
re the surrounding surface, from which they rise abruptly. They 
dark-red in color, present an umbilicated appearance, and are 
t gurrounded by an inflammatory aureola. They are firm to the 
ach, hut not painful 'J'hcir surfaces arc usually smooth, but may 
lly become the seat of slight furfuraceous desquamation. The 
pules may be isolated and disseminated over a wide area, but gener- 





280 



DISEASES OF THE SKIN. 



ally mflnifost a tonilenc}^ to form groupa or bands of various sizes. In 
Bomc iostanoes tliey exhibit a linear arrangemeat aud follow the course 
of certain cutaneous nerves. Thej renmin discrete, however, and do 
not coalesce and form large patches. Individual ])apules pursue an 
iudepciident course of development, somo attaining greater size or 
persisting longer than their fellows. The course of the eruption 
varies. It may subside spontaneously in a few weeks, or it may re- 
main for an indefinite period. Fresh lesions occur from time to time. 
When the papules finally disappear, marked pigmentation of the epi- 
dermis is seen at their site, Tiiis pigmentatio]! may tiimlly fade and 
the normal appearance of the skin be regained. In some cases, how- 
ever, atrophi(* spots or patches may follow. In others more or less 
desquamation may also be observed, but neither vesiculatiuri nor pus- 
tulation takes place. The epiderm covering the papules sometimes be- 
comes markedly tliickeiied. This result mainly occurs in regions where 
the cuticle is normally thick, as upon the knees, elbows, etc., but is not 
restricted to those localities. The intervening skin remains normal in 
Btructure and appearance throughout the course of the disciise. The 
nails are rarely if ever involved. 

Diagnosis. — The only affections which present any resemblance to 
lichen planus are lichen ruber, lichen scrofulosus, papular eczema, 
psoriasis, and the papular syphilide. The papules of lichen niber, 
however, are rounded and acuminated, and accompanied by intense 
itching; those of lichen planus are cpiadrilateral, ilattened, and um- 
bilicated, with little or no itching. In lichen ruber the intervening 
surface becomes reddened and infiltrated, and the wliole system is pro- 
foundly involved. In lichen planus tlie intervening skin remains nor- 
mal, and the general health is unaffected. In lichen scrofulosus the 
papules are reddish-yellow in color, and are situated around the hair- 
follicles. They are only observed in persons of the scrofulous diathesis, 
and rarely occur after the twenty-fifth year. The papules of lichen 
planus are dark-rod in color, and are developed around the orifices of 
the sudoriparous glands. In papular eczema the papules are arranged 
in groups, but they are seated upon an intlained surface, and severe 
itching and more or less vesiculation and desquamation follow. Some 
cases of psoriasis may, in their early stages, present a slight resem- 
blance to lichen planus, but the development of the characteristic 
mother-of-pearl scales will make the diagnosis certain. The papules 
of syphilis are developed in groups, but their large size, coppery color, 
and extensive distribution, and the presence of other symptoms of the 
disease, will ]>revent any diagnostic error. 

Pathology. — ^Tbe lesions of lichen planus are the result of a cir- 
cumscribed inflammation of the papilla and the upper portion of the 
corium. The vessels of the papillary layer are dilated and tortuous, 
and the interspaces are crowded with leucocytes. The unibilicated ap- 



md 



^^^^^^^^^^^^ EXUDATIONS. 281 

pearance of the papules is doe to the fact that they are situated arouini 
Uie orifices of the sudoriparous ducts, aod that while their raargius are 
elevated hy the exudatiou, their eentrea are prevented from rising by 
their attachment to the duet. The pigmeut changes arc due to the 
escape of the red eorpusclea and deposition of the coloring-matter in 
the cutaneous tissues. 

Etiology. — The catise of the eruption has not been definitely ascer- 
tained. It attacks indiscriminately mule and femah', but is apt to be 
more severe and rebellions in women than in men. It is most fre- 
quently observed between the twentieth and fortieth year. According 
to my experience, it is almost invariably associated with evidences of 
general debility. Improper or insufficient food, nervous depression^ 
and mental anxiety are probably the chief causes in its production. 
Dr. C. P. Russell, of Utica, N. Y., reports in the " Journal of Cutane- 
oua and Genito-Urinary Diseases" for June, 18Sf), a c^ise in which 
lichen planus invaded the forearm and arm of a man in whom four fin- 
gers of thecorrespondiug hand Imd been partially amputated on account 
of injury. The reporter quotes a few other cases in which the evolu- 
tion of lichen planus seemed to depend upon the condition of some 
portion of the nervous system. It sometimes occurs in persons of 
rheumatic tendency. 

Treatment. ^ — This should be both constitutional and local. Exer- 
cise in the open air is essential. The diet should consist priucipally of 
beef, milk, eggs, and fruit The condition of the alimentary canal is 
to be carefully ascertained. If any digestive disturbances exist they 
most be promptly remedied. If constipation is present, it must be 
removed. If there are evidences of general debility, gentian, serpen- 
taria, coptis trifoUa, antl quinine may be given with advantage before, 
and iron and nnx vomica after, meals. In cases arising from nervous 
depression or mental fatigue, great benefit will be derived from the 
administration of one draclim of the fluid extract of erythrosylon coca 
half an hour before, and one drachm of the following combination half 
an hour after, meals : 

I^ Liq. pofcassii arsenitis ^ 3 ]• 

Tinct. nucis vomicae f 3 ss. 

Acidi phosphoric! dilut f 3 ij. 

Syr. simp ....,., f S ij- M. 

Kobner, liesnier, and others have practised with good results hypo- 
dermic injections of arsenical solutions. 

In cases accompanied by marked anaemia, rapid improvement will 
result from the administration of ten minims of the tincture of the 
chloride of iron before, and seven to fifteen grains of chlorate of po- 
taaaium after, meals. Cod-liver oil and the extract of malt are valu- 
able in debilitated cases. Arsenic sometimes appears to yield good re- 
salta. Itching may often be relieved, according to Blaschko, by the in- 



DISEASES OF TOE SKIN, 



ternal use of antipyrin. The tincture of belladonna, valerianate of 
ammonium, and carbolic acid are also recomra ended for thig symptom. 
Robinson has liad good results from tbe use of acetate of potasdum 
with spirit of nitroua ether. 

If the eruption consists of a few scattered papules, no local meas- 
ures will be necessary, except to avoid the use of irritating under- 
clothing. When the papules are numerous and grouped, and accom- 
panied by more or less itching, various soothing lotions or ointments 
nuiy be employed, or tlie surface covered with a saturated solution of 
the bicarbonate of sodium. 

A ten-per-eent. solution of ebrysarobin*traumatiein, applied with a 
brush twice weekly, is recommended by Herxheimer. Bran-baths to 
which vinegar has been added, inunction with glycerole of starch or 
glycerine containing tartaric acid, are recommended as useful external 
treatment by Vidul and Hroeq. A corrosive sublimate wash or the 
emplastrum Vigo of the French may also be employed with advantage. 
A two to four per cent, solution of ichthyol in water baa also been 
employed. In obstinate cases Unaa advises the application of diachy- 
lon-ointment containing carbolic acid in a proportion as high, perhaps, 
as four per cent. To this mixture corrosive sublimate is added in quan- 
tities gradually increasing from two gmins to the ounce. 

In severe cases alkaline baths, friction with the compound tincture 
of green soap, and the application of tarry ointments, are advised by 
Dr. R. W. Taylor. 

Prognosis. — The prognosis is always favorable. The eruption is 
not accompanied by any constitutional symptoms, and, while it may 
occasionally manifest a disposition to linger, it eventually becomes 
amenable to treatment ami disappears. More or less pigmentation 
remains for a long time at the site of the eruption, but finally the epi- 
dermis resumes its normal color. 



4' 



UOHUN SOHOFULOBTJS. 

Lichen scrofnlosus is a chronic inllammatory cutaneous disease, at- 
tacking persons of a scrofulous diathesis, and characterized by the for- 
mation of a number of minute papules, which are situated around and 
over the hair- follicles. 

S7mptoiEi& — The eruption of lichen scrofulosus consists of a num- 
ber of small papules; in size ranging from a mustard-seed to a small 
pea. They vary in color frotn pale red to yellow, or reddish-brown. 
They are firm to the touch, and are slightly elevated above the surround- 
ing surface. The lesions are observed most frequently upon the thorax 
and abdomen, but may occur upon the back, the extremities, the face, 
the scalp, or any other region of the boily. They are usually devel- 
oped in groups, which occasionally coalesce and form large, irregular 



i 



MTOATIONR 






patches. The apex of each papule is covered with a small whitish 
scale. The eruption pursues a chronic course. The papules, which 
are first dereloped, gnidiially disappear by absorption and desquama- 
tion, but are followed by a second crop. These in turn become ab- 
sorbed and are succeeded by others. Finally, the morbid process 
ceases, the existing lesions disappear, and recovery ensues. 

The papules of lichen scrofulosus do not itch, and are not accom- 
panied by any subjective 8ym]>toms ; but 1 lie presence of the scrofu- 
lous diathesis is usually manifested by enlargement of the cervical or 
axillary glands, or other significant signs. More or less discoloration 
of the general surface may also exist. 

Diagnosis. — The lesions of lichen scrofulosus resemble somewhat 
those of lichen ruber, keratosis pilaris, papular eczema, and the small 
papular syphilide. In liclien ruber the papules are brighl^red in color, 
however, and gradually involve the whole surface, but they do not man- 
ifest any tendency toward grouping. In keratosis pilaris the papules 
are gray in color, and are generally confined to the extremities. They 
arc formed exclusively of e|ndennic scales, and are not developed in 
groups. 

The papules of eczema are irregular in size, bright*red in color, 
and nsually limited to one area of the surface. They are complicated 
by the formation of vesicles, and are accompanied by severe itching 
and burning sensations. They run an acute course. The papules of 
syphilis are dark-red or reddish-brown in color, and irregular in size. 
They are widely distributed, and are attended by other symptoms of 
the disease. 

Pathology. — The pathology of lichen scrofulosus Itas been thor- 
oughly studied by Kaposi. The papules are jiroduced by inflamma- 
tory exudation and cell -in filtration into the hair- follicles and sebaceous 
glands, and into the tissues which immediately surround them. The 
morbid process begins at first around the blood-vessels and in the con- 
nective tissue at the base of the hair-follicles. The colls finally pene- 
trate into the cavities of the follicles and the glands, distending them 
such an extent as to elevate the epidermis and produce the charac- 
ristic papules. The*lesions may disappear by absorption, or by super- 
ficial ulceration and the formation of minute cicatrices. 

Etiology. — Lichen scrofulosus is rarely met with in the United 
tates. It appears to be more common in males than in females, and 
nsually encountered about the age of puberty. It niay, however, 
pear at any age* It is probably due indirectly to the scrofulous 
thesis, but its immediate exciting cause is not known. 
Treatment. — Nutritious food, fresh air, sunlight, and warm cloth- 
are of jmnimount importance in the treatruent of lichen scrofu- 
Tbe patient should also be directed to sponge the entire surface 
salt water two or three times a week. 




DISEASES OF THE SKIN. 

ternal use of antipyrin. The tincture of belladonna, valerianate of 
ammonium, aud carbolic acid are also recommeoded for this symptom. 
Kobinson has had good results from the use of acetate of potassiuui 
with Rpirit of uitrous ether. 

If the eruption consista of a few scattered papules, no local meas- 
ures will be necessary, except to avoid the use of irritating under- 
clothing. When the papules are numerous and grouped, and accom- 
panied by more or less itching, various soothing lotions or ointments 
may be employed, or tlie surface covered with a saturated solution of 
the bicarbonate of sodium. 

A ten-per-cent. sohition of ehrysarobin-tmumaticin, applied with a 
brush twice weekly, is recotntnended by Herxheimer. Bran-baths to 
which vinegar has been added, inunction with glycerole of starch or 
glycerine containing tartaric acid, are recommended as useful external 
treatment by Vidal and Brocq. A corrosive sublimate wa.sh or the 
emplastrum Vigo of the French may also be emjdoyed with advantage, 
A two to four per cent, solution of iehthyol in water has also beea 
em])loyed. In obstinate cases Unna advises the application of diachy- 
lon-ointment containing carbolic acid in a proportion as high, perhaps, 
as four per cent. To this mixture corrosive sublimate is added in quan- 
tities gradually increasing from two grains to the ounce. 

In severe cases alkaline baths, friction with the compound tincture 
of green soap, and the application of tarry ointments, are advised by 
Dr. R. W. Tnylor. 

Prognosis. — The prognosis is always favorable. The eruption ia 
not accompanied by any constitutional symptoms, and, while it may 
occasionally manifest a disposition to linger, it eventually becomes 
amenable to treatment and disappears. More or less pigmentation 
remains for a long time at the site of the eruption, but finally the epi- 
dermis resumes ita normal color. 



UOHEIf SOROFUIiOStJS. 

Lichen scrofulosus is a chronic inflammatory cutaneous disease, at- 
tacking persons of a scrofulous diathesis, and charaeterisied by the for- 
mation of a number of minute papules, wliich are situated around and 
over the hair- foil ides. 

Symptoms. — The eruption of lichen scrofulosus consista of a num- 
ber of small papnles; in size ranging from a mustard-seed to a small 
pea. They vary in color from pale red to yellow, or reddish-brown. 
They are firm to the touch, and are slightly elevated above the surround- 
ing surface. The lesions are observed most frequently upon the thorax 
and abdomen, bnt may occur upon the back, the extremities, the face^ 
the scrtlp^ or any other region of the body. They are usually devel- 
oped in groups, which occasionally coalesce and form large, irregular 



IXFDATIOM 



283 



Ltcbea. The apex of each papule is covered with a small whitish 
de. The eruption pursuea a chronic course. The papules, which 
re first deyelopeii, gnidually dii^apivear by absorption and dcsquauia- 
"tion, but are followed by a second crop. These iu turn become ab- 
sorbed and are succeeded by others. Finally, the morbid process 
ceases, the existing let^ions disappear, and recovery ensueB. 

The papules of lichen scrofulosos do not itch, and are not accom- 
panied by any subjective symptonis; but the presence of the scrofu- 
lous diathesis is usually manifested by enlargement of the cervical or 
:illary gland«, or other significant signs. More or lees discoloration 

the general surface may also exist. 

DiagBOSis,^ — ^The lesions of lichen scrofulosus resemble somewhat 
loee of lichen ruber, keratosis pilaris, papular eczenui, and the small 
kpular eyphilide. In lichen ruber the papules are bright-red in color, 
lowever, and gradually involve the whole surface^ but they do not man- 
fest any tendency toward grouping. In keratosis pilaris the papules 

gray in color, and are generally confined to the extremities. They 
are formed exclusively of epidermic scales, and are not developed in 
groups. 

The papules of eczema are irregular in size, bright-red in color, 
and usually limited to one area of the surface. They are complicated 
by the formation of vesicles, and are accompanied by severe itching 
and burning sensations. They run au acute course. The papules of 
syphilis are dark-red or reddish- brown iu color, and irregular in size. 
They are widely distributed, and are attended by other symptoms of 
the disease. 

Pathology. — The pathology of lichen scrofulosus has been thor- 
oughly studied by Kaposi. The papules are produced by inilamma- 
tory exudation and cell-in dltration into the hair-follicles and sebaceous 
glands, and into the tissues which immediately surround them. The 
morbid process begins at first around the blood-vessels and in the con- 
nective tissue at the base of the hair-follicles. The cells finally pene- 
trate into the cavitie-s of the follicles and the glands, distending them 
to BUch an extent as to elevate the epidei'mis and produce the charac- 
teristic papules. The'le.sions may disappear by absorption, or by super- 
ficial ulceration and the formation of minute cicatrices. 

Etiology.— Lichen scrofulosus is rarely met with in the United 
States. It appears to be more common in males than in females, and 
ia usually encountered about the age of puberty. It may, however, 
appear at any age. It is probably due indirectly to the scrofulous 
diathesis, but its immediate exciting cause is not known. 

Treatment. — Xutritious food, fresh air, sunlight, and w^arm cloth- 
ing are of paramount importance in the treatment of lichen scrofu- 
losus. The patient should also be directed to sponge the entire surface 
with salt water two or three times a week. 



284 



DISEASES OF THE SKIN. 



Medicinally, the best results can be obtained from the administra- 
tion of large doaea of cod-liver oil. Inunctions or hypodermic injec- 
tions of the earae remedy are also of service. The iodide of iron will 
often be found Yaluiible. Quinine, strychnine, and phosphorus may 
also be administered. 

Arsenic is sometimea of service. The external treatment consista 
of baths containing bran or starch, washing the affected surface with 
tar-soap, or inunction with cod-liver oil. 

Prognosis.^ — The prognosis is always favorable. The eruption may 
prove obiitiuate, but time and proper treatment will finally effect a 
cure. 

PHURiaO. 

Stjiomtms.— Prarigo (Ilebra) — Juckblattern — Btrophulas prarigineui (Hardj), 

Prurigo is a chronic disease, characterized by the development of 
small solid, pale, or somewhat red and isolated, deeply seated, or slightly 
elevated papules, accompanied with intolerable itching, thickening and 
pigmentation of the skin. 

Symptoms, — The disease almost invariably appears early in life, 
often during the first or secnud year, by the formation of wheals or 
a general irritability of the skin. It occasions violent scratching, the 
symptoms disjippearing to again reappear, and the peculiar eruption 
gradnally developing from the second to the seventh year. The small, 
isolated, and irregularly distributed papules which make their appear- 
ance are sub-epidermic, and about the size of a pin*s-head, or a little 
larger. Tliey are detected better by touch tliun by sight, as they are 
scarcely raised above the level of the skin. They are firm, and differ 
little, if any, from the surrounding integument in color, but at times 
present a red or purplish hue. They may be pierced with hairs, and 
covered with a dry and attenuated epidermis. They occur most 
frequently upon the outer surfaces of the extremities, particularly of 
the legs; the extensor part of the arms, the lumbar and gluteal regions, 
may also be involved. The other portions of the skin may be affected 
likewise; the axillary, popliteal, palmar, and plantar regions are, how- 
ever, always exempt, and in well-marked cases pj'csent quite a contrast 
to the adjoining invaded skin. 

The lesions, even before being perfectly developed, are attended 
with intolerable and persistent itching, which causes the sufferer to 
scratch and tear off the apices of the papules, from which exude serum 
and blood, which dry into crusts. The itching and scratching con- 
tinue as the disease progresses, the skin becoming, in addition, thick- 
ened, rough, fissured, and pigmented. In a case closely observed dur- 
ing a period of eight months by Dr. H, W. Taylor, individual papules 
at times underwent involution, and with this comparative quiescence of 
the disease the pigmentation became less marked. Small scattered white 



^ 



EXUDATIONS. 



285 



spots, denoting slight loss of tissue and resulting from involution of pap- 
Dies. were also perceived. These atrophic spots gradually disappeared.* 
The hairs may bo removed or torn of! hy the scratching. At times 
buboes may follow from the severe irritation^ or inllanimation, which is 
§et up in the same way. Eczema may also arise as a complication, 
either from the use of the finger-nails in scratching, in the vain effort to 
obtain relief, or from the application of irritatiug remedies. Prurigo 
is divided into two forms, namely, prurigo mitis and prurigo ferox or 
agria; in the first the symptoms are mild, while in the second they 
are more severe* They begin in one or the other form, and, as such, 
run their course singly. TIic disease generally lasts a lifetime, and, 
by its constant annoyance, exhausts the patient, giving rise to debility 
and often great emaciation. 

Diagnosis. — The symptoms of prurigo are so marked and charac- 
^K teristic as to be rarely mistaken fur any other alTectioiL Occasionally 
^Vit is liable to be confounded with pediculosis, scabies, panesthesia, and 
eczema. The absence of the pediculus on the skin or in the clothing, 
and the exemption of the hands from its ravages, are sufficient to es- 
tablish the diagnosis. Prurigo may be confounded with scabies, but 
the latter generally attacks tlie flexures, the penis, the scrotum, or fi la- 
gers, while the former involves particularly the extensor portions of 
the legs. Paraesthesia, of all diseases, is most likely to be mistaken for 
prurigo. ParEesthesia may happen at any period of life, and the lesions 
are secondar}^; prurigo commences generally in childhood, and the 
leelons are primary. Prurigo occurs, aa a rule, among the badly nour- 
ished, and paraesthesia among all classes. In paraesthesia the integ- 
ument is normal, except when irritated ; in prurigo it is the seat 
of papules primarily, and is accompanied with thickening of tlie skin, 
which seldom follows in the former. Prurigo invades particularly 
the extensor surfaces of the legs, while in parajsthesia any part or the 
entire body may be involved. Prurigo is attended with persistent 

bitching; the disease continues for years, or a lifetime. In pariesthesia 
-the irritation is frequently relieved or cured by a suitable course of 
treatment. 

Eczema may arise as a complication of prurigo from scratching, bat 
the location of the papules, their color, grouping, and the existence of 
other lesions or evidences of eczema, are sufficient for the diagnosis. 

Pathology. — ^Microscopical examination reveals that the appear- 
ances observed are similar, iti many respects, to those of papular ecze- 
ma. The papillae and the rete are filled with young cells and an exu- 
of serum occurs. As the disease becomes chronic more or less 
rophy takes place in tlie corium, with pigmetation, the glands 
ing enlarged or atrophied, and the epithelium may undergo 
fatty degeneration. 

* New York Medical Journal, January ", 1S91, 




DISEASES OF THE SKIN, 



Dr. Kromnyer, in a microscopical examiTiation of skin, excised from 
four putients of different ages and sexes suilering from typical pnirigo, 
found the horny layer of the epidermis thickened. Small cy&is were 
present in or uuder that luyer. These cysts^ which were only twice 
fonnd in the rete nmcosum, are probably the results of an exudation. 
He considera that the essential cause of prurigo consists in vaso-motor 
changes in the blood- vessels by which the epidermis is nourished,* 
Prof. Campana, of Genoa, ascribes the origin of this affection to some 
alteration in the nervous system, and asserts that in prurigo he hai 
found changes in the terminal fibrils of the nerves, lie has seen that 
in the subcntaneons tissue many of the nerves of the skin have lost 
their form and are mucli thicker than normaLf 

Portions of skin from Dr. Taylor's case were submitted to micro- 
scopical examination by Dr. Ira Yan Gieson, who describes the blood- 
vessels of the lower corium as Bnrrounded by groups of small round 
and small polygonal cells. The papilla? w^ere but little changed, 
though some were infiltratetl by the game small round and polygonal 
cells. The hair-follieles exhibited alterations, some being shrunken 
while in others poucli-like dilat^itions were observed. The nerve- 
trucks were unchanged except when situated in or near the cell clus- 
ters in the derma. Some of the papules were due to small cysts in the 
epidermis* These appeared to be due to distention of the intereellulai 
spaces in the rete Malpigiiii by exudation of fluid from a subjaceni 
oidematous papilla together with degenerative liquefaction of the c^?lls. 
The cyst« may subscfiuently ati'ophy. Those nodules wliicli were only 
perceptible to the touch disiippeared in the process of hardening by 
osmic acid. With the exception of some cell-clusters in the demia 
the skin was almost normal. Van Gieson coincides with Kromayer's 
statement, especially in regard to the sub-epidernud nodules, that 
hardened material is not suitable for a study of the changes in jirurigo. 

Etiologji — The cause of prurigo is obseare. It is rare in this 
and other countries, but is common in Austria. During a period of 
five years Dr. Zeisler met with twelve cases of pnirigo in Glncago, and 
concludes that the disease is not so extremely rare in this country as 
had been supposed. In many of Ids patients t lie disease was of the 
mild variety, though most of his cases of prurigo ferox were imported, 
yet typical examples of the severe form do occur in natives. It devel- 
ops, according to the experience of Hebra, usually among poor cliil- 
dren who are badly nourished. Sonietiiuos it is also observed among 
the better classes. It is more severe in winter than at any other 
time of the year. Krastilefsky has reported the case of a woman wlio 
had borne iiftcen children and on each occasion had suffered from 
prurigo, the attack beginning a week before and continuing until the 
second day after delivery. 
♦ Brilit.li Medical Journal, Mny 17, ISOO, f Brili^h Medical JourDal, October 13, 1888. 



EXIJBATIONa 28T 

Treatment* — Remedies which improve tliG general health assist the 
actiou of the local agents whieh uve necessary to relieve the sufferer 
from the persistent itching which is i3resent. Cod-Hver oil, iron, 

Iquioine, and arsenic may be used, according to the requirements of 
tlie case. The association of carbolic acid with cod-liver oil seems, ac- 
iConiiug to the statement of Brocq, to relieve the intense itching, lie 
^^ises the acid to be given in daily doses of twenty to sixty ceiiti- 
:grammes. The sirup of the iodide of iron or of hypophosphites may 
be employed when cod-liver oil is badly borne. Antispasmodic reme- 
dies are indicated when the patient is of an extremely nervous tempera- 
ment. Simon, Pick, and Schwimmer have given daily hypodermic in- 
jections of 0*01 grammt! of pilocarpine with beueticiul eilect. Schwim- 
mer states that the simie may be said of ergotin, in doses of from 0*05 
to one gramme per day. In one case I obtained good results from sub- 

I cutaneous injections of one eighth to one fourth of a grain of cocaine 
hydrochlorate. The local treatment, which is all-important, should 
consist of baths, particularly the water bath with soap, the vapor and 
the medicated vapor. Tar, nsiphthol, and sulphur, used alone or com- 
bined in the form of ointments, may remove or temporarily arrest the 
I disease. The occasional application of sapo viridia, followed by the in- 
unction of one of the oils, is often serviceable. Cod-liver oil is partic- 
tikrly recommended as a topical remedy in this disease. 

Prognosis. — Prurigo is generally considered incurable, but the 
milder forms occurring in children are reported by Kaposi to be 
amenable to treatment 

IHXSRFES. 
Herpes is an acute, non-contagious, inflammatory affection, charac- 
^rised by the development of one or more clusters of vesicles, seated 
pon a somewhat reddened base. 
Symptoms, — The eruption may be preceded by chilliness, headache, 
and fever, or it may be developed without any constitutional symp- 
^Htoma. Again, it may appear in connection with fevers, other dia- 
^Bmks, or exist alone ; or be preceded by sensations of heat, burning, 
^Hh itching. Sometimes it is accompanied with pain. The lesions 
^Bppear as vesicles, from the size of a pin's- head to a split pea, situated 
^■Vipon a reddened base. They are usually few in number, and arranged 
in clusters. They generally contain a serous or purulent fluid, and 
seldom burst, the contents usually drying into yellowish or brownish 

ICTOStg, which fall otf, exposing a reddened and afterward normal skin. 
An excoriation occasionally results from rubbing or interfering with 
the vehicles, but it also heals kindly, cicatrices rarely resulting. Heq>e8 
is an acute afifection, lasting about one week, and liable to relapses. 
In some instances so much constitutional disturbance accompanies the 
eruption as to warrant the designation of herpetic fever. The lesions 




^8 DISEASES OF THE SKIN. M 

of herpetic fever are nsoally located upon mucous membranes, as tbofltl 
of tiie mouth, genitalia, or conjunctiva. More rarely the skin alone or 
skin and mucous membranevS are aftected. Herpes zoster may occur 
at any tige, but is probably irioro frequent between the twelfth and 
twenty-foitrth year. It is thought to be rather more common among 
men than women. Tuberculosia and other thoracic affections, rheu- 
matism, and gout Room to predispose to attacks. Herpen is divided 
into several varieties, according to the location and arruugement of the 
lesions, which may be separately described as follows: 

LIehpes Facia LIB- — Herpes occurring on the face is also known 
as herpes or hydroa febrilis, and fever-sores. It may be observed upon 
any part of the face, as the forehead, checks, cars, eyelids, conjunctiva, 
cornea, and chin. The lips, especially the upper, are a favorite point 
of attack ; the vesicles being small, few iu number, and forming gen- 
erally but one group. They may continue isolated, or they may run 
together. The vesicles may also involve the nnicous membrane of tiie 
anterior nares, the mouth, and tongue. They develop and run their 
course in the manner already described, except when the mucous mem- 
brane is affected, when, owing to its delicate structure and the heat and 
moisture present, they usually rupture early, exposing an excoriated 
patch, or patches, covered with a j>urulent secretion, or with a yellow- 
ish or brownish crust. 

Herpes facialis may follow cold, pneumonia, fever, or any impair- 
ment of the mucous membrane of the respiratory f»r digestive tract. 
Relapses are frequent. Recurrent attacks of herpes of the tongue 
sometimes occur in those who had been infected with syphilis, but 
who had apparently been cured. Tixe erosions are small, scattered, of 
short duration, and seem iu)t to be specific manifestations, since they 
are aggravated rather than ameliorated by anti-sypbilitie. treatment. 
They seem to be due, in fact, to prior irritation of the mouth by mer- 
cury and the use of tobacco.* 

IIet<pE8 Iras. — This vanety is similar in many respecta to erythe- 
ma multiforme. It begins as one or more vesicles, or vesico-papules, 
arranged in the form of a ring on the dorsal surfaces of the hands and 
feet. At times two or more rings develop, ami the changes which 
they undergo give the patch a varied hue, resembling somewhat the 
colors of the rainbow, whence the name iris. Oceasiouidly the vesicles 
run together, forming large bullae. It is one of the rare forms of 
herpes, occurring most frequently in young persons iu spring and 
autumn. The subjective symptoms of itching or burning are not, as 
a rule, marked, and in some cases are absent. The eruption usuallj 
disappears in one or two weeks, but the skin remains pigmented, and 
rehipaes may occur. 

Dr. J. H. Thompson, of Kansas City, Mo., has reported f a rare 
♦ Fournier, La SeniaJne MfiiUcale, 1887. f Kansas Citj Medical Record, Nov., 1889. 




EXUDATlOXa 



condition in which a very diffuse herpes iris coexisted with croupous 
mjunctivitis. The eruption was abundant upon head, trunk, and 
imba. It was confluent upon the soles and palms. The conjunctival 
was entirely filled by a croupous membrane, which j2:lued the lids 
)gether and to the eyeball. The disease lasted a month. The skin 
•uption disappeared and the eyes recovered their usefulness. The 
itient was a widow, aged twenty-seven ye^rs, of delicate physique. 
Herpes Prog en it a lis. — This is also known as herpes prieputialis. 
occurs in the male, ordinarily on the prepuce, either on the external 
internal surface, and on the ghins and other portions of the skin of 
le penis. In the female the disease is more rare, and appears about 
'the vulva, especially upon the labia niajora and rainoni. In excep- 
tional cases these become immensely swollen, the herpetic vesicles coa- 
5CC, the parts are the seat of itching and burning sensations, together 
pain- The patient is unable to walk, the content*? of the vesicles 
?ape and, mingled with the Icucorrboal or gonorrha'al discharge 
lieh may be present, produce a very offensive odor. In rare instances 
vagina or neck of the uterus is the seat of herpes. The eruption 
lerally observed in young people and during adult age. It is 
?ceded or accompanied with itclsiog aud burning, and at times 
neuralgic pains, followed by the development of one or more 
lusters of vesicles, seated upon an inOamed base. The lesions may 
few or many, and are about a pin's-head in size. They may be 
icompanied with much infiammation, leading, in addition, to more 
or less swelling. The lesions occasionally dry up, and the resulting 
frusta fall olf in one or two weeks. As a rule, owing to the heat and 
loisture present around these parts, the vesicles burst within a very 
lort time lifter their formation, and serum, pus, or blood, is poure<l out 
m the surface. The excoriations and superficial ulcers which result 
covered with serous, bloody, or purulent exudation, or with a crust, 
>m their apix^arance, be mistaken for syphilitic lesions, 
becomes at times even more perplexing, from scratch- 
or irritating applications, leading to severe infiammation, harden- 
ig of the tissues and enlargement of the inguinal glands, simulating 
laucre or chancroid* 

Herpes may be distinguished from chancroid by the fact that the 

tlcerativo action of the latter leads to a depression or excavation. A 

chancre is usually attended by dryness and pressure at its base, and will 

lot cause the escape of serum or pus as in the case of herpes or chan- 

roid. An accurate and positive diagnosis can, in the above condition, 

obtained only by inoculation, or by treating the case for a time and 

raiting the result If the disease is herpetic, it will yield under sim- 

treatment within a few days or a week's time, but if, on the con- 

iry, it be sy])hilis, little or no impression will be made from simple 

^plications. Herpes progenitidis is liable to frequent relapses. It 

19 



290 



DISEASES OF THE SKIN. 



may arise from gastric or intestinal disturbance, and follows often 
from coitus, particularly in those having a long prepuce. It is apt 
also to develop iu those who have suffered from gonorrha^a, chancroid, 
and chancre. 

Hekfes Gestatioxis. — This form of herpes occurs during or after 
pregnancy. It appears an the extremities as vesicles^ papules, or bul- 
IsB, attended with itching and burning. The vesicles, which are tlie 
most predominant lesions, are ordinarily grouped, and vary in size from 
a pea to a walnut. It may he complicated with nrtitiaria, neuralgia, 
and other diseases of a similar nature, lielapses tend to follow with 
other pregnancies. 

Iltii-pes gestation is may begin as e^rly m the third or fourth week 
of a pregnancy, but not osually until the third or fourth month, remains 
until iifter delivery, and during a few days subsequent to parturition the 
eruption may experience a decided aggmvation. It then, aa a rule* more 
or less gradually disappears. In some cases its first appearance has oc- 
curred after coniinement, but lias recurred during the progress of sub- 
sequent pregnancies. In a case observed by Liveing intense pruritus 
and neuralgic pains in the limbs marked the Jatter months of a preg- 
nancy, but the eruption did not appear until the third day after ac- 
couchement. In after-years relapses oeeurred in the absence of preg- 
nancy. In two of these rehipses the mucous m^nbrane of the nionih 
was severely afTected. The herjies of gestation has been identified by 
Duhring and Broeq with the herpes dermatitis described by the for- 
mer author. To nse tlie words of the French writer, it is the derma- 
titis herpetiformis of pregnancy. Xo exact knowledge exists concern- 
ing the pathogenesis of this atfection. Leloir and Vidal suggest that 
it is caused by the nuHlitication of nervous activity due to pregnancy. 
In one case Leloir f*->und the Btaphylococcus pyogenes aureus and a 
streptococcus in the purulent contents of vesicles of this affection. 

Herpes Zoster (Stfnompfts : Zoster j Zona; Ignis sacer; Shingles). 
— In herpes zoster or shingles the lesions are similar to those jdready 
described, hut the groups of vesicles differ somewhat in their arrange- 
ment They develop along the course of, or near, several cutaneous 
nerves, often extend iug around one half of the body. The disease is 
often preceded or ushered in by eonstitutional symjttonss of varying 
severity. Fever occurs in some cases. Pain of a neundgie character 
may occur for days, rarely weeks, and commonly some hours, before 
the appearance of the eruption, or it may be altogether wanting. If 
present, it mny be felt over the entire affected surface, or it may be 
limited to one or several points. It is generally severe, is a promi- 
nent symptom, and may be of a lancinating, smarting, or burning 
character. The erujition appears first as a patch or patches of red- 
dened skin, surrounding the seat of pain. Sooner or later there occur 
one or more groups of red papulesj which develop into vesiciesj gen- 



A 



EXUDATlONa 



291 



^^■ully discrete, bnt occasionally they may coalesce, producing bullse. 

^^Blie lesions thus formed are iisiialiy in size from a piu's-head to a 
split pea. Succe^ivo crops of the vesicles continue to form from 
time to tirae during the course of the disease, and undergo their 
respective changes, giving a different appearance to the lesions in 
different parts of the patch or patches. In the course of three or four 
days after the appearance of each group of vesicles, their contents be- 
come opaque, and in time piirolenL In one or two vt'eeks they have 
dried into yellowisli-brown cru8t8, which full off, exposing a normal, 
pigmented, or more or less scarred, state of the skin. 

Neighboring lymphatic glands sometimes become enlarged. Occa- 
sionally the muscles in the vicinity of the eruption are the seat of pain- 
ful cramps or clonic spasms. In rare instances local paralysis accom- 
panies or follows an attack of herpes zoster, The vesicles show no 
inclination to burst, as in eczema; they are deeply located, and remain 
until they dry up, unless interfered with. In some rare cases the con- 
tents of the lesions may be discolored by an infusion of blond into them 
(herpes zoster ha^morrhagicus). They may run the usual course of 
the eruption just described, or they may burst, leaving an ulcerating 
surface, which is followed by cicatrization. Ulceration and cicatriza- 
tion may also result fiom scratching or rubbing the patch. This pro- 
cess has been termed herpes zoster gangrteuosus. Occasionally the 
initial lesions forming tlie papules do not pass into vesicles, hut grad- 
ually disappear, with desquamation; this is known as the abortive form 
of the disease. 

Herpes zoster is an acute aJToction, and, according as it is slight or 
severe, it may run its course in from one to two weeks, or longer. It 
occurs equally in both sexes, but more frequently in the young, espe- 
cially during atmospheric changes. It may attack almost any part of 
the body, but it has a predilection for certain regions, as the face, 
shoulders, back, abdomen, and upper portion of the thigh- A case of 
herpes zoster which involved the anus, left side of buttocks, scrotum, 
and penis, C4iusing paresis of the bUiihier and inactivity of the bowels, 
has been reported by Hugo Davidsohn.* Zoster is usually limited to 
one half of the body, especially the right side, but at times, and rarely, 
it may be bilateral. It very seldom attacks the patient a second time. 
Tho neuralgic pains and burning, as a rule, disappear with the evolu- 
tion of the eruption, but they may persist during its entire course, or 

^^main for a long time after all traces of the disease have vanished, 

P^Wpc^cially in elderly persons. Neuralgia is generally much less severe 
in children than in adults. And to this great annoyance there may 
also follow, particularly in the aged, anopsthesia of the region involved, 
local paralysis, muscular atrophy, and falling of the hair and teeth. 
The eye may also at times be involved in zoster of the orbital region, 
• Deutsche Medidiml Zcitun-', Judc 2tJ, 1890. 




292 



DISEASES OF THE SKIN. 



with consequent inflamniation of the organ and loss of sight, or death. 
11) esc complications, however, do not often happen* 

Though ordinarily of rather rare occurrence^ zona nevertheless 8om( 
times presents itself as an epidemic. The type of the epidemic varies, 
being someiimes mild and at other times severe. The atfection, more- 
over, usiuiily manifests itself but once. In these circumstaTices of its 
history, herpes zoster resembles the infectious fevers, and the theory is 
now supported by a number of distinguished authors that it is primarily 
a constitutional disorder which exerts a special influence upon nerve- 
ganglia and that the cutaneous lesions are secondary consequences. A 
few cases have been observed in which a succession of vesicles was of 
constant recurrence, arranged along the course of a nerve-tract and 
accompanied by neuralgic pain. To this form the term chronic zos- 
ter has been applied. 

According to the anatomical region or the nerve- tract invaded the 
disease is named : Z. frontalis, Z. ophthalmicus, Z, anricularis, Z. 
faciei, Z, occipito-collaris, Z. eervico-subclavicularis, Z. cervieo-bra- 
chiulis, Z. pectoralis, Z. lumbo-femoralis, Z. sacro-ischiadicus, Z. 
sacro-geuitalis, etc. 

Of all the above varieties, the most common is that affecting the 
chest and abdomen. 

Kaposi has described * four cases of what he considers to be atvpi- 
cal herpes zoster. Three occurred in hysterical young women, the 
fourth in a male. The lesions consisted of groups of papides and vesi- 
cles, jsome of which were associateil with necrosis of the corinm and a 
keloid development of the scar. Though symmetrical, recurrent, and 
not following the course of any cranial or spinal nerve, yet the erup- 
tion presented characters which, while unusual, are uot unknown in 
herpes zoster, A vesicular eru[ition sometimes appears upon the tongue, 
mouth, or throat, and has been described by various writers under the 
name of herpetic angina. The vesicles frequently coalesce, rupture, 
and leave an erosion or ulcer. In some instances this alTection of 
a mucous membrane appears to be identical with herpes zoster, as 
maintained by Ollivier and other writers. Dr. B. Pouzin f has ob- 
served two cases of her|>etic angina with vesicular lesions, which cor- 
responded in situation to the course of various mucous and cutaneous 
branches of the trifacial nerve, 

BiagBOsis. — Herpes is not often confounded with other diseases. 
It may bear some resemblance to eczema, but the vesicles are larger, 
ditferently arranged, and tend to dry up, symptoms which serve to dis- 
tinguish it from the latter affection. 

Herpes zoster is to be diagnosed by its history, the premonitory or 



* Archiv fiir Dermatolo^e und Sypbilis, 1S80, p. B61. 
t Kevue tie Lsirytiijolo^t;, d'Otologie et de Rhiuologie, ^laich I, 1891. 
Bulletin, May, im\. 



MedioLt 



EXUDATIONS. 



293 



attendant neuralgic pain, the distribution of the lesions, and the tend- 
ency not to rupture. Htrpcs is idso known from herpes zostor by ap- 
pealing as one group of vesicks, iit tacking certain regions by prefer- 
ence, as the face and genitalia, with a liability to relapses^ — diagnostic 
points which are wanting in herpes zoster. 

Pathology. — Herpes, und especially zoster, is due to irritation or 
inflamraation of the sensilive nerves or ganglia, the Gasserian, or 
spinal, being especially affected. Biirensprnng, who probably made 
the most extensive investigations of this disease, first demonstrated ita 
seat in the nervous system, aTid particularly involving, in zoster, the 
epinal ganglia. Wyass showed in a fatal case of zoster facialis the 
Gasserian ganglion softened and altered, together with inflammatory 
changes along the nerve after entering the ganglion. Similar patho- 
logical changes in the sensitive nerves and the Gasserian and spinal 
Rtj^nglia have been pointed out by other observers. Dr. Graham has 
■ found bacilli and diplococci within the blood-vessels of the Gasserian 
ganglion, bunches of leptothrix-like cells within the arterioles and 
leptothrix in the sheath of the ganglia. These organisms were absent 
in other portions of the brain and medulla. Kaposi, from his investi- 
gations, has concluded that the disease is not alwsya occasioned by 
inflammation of the ganglia, hut that it may arise in the nerve, often 
at its peripheral distribution, and that it may likewise be spinal or cere- 
bral in origin. Microscopic examiuation of the vesicles in zoster shows 
that they are developed in the rete. Bitrensprung, in his examina- 
tions, found in the atlected part the papilla? enlarged, the blood-vessels 
dilated and infiltrated, with new cells extending even into the coriuni 
and the subcutaneous tissue. Spindle-shaped cells were noted also, 
passing from the papilla into the rete, which were pushed aside, the 
latter being thus made to appear linear in form. The nerve at the 
site of the erujition was found to be attended with inflammatory 
changes, the neurilcmraa being filled with cell infiltration. 

Etiology. — Herpes occurs mostly in those possessing an irritable or 

a delicate skin. It. may be due to a variety of causes, but is ehietly pro- 

^Bkced by some demugcment of the mucous membrane of the respira- 

^Hory, digestive, or geni to-urinary tract. It frequently results from cold, 

^Bltmospheric changes, nervous depression, and from injury to the nerves 

■^from blows or pressure, and from direct action of local irritants on the 

skin. Dr. Bulklcy, of New York, has seen herpes zoster develop in 

consequence of Pott's disease, and in another ease where a tumor of 

the neck pressed upon the nerves. Zoster has been observed to follow 

the inhalation of carbonic-oxide gas, and the internal use of arsenic. 

I Dr. Janin relates a case* in which an exceedingly painful herpes 

tt»ter developed in immediate consequence of a trifling traumatism. 

Zona has been seen as a sequela of epidemic influenza, and M. Fere re- 

* British Medical Journal, August 80, 1890. 



2M 



DISEASES OF THE SKIN* 



ports four cases whicli occurred almost contemporaneously among his 
one hundred and fift}^ patients at the Bicetre. The manLfestiition was 
attributed by the writer to a slight epidemic cerebro-spinal meningitis. 
M. K. Koebner has reported a case in which the application of a weak 
galvanic current in the treatment of nervous headache excited intense 
pain, followed tlie next day by an eruption of herpetic vesicles. They 
occupied positions corresponding to the transverse cervit-al branch of 
the superficial cervical plexus * An interesting observation has been 
reported by William 8t. Clair 8ymmers^ iL B., from tlie Pathological 
Laboratoi'y of the University of Aberdeen. f In tlie lymph of her[>etic 
vesicles on the lip of a boy suffering from croupous pnuunionia a great 
Dumber of bacilli were found. These, when cultivated under favor- 
able conditions, elaborated a beautiful pea-green pigment. lis growth 
and power to produce this pigment are uuatTected by light. The 
organism flourishes best at 100^ h\ It is capable of growing in the 
absence of oxygen, but will not then produce its pigment. Upon 
certain nntrient media it will develop without producing the green 
color. The generation of pigment is also prevented by the presence of 
an antiseptic substance. Though unfavorable circumstances may abol- 
ish the chromogenic power during several generations, this is restored 
when the micro-organism is cultivated under suitable conditions. 

Treatment, — The excitiug cause, if found, should be removed. 
Aperients and diaphoretics may be useful, as well as occasional blood- 
letting. Opiates, bromides, or chloral may also be necessary to relieve 
the paiu, partieuiarly in zoster. The latter is often greatly ameliorated 
by hypoilurmic injections of one quarter to half a grain of sulphate of 
morphine with one eightieth of a grain of sulphate of atropine. Anti- 
febrin and antipyrin have been used for the relief of pain, given either 
by the month or by hypodermic injection. Ether and chloroform have 
been subcutaneously injected for the same purpose. Three or four five- 
grain doses of phenacetin, administered at liourly intervals, have nsually 
alleviated the pain of zoster. The phosphide of zinc, given in one- 
fiftieth-grain doses every three or four hours, may also mitigate all the 
symptoms. Irou, qniuine, arsenic, and tlie varions hitters or the mineral 
acids, are remedies that can be resorted to, according to the indica- 
tinus. A course of cod-liver oil may prove beneficial. Jamieson ad- 
vises a mixture of equal parts of tincture of nux vomica and tincture 
of gelseniium, of which he orders twenty to forty drops to be given 
duri ug the day. According to Phillips, rhus toxicodendron is occa- 
sionally of advantage. In some cases the salicylate of sodium has been 
reported of service. The local treatment is especially useful. The object 
should be to protect the lesions, prevent their rupture, and all irrita- 
tion which may follow. If seen very early, Unna states that painting 

• I/J^lectroth/srapie, Septombor, 18&0. Medfcnl Bulletin, December, 1890, 
f British Medical Juurnal, Det^eiuber 12, 18&I. 



EXUDATIONS. 



295 



Vbel 



%ith ichtbyol, covering the eruption with wadding saturated witli a 
len-per-cent. solution of iclithyol or resoroin, or the application of equal 
parts of zinc-paste and resorcin will cause the vesicles to abort Kut 
If vesicles have already formed, supfmration may be prevented by the 
U»e of a zinc'snlphur paste or alcoholic solution of corrosive sublimate, 
iodoform, carbolic acid, or resorcin. In order to abort the vesicles, it 
Has been proposed to open them and lightly touch their cavities with a 
fitick of nitrate of silver, or to paint the alTected surface with a solu- 
tion of the same salt. Other substances which have been recommended 
in the local treatra^ent of zoster are carbolic acid, ointments of lead, 
lladonna, opium, or eocaiue, liniuieiits containing chloral or chloro- 
form, a two-per-cent alcoholic solution of menthol, grindelia robusta, 
etc. Brocq's method is to carefully open all the vesicles as soon as 
they have formed, w^ash with an aqueous solution of boric acid con- 
taining a little alcohol, and cover the surface either witl> a layer of 
antiseptic cotton or a paste composed of oxide of zinc and boric acid, 
as follows : 

fe^ Acid, borici. 1 gramme. 
Zinci oxidi 2 '' 
Pulv. amyl 2 *' 
Vaseliu pur 16 ** 
f this preparation is not sufficiently adherent, six parts of the 
*c»i^«ine may be replaced by lanolin. Starch-powder is dusteil over 
the ointment, and a thick layer of cotton completes the dressing. A 
suitable quantity of cocaine or morphine may be incorporated in the 
Labove formula if the pain be excessive. Some practitioners prefer 
^«oating the lesions with flexible collodion or solution of gutta-percha. 
Five grains of morjihine sulphate to the ounce of collodion will often 
soothe the pain. Dusting-powders are valuable, both for the protec- 
tion which they afford and for the medicinal action which they have 
upon the resulting excoriation. They are particularly to be recom- 
mended for use in herpes of the genitals. They not only are llie best 
means of medicating these parts, but, in instances in which it may be 
a question of the lesion being specific or not, the application of a 
dusting- powder speedily settles all doubt. If tlie lesion is her]>etic, 
the dusting- powder usually catises it rapidly to dry up and disappear, 
^^rhile but little change will be observed should the disease be of 
^B|>e€ific origin. The subnitrate of bismuth, lycopodium, carbonate 
of zinc, calomel, alone or combined with some other powder, the oleate 
of zinc, and powdered red cinchona- bark, are all useful applications, 
U may be well to add morphine and camphor if there be much pain, 

Aristol, europhen, and iodoform are also useful dusting- powders, 
the two former remedies being preferable on account of their compara- 
tive freedom from odor. Some practitioners prefer to make use of 
lotions in the treatment of herpes progenitalis, and Feulard recom- 



DISEASES OF THE SKIN, 



menda weak sohrtions of acetate of lead, vinegar, and water^ or aromatic 
wine. If the uicers are slow to heul, a weak solution (two to four per 
ccmt,) of nitrate of silver is applied to them, or they are dressed with 
an ointment of the same strength. In order to prevent recurrence lint 
may be laid between the glaiisand the prepuce, either dry or moistened 
in some tonic and astringent solution. 

Compression with a bandage, or a simple or medieated plaster, is a 
most useful means of relieving herpes. Sometimes herpes of the hp 
is better treat^jd by applying a plaster at once to the part. It lessens 
the irritation, and often speedily gives relief. Simple absorbent cot- 
ton, or borated cotton, is a valuable application, particularly if the 
lesions have ruptured. A solution of borax with the addition of a 
grain or two of coeaine and of morphine is likewise a good application 
to herpes of the mouth and lips. Anodyne lotions, containing lead- 
water and witch-hazel, are valuable. A ten-per-cent. ointment or al- 
coholic solution of anthrarobin has sometimes proved useful. Astrin- 
gent lotions of tannic acid, alum, snlphate of zinc, or boric acid, are 
frequently best borne, especially if the part has become excoriated. 
Prof. Schwemmer reports good results in zoster from a ten-per-cent. 
Bolution of thiol used twice a day. A lotion containing menthol 
affords relief. 

Kapidly curative or even abortive virtue is ascribed by Prof. Leloir, 
of Lille, to alcohol and alcoholic solutions, according to the inaugnral 
thesis of Dr. Dupas. Compresses saturated in the solution are ap- 
plied to the lesions and kept in position by means of absorbent cotton 
or some iinjiermeable material. The dressings should be changed fre- 
quently during the day. The substances employed are ninety per 
cent, alcohol, two or three parts of resorcin to one hundred of alcohol, 
one f>er cent, of thymol, or three per cent, of menthol in ninety five 
per cent, alcohol. Two per cent, of hydrochlomfce of cocaine or fire 
per cent of extract of cannabis Indica may be added wlien the pain is 
severe. This plan of treatment has been found useful both in herpes 
labialis and zoster. Sedative or astringent ointments, possessing any of 
the ingredients just named, may be employed. Ointments cont4iining 
cocaine, cnninm, or aconitine, have a local analgesic effect, though the 
use of the last two requires great caution, especiidly if the surface be 
abraded. 

The use of the galvanic current applied directly to the affected 
nerves, every day, will often lessen or relieve the jjain of zoster. Olenm 
cha}noceti, or whale-oil, is extolled by Dr. (Justav Guldberg as pos- 
sessed of great penetrative powers and as a valuable vehicle for chloro- 
form when a local analgesic is required, as in herpes zoster. It is a 
refined oil derived from the [ifthvita rosfr(if(u ftnd is *if lower specific 
gravity than any other animal oil. A mixture of equal parts of tiie oil 
and chloroform is rapidly absorbed, and produces a sedative effect upon 




EXUDATIONa 



297 



terminal nerve-fibres. The treatment of herpes gestationis is identical 
with that of dermatitis herpetiformis, and is given in the description 
of the hitter affection. 

Prognosis. — The prognosis is favorable^ except in orbital zoster^ 
which it is said may occasionally be fatal. The other varieties disap- 
pear in one or more weeks, but they are liable to relapses. 

Herpes zoster may be persistent, often continuing for some timej 
and disappearing, to be followed by a relapse. Obstinate neuralgic 
paina may also occasionally remain in the part for months or years 
after the eruption has been removed. This is especially apt to be the 
c&se in the aged. 

Dn Lemoiinier* hits eiicountered ten cases in which zona was fol- 
lowed by tuberculosis. In some patients the latter developed immedi- 
ately or within a few months after the appearance of the zoster. In 
one case the outbreak of tuberculosis was delayed four and a half years. 



^ 



MILiAHIA. 
STSOXnre. — Miliaria rubra — ^Miliaria alba — Liebcn tropicuB — Prickly heat. 

Miliaria is an acute intlammatory affection of the sudoriparous 
glands, characterized by tlie formation of numerous minute papules 
or vesiclefi, and accompanied by marked prickling, tingling, or burning 
8ensatinn&, and more or less itching, 

Syroptoms. — The erujJtion of miliaria usually appears without any 
premonitory symptoms. In the majority of cases it consists entirely 
of papules. It may^ however, be purely vesicular in character, or it 
may consist of both papules and vesicles. 

The papular variety is sometimes termed lichen tropicus, from its 
frequent occurrence in tropical climates, but it is popularly known as 
prickly heat. It is characterized by the sudden development of a 
number of exceedingly minute papules. They are acuminated in form, 
and briglit-red in color. The papules vary in size from a email pinV 
head to a grain of mustard-seed. They are situated around the ori- 
fices of the sudoriparous ducts, and are slightly elevated above the sur- 
rounding surface. They are usually developed in great nundjers, and 
are closely set together. They do not coalesce, but remain discrete 
throaghout their existence. The lesions may appear upon any portion 
of the boily, and in severe eases not infrequently involve the entire sur- 
face. They are mo?t frequently observed, however, upon the scalp, 
neck, cheat,, back, and arms, and generally remain for a few hours or 
days and then disappear as suddenly as they came. In severe cases 
the papules may be present for several weeks. Relapses are of fre- 
qnent occurrence. 

The eruption is almost invariably preceded and accompanied by 

* BuUetin Medicale, No. 38, 1S90. 




2i)8 



DISEASES OF THE SKIN. 



raiirked increase of sweat. In some exceptional cases the seci-etion of 
sweat is notably diminished* 

The entire eutiioeotjs surface upon wliich the papules are developed 
is intensely reddened, and is the seat of more or less itching, stinging, 
and burning sensations. The eruption may be complicated by the 
formation of ye^icles and vesico-papules. 

The vesicular variety of miliaria is characterized by the develop- 
ment of a number of exceedingly small vesicles, which are acuminated 
in form and surrounded by an erythematous aureola. Tliey are trans- 
parent at first, and conUiin a drop of clear serous tluiil, but become 
opa^jiie or yellowish in a few days. Tiie vesicles generally occur in lar^^e 
numbere, and are placed close together. They may appear upon any 
portion of the body, but are most frequently observed upon the neck, 
chest, back, and anus* They run an acute course, usually terminating 
in absorption and desquamation in a few days. The eruption is 
accompanied by itching and burning sensations, which are sometimes 
so severe that the patient tears the skin and ruptures tiie vesicles in 
order to obtain relief. The crusts which are formed by this procedure 
ai'e small in size and insignificant in character, and usually disappear 
by desquamation in a few days. Relapses may occur, however, and 
protract the disease for several weeks. 1 have seen cases in which the 
eruption recurred at intervals for four months before it finally die- 
apj)eared. 

Diagnosis, -*The only affection which presents any resemblance to 
the papular variety of the disease is cczenui pajjulosum, but the dis- 
tinction between them can readily be made by considering the historv, 
course, and subjective 8ymi>tonis of each. The papules of miliaria 
appear siKidenly during intensely hot weather. They are exceedingly 
numerous and closely set together, but never coalesce to form large 
patches. They are usually accompanied by excessive perspiration and 
marked stinging, prickliug, or burning sensiitions, and more or lees 
itching. Tliey are ephemeral in character, and ordinarily disixppeariis 
soon as their exciting cause is removed. The papules of eczema occur 
more frequently during winter than in summer. 'They are compara- 
tively large in size and few in number, and are not so closely aggre- 
gated as in miliaria. They are developed slowly, aud manifest a tend- 
ency to remain fur weeks. They are nut accompanied hj any increase 
of perspiration, or by the characteristic prickling of miliaria. The 
itching in eczema, however, is distressingly severe. 

The vesicular variety of miliaria may be mistaken for sudamina or 
for vesicular eczema. In sudamina, however, the lesions usually ap- 
pear as pearl-colored drops of sweat beneath the superficial layers of 
the epidermis, and are rarely elevated in tlie forni of vesicles. They 
are not accompanied by any inflammatory or subjective symptoms, 
and disappear by absorption, without any noticeable desquamation. 



EXUDATIONa 



S99 



* 



In miliaria vesiculosum the vosicleB are numerous and well defined. 
They are surrounded by an inflammatory aureola, and are accom- 
panied by marked prickling, burniufj, and itching sensutious. In 
eczema the vesicles are not surrounded by a distinct aurcolu, but 
are situated upon an intensely reddened surface. There is intense 
iicbingf and they usually rupture spontaneously, terminating in the 
formation of crusts, beneath which mure or less exudation occurs. In 
some cases the vesicles liecome tnmsfornied into pustules. In miliaria, 
however, the vesicles never rupture spontaneously, or became pustular, 
but usually disappear by absorption as soon as the exciting cause has 
ceased to act. 

Pathology.^ — The pathologicid process concerned in the production 
of the lesions of miiiiiria consists of active hypera'miu of the vessels of 
the sudoriparous glands, producing, primarily, a marked increase of 
the sudoriparous secretiou, and, secondarily, more or less exudation 
into the substance of the glands and their ducts, and into the sur- 
ronnding tissues. If the exndation is small in amount, the resulting 
eruption is papular in character; if it is large in quantity, veaicle^ are 
formed. When the hypenwuia subsides, tfic exudation is absorbed and 
the eniption disappears. 

Etiology. — Miliaria is produced by exposure to unusual heat. It 
may happen in tropical climates at any time during the year, but in 
countries situated in the temperate zone it is met with only during 
warm weather. It may be developed or aggravated by wearing too 
heavy or too light clothing. 

The corpulent and cliildren are most liable to the attacks of the 
papular variety. According to my experience, it is much more prevtv- 
valent in subjects of nervous temperament and fair complexion than in 
those of lymphatic disposition and dark complexion. As those who 
are subject to it are usually in robust health, its appearance is fre- 
quently regarded by the laity as **a healthy sign." 

Weak and anaemic persons are more subject to the vesicular variety 
than the stout and well-nounshed. It is often observed in pale, over- 
worked women, and in puny, ilUftnl infants and young ehiUlren, 

Treatment — The majority of citses of papular miliaria require no 
treatment other than the substitution of light for heavy uiuier-cloth- 
ing, and the frequent application of cold water to the seat of the 
eruption. In obstinate cases, or in ^"ery fat persons, the bowels should 
be freely o|>cned with saline cathartics, and meats and condimenta 
^_^ excluded from the diet for a few days. Acidulated drinks may be 
^B partaken of with advantage. Chalybeate and other tonics may be 
^^ employed with benefit in the vesicular form of the disease when it 
^^ occurs in debilitated patients. 

^H The best local treatment consists in the free application of cold 

^^ water, after which the parts should be mopped dry with a soft cloth, 



300 



DISEASES OF THE SKIN. 



and dusted with bismuth subnitrate or oxide of zinc. Jf the itching 
and etinging be severe, inimediato relief can usually be obtained by 
the use of a lotion containiDg two grains of carbolic acid to an ounee 
of water. Good results can also be derived from the use of the 
ordinary officinal pepperment-water, or from a solution of menthol, 
five grains to the ounce. In India, a lotion composed of ten gi-ains of 
Bulphate of copper to the ounce of water is inucli employed. Aqua 
creasoti will also be found palliative. Lotions of alum, or of milphate 
of zinc, or of acetate of lead, are occasionally serviceable. In some 
cases soothing ointments will be found more available. The ointment 
of tlie oleate of bismuth is especially valuable. 

Progllosi& — "riie prognosis is always favorable. The eruption 
speedily disappears as soon as measures are taken to counteract the 
etiect of the excessive lieat. 

PEMFHiaUB. 

Syno'tm.^ — Blasenaus^chlag. 

Pemphigus is an acute or chronic disease, characterized by the 
Bueeessive development of variously sized and shaped bullro, whicli are 
filled with a cokjrless or yellowir^h serous liquid. It mostl^v runs a 
protracted course, and in subsiding leaves on the skin only dark stains. 

Symptoms. — There are two varieties of pempliigus, namely, jiem- 
phigus vulgaris and pemphigus foliaceue, each of which, on account of 
the marked variation in their symptoms, requires separate considera- 
tion. The former, which is most frequently observed, is generally 
either acute or clironie, while the latter, which is very rare, is at all 
times clironie. 

PEiiririGus VuLGARis.^The disease may be either acute, pem- 
phigus acntus, or chronic, pemphigus chronicus. The acute variety 
occurs usually in children, sometimes in the form of an epidemic, and 
runs its course in from two to three weeks. This form may or may 
not be attended by marked constitutional disturbance. In pronounced 
ejvidemics it is apt, in infants, to be comi^licatcd by purulent con- 
junctivitis. The chronic form is the one most frequently observed, 
especially in the adult. The disease may be ushered in without any 
prodromal, or with mild or severe constitutional symptoms. If consti- 
tutional symptoms are present, they may simply consist of a feeling of 
lassitude, or of chilliness or rigors, headache, pains through the lx)dy, 
quick pulse, occasionally delirium, and irritability of the mucous 
membrane, especially of the stomach. Fever, if present, usually ceases 
with the subsidence of the eruption, to return again on a fresh out- 
break. The eruption may appear first in the form of erythematoua 
spots or wheals, on which blebs develop. At other times blebs may 
form at once on the skin, and neither be preceded by erythematous 



ii 



Hi 



EXUDATIOXS. 



301 



^ 



or wheals. The formed blebs ai'e seldom accompanied with any 
inflammation, their bases only being ruddeued, and the encircling akin 
normal or slightly erythematous. They may be attended with itching 
and burning, the former sensation being usually more marked. Occa- 
Bionally both these symptoms may occur to a decided degreCj leading 
to great suifering; this form of the disease ia spoken of as peniphigus 
pruriginosus. The blebs may develop rapidly or slowly, and may 
attack all portions of the skin or mucous mcnibrane. The scalp, the 
palmar and plantar surfaces, and the conjunctivae * are, however, rarely 
in faded. 

Steffan, in 1884, contributed an article to Zehender's Monatsbliit- 
tern upon pemphigus of the conjunctiva, and its relation to so-called 
essential xerosis of the conjunctiva, in which, in addition to his own 
case, he collected fifteen observations from other authors. Since that 
time similar cases have been placed upon record by Gclpke, Biiuni- 
ler, Schmidt- Ttinipler, and l>eutschniaun.t Stetlan concluded that the 
rare cases hitherto described as essential xerosis of the conjyuctiva are 
really due to localized chronic pemphigus of that membrane. With 
this opinion Prof. Deutschmann coiucides» since be has bad under 
observation a decrepit old lady, seventy-one years of age, in whom a 
typical process of xerosis was associated with pemphigus of the con- 
junctiva and roof of the mouth. 

In pemphigus the number of the blebs vary from one to many^ 
and they may be isolated or arranged in groui)s. In size they range 
from a pea to a heuVegg, or larger. In form they are mostly benu- 
»pherical or oval, but if they become confluent their shape is do- 
Btroyed, Their walls are tense at first, but, by absorption of the 
poared-out fluid they may become somewhat ilabby. Their contents, 
in the beginning clear or opai^ue, gradually become in time sero- 
pnrulent In some iustancea they present a reddish or dark appear* 
ance, from blood being effused into them. They run their course in 
from two to eight days, and are succeeded by successive crops of new 
blebs. They disappear, as a rule, by absorption, their walls becoming 
flhmelled, with newly formed epidermis beneath. At times they burst, 
developing excoriated surfaces, or, after rupturing, their contents may 
dry into thin scabs. Dark stains are always left, for a long time, to 
mark their location. The skin in pemphigus may therefore present 
the characteristic appearance of being covered with few or many blebs, 
in tlieir various stages of formation, with excoriated spots, thin scabs, 
and dark stains. 



• Cohn describes only one ease in fiftj Lfaousund cje-putients. — BretloMer aerd, Ztsek.y 
1985. 

f Ueber pemphigus conjunctivae und pftsentielle nintJebinitschrumpfung:^ von Prof. R. 
io Beiir^e «ur AMgonheilknodej \L Ueft. Hamburg und Leipzig, Leopold 
189L 




302 



DISEASES OF TUE SKIN. 



The differing appearances produced by the bulla' in their different 
stagea and shes have led to a needless and confusing enumeration of 
varieties of the disease, no less than ninety forms having been distiii- 
guished by various writers. 

In a case narrated by Mr. Arthur Clarke, of Street, Somerset^ Eng- 
land, bulla?^ some of which were as large as small oranges, developed 
upon the inner side of the forearms, arms, ami in the axillit' ; alj«o 
along the inner side of both thighs^ The attack occurred in a multi- 
para, thirty-six years of ago, on the fourth day after delivery, lasted but 
a few weeks, and was not accompanied by much constitutional disturb- 
ance. The course of the disease will largely dejiend upon the state of 
the patient*s health, which iuflnences the development of either benign 
or malignant pemphigus. The former is of a mild ty]>e, and usuiUly 
runs its course rapidly. In the latter variety the blebs are large in size 
and number ; they develop rapidly, coalesce, dry up, or nipture, dis- 
charging puriform or bloody exudation ; crusts form, and perhaps ex- 
coriated or ulcerated surfaces result. The subjective symptoms of 
itching and burning are markedly severe, the health becomes under- 
mined, and death often follows, especially in cachectic patients. 

Pemphigus Foliaceus, — This variety of pemphigus is exceedingly 
chrouic. It usually appears as one or more bullae on the front of the 
chest, which are not tense, as in pemphigug vulgaris, but flaccid, the 
fluid tending to borrow beneath the epidermis, instead of elevating it 
in blelfs. These imperfect formations are the characteristic features^ 
of the disease, and contain a milky or yellowish-red Jhnd. The bleb, 
or blebs, thus formed is succeeded by others, which flevelop around 
or unite with them ; or the primary bleb spreiida by peripheral exten- 
sion. The contents are jiourcd out by the rupturing of the bullas and 
dry into thin and friable crustt?. The epidermis hangs in shreds from 
the excoriated surface, giving it the appearance of a superficial scald. 
It seldom reforms on the invaded part, or, if it should, it is removed 
by successive formations of blebs. The disease grail luilly, as the bidhe 
increase and multiply, spreads until the entire body is involved. The 
epidermis no longer forms a sufTicieut covering, the surface becomes 
the seat of fissures, with here and there crusts, and the movements 
even are painful. The hairs become thin and fall out, the eyelids 
ectropic, and the nails friable. The genemi heidth is decidedly inter- 
fered with, usually after the disease has lasted for some time. Sleep- 
lessness, fever, loss of appetite, diarrhosa, and other serious systemic 
disturbances follow, which may ultinuilcly terniinate in death. The 
cure of the foliaceous variety, though not impossible, is rare. In some 
cases death supervenes within a few months from the beginning of the 
attack. 

Pemphigis Vegetans. — A few CiOses of a fatjil varietj^ known as 
pemphigus vegetans, have been eucountered, mostly in Germany. An 



EXUDATIONS. 



* 



BCOonnt of this form was given at a mGCting of the Royal Metlical 
and Chirurgical Society, Miuch 12, 1889, by Dr. H. liadcliire Crocker, 
who bad met with a case, the first known to have occurred in Eng- 
land. Dr, J, Kevins Hyde, of Chicago, has reported the first observed 
case in the United Stjites* 

The first s3'njptom usually experienced is pain in the month from 
lomiation of bullre upon the mucous membrane. In a few days or 
weeks bullaj form upon ihe integument, lusteutl of dbappearing in 
the nsual way these blebs burst and leave superliciul ulcers, which 
remain unhealed for a long time. In some cases the larynx and con- 
junctiva are attacked. Owing to the condition of the mouth, it ia 
with great diffienlty that nourishment can be administered. Suppura- 
tive onychitis, with loss of nails, occurred in live cases. Jiut seventeen 
undoubted cases of this grave disorder are on record. In women the 
disease may begin upon tlie vulva and invade the rectum and cervix 
uteri. In warm and moist regions, audi as the groins and axilhe, fun- 
gating papillary growtlis develop upon the site of the ulcers, and fur- 
nish a very oflFensive muco-pnrulent discharge. The strength is gradu- 
ally undermined, and all the eases terminate in death. 

Diagnosis, — The diagnosis of pemphigus, when fully developed, is 
not, as a rule, difficult. It must, however, be remembered that the 
mere presence of blebs is not always indicative of pemphigus. They 
may be produced by artificial means, and in tlie course of certain dis- 
eases, such as scabies, ecwma, sy]>hilifi, herpes iris, impetigo contagiosa, 
erysipelas, urticaria, and leprosy. They may be caused by friction and 
pressure, as from walking, riding, rowing, and wearing tight apparel or 
bands, or from ap]>hcations to the skin of chemical substances, as 
nitric acid* The non-existence of successive outbreaks of blebs over a 
large surface, and the absence of depression, weakness, and emaciation, 
attendant, as a rule, upon pemphigus, will usually estjihlish the diag- 
nosis. In ca.se of doubt, the ojiinion should be suspended, and the 
pitient carefully watchcfl, to decide whether the eruption is the result 
of accident or design, in order to feign disease. 

Scabies may at times simulate pemphigus. The history of scabies, 
its contagiousness and peculiar predilection, and possibly the recogni- 
tion of the burrows and the itch-mite, point at once to the nature of 
the disease. Eczema rnbrum may bo confounded with chronic pern- 
phigna foliaceus; the denuded surface, covered, perhaps, with more 
or less crusts and scales in botli diseases, miglit readily lend to a mis- 
lake in diagnosis. The characteristic constitutional symptoms in 
pemphigus, with possibly the successive outbreak of the blebs, the 
slight itching, and the absence of iniiUration, with the deeply pig- 
mented skin, cause the disease at once to be recognized- Syphilis 
may give rise to a bullous eruption, which is incorrectly called syphi- 
litic pemphigus. The use of the latter term should always be avoided, 



304 DISEASES OF THE SEIN. ^^^^^^1 

as it impliei a connection between syphilis and true pemphigus, whicli 
is erroneous. In sj-pliilis tlie blebs dry into thick, bulky, greenish 
cnistSj beneath which exist excoriations or nlcers; in pcmphigni 
these conditions are wanting. In herpes iris the bulhe may likely be 
mistaken for peniphigns, Ifcrpes iris is alwa}^^ an acut€ aJTectiou, 
continuing usually a few weeks ; pemphigus is mostly a chrnnic dis- 
eiise, lasting for some time. In heri>e8 iris severe systemic symptoms 
are absent, and the eruption occurs generally on the arms, hands, and 
feet; in iwm]diigU8 constitutional symptoms exist, often severe, and 
the disease has no particular seat. Again, in herjies iris the vesicles 
and blebs are of varied colors, being arranged concentrically, and 
surrounded by an erythematous aureola; in pemphigua there is an 
absence of color, the lesions are not arranged concentrically, and llie 
surrounding skin is usually normal Impetigo contagiosa may bear a 
^lose resemblance to pemiihigus, but the absence of constitutional 
Bjrmptoma in the former, and its tendency to involve the lower ex- 
tremities, with the slow course of its lesions, should assist in distin- 
guishing it from pemphigus. In erysipelas the development of bleba 
is not uncommon, but the course of the eruption, which is so distinct 
from pemphigus, enables one to detect lis real nature. Blebs may 
occasionally develop in urticaria, but the occurrence also of ordinary 
wheals should clearly demonstrate the disease. Tlie blebs of leprosy 
are usually attended with cutuncons anaesthesia and other character- 
istic symptoms which are not present in pemphigus. 

Pathology.^Tho fornuUion of the bulla? may be preceded by hy- 
peni^mia, or they may appear before any congestion can be detected. 
Their contents, in the early stages, are a colorless or yellowish fluid, 
which consist of serum, epithelial cells, and sometimes blood-corpus- 
cles, pus^ and fatty acid crystals. Some observers have also claimed 
to have discovered free ammonia and uric-acid crystals. The fluid is 
either neutral or alkaline in reaction, and becomes more alkaline m it 
grows older. Jarisch gives its specific gravity as 1*0190, and adds 
that it is composed of V>41"0 parts of water and 58-1 parts of solid 
matter. A microscopical examination of the blebs, in chronic pern- 
phigtis, shows that they exist betw^een the rete cells, or between 
them and tlie corium. The lower rows of rete cells may remain nor- 
mal, or bo destroyetl. Tlio bullae after having attained a certain size, 
usually consist of but one chamber, but they may be divided into 
compartments by bands of a fibrinous material. The corneous layer, 
as ft rule, is normal, but the papillns and blood-vessels are enlarged, 
and the corium and subcutaneous tissue are infiltrated. In pemphigus 
foliacous, Xeuraann also discovered "the connective-tissue bundles of 
the cutis thickened, the rete cells clouded by finely granular masses, 
the sw^eat-glands enlarged and filled with necrotic cells, the excretory 
ductfi dilatedj and the liorny layer imperfect.*' In fatal cases an ex- 



4 



amination may show general anaemia, fiabbiness of tho muscles, cedcma 

l^t the brain and lungs, and chronic degeneration of the liver, spleen, 

id kidneys. 

Etiology. — Pemphigus is a rare, and, as a rule, non-contagious 

affection. Cases not infrequently occnr, however, of communication 

)i the disease by direct contagion.* I>r. Salvage relates the ciise of 

infant in whom pemphigus manifested ittjelf on the third day 

fter birth. Four days before the bullffi ceased to develop on the 

did seyeral appeared on the breasts and forearms of the mother, 

^giona which came into direct contact with the lesions npon the babe. 

Ihoenberg reports the case of a child, five years old, who suffered from 

?mphigua universalis. Two cows belonging to the farm upon which 

le child lived were affected with a vesicular exanthem upon the udder. 

'he disease began in a vesicle, which developed from a scratch upon 

le finger, f 

The qaestion of the infectious character of the disease has been 

^itated, bub the evidence is at present conflicting. Experimental 

boculations have generally proved unsuccessful, and cultures have 

led to reveal the presence of a specific micro-organism. On the 

other hand, as has been said, cases of transmission are sometimes met 

with in practice ; wliile Vidal and Colzafc claim to have successfully 

inoculated adults from the liquid contained in buihe, and Gibier has 

described a special bacillus. An organism has also been studied by 

Lukasiewicz. The disease is sometimes epidemic among infants and 

young children. Pempliigus in children has been known to follow 

^Lfche attendance of certain midwives or nurses. It is met with in all 

^■countries, but more frequently in Europe than in tlie United States. 

Bits causes are obscure. It is more common in infants and children 

^^than in adults. After childhood it occurs ivith equal frequency at all 

^f periods of life. It atTects alike both sexes, except pemphigus foli- 

aceus, which is said to be more frequent in women than men. Occa- 

aionaJly it has been known to be hereditary. It ia prevalent at all sea- 

•0118 of the year. Atmospheric conditions do not appear to influence 

[action. Unsuitable diet may assist in developing it. Pemphigus 

as a rule, from a depraved state of the system. This condition 

be caused primarily through the blood, as Biirensprnng believes, 

it may be due directly to an impairment of the nervous system. 

farisch has shown tlie connection with tho latter, in a case in which he 

discovered anatomical changes in the spinal cord. Dejcrino and Leloir 

■iiave also demonstrated its relationship with the nervous system as 
bnanifested by changes in the peripheral nerves. Mental worry, over- 
work, excesses, exhaustion, and menstrua! troubles are fruitful causes 
of its development Henoch has met with acute pemphigus in chil- 

♦ The London Lancet, April 1^, IfiflO. 
t Kediciil BuUetin, October, 188^, p. 823. 





3oe 



DISEASES OF THE SKIN. 



dren, as a sequel of one of tlie exantliematoiis feverB, It may make ita 
appeftraoce after recovery from scarlet fever or nieiisles, may be accom- 
panied by a tolerably bigh fever, and may even prove fatal. On the other 
hand, it may pass into the chronic variety, and Ijist for months or years. 
Uenoeh conceives that these ca^es may be due to the influence of yari- 
0U3 deleterious products which had been produced during the course 
of the fever, and which had not yet been eliminated from the circula- 
tion. Pemphigus has been known to develoj) after severe fright. In 
a case reported by Kaposi,* an injury to the right middle finger was 
followed by the development of a pemphigus, which gradually ascended 
the right arm to tlie right side of the neck, passed thence to the left 
side, and tinally invaded a great j)ortion of the bod}^ 

Treatment — Holli local and constitutional treatment are necessary. 
Attention to hygiene and rest, with freedom from all excitement, are 
essential. Tlie food should be of the must nutritions nature^ and should 
consist principally of meat, eggs, and milk. Attention should also 
be directed to correcting any functional derangement, aud remedies 
given which will overcome dobiiity and tone up the system. Spirit- 
nous and malt lifpiors, the ]ireparationB of malt, and t!ie oiLs, particu- 
larly cod-liver oil, or substances containing oil, as linseed-meal— nsed 
successfully by Sherw^ell — are very good for this purpose. The gen- 
eral tonics, the mineral acids, the preparations of ammonia, are some- 
times indicated. In the acute forms, in which the febrile symptoms 
are severe, it may be necessary to have recourse to general blood-letting', 
with purgatives and antiphlogistic regimen, so well advised by Wilson- 
Pain, if present, may be counteracted with an opiate, particularly in 
the form of a hypodermic injection of morphine. All complications 
which may arise are to be treated according to the indication in e^ich 
case. Arsenic is effective, especially in the form of snudl doses of so- 
dium arsenite. Hutchinson reports the curative action of arsenic, and 
believes it acts almost as a specific for the disease. Quinine, in full 
doses, is a valuable remedy, as well as hydriodate of potassium, which 
was recommended by Wdson. T. McCall Anderson f recommends 
quinine and arsenic as being more certainly effectual if injected subcu- 
taneously. Potassium chloriite Imls been used with bene lit by Baren- 
sprung, and 1 have also found it a useful remedy in large doses. Til- 
bury Fox likewise employed potassium chlorate from the outset of the 
disease, in children, with quinine and wine. In one case, unamenable 
to the iniluence of arsenic, G. II. Fox saw improvement follow the 
administration of chauhiioogra-oil. Blaschko has found that the 
internal administration of antipyrin gives relief to the itching which 

* Ardiiv fiir Dertnutologio und Svjjhllia, Deft vi^ iSftO; British Medical Jmirnal, 
Dect" ruber 20, 181>0. 

f A Treatise on DiBeaeeB of the Skin, by T. McCall Anderson, M. D, LondoD, Charles 
Griffin & Ca, 1887. 



EXUDATIONS. 



307 



attends some cases of pemphigus. In pemphigus Tegetans Hutch in- 
fiOQ recommends small doses of opium, given three tiiiies a day. 

Local treatment is of great advantage, in at once relieving the dis- 
comfort proiiuced by the eruption. Tlie blebs should first be punct- 
ured, and the contents permitted to escape. This operation is need- 
ful, in order to bring tlie elevated epidermis in contact with the corium, 
and thus prevent the t^ebs from rupturing spontaneously and causing 
excoriations* A dusting-powder of equal parts of starch and the im- 
pure carbonate of zinc, or ono more stimulating and astringent^ as 
three parts of starch to one of powdered zinc olcate, should then be 
applied over the surface. It is sometimes more beneficial first to use 
either a lotion or an ointment, and afterward dust tlie powder over the 
surface Ix)tions of tincture of witch-hazel, fluid extract of arnica, 
likewise of grindelia robnsta, the tincture of opium, lead -water, and 
chlorate of potassium may be used ; the latter being especially service- 
able when the mucona membrane of the mouth is involved, Oint- 
menta of zinc, lead, and bismuth are also of benefit. The external use 
of cod-liver oil is likewise advantageous. Naphthol-ointment is a use- 
ful application and relieves the itching, which is often troublesome, 
Tar-ointment, either full strength or diluted, or the compound tar- 
ointment of our national formulary, is also of service. If the blebs 
have burst, and excoriations resulted, the same applications are rec- 
ommended. If the sores persist, a weak mereurud ointment— five or 
ten grains of calomel to the ounce — may be applied, or they may be 
touched with lotions of two to ten grains of silver nitrate or zinc sul- 
phate to the ounce. Baths, either simple or medicated, are frequently 
of service, [larticularly if there is much irrilation or infiammation of 
the skin. The bath may be either warm or tepid, or made emollient 
by starch, bran^ or gelatin, or alkaline by bicarbonate of sodium. The 
bath of corrosive chloride of mercury — one to two drachnis of the salt 
being sufficient— htis been of advantage. The liquid tar-bath has also 
been recommended, especially in pruriginous pemphigus. Severe cases 
are benefited by the constant application of one of the ointments 
already mentioned, or by the continuous water-bath, as recommended 
by Ilebra and Kaposi. The bath just alluded to, however, is not well 
borne in all cases, and, when it is, can only be practically used in hos- 
pitala. It requires a bath-tub specially arranged, in which the patient 
eats and sleeps. Antiseptic and slightly astringent ])owders or oint- 
ments are advised in pemphigus vegetans. 

Prognosis.— Pemphigus is an obstinate and at times a fatal disease. 
The prognosis, however, depends much upon tlie variety, being more 
favorable in pemphigus vulgaris than in pemphigus foliaceus. In the 
former, occurring in young and vigorous persons, if the lesions appear 
slowly and are not attended by fever, the result is, as a rule, favorable. 
In old persona, on the contrary, or if attended in the young with bron- 



308 



DLSEASES OF THE SKIN, 



chial, intestinal, or kidney complications, the terminatioB may be fat-al. 
Tho prognosis is also nnfuvorable in cases attended with continuous 
fever and debility, and in which the blebs appear in numbers, rapidly 
and successively, and whose walls are flabby and tend to rupture. The 
disease is liable to frequent relapses. 



Stnonths. — Fetaphi^a prtirigineu&e — ^Uerpcs gcs La tioni^^ Herpes circmatus bullosus. 

Hydroa is an acute or chronic inHammatory cutaneoua affection, . 
characterized by the appearance of circular erythematous patches of 
Yarious sizes, upon wliieh vesicleB or bullaj become developed, It is 
accompanied by intense itching aud more or less constitutional de- 
pression. 

Synptoras.— 'Hydroa is usually preceded by general malaise, loss of 
appetite, aud varions ga.stric disturbances. Tlie eruption is more or 
lesH symmetrical in character, and ngually commences as email, red, 
circular spots, which itch intensely. They rapidly increase in size, and 
become slightly elevated above the surrounding surface, assuming a 
papular or st^mi-papular form. Occasionally adjacent spots mingle and 
form large, irregular patches. They may appear upon any portion 
of the body, but are more frequent on the face and the extremities. 
After a periml, extending from a few hours to several days, a number 
of Ycsicles may be observed upon each erjthematous area. They are 
arranged in groups, and frequently coalesce and form large bulla?, 
from half an inch to an inch in diameter The further course of the 
enijitioii varies in different cases. The vesicles and bolhe may dis- 
appear by resolution, they may rupture spontaneously and terminate in 
the formation of crusts, or they may be ruptured by the patietit while 
Bcratching. In rare cases they become tnmsformed into pustules, 
which finally break down aud cover the surface with yellowish or 
greenish cnista. The eruj)lion may pursue an acute course, but it 
usually remains with remissions and exacerbations for several months, 
or even for two or three years. It is always accompanied by marked 
itching and burning sensations, and various symptoms of nervous de- 
pression or general debility, Hydroa may occur at any age and in 
either sex. It is not infrequently observed during pregnancy. 

Quinquaud baa published the description of a case which he de- 
nominates hydrua-stumatitis. The patient was a young woman in 
whose mouth were found small bulla?, A similar eruption, without a 
trace of erythema, was found upon the band. Their development was 
accom]ianied by fever, and microbes were found in the urine and the 
bluoiL* 

DiagEOsis.— The affections from which hydroa is to be distin- 

* Medical Bulletin, July, 1890, p, 251. 



4 



I 

I 



^ EXCDATIONa !■ 

gnished are herpes zoster, herpes iris, pemphigus, and varicella. In 
herpes zoster the vesicles are seated upon a reddened base, but they 
are usually small in size, and are developed over the course of the 
peripheral nerves. In hydroa the lesions consist of large vesicles or 
bullae, and are not limited to the track of the nerve-supply. In herpes 
Boster there is little itehing., hut the pain is intense, and the lesions 
are almost invariably limited to one side of the body. In liydroa the 
pain is trivial, but the itching is violent, and the eruiJtion appears on 
both sides of the body. Herpes iris frequently closely resembles hy- 
dros, but the concentric character of the rings, and the absence or 
trivial character of the itching, will prevent any error from being 
made. The large bulla? of hydroa have been mistaken for those of 
pemphigus. In pemphigus, however, the itching is seldom marked, 
and a fatal result not infrequently ensues. In hydroa the itching is 
intense, and recovery is the rule. The vesicles of varicella present a 
superficial resemblance to those of hydroa. Yaricclla, however, is a 
disease of childhood, characterized by the development of a variable 
number of isolated disseminated vesicles, accompanied hy elevation of 
temperature, but unattended by marked itching. Hydroa usually ap- 
pears during adult life, the vesicles are grouped, there ia no fever, but 
the itching is intolerable. 

Pathology. — Keflex irritation of the peripheral nerves is probably 
an important factor in the production of the various lesions of the 
disease. The capillary vessels of the corium become dilated, and an 
extensive exudation of serum occurs, resulting in the infiltration and 
elevation of the papillary layer, and the formation of vesicles and 
bullsp. 

Etiology. — Hydroa is probably neurotic in origin, and dependent 
upon mental depression or anxiety. It is usually associated with evi- 
dences of general debility or ill-health. In some cases it is apparently 
due to malarial infection. When it occurs iu jyregnant women, it 
may be symptomatic of an irritable condition of the nervous system, 
dependent upon impoverished blood. Gibier supposes the exciting 
cause to be a specific micro-organism. 

Treatment. — The treatment should be directed to improving the 
general nutrition of the patient, and removing any sources of irrita- 
tion that may be observcil. The patient should be placed upon a diet 
of milk, eggs, fruit, and bread. Ail the bodily functions should be 
regulated, and exercise taken daily in the fresh air. In cases in 
which a malarial origin is suspected, quinine may be given in large 
In those in which nervous depression is the most prominent 

iptom, the best results can be obtained from the administration 
of nni vomica and phosphoric acid. Anaemic individuals will be bene- 
fited by the various chalybeate preparations. According to Crocker,* 
* Briiifib Medical Jonra&l, May 22, IBSd. 





DISEASES OP 



arsenic and belladonna exercise almost a specific effect upon the dia- 
ease. In u well-marked case wliich recently came under my observa* 
tion, tbe eruption disappeiired rapidly under the administration, after* 
niealn^ of three minims of Fowlers solution combined with one niioim 
of tinct. opii deodonita and half a minim of tiuet. capsici. The in- 
tense itching can usually be rapidly relieved by the application of 
lotions or ointments of cjirboHc ai-id and other anti-pruritics. Secretan 
has reported a case in wliich lotions of oue-por-oent. carbolized water 
not only relieved the itching, but were followed by gradual improve* 
mcnt of the lesions. 

Prognosis*— The prognosis is favorable if time be conceded. The 
eruption somctimcB proves obstinate to treatment, but it finally dis- 
aj>poars when the general health improTee, or when the source of irri- 
tation h removed. 



POMPHOLTX. 
STMONTiffi. — DjaidroHiiir— Cheiro-pompholji. 

Pompholyx is an acute, exudative, cutaneous disease, characterized 
by the formation of a variable number of deep-seated vesicles, which 
terminate in a few days by spontaneous rupture or absorption, and are 
followed by slight desquamation of the epidermis. 

SymptoniS.— The eruption is symmetrical in character, and is nsu- 
ally limited to the sidca of the fingers and the palms of the hands. It 
may, hrnvever, appear upon the soles of the feet and other portions of 
the body. Jamieson has seen a case in which the face and mucous 
membrane of the mouth and tongue were attacked, in addition to the 
hands and feet. At first they are minute, isolated, transparent vesicles, 
deeply imbedded in the skin. They slowly increase in size, and be- 
come whitish or opaque, resembling grains of rice or sago beneath 
the epidermis. The process may be arrested at this stage, and reso- 
lution take place by absorption. Generally, however, the exudation 
continues, the vesicles increase in size and are elevated above the sur- 
face, and may even coalesce and form largo holla?. In a few days the 
fluid begins to disappear by absorption, or the walls of the vesicles and 
biillie rupture and the contents escape. More or less dej^quumation of 
the epidermis follows, resulting in tbe exposure of a reddened, abrati- 
ed, non-discharging surface, which rapidly heals. The eruption is 
usually iiccompauied by slight itching and burning, and more or less 
nervous depression. When the eruption is extensive, it occasions stiff- 
ness of the hands and fingers. Pompholyx of the face may cause pain- 
ful fissures. 

Biagnosi8,^Mild forms of this affection miglit be mistaken for 
sudamina, hut tlie presence of more or less itching and burning will 
sufUce to make the diagnosis. Severe cases may present a slight re* 
semblance to eczema vesiculosum. In eczema, however, the Bubjective 



* 




EXUDATIONS. 



iptoms are more intense, the fiurroiinding surface is hot and ery- 
themiitous, and tlie rupture of the vesicles is followed by tlie formation 
of crusts and the exposure of an exudative surface. 
, Pathology. — Fox and Crocker believed this affection to bo due to 
retention of sweat and dilatation of the sweat ducts or glands, and 
termed it dysidrosis. Robinson,* however, has Bhovrn that these 
structures are perfectly normal, and tliat tlie veeieles are formed by 
an exudation of serum from the papillary vesselij into the deeper layers 
of the rete mucosum. 

Etiology.— The etiology of pompholyx is unknown, bufc it is 

probably associated with some disturbance of the nervous system. It 

in those sulTering from depressed nutrition and ako in those 

general health appears to be good. It is most frequent during 

adult life and in the summer season. In winter it commonly attacks 

those who, like cooks, are exposed to the inliuence of he^t. 

[ Treatnuent.^— According to Robinson, arsenic exercises almoat a 

^Japecific effect, and, when given in time, will invariably abort the 

■ eruption. Full doses of Fowler's solution, or arsenious acid, should be 

H given until all tnices of the vesicles have dii>a]>peared. Quinine, iron, 

and strychnine, and the mineral acids, will also be found serviceable. 

A full supply of nourishing food is of the utmost importance. 

Locally, any soothing ointments or lotions may bo applied to lessen 
the iUjhing and burning, or to protect the abraded surface. 

Prognosis. — The prognosis is always favomble. The eruption dis- 
B appears, with or without treatment, in a few days or weeks, but relapses 
" ma? occur at intervals. 



may occur 



AONS. 






Btsosttms. — .icne di^cmlnatft — Acne vulgaris — Acne boutonneu&e — Vania-Finnen. 

Acne is an inflammatory disease, involving the sebaceous glands, 
usually chronic in character, and appearing in the form of papules, 
tubercles, pustules, or abscesses, either alone or combined, and affect- 
ing more particularly the face, neck, chest, or back. 

Symptoms, — Acne is one of the most common diseases of the skin, 
existing either alone or in combination with comedo or seborrha^a. It 
appears in the form of papules, pustules, tubercles, or nodules, from 
the size of a pinVhead to a bean, solid or filled with pus, isolated or 
arranged in patches. It may occur on any portion of the body ex- 
cepting the palmar and planter surfaces, hut its chief predilection is 
for the face, neck, chest, ami back, the regions most plentifully pro- 
vided with sebaceous glands. 

When acne attacks tiie face, the forehead, cheeks, and chin are the 
portions usually involved. It may appear on the face and trunk at 

* A Manoal of Dermftloiogy, hj A. R. Robinson, M. D. D. Appleton & Ckx, New York, 
88A. 





312 



DISEASES OF THE SKIN. 



the sjime time. In other instances the trunks arms, and thighs alone 
will be the seat of the ernptioo. Acno is usiiully sym metrical, but 
irregular in its distributioD. It is observed in both sexes, especially 
about the age of puberty- Acne may occur at any time of life, but is 
rarely seen after youth and middle age. 

Acne may be acute or chronic, the latter being the general rule, suc- 
cessive crops of the eruption appearing, disappearing, and reappearing 
from time to time for many years. The eruption may be mild or 
severe — consisting in the former case of a few isolated or scattered, 
pale, bright, or dark-red papules, and in the latter of groups or bunches 
of papules, of various shades of color, with or without a central point 
of suppuration — with pustules, nodules, and abscesses, of ten accompa- 
nied by comedo and seborrha?a. 

In many csises the disease may be observed in all its stages, from 
the retention of yecretion to the inflammation and suppuration of the 
glands. The inflammation may bo superficial or deep-seated, giving 
rise, in the latter event, to the formation of pustules and abscesses, which 
will leave the skin marked with indelible sears. These scars may be 
slight or severe, and when the latter occurs the face, when involved, 
is very much disfigured. There are several well-marked varieties of 
the disease. 

AcXK Papulosa. — In this, the mildest form of acne, the eruption 
consists of a number of more or less conical, pale-red papules, varying 
in size from a jiin's-head to that of a pea. The lesions are generally 
mingled with comedones, and are scattered over the face, especially 
around the forehead. 

The centre of the papules may present a darkened appearance, 
exhibiting the opening of the ducts, blackened by dirt and exp08un% 
forming the condition known as acne jtnnctata. The eruption exhibits 
different degrees of severity in different individuals, from a few irregit- 
larly scattered to many papules, at times associated with pustules in 
various stages of development. 

Acne PrsTULosA,— This is the most frequently observed variety 
of acne. The lesions vary in size from a pin's-head to a split pea. 
They are in all stages of development, and are generally associated 
with papules, pnjinlo-pnstules, and at times with seborrhcea. The 
inflammation may be mild or severe, and consequently the amount of 
suppuration may be slight _ or abundant, leading to the formation of 
either small or largo pustules. Each pustule contains a drop or more 
of pus. When the inflammation is severe, abscesses containiTig a large 
amonnt of pus mixed with bloody serum may develop. 

The pustules generally form rapidly, and terminate by absorption 
and desiccation, or burst, and in scabbing over and healing leave behind 
a slight cicatrix. The pustules are either round or conical in shape, 
and are surrounded by an inflammatory aureola. In some instances 



m 




Plate III. 





A€iiu linkuata ^fr*)iii Nature). 



EXUDATIONS. 

^ring lesions coalesce, lose their hemispherical form, and become 
l-shaped. This appearance has been called acno hordeolaris (that 
in the shape of an oat or barley grain). 

The larger pustules are frequently attended by pricking and barn- 
mg sensations and the abscesses by considerable tenderness. 

If the inflammation is deep-seated, the snbcutaneous cellular tissue 

(is involved to a considerable extent, the base of the pustule is hard 
and indolent, and perhaps purplish, with little or no tendency to sup- 
purate. This condition is known as acxe jnduu.^ta, and is fre- 
quently met with on the face, but more particularly about the sub* 
maxillary region. 

In consequence of long-eontinued congestion of the parts, hyper- 
trophic growth of the connective tissue may set in, the skin becomes 
t, rough, and greasy, the glands enlarge, and small tumors form, 
tving rise to what is termed atne TTYPEitTROPiricA. At times the 
racne-spots are succeeded by atrophy of the skin, and they are then 
lamed acne atrophica. 

Under the title acno varioliformis Ilebra describes an eruption which 

ittacks the forehead near the margin of the hair, and may involve the 

^hairj scalp. The lesions are reddish-brown papules varying in size, 

►m a pinVheadto that of a lentil, and sometimoa surrounded by an 

inflammatory zone. These papules do not develop in connection with 

the sebaceous glands. To tlieir summit a dry, brown crust is closely 

^Attached, and so remains for a long time, leaving a cicatrix when it 

falls. Boeck gives the name acne necrotiea to an eruption of small, 

||jlhining papnles of a pale-red or yellow color, npon which after a time 

Iry, brownish-red crusts form. Large crusts result from a coalescence 

)t many papules, and beneath these crusts the enrium is eroded. 

The eruption, when appearing in struraoug, anemic, and tubcrcu- 

subjects, is known as acne caciiecticorum. The lesions gener- 

ly develop on the trunk and extremities, are dark-red, purplish, or 

[violaceous papnlo-pustnles, of all sizes, anil are noted for their indolent 

md sluggish course. 

Arsz Artificialis. — Acne-.?pots are often developed during the 

ise of various drugs, either internally or externally, as well as by the 

pplication of various irritating substances to the skin. Thii.«, the 

iternal administration of iodine and iodide and bromide of potiussium 

followed in many persons by numerous crops of jiapiiles on the face, 

back, chest, and at times on the thighs and arms, which may 

in unaltered or rapidly changed to pustules. Again, the use of 

dn cosmetics, powders, and paints, on the face, neck, and chest, 

resorted to by ladies, or rubbing the same parts with dyed ribbons or 

flannel, to give a healthy hue to the countenance, will often cause an 

[Outbreak of papules and pustules. The enamelled bands of men's hats 

)metimea give rise to an eruption of acne npon the forehead. The 




314 



DISEASES OF TEE SKIN. 



wearing of chest-protectors, bands, and ilanncl next to the skin, fre- 
quently causes an onthreak of papulo-pnstules. The us© of tar, carbolic 
acid, and chrysarobin will produce an attack of acne, which will per- 
sist until these substances are discontinued. The summits of the pap- 
ules, in these cases, osually present a black point, corresponding to the 
duct of the sebaceous gland or hair-folHcle, from one or another of 
the substances having lodged there. The same effect may be observed 
in those who work among grease, petroleum products, tar, and arsenic 
preparations, and especially in dyein^^ establishments wliere woollen 
fabrics are colored. In many instances the vapor, coming in contact 
with the skin, is suflicient to set up an irritation and iullammation of 
the g"lands, and the development of acne. 

Diagnosis.— T lie characteristic symptoms of acne are so well marked 
in the great majority of ca^es as to make tlie diagnosis simple and 
easy. The ago of the patient, the situation and chronic course of tlie 
eruption, the typical, irregular, scattered or grouped lesions, appearing 
and disappearing, are significant. It migiit, however, be confounded 
with papular, pap uh>- pustular, or tubercuhir syphilis, variola, eczema, 
and rosacea. Syphilis and variola may both assume precisely the same 
appearances as acne. The examination should, therefore, be made 
with great care, and an opinion expressed only after a tliorough study 
of the course of the eruptiun. Acne can be distinguislied from s}^*hilis 
by the history and course of the hitter, and its tendency to ulceration, 
and its appearance at the same time in other parts of the body, 1 
have seen subjects, however, in which both affections were commingled, 
the acne appealing either before or during the eruption of syphilis, and 
very often hiding the true nature of the latter affection. 

It will he found, upon inquiry in these cases, that iodide of potas- 
sium, or some medicinal substance, has been taken internally or 
applicil locally, and produced an outbreak of acne. The discontinu- 
ance, for a time, of the medicine or local application used, will en- 
able the physician to say which is the predominating atlcctiou. 

Variola difTers from acne in its history, course, and cunstitutiona! 
symptoms. The eruption of variola is first papular, then vesicular, and 
finally pustular. It is acute in character, preceded by a chill, and ac- 
eompjmied by Iiigli fever and other grave synipfoms. In acne there 
are neither vesicles, chDl, nor fever, and the eruption jitirsues a chronic 
course. 

Papular and papulo-pustnlar eczema may simulate acne. In the 
former the lesions are not necessarily located in the follicles, and scales 
and an interpapnlar infiltration are nsnally observed, which are not 
present in the latter. 

Rosacea, although frequently complicated with acne, difTers from it 
in the local congestion which primarily arises without partictikrly in- 
volving the sebaceous glands. 



EXUDATIONS. 



315 



I 



Pathology. — Acne is due iiaiially to a retention of the sebum within 
the liuir-foUicIes and sebaceons glands connected with them,' followed 
%y its decomposition, which often leads fco a pcri-folliculitiij. During 
the first stage hyperaeniia, with exudation and enngration of corpus- 
cles, may take place, followed sometimes by a destruction of the 
follicles and glands. If the inflammation ia active, suppuration gen- 
j erally ensues, resulting at times in induration, h}T>crtrophy, and atro- 
i phy of the tissuea of the parts. In some cases, as llc^bra observed, the 
sebaceous plug is wanting, and the epidermis lining the follicles ap- 
^^pears to be abnormally developed, setting up irritation and occasioning 
^^Unflammation of the parts around. In others, the changes may occur 
^■ybne within the sebaceous glands. As a rule, the disease is primarily 
^K loUiculitis, and, as Robinson hiis noted, diHers from sycosis, which 

begins as a peri-folliculitis. 
I The vessels which surround the hair-follicle are dilated and en- 

gorged. According to Leloir and Vidal,* the pus is primarily derived 
from the adjacent derma. They speak of having seen the distended 
hair-follicle crowded with epithelial cells but perfectly free from ]ms, 
while little collections of pus surrounded or lay beneath the follicle, 
ventually the lining meuibrauo of the follicle is destroyed, and the 
US gains entrance to the cavity. The sebaceous gland itself may or 
not become involved. These authors consider that acne, in most 
owes, begins with a peri-folliculitis. In atrophic atnic the hair-follicle 
I and its sebaceous gland are entirely destroyed, their place being taken 
j by a ma^ of epithelial cells which, to a certain degree, preserves the 

form of the gland and follicle. 
L Etiology-— Acne appears in both sexes, and can be induced by 

^Keither constitutional or local irritiitiou. In many instances it arises 
^■from some reflex afifection. Among the various internal causes arc the 
physiological changes which take place at the period of puberty, a 
time when the blood-vessels and nerves of the sebaceous glands and tho 
hair- forming apparatus are especially active. Any constitutional or 
local irritation that may then arise will Yerj often, more than under 
ordinary circumstances, excite congestion of the parts, lead to the 
retention of the sebaceous secretion, inflammation, and the develop- 
ment of the disease. 

It is under such circumstances that all debilitating conditions, dis- 
orders of organs or portions of the economy which have a reflex action 
n the face (particularly the gastro-intestinal canal, genito-urinary 
act, and mental troubles), excite and aggravate it. That mental 
emotions will affect imnsl circulation is well shown by the sudden 
dilatation and contraction of the cutaneous cn[nlhiries in blushing and 
in paling. 

Puberty, with the attending physiological changes, therefore, fre- 
♦ TraiU deacriptlf des Mftladiei de la Pcau, p. 14. 




DrSlASES OF THE SKIN. 



qiieiitly gives rise to acne, especially when some irritation is present, 
whicli may continue until the system has passed through this period 
and has returned to a state of rest. 

Again, some persona are born with the organ of the skin naturally 
weak. The skin ii then oily or scaly, or both conditions are combined, 
from the debility of the glands. 

The lymphatic and strumous frequently present this condition of 
the skin. They are therefore prone to acne, and any ref!e.x irritation 
will lead to the retention of the sebaceous secretion ; the glands be- 
come blocked up, and inflammation sets in, often with the formation of 
puB, The amount of pus production will depend ujion the intensity 
of the inflammation and the state of the constitution. In subjects pre- 
senting a strumous condition the inflammation is usually severe, the 
connective tissue around the glands is implicated with a free formation 
of pus, with resulting atrophy or pitting of the surface. In persons of 
this diathesis the lesions will usually present the appearance of a 
scrofulous affection, differing only from ordinary acne by its obstinate 
and indolent nature, the intense inflammation, the rapid and abun- 
dant formation of pus, and the tendency to leave behind indelible 
cicatrices. 

Acne may occur at any period of life, but is most common at 
puberty. It attacks both rich and poor, regardless of nationality, 
climate, or complexion, although those having a light skin are more 
predisposed to it than those of a dark one. Ifc may be occasioned by 
debility, anaemia, chlorosis, or from a derangement of the alimentary 
canal or genito-urinary system. 

Experience will point out to every physician that stomachic and 
intestinal disordei-s, especially when attended with constipation, andi 
ovarian and uterine atfections, will, by their reflex action, cause ita 
appearance. The lesions will abate, to crop out again, depending 
entirely upon the treatment they receive, whether judicious or other- 
wise. In the subjects of acne the eruption is frequently aggravated 
by dietetic errors. The ingestion of certain articles of food, par- 
ticularly cheese, may be suflicient to cause a fresh outbreak of ptist- 
ulea. 

Barthclemy, of Paris, lays especial stress upon the existence of 
dyspepsia with dilatation of the stomach as a cause of acne. He de- 
clares that of 169 cases studied within the period of five years, he has 
in 105 detected splashing {vhipofage)^ an important sign of dilatation 
of the stomach. A seborrhea is fii*st excited in consequence of the ill 
ehibonition of aliments in the stomach. The oily, seborrhoeic skin be- 
comes an excellent culture-medium for the acne-germ, assuming the 
existence of such a germ. This writer supposes that acne, pure and 
simple, is always papular, and that it is by the co-operation of other 
germs— generally, according to Gibert, the staphylococcus albus — ^that 



►ATIONS. 



817 



acne becomes pustular, Bodulur, phlegmonous, etc. He sums up the 
etiology of acne in the following phrase : The interior prepares the soil, 
from the exterior comes the seed.* Climate has a certain iufluenee Iti 
the pri^ action of acne, which is more common along the sea-coast 
than in the interior. Piitienta will, however, occusionally present 
themselves in whom the physician will not be ahle to trace the disease 
to any assignable aiuse* Acne may also result, as has already been 
stated, from the internal use of the iodides, hromidos, uud other me- 
dicinal substances. It may likewise be developed by auy local irrita- 
tion, as nncle-auliness, the use of caustics, soaps, tar, carbolic acid, 
chrysjirobin, creasote, powders, paints, and various cosmetics. Those 
who work among oils, dyes, arsenic, and woollen fabrics are often 
affected. 

Among the causes occasionally productive of acne Brocq names 
epilation or the application of depilatory ointments. The micro- 
organisms known to excite suppuration are generally found in jjua 
from the lesions of acne. Tbe form most frequently met with is the 
staphylococcus albus. 

Treatment. — Although acne is at times a very obstinate affection, 
nevertheless it can be relieved and cured by good management and 
patience on the part of both physician and patient The treatment 
usually pursued is constitutional and local. With some, attention to 
the general health suffices; with others, direct application alone an- 
swers; while in certain instances a combination of both iuternal and 
ext4?rnaJ remedies is required. 

CoxsTiTUTioxAL TREATMENT. — It IS necessary in every case care- 
fully to inquire into the habits of the patient ; in fact, to attempt no 
treatment until it h^is been satisfactorily settled that the affection is or 
is not dependent upon an exciting cause. The first point should be an 
examination into the condition of the alimentary cana!, to see if a 
coated tongue, ernctiitiotis, diarrhoea, constipation, or one of the many 
fanctional derangements of this part of the economy, which are such 
prolific sources of acne, is an active factor in producing the affec- 
tion. 

To find the cause and remove the lesions, the pmctitioner must be 
proficient in the principles of general medicine, and able to apply a 
thorough knowledge of therapeutics to the case under consideration. 
If the tongue is furred, small doses of the mild chloride of mercury, 
blue pill, or mercury with chalk, given alone or in combination, occa- 
sionally with jalap, or compound extract of colocynth, will be found 
efficacious for the abnormal state of that organ, as well as for constipa- 
tion often alternating with diarrhoea. The late Prof, Joseph Pancoast 
frequently prescribed, during my service on his clinic, for similar con- 
ditions, with much advantage, the following: 

♦ Medical Bulletin, May, 18B0, p. 172. 



DISEASES OF THE SKIX. 



^ Pilulse hydrargyri, 
Piilveria jalapsp, 

Extract! colocyntbidis co aa gr. lij, 

Olei mciithii? piperita^ n^ j. 

M. Ft. pil. no. xij. 

Sig. : One or two pills when necessary, every second or third night 
on retiring, 

Consti])ation may also bo combated with aloin, podophyllin, cj 
sagrada, or any one of the nnmerons vegetable or saline laxatives. 
When the inteslinul canal is torpid, small doses of nux vomica, bella- 
donna, physostigma, or muscarine, or the use of farad izalion over the 
abdomen, will often afford relief, or entirely remove tlie constipation. 
The use of the natural mineral waters, especially the Bedford, the 
Congress and Hawthorn Springs of Saratoga, the Capon Springs of 
West Virginia, taken regularly before meals, will be found beneficial 
in overcoming constipation and in toning up the alimentary canaL 
In case the patient can not go to the springs, it will then be best to 
have the spring- water procured in bottles or barrels, and taken at 
home. It is often advantageous to combine the internal administra- 
tion of one of the ferniginous preparations with a natural mineral 
water, or to give a salitie containing a large quantity of iron, which 
adds additional vigor to the aMmentary canal. Or, a sea- voyage, and 
residence at Clieltcnham in England, Baden-Baden or Kissingcn in 
Bavaria, or Carlsbad in Bohemia, and drinking their waters, will often 
effect a very happy change. If this IJ impracticable, beneficial results 
may bo obtained by taking, at home, before meals, the mineral waters 
of these places, imported in bottles, but they should be drunk in a 
regular and systematic manner; the Carlsbad in particular being noted.^ 
for ciiriug many derangements of the digestive tract The use of 
stewed fruits for their laxative effects is also of benefit. 

The following prescription has proved beneficial in many under 
my care, suffering from acne due to stomachic and intestinal dis- 
orders : 

IJ Tincturae ignatire ill Ixxx. 

Tiacturne coptis trifolia q. s. ad. f 5 iv. 

M. Sig. : Two teaspooufuls in water lialf an hour before meals. 

The tincture of the burdock-seed combined with the tincture of 
the gold-thread and ignatia also forms ar most excellent tonic^ and acts 
beneficially on the glands of t!ie akin, 

lloang-nan is another remedy which I have employed with much 
satisfaction in those cases which are obviously linked with dietetic 
errors. This drug fulfils a nnmber of important indications in the 
management of acne. It stimulates the appetite, improves digestion, 
both gastric and intestinal, promotes intestinal secretion and peristalsis, 
and acts as a gentle laxative. Moreover, it exerts a peculiar selective 



EXUDATIONS. 



319 



^H l0Z€ 



influence upon the sebaceous glands, correcting both the quantity and 
quality of their secretion when disordered, softening the sebaceous 
plug and facilitating its expulsion, and therefore iodircctly favoring the 
subsidence of the inltanimaliuTi in and around the glands. I am usu- 
ally accustomed to administer the fluid extract in doses of live to 
thirty drops in water just before meals. Naphthol, likewise, as an 
agent powerful in securing intestiual antisepsis, is a valuable constitu- 
tional remedy in the treatoient of acne. 

In other casea, where there is much acidity^ the subuitrate of bis- 
muth, in ten-grain doses, can be employed with decided benefit. When 
it is desired to give the bismuth in a mixture, the following preacrip- 
tioD is of service : 

5 Bismuthi subnitratis, , 3 ij* 

Pulvcris myristica? gr. xl. 

^ft Synipi zirigiboria f S iij- 

^F M. Sig. : Two teaspoonfuls in water after meals. 

An equally good and often preferable preparation is pepsio, bia- 
BiQth, and strychnioe, given in the form of a powder or pill after 
l&eals. In scrofulous subjects, and in tliose wlio are poorly nourished, 
the preparations of malt, or cod-liver oil, either alone or combined, are 
especially indicated. If the digestive organs are weak, it will bo better 
to give dilute phosphoric acid with the compound tincture of cinchona 
or with cod-liver oil. 

The hypophosp bites and phosphates, in this same class of patients, 
and in those who are pale, with loss of appetite and lack of vigor, cer- 
tainly prove efficacious. 

Quinine and strychnine are likewise beneficial, improving the appe- 
tite, digestion, and general strength. 

The preparations of sulphur and arsenic can frequently be given 
with excellent results. The first can be used in the form of the sul- 
phide of calcium,* as recommended by Ringer, in from one tenth to 

half grain, four times daily. 

The continued use of five-grain doses of precipitated or washed 
Snlphur, given in milk or capsules, or the same quantity made into a 
lozenge, with one grain of cream of tartiir, as suggested by Garrod, 
will algo be found beneficial in mauy cases. This remedy acts favor- 
ably upon the biliary and intestinal secretions, stimulates the muscu- 
lar coat of the bowel, and is therefore an efficacious depurant. 

Unna is fond of using icbthyol internally in acne, but the virtues 
of this substance principally depend upon the sulphur which it con- 
tains, and I have found it frequently irritatiug to the gastro-intestinal 
canaL 

* For further re<eapch on thi* remedy, see *' Report of Committee on Roatoratives, of 
the Tbenipcutir Society of Xew York, on the Cue of the Calciimi Sulphide aa an AntU 
•nppurBtive." New York, April 24, 1882. 



DIBEASES OP THE SKIN. 



Arsenic can be used, either in pill form or given as the liquor 
potassii arsenitis, in one or two drop doses before meals. It is a valu- 
able agent in relieving certain forms of dyspepsia, particularly chronic- 
gastric catarrh, chlorosis, and ana-mia, and will thus often, after bene- 
fiting or curing one or another of tliese affections that may be pres- 
ent, also corapletely eradicate acne. Piffard hns derived good results 
from the use of bromide of arsenic in small doses. The chlorate of 
potassium is a serviceable constitutional remedy in acne, and checks 
the tendency to suppuration. It ia stated by Gubler, of Paris, that 
glycerine, in acne punctata, will sometimes he found useful. In some 
cases of acne very good results have been yielded by Ihe udministration 
of ergot, as suggested by Denslow ; one half drachm of the fluid extract 
or three grains of ergo tin are given three times a day. Accord lug to 
Dr. Q. II. Fox, it sncceeda best in lymphatic subjects in whom the skin 
ia thick and piisty and the circulation eluggish. 

Prof. Hardy recommends the administration of 30 grains of cMo- 
ride of sodium daily in severe and obstinate cases of acne indorata. ; 

Young adults sufTering from derangements of the genital orga 
should have, if possible, all such irritation removed by suitable trea 
ment, and should be advised to gratify their sexual desires by ma 
riage, after being comjiletely cured. The passage of a cold steel sound 
twice a week is serviceable in some cases. 

Yuung women having uterine and ovarian affections, being usually 
those that are anamiic und debilitated from leading a sedentary or a 
gay or dissipated life, or one of over-work in schools, stores, or 
machine-rooms, need, above uH things, a complete change in their 
mode of living, and should take iron, quinine, or strychnine, or one of 
tlje many bitter tonics. Appropriate treatment addressed to the 
uterine disorder may be required, and the hoi vaginal douclie is some- 
times of value in chronic cases. The disease in some may be so severe 
as to require a uterine examination and appropriate local treatment. 

Hygienic measures are of the utmost imiiortunee in acne, especially 
in scrofulous subjects. The general surface of the body should be 
bathed frequently, to promote a more healthy and vigorous action of 
the skin. Cold water is to be used, wlien there is no counter-indica- 
tion, by either sponging tlic surface, or by the cold douche, or by im- 
mersion of the entire body. II any are not able to bear cold water in 
one or other of the forms just suggested, and with such the warm, hot, 
or vapor bath may be substituted. Moderate and regular exercise in 
the open air during sunlight, either walking, riding, driving, boating, 
skating, or in taking sun-baths, will have the happiest effect in bring- 
ing about a cure. 

The last but by far the most important consideration in treating the 
disease, is the selection and use of proper food. During youth, whea 
there is such a physiological activity of the glands, blood-vessels, and 




EXTJBATlOXa. 



321 



nerves, there is active waste and repair taking place in the economy. 
It therefore behooves acne subjects to be abuudaiitly supplied with 
food that is rich in nitrogen and inorganic constitnents, to meet the 
demand of the growing bcniy. Food that is indigcatiblo and nuwliole- 
some, such &s pastries. Jams, sweetmeats, pickles, and cheese, should 
always be avoided. 

The he^ilth and functions of the skin in acne may be decidedly 
promoted by the employment of electricity and by the practice of 
massage. The use nf these agents has a stimulating and corrective 
influence upon the sebaceous glands, and they may be very beneficially 
employed in acne, especially w^hen the disease presents itself in a stub- 
bom form, as acne indurata, or occurs in a markedly deliilitated subject 

Massage performed daily along the course of the large intestine is 
also to be recommended* This manipulation materially assists the 
action of medicines given to act upon the gastro-inteatinai secretions. 

It is of importance, moreover, that the feet should bo kept warm, 
as patients wit!i acne are habitually troubled with cold feet. The 
usual means of stimulating local circulation should bo employed, as 
by walking, massage, foot-batlis impregnated with salt or mustard, 
flagellation with hot and cold water, frictions with camphorated 
alcohol, etc. 

Local Tbeatmext. — ^As acne is an inflammatory affection, due to 
an irritation, the local treatment should first be directed to the removal 
of this irritation, after which the parts should be soothed, and the con- 
gestion relieved with appropriate remedies. A very simple and appro- 
priate remedy consists in the application of hot water to tJic jiarts, ad- 
vising that it should be as hot as the patient can bear; the addition of 
a small quantity of starch, or borax, or both, can be made to the water 
when the congestion is very great. 

The systematic use of hot water is, in fact, an excellent topical 
remedy in tins disease. The application may be made two or three 
times a day for about five minutes at a time, and may be made by 
means of a sponge or a soft handkerchief. A cheap and convenient 
little instrument for the application of hot water hiis been devised by 
Dr. I^visenr, of New York. It consists essentially of a glass test-tube 
fitted to a holder. The tube is half filled with cold water and its 
opening lightly phigged with absorbent cotton. Reversing the tube 
the pressure and adhesion of the water holds the cotton firndy in place. 
The holder with the cotton is then dipped in hot water and can be ex- 
actly expressed upon the area of disease. 

After the use of the hot water, Brocq advises touching the lesions 
with absorbent cotton which has been dipped in equal parts of hot 
water and eau de Cologne or camphorated alcohol, the latter of which 
he esteems more generally efficacious. The quantity of water is gradu- 
aUj lessened until the alcoholic lotions can be borne without dilution, 
21 




322 DISEASES OF THE SKIN. 

Alcohol containing one- thirtieth of salicylic acid has also been recom- 
mcDii<3d. 

In the early stages of the affection I usually prescribe applications 
of the ointment of the oleate of lead, or the ointment of the oleate of 
bismuth, or zinc^ adding at times arrow-root, mercury, creasote, or 
morphine, as in the following combination : 

^ Ungueuti phimbi oleatia 3 ij* 

Pulveris marantse , . , , » 3 j. 

Olei oIivi>? q. 8, 

M, Ft, unguentnm. 

Sig. : Apply lightly over the surface. 
In case it is necessary to stimulate the lesions, the addition of from 
ten to thirty grttins of beta-naphthol can he advantageously made. 
Another very good application is: 

5 Ungnenti bismuthi oleatia 3 J- 

Sig, : Apply night and morning. 
An ointment containing iodide of sulphur will often prove bene- 
ficial. It is advisable to begin with a strength not exceeding ten grains 
to the ounce. 

If the parts are thickened and indn rated, add from one to five 
grains of naphthol. Another excellent combination is : 

ft Ungnenti zinci oleatis 3 ij* 

Naphthol gJ*' ij* 

Pulverirf marantte. 3 bs. 

Cerati simplicis 3 ij. 

H, Sig. : Apply frequently to the parts. 
Many other medicinal substances of a soothing or stimulating na- 
ture, according to the indications, can ho beneficially combined with 
the above oleates. Soothing lotions may also be used in some cases, 
and are often mare acceptable than ointments. I occasionally recom- 
mend : 

ft Atropine sulphatis gr. 

Puheris sodii biboratis 3 jss, 

Aqua3 rosa* f 5 iv. 

M. Sig. : Sponge over the surface. 
Again, I often use : 

ft Liquoris phimbi subacetatis, ? ij. 

AquoB sambuci flor f 1 ij* 

M, Sig, : Saturate an old piece of muslin, and apply for a 
short time, night and morning. 

The following will also bo found beneficial : 

ft Acidi boriei 3 iij. 

Aquae aurantii fior f 5 ij. 

AquEB rosfe ^ 3 ij* 

M, Sig. : Use externally. 



EXTIDATIONa 



323 



Bartbelemy recommenda as local applications carbolis^ed and sul- 
phurated pastes, paintjs of campliorated naplithol^ or atomization with 
ether holding in saturated solution camphorated tanniiij salicylic acid, 
or even iodoform. For especially stubborn cases the following formula 
u employed in Lassar*s clinic : 

IJ Pulv. cret^ albie. ...,,, » 5.0. 

Naphtholj 
Camphor, 

Vaseliu ail 10.0. 

Sapon. virid , , . 15. 

M. 8ulphnr precipitat 50. 

The above preparation should not be left upon the skin more than 
fifteen minutes, on account of the irritant projM?rties of the camphor. 
Another useful formula is : 
}^ Resorein, 

Zinc, oxid aa 5.0. 

M. Vaselin 10,0. 

In many cases where large portions of the body are covered with 
the eruption it is of great value, either to soothe or slightly Btirnulatc 
the lesions by the addition of a medicinal substance to the bath. I 
frequently in this way use with advantage a steam, medicated, or a 
liquid bath. The last can be made emollient by the addition of starch 
or linseed; alkaline, with bicarbonate or biborate of soda; acid or 
io<iine bath, by the addition of one or another to the water. Medici- 
nal vapor-baths of sulphur, mercury, and naphthol have likewise proved 
of service. Soap may also be used with the bath, either alone or com- 
bined with such drugs as sulphur, tai", mercury, carbolic acid, naph- 
thol, thymol, and chamomile. 

Mr. James Startin describes * a method by w^hich^ in addition to 
dietetic and medicinal treatment, he has in a number of cases obtained 
some very good results. It consists in applying to the diseased area a 
local plain or medicated steam bath by mc^ns of an apparatus similar 
to the familiar carbolic spray-producer, but smaller in size. As soon 
sa steam is produced it can be applied at about a foot and a half from 
the patient for twenty minutes or half an hour. Its action is similar 
to that of the Turkish bath ; it is refreshing to the skin, beneficial to 
the complexion, and speedily removes comedones. 

If a simple case should not yield to the foregoing treatment, I 
then resort to the use of a mechanical remedy by puncturing all the 
papciles and pustules, and scooping out the sebaceous plugs with the 
needle-knife wdiich is represented in Fig. 10, and which I described 
in 18T8.f This knife is like a fine needle, having flat sides pointed 
tipon the extremity, and presenting the appearance ol a spear* Each 

*LaDO(*t» May 11, 1889. 

f " A Clinical Stud? of Acne," McdicaJ and Sttrgital RDporter, August 10^ 1878. 



S24 



OF THE BKW. 



paptile, pustule, or abscoss is pimeturpd by inserting" iu a perpendicu- 
Inr manner tlie needle-knife, and the black blood and broken-down 
sebum will then readily flow from most of them. Occasionally the 
accumulated sebum munifegts a tendency to remain, but gentle press- 
ure at the sides of the lesion will usually bring it away. It will like- 
wise be necessary to nick the sides of the dilated follicles that contain 
sebaceous plugs, pass the little needle down, and scoop out the sebum. 
The use of this needle-knife will be found to free the follicles aud deli- 
cate tissue of a substance that acta as an irritant, and to <3eplete the 
congested skin. It will also relieve all stagnation, and awaken the ac-^H 
tion of the absorbent vessels, so that applications can now be more»^H 
effective when used on the parts. This operation not only accom- ' 
jjlishes the pui'pose just set forth, but it likewise prevents the rupture 
of the epidermis, the discbarge of pus, and the formation of scars. 
The lesions, when jiunctiired or cut in the manner I have described, 
will always heal nicely, and will not leave any trace of the oper- 
ation. 

On the other band, tlie various means used by some to rid them- 
selves of these acne-spots by squeezing out their contents between the 
nails or fingers, or pressing over them a watch-key, in order to remove 
the plug of the sebum in the follicle, inflicts on the skin a large amount 
of injury. It intensities the disease by breaking the soft and delicate 
epithelium, produces scarring on healing, and leads to disfigurement 
Patients in whom these scars have fonrjed, either from neglecting the 
eruption or resorting to the injurious habit just mentioned, can be 
benefited and often cured (when the subject is not too old) by tapping 
the si>ots thoroughly with the needle-knife. After the operation, 
which should again be re]*eated iu from tliree to four days, the lesions 
should be allowed to bleed freely, and very warm or hot water dashed 
o?i the surface to fiivor as much as possible a copious flow of blood. 
The parts are then to bo mopped dry with an old towel or piece of 
muslin, and one of the soothing oleates or lotions previously recom- 
mended lightly applied over the surface. In extremely obstinate cases 
it is well to have recourse to electro-cautery. 

The use of stimulating remedies, such as sulphur, mercurials, alco- 
hol, the distilled water, and the tincture of witch-hazel, etc., separately 
or in combination with other substances, is at times serviceable. The 
hydrochlorate of hydrastin is also a useful remedy when a mild stimu- 
lant is required, made into an ointment in the strength of 10 or 20 
gruiuB to the ounce. Both alpha- and beta-naphthol are valuable in 
sluggish cases. They may be employed in the form of a lotion, being 
slightly soluble in water, or may be incorporated iu lard in tlie projwr- 
tion of 10 grains or more to the ounce. Occasionally patients will pre- 
sent themselves who can not at once be induced to try the mechanic^il 
treatment- In such instances, which are very rare, if the soothing 



EXUDATIONS 326 

Temedies with or witljoiit the baths will not succeedj I then resort to 
&n ointment composed of— 

3 iSulphuris suhlimati 3 j. 

Ziuci carbonatia 3 ij- 

Xwphthol gr. ij. 

M. Aclipis recentis 5 J- 

TLe following prescription may be applied with advantage: 

I^ Siilpbiiris tjiiblimHti 3 j. 

Olei antbemidis ta x, 

Zinci oleatis 3 j- 

M, Adipis recentis z }• 

B Olei eucalypti ni iv. 

Zinci carboiiut 3 j- 

M. Ungt. sulphuna iodid. 3 ss. 

Stimulating substances nuiy be employed in the form of lotions, viz. : 

R 8ulp!iuris subliniati 3 ij. 

^Etheris sulpburia, 

iSpiritus vini recti ficati iia f 3 ij. 

M. Sig. : Shitkc well, iLiid mop over the surface. 
Again^ the use of the following formula will give gratifying 
results: 

9 Hydrargyri chlon corros gr. ij. 

Aquae hamamelis Virginicie dest f 5 89. 

AqM« rosie, f 5 vss. 

M* Sig-: Apply over tlie face on retiring. Shake the vial 
before using. 

Benaut recommends a preparation tliua composed r 
9 Ilydrarg. chlor. corros.^ 

Ammouii cblorid , , , . , aa 0,1. 

Emuls. amygdal amar 200 

M. Sig. ; Tu be applied morning and evening. 
A favorite fornmla at the Ilopital de Saint-Louis is : 

5 Sulphuris precip 15 to 30 grm. 

Alcohol caniphorat 30 grm. 

AquiB rosaj 100 " 

M. Aquie destillat laO " 

Insteail of sulphur we may tisc ichthyo], so highly lauded by Unna. 
Tliifl substance may bo applied as a lotion dissolved in alcohol and 
ether or aa an ointment. For indurated acne the following combina^ 
tion may be of service : 

8 Calaminae prep 3 j. 

lodol gr. XX, 

Ichthyo] 3 jsa. 

Adipis 3 j, 

M. Ft. ungt. 



DISEASES OF THE SKIN. 



Among many other substances employed in ointment form are the 
Englisli bypochloride of sulphur, the sulpburet of potiissium, the mild 
chloride, the biniodide, and the amoionio-ehloride of niercuiT com- 
pounded of various strengths, or the mercurial plaster^ as recommend- 
ed by Neumann, or a plaster made of salicylic acid and gutta-percha, 
applied on strips of linen. The sulphate or acetate of copper, the 
oleate of copper in the form of a 10 to 20 per cent, ointment, erythrox- 
ylon coca (gr, xxx- 3 j), bamanielisj and iodide of lead are applicable to 
certain cases. The same may be said of glycerine, brushed upon the 
papules or pustules. Osmic acid has been found bcneficiiil in chronic 
indurated acne, and Piffard has seen improvement in some cases from 
the application of a mixture of quillaia with glycerine. The iodo-sul- 
phate of cinchoniue, a recently introduced non-toxic antiseptic powder, 
containing 50 per cent, of iodine is of value in chronic acne, and I have 
witnessed very good results from an ointment composed of 20 grains of 
this Bubstance rubbed up with an ounce of oxide-of-xinc ointment. 
Another method of treating acne locally is to dust the lesions freely 
with sulphur and other stimulating powders. It should, however, be 
remembered that if sulphur or any of its salts be ap[ilied with a mer- 
curial, the sulpburet of mercury will form on the skin, tilling up the 
follicles with black points and causing disfigurement of the counte- 
nance. I have been consulted by persons wdio have been disfigured by 
these applications, and, for removal, have advised the sponging of the 
skin witb a solution of boric acid. Chrysarobin, carbolic, aiid sali- 
cylic acid ointments have been recommended by different writers. 
An ointment containing hydrastine hydrochlorate, thymol, or iodide of 
sulphur is also of service. The s;ime may be siud of tlie ollicinal alka- 
line sulphur ointment. 

The soap treatment of acne, which was recommended and so largely 
used by llebra in the form of his alcoholic solution of soap-— the tinct- 
ure of green soap^consists in vigorously rubbing the aflected part 
with tbe alcoholic solution of the potash soap, and is efficacious with 
some patients, particularly those having a thick and tough skin. For 
the majority of Americans, whose epidermic covering is usually soft 
and delicate, I have found less powerful stimulants snflicient. In 
rebellious cases Fournier advises friction with the oil of cade, or the 
application of Vigo's plaster 

kSome authorities touch the acne spots with tincture of iotline, tinct- 
ure of cantharides, the acid nitmte of mercury, and other caustics, but 
I have never seen any good results follow their use. Tbey are even 
more severe than the alcoholic solution of soap, and when employed 
will at times run off on the surrounding skin, producing gre^t pain 
and distress. 

Ellinger * strongly recommends for acne frictions of the skin with 

* Wiener med. Wochenscbrift, No. <B, 1876* 



EXUDATIONS. 



S2T 



: 



I 



fine sand* It should be free from dust, and tlie grains almost as largo 
as a poppy-seed. The skin Blioiild be washed with ordiniiry soap and 
water, after wliich the affected parts are to be rubbed for a short time 
with the sand slightly wet. After tliis procedure any adhering par- 
ticles must be sponged or brushed away. 

I have had good results in obstinate cases of acne from the frequent 
local applications of electricity, either in tlie form of the faradic, gal- 
vanic, or st-atic currents. 

Prognosis. — Acne, although one of the most obstinate and relapsing 
of the ekin afifections, can either be limited or cured by remedies, or 
may terminate spontaneously after the individual has passed beyond the 
ago of puberty, and the system is in a state of repose. The prognoeis 
is, therefore, always favonibloj but an early cure can seldom be promised. 

The probable duration of the disease^an inquiry usually made of 
physicians — will largely depend upon the exciting cause, the amount 
of the eruption, and the habits and occupation of the subject. Simple 
acne, with a small number of papules and pustules, and those due to 
external irritants, can often be rapidly cured by mild treatment and a 
removal of the exciting cause. 

Acne indurata and acne eachccticorum, occurring in the debilitated 
and scrofulous, accompanied witli many lesious, often last for years, 
and are followed by much scarring, and relai>se with the least indis- 
eretioti or neglect 

ROSACBA. 

Sykokyms. — Acne rosacea— GiJtta rosacea — Couperose. 



Rosacea* is a chronic inflammatory disease of the face, characterized 
by vivid redness, due to an enlargement of the capillary blood-vessels, 
and later by hypertrophy of the subcutaneous cellular tissue. 

Symptoms. — Rosacea usually attacks the nose, cheeks, forehead, and 
chin. In rare cases it may aifect the entire face, and also involve the 
flcalp and the neck. 

Bazin speaks of having once seen rosacea devoloj) in the groin. 
This disease is confined to the hairless portions of the face, and is, eon- 
_ sequently, more common upon the chin in women than in men, and 

^K only appears upon the bald scalp. It may present three stages — ^the 
^" congestive, varicose, and hypertrophic. It may not, however, run sue- 
I cessively through all of them, Hosacea is a chronic and obstinate affec- 

I tion^ beginning in one or another of the above forms, remaining for 

I months or years in that condition, or paissing on to tiie most advanced. 

I The first stage consists in an intense reddening of the noae, at times the 

^^ same condition existiug on the cheeks, forehead, or chin, without either 
^H fwelliug or tension of the parts. This redness will disajipear on press- 

L 



* Thb description of the difleiise has been esttrocted from my pajior on " Eosacca.* 
See TruittciioDfl of the Medical Society of the State of Peansylrama, vol xil., 1^78. 



DISEASES OF THE SKIN. 



ure, to reappear npon its remoTal. Rosacea will be scon on close in- 
spection to be due to an engorgement of the blood-vessels. The 
enlarged and tortnons vessels are particularly apparent npon the sides 
and bridge of the nose. It is, however, more common for rosacea to 
occur alone upon the nose, but it may also be found occasionally 
isolated on the cheeka, foreheail, and lips. It may either be uni- 
formly distributed over the part involved, or appear as small patches 
with uornnil skin between them. The disease usually begins in the 
form of spots, and spreads until the most prominent portion of the 
face is covered by a dilluse redness, which when exposed to the cold 
assumes a livid tint The detiuite establishment of the lirst stage is 
preceded, during an indeterminate perioil,by attacks of erythema upon 
the nose or cheeks* These attacks are of temporary duration, and 
generally occur tu Jing or after a meal They may also be eicited by 
exposure to a strong or cold wind. 

Sometimes, owing to the excessive vascularity of the part, the seba- 
ceous glauds are excited, and rapidly accumulate and discharge oily 
Bebiun, The nose will then have, in addition to the redness, an oily 
and sliining aspect, and the patient will complain, especially after meals, 
or after walking against the wind, or from exposure to cold, of a warm 
gensation in the parts. The progress of the disease in the majority 
of cases is Tery sJow, often requiring months, and even years, for its 
development Rosacea occasionally, however, runs rapidly through the 
different stages, this being generally due to the condition of the system 
and the violence of the exciting cause. It may continue in the first 
stage for an indefinite period, but this is more frequently succeeded 
by the next, in which small capillary blood-vessels appear upon the 
surface. The skin now remains constantly injected, and the Rupertieial 
vessels become tortuous and varicose. The vessels may be One or thick 
in calibre, and usually run in an irregular manner. The integument 
thickens, and as the disease encroaches upon the glands it causes in- 
flamnuition, suppuration, and the fornuition of sciittercd papules and 
pustules. The habitually injected skin, covered with papules or pust- 
ules, and the enlarged features, cause great mental distress, especially 
in females. The disease, whieli at first involved only the nose, nmy now 
extend to the cheeks, forehead, chin, and at last cover the whole face. 
The redness may no lotiger remain uniform, but it nmy become livid 
in hue where there are papules and pustules. The skin in this stage 
is often rough and granulated, giving to the patient a very repulsive 
appearance. The second stage, like the first, is usually very slow in its 
development, and the affection may not pass be3*ond it. 

The morbid action may, however, in some rare cases, still continue, 
more especially in men, until either the suhcutimeous cellular tissue 
undergoes successive hypertrophy, or the glands and blood-vessels be- 
come distended and enlarircd. 




EXUDATIONS. 



In one form of the disease the blood-vessels become enormously 
distended, the skin hiis a greasy and shining uppearuoce, tlie temper- 
ature of the nose is ioweied, and it is cold to tlie toiicli. In another 
form the intervening skin between the blood- vessels is very much 
thickened, and of a dark-purple color. 

In the most severe form of the third stage, tubercular elevations, 
or a lobnlatcd condition, livid in color^ may also appear on the nose, 
owing to the thickeuing and hypertrophy of the parts. Noses having 
these pendulous m^isses seriously alter the appearHUce of the counte- 
nance, and have been termed rhinophyma. Flucllen's alkision, in 
Shakespeare's " King Henry V,," to Bardolph's countenance, aptly ex- 
presses in the following words the distortion of this stage of rosacea: 
**His face is all bubuklea, and welks, and knobs, and Uames of fire; 
and his lips plows at his nose, and it is like a coal of fire, somotimea 
plue and sometimes red." 

In a case which came under my observation some six years ago — 
an old English brandy-drinker — the nose assumed, as Hebra has ex- 
pressed it, the form of a elapijer of a hell ; the excrescences were enor- 
mous, the sebaceous glands very large and filled with phigs of sebum; 
the skin was almost purple in color, and cold to tlie touch. The 
nose has been known to acquire the size of two fists, and hang down in 
front of the mouth as far as the chin. 

The hypertrophic form of the disease is restricted almost exclusively 

males. 

Diagnosis. — Rosacea can be diagnosed from other diseases by its his- 
tory, course, and the alterations in the skin. It may be distinguished 
from acne by the increjised vikscularity in the former affection, its per- 
sistence, the varicose condition of the blood -vCvSsels, the tliickening of 
the integument, and its limitation to the face. Acne, on the other 
hftod, when present as the primary disea.se, is simply an acute in- 
flammation of the glands and follicles, and is not confined to the 
face. 

Rosacea may likowise be mistaken for sypbilia or lupus ; but such an 
error should not occur, and, to avoid it> tlie following diagnostic points 
will be given between these atTeetions : Syphilis is attended with a his- 
tory ; it is preceded by malaise, sore tiiroat, and the roseolous rash, 
and nsually attacks one side of the nose. Syphilitic tubercles and pust- 
ules do not involve the cutaneous glands ; they are rarely developed 
Alone on the face; have a dull, cnppery color, and may be complicated 
with fissures, ulceration, or the formation of crusts. Again, they are 
usually larger and more firm than in rosacea. In rosacea there is no 
gj'philitic history, nor any of the concomitants of specific disease. As 
a role, the disease involves first the end of the nose, and the color cf 
the patches is a vivid red from tlie enlarged and tortuous blood-vessels, 
which are absent in syphilis. The pustules and tubercles of rosacea 



DISEASES OF 



are of a bright tint, and have tlioir seat in the glands of the face, but 
do not ulcerate or form fissures or crusts. 

Lupus erythematosus may be mistaken for rosacea. The surface 
of the diseased patches in hi pus erythematosus is covered with fine 
yellowish scales, adhercDt to the follicles beneath, which are not present 
in rosacea. 

The margins of a patch of erythematous lupus are more distinctly, 
marked, its color is usually a brighter red, it exhibits some tendernesaj 
upon pressure, projects slightly above the level of the surroundiurf 
skin, and the cieatriform spots are distinctive. Lupus vulgaris may 
bear a resemblance to rosacea. In lupus vulgaris the well-known 
papules, tubercles, and scales are present ; ulceration occurg, and cica- 
trices result 

In rosacea no scales are present; the ptirt is covered with varicose 
blood-vessels, the tubercles never idcerate, and no attempt is made at. 
the formation of cicatrices. Hyde * refers to a case of herpes zoster' 
which ho had seen, which involved the nose and resembled rosacea. 
lie adds that the painful character of the disorder, its limitations to 
one side ol the face, its trausitury career, with the vesicular lesions, were 
sutliciently elmrac teristic. 

Finally, rosacea may have the aj^pearauce of frost-bite. In the 
latter the parts are bhiish-red, shining, and much swollen; in the 
former the skin is red, grea^sy, and little or no swelling is present 

Pathology. — The anatomical changes in rosacea consist first in con- 
gestion of the minute blood-vessels of the parts. The vessels of the 
deeper portion of t!ie skin are involved from the first. In the second 
stage the blood-vessels become hypertroplned and permanently dilated^ 
develop seborrlKca or acne-spots, and those surrounding the liair folli- 
cles and sebaceous glands become enlarged. An infiltration of lym- 
phoid cells takes place into the tissue surrounding tlie vessels, and the 
connective-tissue corpusck\s proliferate. 

This second stage, with the altenitj(m in the blood-vessels, may 
continue for a long period, improving and again relapsing from time 
to time, or passing into the third stage, in which there is hvpertrophy 
of the cutaneous glands and tissues of the part, and the growth of a 
new connective-tissue element 

Ilebra has shown an abnormal growth and development of con- 
nective tissue* Piffard f found that the horny portion of the epider- 
mis was insuflicient; the mucous layer thickened, tliat the papilla? con- 
tained round and fusiform cells, and were enlarged botii in lengtli and 
breadth. The corium had the appearance of a formed tissue, bein| 
very much tliickened; some of the sebaceous glands were noi-mal, 
while others were undergoing degenerative changes. 

* Hyde's Diseases of the Skiu, Philaddphiii, 1S88. 
f Archives of Cliniea] SurgerVi vol. i., p. 21, 



EXUDATIONS. 



831 



I 



• 



A microscopical examination whicli I made of a piece cut from 
the nose of a patient in attendance at the Dispensary for Skin Dis- 
eases, riiihwlelphia^ and reported,* showed Just a vestige of the horny 
layer of the epidermis, while the mucoos layer was very thick. The 
papilla were much enlarged, and tlie blood-vessels markedly dilated 
and varicose. The subcutuneous cellular tissue was hj-pertrophied, and 
the sebaceons glands were degenerated by the pressure of the surround- 
ing tissue. 

Leloir and Vidal distinguish two varieties of the hyiiertrophic form 
of rosacea. In one, hypertrophy of the sebaceous glands is the most 
prominent feature. These may attain twelve or tifleen times their 
normal size. In a second, that to which the name rhinophyma is 
generally applied, the glandular lesions are entirely secondary. The 
Te&sels, and especially tlie veins, are dilated and engorged, so that in 
some places they form sinuses and constitute a sort of erectile tissue. 
The arteries are thickened and sclerotic. In extreme cases the lym- 
phatic vessels are implicated, and a section presents an appearance 
compaT'able to that of an angioma or lymphangioma. 

Etiology. — Rosacea is met with in both sexes, but more frequently 
in men. It may happen in youth, but it appears mostly in middle or 
advanced life. In women it may occur about the age of puberty, dur- 
ing uterine and ovarian disorders, and ut the cessation of the menses, 
and will not usually pass beyond the first and rarely to the second 
stage of the disease. Iji men rosacea seldom appears before the fortieth 
jear. Heredity has a certain degree of infiuence in the production of 
rosacea, and a predisposition to this afFoction exists in the gouty and 
rheumatic. 

The application of cosmetics, paints, and irritating lotions is an 
immediate cause of it- I have found these preparations to be produc- 
tive of the disease in both men and women in the theatrical profession, 
and in women in the decline of life, notwithstanding all the care that 
they have taken in applying the cosmetics. Among other of the 
prominent causes are chlorosis, aniemia, excesses of the table leading 
to dyspepsia, chronic affections of the stomach and intestines, morbid 
conditions of the Hver, and want of cleanliness. The attitude made 
necessary by certain occupations, which causes an increased flow of 
bloo^l to the face, is also an inciting factor. Thus we see it in bakers, 
engineers, etc., who are compelled to work with their faces in prox- 
imity to hot fires. In some instances rosacea is consecutive to acne, the 
long-continued congestion accompanying repeated attacks of acne at 
length becoming permanent, and 'causing dilatation and engorgement 
of the vessels. The habitual use of vinous, spirituous, and malt liquors 
is also a common source of the disease. The powerful action of these 



* See TraoaactioDi of the FeonsTlvjinia Medical Socletj, l&IB, 



12" DISEASES OF THE SKLN. 

liquors in pradnciug increased facial circulation, leading to a hideously 
BWolJen condition of the nost?, can be observed daily. These deformi- 
ties are commonly knoi^Ti as " grog-blossoms," " brandy-nose,'* and 
"wine-nose." Frequent exposure to cold winds often provokes rosa- 
cea. In a few eases it is impossible to truce the disease to any ext^imal 
or internal influence. 

Treatment. — The method of treatment to be employed will largely 
depend uj*oq the stage and the cause of the affection. The physician 
should therefore, in all cases, carefully examine into the patient^s con- 
dition, and, if any constitutional derangement exist, give the appro- 
priate remedies. Women suffering from uterine or ovarian disorders 
should have the proper treatment to eradicate them. i[en who in- 
dulge in liquors and dissipation of other forms should be advised to 
adopt a temperate mode of living. The diet should be plain and sub- 
stantial, especial care being taken to avoid rich food of all kinds. It 
is of extreme importance that the functions of the liver and bowels 
bo properly performed. Alkaline mineral waters may be recom- 
mended. 

In those who are anaemic and debilitated^ the ferruginous prepara- 
tions, minute doses of arsenic, cod-liver oil, the extract of malt, nux 
vomica, and the dilute phosphoric aeid, with bitter tonics, are of great 
advantage. Those in whom no cause can be traced are often benefited 
by a change of climate. In women who have depraved health, nerv- 
ous depression, menstrual disorders, or are at the change of life, and 
who are often great sufTerers from rosacea, with frequent flushing of the 
face and throbbing of the blood-vessels, the Judicious use of the nitrite of 
amyl, as snggested by Ringer^* will often bring relief, either given by 
inhalation or the stomach, the latter form being usually preferred-* 
two minims dissolved in one drachm of rectified spirits; the dose of 
this is from three to five drops on sugar every three hours, the first 
dose to be taken as soon as the flush appears. When rosacea seems to 
depend upon the presence of a rheumatic or gouty habit, it may he of 
advantage to administer an alkali, or advise the use of an alkaline min- 
eral water. 

Under the same circumstances Brocq speaks favorably of the effects 
of the following combinations: 
IJ Quinin. bromhdydrat., 

Ergotin aa 5 cgm. (gr, J). 

Extract, belludonn 1-3 mgm. (gr. ^ to 5^)- 

Lithii benzoat 5 cgm. (gr, J). 

Glyceriui q. s. 

Ft. in pil. no. j. Mitte tales no. xl. 

Two of these pills are given before breakfast and dinner* 

* Eitigcr^a HaDdbook of Thorapcutica, BOTanth American edition^ fk. S70. 



EXUDATIONS. 



333 



^ Puk. digitalis 5 mgm, (gr. ^). 

Extract, hamiimelidis 5 mgm. (gr, ^i^). 

Extr. gentian,, 

Liihii l>enzoat. iia 5 cgm. (gr. f ). 

Glycerin .......,, q. s. 

Ft in pil. no. j. Mitte tales no. xL 

Two pills are ordered to be tfiken before each meal. Rhubarb or 
aloes may be added to the above formidiLs aceording to the indications. 
The use of electricity and massage will often likewise be found to be 
yalnable adjuvants for their beneficial effect upon the system. 

The local treatment is, however, important and advantageous in 
almost all cases. Soothing remedies will answer in some, in others 
stimulating, and often the addition of one or another of the many 
mechanical means will modify and frequently arrest the diBease. In 
the first stage I endeavor by soothing applications to relieve the 
congestion and allay the irritation. The ointment of the oleate of 
bismuth, which I suggested in papers read before tlie Pennsylvania 
State Medical Society in 1871* and 1882, will often fulfil this purpose. 
Tbe ointment, lightly pencilled over the surface two or three times 
daily, will soothe the hypenemic skin, relieve the engorgement of the 
glands, and bring comfort and ease to the patient. In some, a dusting- 
powder of either the oleate of zinc, the subnitrate of bismuth, or equal 
parte of each combined, with powJered starch or arrow-root diluted 
over the surface after using the ointment of the oleate of bismuth, will 
not only assist very much the action of the oleate, but will relieve the 
face of its greasy appearance. Ladies can in this manner use t!ie above 
preparations, lightly applied as a cosmetic, to hide the disease in j)lace 
of one of the many injurious face-powders, and can have the satisfac- 
tion of knowing that the application is beneficial, and may cure the dis- 
The following soothing ointment has also been effieacioua in other 
used either alone or with one of the dusting-powders just named : 

5 Zinci carbonatis 3 j. 

Pulveris marantse 3 j. 

Hydrargyri ammoniati gr. x, 

Unguenti simjdicis 3 j. 



M. Ft, 



unguentum. 



t Soothing lotions are especially effective in sonte instances: 
3 Plumbi acetatis, 
L Zinci acetatis lia gr. x. 
r Aqufe rosa; f 5 iv. 
M. Sig. : Apply with an old piece of muslin spread over the sur- 
face for an hour or two night and morning. 
Sulphur ointment may be used with good effect in the first stage or 
chryBarobin in sohition of gutta-perchii, beginning with ten grains to 
the ounce, increasing or dimiuishiug the strength as required. 



334 DISEASES OF THE SKINT 

In the second stag© 1 have liad^ood results from the extract and 
tincture of witch-hazel, weak solutioiia of chloride of zinc, and caustic 
potash, glycerine, the various mercurials, precipitated sulphur, chrys- 
arobin, and the English hypochloride of sidplmr. Some practitioners 
make use of Vleminck'a solution diluted with live parts of water, whicli 
may gradually be withdrawn if the preparation does not provoke irri- 
tation. Besnier recommends the following combination : 

5 Sulphur, precip 50 grammes. 

Glycerin 30 " 

M. Aleohol. camphor 80 " 

Some of these remedies can be used in the form of an ointments* 
and others as lotions. It ia a good ]tkn sometimes, especially when 
the nose alone is involved, to brush collodion along the course of the 
blood-vessels, which compresses them, and thus lessens their calibre. 
In several cases I have obtained excellent results from this method 
alone. Again^ the vapor-bath is valuable both in the first and second 
stages ; it renders the skin soft and smooth, and hastens the absorption 
of the lesions. Another efficacious application is the oil of ergot, or 
half an ounce each of glycerine and oil of ergot, with one drachm of 
the extract of belladonna. 

Unna recommends ichthyol internally and externally. Intenially he 
gives it for a long time, fifteen to thirty grains daily, and applies it exter- 
nally in watery solution, lie also makes use of the following ointment : 

IJ Zinc ointment 20 grammes. 

Pow<lered rice 5 '' 

M. Sulphur 3 

More recently Unna has devised an impermeable applicjition which 
he terms iehthyol-varnish, and recommends as a decided improvement 
on his earlier preparations. The formula for this varnish is : 

B Ichthyol ,,,.,,. . 40 parts. 

Starch , 40 ** 

Solution of albumin 1-1^ '* 

M. Water enough to make 100 " 

The varnish is brushed upon the affected skin at night, dries in 
about two minutes, and can be readily removed by water in the mom- 
ing.* In rebellious cases, Brocq f advises the use of green soap, alone 
or associated with sulphur, naphthol, or salicylic acid. Among other 
applications which may prove of service may be mentioned Goularti's 
extract, solution of sulphate of zinc or of alum, pyrogallic acid, iodized 
glycerine, and erythroxylon or cocaine hydrochl orate. Natural sulphur 
baths, whenever attainable, are of service. A solution of alpha-naph- 
thol frequeDtly proves beneficial. The ointment of lead oleatc is often- 
times useful, while an ointment of iron olcate is of decided advantage 
in either the first or second stage. 

* Medical Bulletm, July, 1891. f Op, cii , p. 63. 



EXUDATIONS. 



335 



If the preparations named should fail, poultices and fomentations 
may next be employed. In obstinate cases I have a good starch- 
poultice prepared, which is bland and nuirritating to the skin, and 
applied moderately warm, nsnally just before retiring, and allow it to 
remain one hour. It is a ready and convenient method of applying 
a hot bath directly and efTcctually to the parts, A ponltice allays all 
irritation, burning, flushing, pricking, or pain, limits and checks the 
inflammation, and abates the tensioiL It also relaxes the tissue, and 
renders the absorbents more active in the application of the oleate of 
bismuth or any other soothing remedy, which should be immediately 
applied after the removal of the poidtice. 

All stages of rosacea are often nmlerially benefited by tlie local use 
of massage and the application of the faradic and galvanic currents. 
In case the congestion of the skin still lingers and remains obstinate, I 
puncture the surface with the needle- knife. During the operation I hold 
the knife in the right hand, aud rapidly apply it over the patches, while 
with the left hand I sponge the surface with hot or very warm water, in 
order that the bleeding may continue freely. The water applied in this 
manner will remove the poured-out blood, and will prevent it from 
clotting in the incisions and obscuring the operation, I always allow 
the knife to penetrate to various depths according to the thickened 
condition of the iutegument In some points of the diseased patch 
simple hyper^emia may be present, while in others tubercles and ex- 
cessive hypertrophy may exist ; coosequeotly, the former will need very 
slight punctures, while the latter will require deep incisions according 
to the amount of hypertrophic growth. In this manner I reach all 
the larger and smaller patches, relieve the congestion and stagnation, 
equalize the circulation, and awaken the action of the absorbents, so 
that local applications may have some effect. This operation should 
be repeated after an interval of from four to seven days, according to 
the requirements of the pase. After each operation one of the bland 
and soothing preparations, or one of the astringent and stimulating 
remedies recommended, can be used much more effectually. Hebra* 
suggests, in treating this affection, the use of an instrument made after 
the form of a lancet- needle, with cutting edges on both sides, aud pro- 
vided with a stop, so that it may not penetrate too deeply into the 
derma. He adds that the perpendicular punctures are made for the 
purpose of destroying the blood-vessels, and that the bleeding can be 
eaaily arrested by compressed wtniding. Squire operates on rosacea by 
meozLS of an instrument which he calls the multiple scarifier. It con- 
sists of a number of needles attached to a handle, and arranged par- 
allel to one another with a covered shield on each side. He maps 
out the diseased patches with a solution of black sealing wax, freezes 
the surface with an ether-spray, and then applies the multiple scarifier. 
* WUjn rood. Woehonachrifl, Januaryj 1878. 



DISEASES OF THE SKIN. 

Should the scarifiOT be too broad for some of the emaller patches, he 
advises thiit they be opcnittHi on at a Biibscquent sitting witli a single 
scalpel The bleeding which follows thtj use of this instrument, 
he sUites, mtiy be copious, bnt it can be iin mediately iirrested by press-, 
nre with the lingers, a layer of wet bh>t ting-paper being interposed'' 
between the fingers and the skin pressed. Anbe, who recommended 
linear scarification, believes that it is to be relied upon in rosacea only 
before the hypertrophy has become far advanced. Tlie same object, 
it can be seen, is ubtaintMl by either of the oj^erafions named, but the 
one I am accustomed to employ appears to be the easiest and simplest 
for practical use in all resj^ecta. The tortuous and varicose blood- 
vessels may be obliterated by passing into them an ordinary neetlie 
heated to redness, by using the galvano-cautery with a fine-pointt'd 
needle, or by electrolysis. In this latter method a very fine cambric- 
needle is selected and connected with the negative electrode of a gal- 
vanic battery of from six to ten cells. The needle is then in.sertcd 
into the varicose vessel, after which the patient is handed the positive 
electrode, wliieh completes tlie circuit; tlie latter electrode is dropped 
before withdrawing the needle, which will prevent the patient from 
exj>ericncirig a shock on breaking the circuit. The deformity of 
the third stage may be reduced by either puncturing deeply the 
hypertrophic blood-vessels and tisane, by scarification, by using the 
ordinary needle heated to redness, by electrolysis, by faradization, by 
the galvano-cantery, or by operative procedure with the knife, Chea- 
die* repoi'ts good results from the farad ic current. Pilfard states that 
he has obtained very decidetl shrinkage of hypertrophic noses by the 
use of the galvanic current. 

Prognosis* — The prognosis depends largely upon the cause of the 
disease. If the alfeetion has not passed beyond the first or second 
stages and the exciting cause can be eradicated, it can usually be re- 
lieved or cured. The result, however, depends essentially upon tlie 
habits of tlie patient. Rosacea will at times in women subside s])on- 
taneously, es]ieeially after the climacteric period. In the third stage, 
as a rule, particularly when it is due to bad habits and all kinds of 
over-indulgences, where a decided change in the tissues luis taken place, 
the results, even under the most experienced practitioners, are not 
usually favorable. 

SYCOSIS. 

Stkosyms. — Sycwla non-parasitica— Mentagra — Acne meDtflgra — Follicolitii birbw 
IiicbcQ mcDti — DartEime — Sycosis non*paruaitaire. 

Sycosis is a non-contagious, inflammatory disease, acute or chronic 
in its course, involving the hair-follicles, chiefly of the bearded part of 
the face, and characterized by the formation together of pustules, 
* Practitioner, London, July, 1874. 




EXUDATIONS. 



8ST 




papales, and perhaps tubercles, usually perforated with hairs, and 
accompanied by more or less intiltration of the pjirt. 

Symptoms. — The disease usually occurs ou those portions of the 
face ou which the beard, whiskers, and mustache grow, although it 
may be seen upon other parts of the body supplied with hair. It gen- 
erally begins on the cheek, chin, or upper Up by the appearance of 
amall, discrete pustules or papules, or botli^ the lesions being perfo- 
rated by hairs, which are usually tirnily fixed at first, but at a later 
stage of the disease become loose, and arc easily removed. The lesions 
may appear in successive crops at longer or shorter intervals, and may 
remain isolated throughout their course, or become crowded together, 
forming well-marked patches. The pustules or papules may be either 
flat or conical, varying in size, being usually about that of a millet- 
ieed. The pustules are not generally inclined to rupture, unless there 
be more or less severe inflammatory action. The surrounding skin is 
reddened, swollen, and infiltrated; there may be present papulo-pusfc- 
ules and tubercles, and, if the pustules rupture, scales and cruata 
may also exist. The disease is usually preceded or accompanied by 
heat, tension, smarting, burning, and occasionally pricking or painful 
sensations. Sometimes patients will describe the jiain as proceeding 
along the course of the hair which traverses the lesion, and refer to it 
now and then as a hair-pain. Sycosis may commence in some casea 
within the nostril, or pass up from the ui>per lij) and alfect the follicles 
of the stiff hairs or vibrissa^ the disease becoming excessively obstinate 
and at times extending to the Schneiderian membrane- In this event 
the columna that divides the nose becomes swollen and inflamed, the 
org;m itself hot and very jminful, upon the slightest movement of it 
tears flowing from the eyes. The disease, while affecting most com- 
monly the cheeks, chin, and upper lip, may also appear on the scalp, 
eyebrows, eyelashes, neck, axilla?, ami pul>ic regions. Sycosis may 
appear in one or more points, and spread until it involves all of the 
region invaded, or it may develop simultaueously over all the parts 
just named. 

The character of the diseiise will also vary considerably, according 
as the eniption is isolated or conflitent. In some the lesions are dis- 
tinct and few in number, while in others they coalesce, the inflam- 
mation penetrates deeply into the derma and subcutaneous cellular 
tissue, infiltration and thickening are marked, the parts become cov- 
ered with tul>ercular elevations, scales, and crusts, and occasionally 
nnheulthy granulations and abscesses appear, with many openings, 
and the surface becomes extremely tender and painful. If the affec- 
tion be allowed to progress, the follicles and the tissues of the parts 
will \ie destroyeti by ulcerative action, leading to perniancut scars 
and loss of hair. Sycosis is modified according to the condition 
of the hair of the affected part If the hair is thin and feeble in 
22 



338 



DISEASES OF THE 




growth, or if it should be cut clnge or shaved, the disease can be better 
seen and managed ; nu the other hand, if the huir is long, thick, and 
vigorous in growth, the diseased surface can be seen only by sepa- 
rating the hairs; it will also be difficult to treat until the hair is cut 
close to the j>art. When the condition of luxuriant growth exists, tlie 
hairs become matted together with poured-out products, ginng the 
countenance a disgusting appearance. The course of the disease i 
usually chronic J often as the result of being improperly managed, or,^ 
more frequently, being over-treated. 

Diagnosis. — Hyeosis is liable to be mi.staken for tinea barbie, or 
barber's itch, as both diseases invade the hair-follicles; but the symp- 
toms of each arc distinct and characteristic. The diagnostic signs of 
pustules, papules, and tubercles, pierced in the centre by hairs in their 
normal condition, firmly seated in the follicles, except when removed 
by suppuration or extraction, when the root-end is found to be enlargi 
and covered with pus, are observed only in sycosis. On tlie ot 
hand, barber^s itch is usually ushered in by small red or scurfy 
patches, the hairs are loosened in the follicles, being brittle, altered in 
texture, and, as the disease advaucos, liually break off, producing the 
characteristic stubbled condition of the surface. In case the di 
under consideration Is attended by marked inflammatory action, judg- 
ment should be suspended until the jwured-out products can be e» 
amined by the microscope, in order to demonstrate the presence or 
absence of the fungus. It is also sometimes ditticult to distinguish 
between sycosis and pustular eczema. All doubt, however, can be set 
at rest by the absence of discharge, the perforation of the pustules by 
hairs, and the limitation of the disease to the parts suj)plicd with hair. 
Again, sliouhl eczema be present, not only may there be a moisture of 
the surface, the eruption extending to the adjacent parts, but the 
symptom of itching is usually marked and characteristic. Syphilitic 
or scrofuhuis pustules and tubercles, developed on the hairy parts of 
the face, might be confounded with sycosis. The former lesions, how- 
ever, are usually preceded by a history, and accompanied by other evi- 
dences of the disease. Further, in specific atTections^ if crusts be 
present, upon their removal a well-marked ulcer, with sharpened 
edges, will be seen, while in sycosis there is little or no loss of integu- 
ment Pustular acne might resemble the early stage of sycosis, but 
the lesions are not pierced by hairs, nor is the disease limited to the 
male in whom the beard has grown. 

Pathology. — Sycosis, in its early stage, is a peri-follicular inflam- 
mation of the skin. While Wortheim * and Kobnerf were the 6rst to 
invoke the aid of the microscope in determining the nature of this dig- 

♦ Zfitwhrfft der k. k. Gesdl«chaft dcr Aerate, 1861. 

f Eliniscbe und ei peri men t elk' ilittburlangcn ftua Dcnufttologie und S.vphilidologiev 
ErlADgeD, 1804. 



EXUDATIONS. 



339 



■ 



jue, yet they conflned themselves to the examination of the extracted 
aairs only, and not the affected tissue. Subsequently, Robitison ex- 
amined portions of the skin obtained from a living subject, and showed 
the changes in the invaded part from the commeneenieDt to the ter- 
mination of the »1isease. Accordiug to tlie observations of this patholo- 
gist, the transuded serum penetrates the hair-follicle, and increases 
in quantity as tlie intlammation proceeds. Pus is also poured out, and 
the follicle- sheaths become softened and more or less destroyed, per- 
mitting free ingress of pus into the cavity of the follicle. The cells of 
the root-sheath and liair-root become swollen and infitratcd with sero- 
pamlent matter and pus-corpuscles, and finally become broken down 
and separated from the follicle-sheatiis, so that the hair lies loose 
within the follicle, and can be easily extracted. The pus readies the 
surface by oozing out between the hair-shaft and the follicle-sheath, or 
by breaking through the epidermis near the hair. In the majority of 
cases the follicle-sheaths are more or less destroyed, but the hair-papilla 
remains uninvolved, and in time produces a new hair. In severe cases 
the follicle-sheath, root-sheath, hair- root, and hair-papilla are all de- 
stroyed, and permanent loss of hair ensues. The sebaceous and sudo- 
riparous glands and other tissues of tlie skin may also become disinte* 
gnited and replaced by cicatricial tissue. 

Etiology. — Sycosis is a non-contagious inflammatory affection, usu- 
ally occurring between the ages of twenty-five and fifty, and is gener- 
ally due to some constitutional derangement. It is often dependent 
upon a debilitated state of the system. It ia observed among those who 
are mentally or physically overworked. Sycosis follows the use of un- 
wholesome and unsuitable food, excesses of all kinda, and occasionally 
appears in individuals convalescing from exhausting diseases. It may 
be excited by local irritants, as want of cleanliness, and in persons who 
are subjected, particularly by their occupation, to either a high or low 
temperature. Chronic rhinitis has also been enumerated among the 
local causes, as well as a faulty relation between the hairs ami the fol- 
licles in which they are contained. According to Bockhart the com- 
mon micro-organism of suppuration is the exciting cause of s^'cosis. 

Treatment.— It will be fuund that the employment of both consti- 
tutional and local treatment will yield the best results. Cases treated 
with only local applications are generally protracted an unusual leugth 
of time, and, under such circumstances, it is by a recuperative action 
of the system that recovery takes place. The internal txeatment is 
often advantageously begun with a brisk purge, the use of one of the 
mercurials being advisable. The diet should be carefully regulated 
and should consist of eiisily digestible and nutritious substances. Cheese 
fihould be strictly prohibited. The simple bitters, alone or combined 
with strychnine and a mineral acid^ will assist very much, especially in 
tlie debilitated or those out of health, in combating the disease. Mas- 



340 



DISEASES OF THE SKIN. 



sage and static electricity are serviceably employed when debility 
is marked. The fluid extract or the tincture of hoang-nan may be 
given with adyantage^ while soine have observed good results to toU 
low the combined internal and external ose of phytohicca. Iron, 
arsenic, phosphorus, and cod-liver oil can be beneficially employed. 
The iodide of iron is particularly serviceable, in from two to three 
grains, in pill-form three or four times daily. Another valuable prepa- 
ration is the liqnor arsenici et hydrargyri iodidi, as recommended by 
Tilbury Fox, in from three to ten drops, three times a day, especially 
if there be much inflammatory thickening of the parts. If there is a 
tendency to the formation of a large quantity of pus, the phosphates, 
hypophospliitea, calcium sulphide, or potassium chlorate will gener- 
ally a.<sist in ctninteraciing this condition of the system. 

The local treatment, which is all important, rerjuircs, in the acute 
stage, emollient and soothing applications. The hair may be cut as 
short as possible, or it may be allowed to remain in tlie natural condi- 
tion, providing it will not ma.sk the disease and interfere with the 
local ap])lications. Shaving, wluch is usually recommended, is pain- 
ful, and I have never seen it attended with good results* Scales and 
crusts, if present, should be removetl by oil-dressings or a poultice. 
As applications, lotions are more agreeable to some patients, either 
warm or cold, and, such being the case, lead-water and laudanum, 
weak solutions of witch-hazel, zinc and lead acetate, or of corrosive 
sublimate, can be tised. Oils are likewise elTective upon others, espe- 
cially the oil of ergot, olive-oil, with tluid mercury oleatc, or cod-liver 
oil, alone or combined with arrow-root, zinc or lead carbonate, opium, 
arnica, or belladonna, lightly pencilled over the surface. Among 
the serviceable ointments at this stage are the zinc, lead, and bis- 
muth oleates, alone or combined with other agents; calomel or white 
precipifate, ten grains to the ounce of cold cream or rose ointment, 
forms a valuable application. Diachylon ointment, with a few grains 
of camphor, will also be found efficacious. Sometimes ajiplications 
that arc more stimulating are more effective, especially in the later 
stages of the disease. One of the very best remedies to use under 
such circumstances is the ointment of oleate of mercury, of from ^ye 
to twenty per cent, strength, according to tlie condition of the parti, 
and applied alone or in conjunction with other remedies. The oint- 
ment of nitrate of mercury, in from one to three drachms to the ounce 
of zinc ointment, is also useful. Sulphur, tar, naphthoic or carbolic 
acid can also be advantageously combined with any of the prepara- 
tions advised. 

Kesorein, ichthyol, corrosive sublimate, salicylic or boric acid may 
also be beneficially brought into requisition. A two-pcr-cent. alcoholic 
solution of pyrogallic acid ts recommended by Veill, and a Bolution of 
tar in alcohol bv Prof. Pick, of Prague. Br. McCall Anderson ad- 




^^^^r EXUDATIONS. g41 

conYCnient application for nse in the daytime, Pro van's 
mtli paste, the formula of which is : 

IJ Tragacunth | sa. 

Glycerin f 3 ss. 

^m Sodii boratis. 5 ss, 

H M. Aq. destitl q. s. 

In addition to the eniploynieiit of the roniedicB jitst sng^gosted^ it 
is often of the utmost value to open the various leeions which may be 
present with a knife, and to puncture the surface thoroughly, thus re- 
lieving the enlarged and congested blood-vessels, allowing the Btagnated 
blood to circulate, the eitiised serum to escape, and preventing the 
formation of pus. Depletion is not only useful in the early stage of 
the disease, in conjunction with other suitable topical remedies, but in 
the fiabacute and chronic forms especially ; if there is much thickening 
of the skin, it is followed by decidedly beneticial results.* 

Epilation, which is resorted to by mauj pliysicians to prevent per- 
manent alopecia from resulting, and which is extremely painful, be- 
comes nnnec^-ssary if the lesions and parts are thoroughly depleted in 
the manner described. Depletion also awakens the activity of tho 
absorbents of the parts much better than such heroic agents as green 
Boap, acetic acid, etc., and thus assists the action of the local applica- 
tions. The abstraction of blood should be resorted to from one to 
three times a week, the parts encouraged to bleed freely by the use of 
warm water, the surface mopped gently dry, and the remedy applied 
well over the surface. The incisions and punctures usually heal rap- 
idly, the thickening lessens, the symptoms disappear, and a cure is 
effected without any scar or deformity. Bockhart advises that for 
some time after active treatment has ceased the patient should wash 
hb face once or twice daily with a one-per-cenL sublimate solution. 

Ptognosis. — SycOsi§ yields rai>idly in some, and in others it is pro- 
tracted for a long period of time, even months and years. Relapses are 
common, especially in i>erson8 who are subjected to continued locid 
irritation. It is, however, curable when properly managed, but tlie 
treatmeat should be continued until all evidence of the disease has 
entirely disiippciired. 

ZMPETiaO. 

Impetigo is an acute inflammatory affection, which is characterized 
by the development of discrete, rounded, elevated pustules, of the 
size of a split pea or larger, situated upon a base inflamed to some 
extent, and which disappears without leaving pigmentation or cica- 
trice-s. 

Symptoms. — I'he eruption may or may not be preceded by mild 

* Report of the treatment of a case of syooais, bf the author, in the Medical and 
Surgical Reporter, p. 298, October 13, 1877. 



M2 



DISEASES OP THE SKIN. 



febrile symptoms. It conaiats of round, elevated pustules, which are 
slightly acuminated, but not umbilieated. Thev are gituuted upon a 
gomewhat iniiatned base, with, in the beginningj a slight surrouiuling 
aureola. Their contcuts are Bero-purulent, purulent, and very rarely 
bloody. They present a whitish, yellowish, and occasionally a reddish 
color. In number they ma}'' vary from one to many. The postulfs are 
isolated, and, even if in close proximity, do not incline to coalesce. They 
do not tend to rupture, but their contents several days aftt^r maturity 
are partially or altogether absorbed, or dry into yellowish or brownish 
crusti?- They may, on the contrary, occasionally bo ruptured through 
fnetion or picking, in which event a thin pnndent secretion escapes, 
which also dries into crusts. The amount of crusting may be slight 
or abundant, and after they have fallen off au erythematous surface 
remainis, without pigmentation or scar. "Jlie disea.se has an acute 
course, the eruption generally appearing suddenly. The duration of 
impetigo is usually several weeks. Subjective synipionis are, as a rule, 
absent, but occasionally there may be slight itching. All parts of the 
body may be invaded, but it occurs by preference on the face, hands, 
and lower extremities, 

DiagllOsis.^ — Impetigo may bear some resemblance to pustular ecze- 
ma, impetigo contagiosa, and ecthyma. The pustules of imi>etigo are 
large, isolated, few in number, and do not incline to coalesce, while 
those of eczema are small, clustered, numerous, and tend to run to- 
gether. The pustules in impetigo, further, are attended with but 
slight if any infiltration and itching, and have no inclination to break; 
in eczema infiltration is present, itching is marked and often constant, 
and the lesions rupture soon, with more or less crusting. 

In impetigo contagiosa the primary lesions are vesicles, and the 
pustules when formed are frerpiently flat and umbilieated, w*ith a 
tendency to coalesce. Impetigo is not contagious, and can not be 
traced to several of the same family, as in impetigo contagiosa- 

In ecthyma the lesions are distinguished from those of impetigo 
by the pustules in the former being flat, UTid seated on a hard, inflam- 
matory baj^c, and surrounded by a marked aureola. The crusts also 
differ materially, being in ecthyma brown or black in color, large, flat, 
aud thick, ami seated upon an excoriated surface. 

Pathology. — The inflammation of the skin in impetigo is super- 
ficial, and is limited to the corium, involving only the papillary layer. 
Itobinson states that it is a corpuscular inflammation, the embryonic 
or pus corpuscles being present in great numbers in comparison with 
tlie amount of serum. 

Etiology, — Impetigo is a rare, non-contagious disease. It is en- 
countered chiefly among children, particularly those that are improp- 
erly cared for and badly fed. It is also associated with disorders of the 
gastro- intestinal tract, and may occur after any debilitating affection. 



EXUDATIONS. 



343 



Its lesion depends upon the development of the microbes of suppura- 
tion. 

Treatment^Suitable hygienic measures, and good, nutritious food 
are of the utmost iinporUmce. If any special functional derangement 
exists it should be corrected. It is often of advantage to put the pa- 
tient upon tonic doses of quinine. The affected surface should be pro- 
tected against irritation, and when the pustules are fully developed 
they should be incised and the pus evacuated. A mild mercurial, or 
other slightly stimulating ointment, may tlien he applied to the parts, 
Sozoiodol has been used mlvantageously as a dressing. If scabs have 
formed, tliey may be removed by water or oil dressings, or poulticiag, 
after which the ointment can be applied to the surface. 

Prognosis. — The prognosis is good. 

Impetigo IIehpetifohmis. — This rare and serious affection was 
first described by llebra, who observed but few ciises, nearly all of them 
terminating fatally. It prevails, according to his experience, only 
among pregnant women. Kaposi, however, has mot with one ease oc- 
curring in a man. 

The eruption is characterized by the development of small, yellow 
pustules, arranged in groups or in the form of rings. The lesions 
incline to run together, and to dry into yelluwish or brownish crusts, 
and at the samo time similar pustules form around the periphery of 
the patch, pursuing the same course as in impetigo. The peculiar 
annular formation of the lesions jiresents a resemblance to herpes iris. 
The surface beneath the crusts is red, moist, excoriated, and infil- 
trated. The disease attacks chiefly the anterior portion of the trunk 
and the inner surfaces of the tbiglis, but may occur upon the face, 
neck, arms, legs, and other parts of the body. In Ilebra's ])atient8 
there was marked constitutional disturbance, ever}^ outbreak of pust- 
ules being preceded by chills and fever. 

Duhring describes the disease as consisting in tlie majority of cases 
of pustular and bullous lesions combined, or occurring alternately. 
The eruption in his cases was similarly arrauf^ed, and had a like course 
to those of Ilebra's, The constitutional symptoms, he reports, were 
Tariable, but the itching was always violent. Duhring's patients were 
not pregnant women, and in no instance was there a fatal result. The 
eruption, he adds, manifested a disi)osition to recur, and was but little 
inBuenced by treatment. 

Heitxmann reports the case of a woman at the climacteric period, 
which was followed by a fata! termination. Robinson also records 
wliat he calls a well-marked case in a boy ten years of age, the lesions 
developed being papular, vesicular, pustular, and bullous, aiul occur- 
ring orer all the body, except the palmar and plantar surfaces. 

Treatment. — The disease is to be managed upon general principles, 
the jiymptonis being the guide. 



344 



DISEASES OF THE SKIK. 



IMPETIGO CONT&aiOSA. ^| 

Impetigo contagiosa is an acute, infianimatorj, contagious affec- 
tion, characterized by the development of isolated, flat, or elevated 
vesicles, blebs, or vesi co-pustules, the size of a split pea, or larger, 
whie]i dry into slightly adherent crusts. 

Symptoms. ^ — The disease is generally ushered in with mild febrile 
symptoms. The eruption appears iis small, isolated, flat or raised 
vesicles, or blebs, which sooii increase in size, and become transformed 
into vesico'pustules or pustules. In shape they are usually round or 
oval, and are occasionally umbilicated. They may, though rarely, be 
irregular in form. They may have a slight aureola around them, or it 
may be ivanting. The number of lesions is, as a rule, enutll, and at times, 
when closely seated, they may run together and form a patch. They 
may appear simultaneously, or in successive crops. In the course of a 
few days they dry into yellowish, straw-colored, and slightly adherent 
crusts, beneatii which some slight excoriation exists, covered with a 
thin, purulent secretion. If the scalp is involved, the patches are cir- 
cular, usually isolated, and covered with flat crusts, which mat the 
hair. The crusts, soon after their formation and drying, fall off, ex- 
jmsing an erytheniatnus surface, which also in time disappears. Sub- 
jective symptoms are generally absent, but tht*re may bo at times slight 
itching. The affection in the majority of instances, attacks the face, 
head, arms, and hands, but it may likewise appear on other parts, even 
the mucous membrane of the eyes and mouth. The lymphatic ghmda 
in connection with the diseased surface may become enlarged and 
tender. Impetigo contagiosa may begin in one region, and, by scratch- 
ing, spread by direct inoculation of the secn^tion to other portions of 
the body. The tliiratian of the disease is from seven to ten days. 

Diagnosis, — Contagious impetigo may be confounded with impeti- 
go, eczema pustulosum, and varicella. In impetigo the pustules are 
raised; in tlie contagious form they are, or become, flat In eczema 
the lesions are not isolated, and the itching is often marked and con- 
sUint, thus differing in these respects from impetigo contagiosa. Vari- 
cella is distinguislied from impetigo contagiosa by the lesions remain- 
ing vesicular throughout the disease, as well as by their smallness in 
size and their general distribution over the body. 

Pathology.- — Vegetable organisms have been detected in the crusts 
by some observers, and from these the eruption is said to arise. Til- 
bury Fox and others declare that they are merely accidental. No de- 
cided evidence has yet been adduced, from an examination of the vesi- 
cles or crusts, to account for the development of the lesions. Piffard 
considers contagious impetigo as connected in some manner with vac- 
cinatinn. 

Etiology. — The disease is contag