(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "Atlas of diseases of the skin, including an epitome of pathology and treatment"

lEDlCAL BOOKStLLERS 

90 MABA5H AVtNUE. 



SAUNDERS' 
MEDICAL HAND-ATLASES. 

The series of books included under this title are authorized translations 
into English of the world-famous 



CarleHJPWiney 




which 
cheapr 

Eac 
ous ilia- 
most sV 
pressioc 
paniedl 
densed 

One 
ready t 
servatio 
and eve 
hospital 
will be 
venient 
by the i 

Wh; 
heretofc 
of their 
enormo 
jected I 
tributioi 
best HI 
elegan 
in che. 
by the | 
langus 
Japane: 

The same carerur ana competenr eaiioriai sujJtfvision has been 
secured in 'he English edition as in the originals. The translations have 
been edited by thi leading American specialists in the different sub- 
jects. The volumes are of a uniform and convenient size (5 x 7^ inches), 
and are substantially bound in cloth. 

(For List of Books, Prices, etc. see back cover.) 

Pamphlet containing specimens of the '^-*- ' '^ ^J 

sent free on applicatioi 



STRATFORD & GREEN 

BOO^SELLERS 

64a-6«»a so MAIN ST 



uid 

ler- 
the 
im- 
S)m- 
on- 

:r a 
ob- 
;rs; 

line 

1 
bks 

on- 

ted 

has 

use 

an 

j)ro- 

kis- 

|the 
lost 

lied 
ted 
pnt 

jch, 



Digitized by tlie Internet Arcliive 

in 2007 witli funding from 

IVIicrosoft Corporation 



littp://www.arcliive.org/details/atlasofdiseasesoOOmraciala 



lATLAS 



DISEASES OF THE SKIN 



,n 



INCLUDING 



AN EPITOME OF PATHOLOGY AND 
TREATMENT 



BY 

PROF. DR. FRANZ MRACEK 

of Vienna 



AUTHORIZED TRANSLATION FROM THE GERMAN 



EDITED BY 



HENRY W. STELWAGON, M.D., Ph.D. 

Clinical Professor of Dermatology, Jefferson Medical College, Philadelphia- 

Physician to the Department for Skin Diseases, Howard Hospital ; 

Dermatologist to the Philadelphia Hospital, etc. 



With 62 Colored Plates and 39 Full-page Half-tone Illustrations 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS & COMPANY 
1900 






Copyright, »8q9 
By W. B. SAUNDERS 



ELEOTROTVPeD BY PRESS OF 

WESTCOTr & THOMSON, PHILAOA, W. B. SAUNDERS. PHILAOA. 



EDITOR'S PREFACE. 



The importance of personal inspection of cases in the 
study of cutaneous diseases is readily recognized. For 
those lacking clinical facilities, the nearest approach to 
this method is the opportunity of having at command 
numerous well-executed colored plates ; and an additional 
advantage is gained in having plates small enough for 
handy reference, and yet sufficiently large for satisfactory 
representation. Dr. Mracek has happily succeeded in 
supplying such atlas-pictures, and the selection of sub- 
jects i>ortrayed is well adapted to the demands of aver- 
age experience. While a few rare diseases — relatively 
rare at least in America — are presented, nearly all are 
pictures of cases of not infrequent occurrence. 

The Editor has endeavored to follow closely the au- 
thor's text, and in the translation of a part of the work he 
has had the aid of Dr. E. J. Stout, Instructor in Derma- 
tology in the Jefferson Medical College. When deemed 
necessary, brief parenthetical notes have been added. 

It is sincerely believed that this volume will be a 

material help to the working physician, especially in that 

most difficult branch of the subject — diagnosis. 

Philadelphia, 223 S. Seventeenth St. 

7 



PREFACE. 



The same motives which guided me in the preparation 
of my "Atlas of Syphilis" have also influenced me in 
preparing the subject-matter and in the selection of 
plates of the present volume — i. e., the practical require- 
ments and an appropriate choice of material. Circum- 
stances have demanded certain limitations. For instance, 
of the acute exanthemata, only morbilli and varicella 
could be included, as the exanthematous infectious dis- 
eases are not allowed in my wards, but are sent to the 
hospital for infectious diseases. 

I am indebted to the kindness of colleagues for some 
cases : to " Hofrat " Prof. Albert, Prof, de Amicis 
(Naples), " Primararzt " Dr. Eugen v. Bamberger, 
"Primararzt" Dr. Rudolf Frank, Prof Lang, Prof. 
Kaposi, and "■ Primararzt " Dr. Ludwig Winternitz. 

Plates 64 and 65 are taken from Kopp's Atlas. The 

water-colors and half-tone drawings have been executed 

by Mr. A. Schmitson, the artist, in his well-known and 

exemplary manner. The publisher has reproduced the 

work in the most careful manner. 

The chapters on general therapeutics and treatment 

9 



10 PREFACE. 

of individual skin-diseases are from the pen of Dr. 

Siegfried Grosz, my assistant for many years. 

I tjike this opportunity to acknowledge my thanks 

to all these gentlemen who have kindly aided me in 

my work. It is sincerely my wish that this book may 

meet with a kind reception and render practical assistance 

to those who consult its pages. 

DR. MRACEK. 
Vienna, November, 1898. 



CONTENTS. 



PAGE 

Introduction 17 

Greneral Therapeutics 20 

Disorders of the Glands » 25 

Osmidrosis 25 

Hyperidrosis 25 

Dysidrosis 26 

Seborrhea 28 

Comedones 29 

Pityriasis Capitis 30 

Milium . . . • • 31 

Molluscum Coutagiosum 32 

Anemia of the Skin 33 

Hyperemia of the Skin 33 

Dermatitis 34 

Erythema 35 

Urticaria 38 

Pellagra 42 

Drug-eruptions 43 

Hemorrhagic Eruptions 44 

Acne 47 

Sycosis 53 

Acne Rosacea 56 

Vesicular and Bullous Eruptions 59 

Herpes Zoster 59 

Herpes Facialis et Progenitalis 63 

Miliaria 64 

Impetigo Herpetiformis 65 

Pemphigus Acutus 66 

Pemphigus Neonatorum 67 

11 



12 CONTENTS. 

PAGE 

Pemphigus Acutus Contagiosus 67 

Pemphigus 68 

Pemphigus Vulgaris 68 

Pemphigus Foliaceus 70 

Inflammatory Dermatoses 73 

Dermatitis 73 

Combustio 75 

Congelatio 79 

Erysipelas 81 

Furunculus 84 

Carbunculus . 85 

Pustula Maligna 85 

Equinia 86 

Squamous Dermatoses 86 

Psoriasis 86 

Pityriasis Eubra 95 

Pityriasis Kubra Pilaris 96 

Lichen Ruber 97 

Lichen Scrofulosorum 101 

Keratosis Pilaris 102 

Eczema 102 

Prurigo 115 

Neuroses 118 

Pruritus 119 

Anesthesia of the Skin 121 

Anomalies of the Epidermis 121 

Callositas 121 

Clavus 122 

Comu Cutaneum 122 

Verruca 122 

Ichthyosis 123 

Acanthosis Nigricans 125 

Psorospermosis Follicularis Vegetans 125 

Anomalies of the Hair 126 

Alopecia 126 

Trichorrhexis Nodosa 128 

Trichoptilosis 129 

Hjrpertrichosis 129 

Albinismus 129 

Graying of the Hair 129 

Anomalies of the Nails 129 

Pigment-anomalies of the Skin 130 



CONTENTS. 13 

PAGE 

New Growths I37 

Verrucous Growths I37 

Nevus 137 

Cicatrix 13Q 

Keloid 139 

Elephantiasis Arabum I39 

Scleroderma 139 

Scleroderma Neonatorum 141 

Myxedema 142 

Partial Atrophy and Thinning of the Skin 142 

Greneral Atrophy of the Skin I43 

Xeroderma 143 

Lupus Erythematosus I45 

Fibroma Molluscum I47 

Lipoma 148 

Xanthoma 148 

Dermatomyomata 149 

Angiomata I49 

Ehinoscleroma 151 

Tuberculous Diseases of the Skin 152 

Lupus 154 

Scrofuloderma 160 

Tuberculous Ulcer 161 

Tuberculosis Verrucosa Cutis 162 

Tuberculosis Fungosa 163 

Lepra 163 

Malignant Growths of the Skin 168 

Granuloma Fungoides 169 

Sarcoma Cutis 171 

Epithelioma 173 

Parasitic Diseases of the Skin 175 

Tinea Favosa 175 

Tinea Trichophytina 175 

Tinea Circinata 179 

Tinea Tonsurans 181 

Tinea Versicolor 183 

Erythrasma 185 

Actinomycosis 185 

Animal Parasites of the Skin - • • 186 

Scabies 186 

Creeping-disease 189 

Pediculosis 189 



LIST OF PLATES. 



Plate 


1. 


Platk 


2. 


Plate 


3. 


Plate 


4. 


Plate 


5. 


Plate 


6. 


Plates 


i 7,7a. 


Plate 


8. 


Plate 


9. 


Plate 


10. 


Plate 


11. 


Plate 


12. 


Plate 


13. 


Plate 


14. 


Plate 


15. 


Plate 


16. 


Plates 17, 18. 


Plates 19, 19 a. 


Plate 


20. 


Plates 21, 21 o, 21 b. 


Plates 22, 22 a. 


Plates 23, 23 a. 


Plate 


24. 


Pl.\tes 


25, 25 a. 


Plate 


26. 


PLATJ! 


27. 


Plates 28, 28 o. 


Plate 


29. 


Plate 


30. 


Plate 


31. 


Plate 


32. 



Pompholyx. 

Milium. 

Adenoma Sebaceum. Comedo. Acne. 

Morbilli (Papular Form). 

Varicella. 

Erjrthema Multiforme (Erythematous and Ery- 
thema topapular) . 

Erythema Multiforme (Vesicular and BuUous). 

Erythema Multiforme (Papular and Nodose). 

Purpura Hsemorrhagica. 

Purpura Hsemorrhagica. 

Purpura Rheumatica (Fulminans). 

Herpes Zoster (Sacrolumbalis, Hsemorrhagicus et 
Gangrseuosus). 

Herpes Zoster (Supraorbital and Palpebral). 

Dermatitis (Cantharides). 

Psoriasis (Punctata et Guttata). 

Psoriasis (Diffusa). 

Psoriasis Nummularis (Eczema Seborrhoicnm ?). 

Psoriasis (Circinate, Annular, Gyrate). 

Psoriasis (Gyrate, Annular). 

Psoriasis. Comua Cutanea (with Degeneratiye 
Changes in Right Hand and Left Foot). 

Lichen Ruber Planus. 

Eczema Artificiale Vesiculosum [Dermatitis]. 

Eczema Artificiale Acutum [Dermatitis]. 

Eczema Pustulosum Artificiale [Dermatitis]. 

Eczema Marginatum (Tinea Trichophytina Cruris). 

Eczema (Mycoticum ?). 

Eczema Madidans et Crustosum (Mycoticum ?). 

Prurigo. 

Acne. 

Sycosis. 

Furnnculosis [£k:thyma ; Impetigo Contagiosa ?]. 

15 



16 



LIST OF PLATES. 



Plates 33, 34, 34 o. 


Plate 


35. 


Plate 


36. 


Plate 


37. 


Plate 


38. 


Plate 


39. 


Plate 


40. 


Plate 


41. 


Plate 


41a. 


Plate 


416. 


Plate 


42. 


Plate 


43. 


Plates 44, 44 a. 


Plate 


45. 


Plate 


45 a. 


Plate 


46. 


Plate 


47. 


Plate 


47 a. 


Platk 


476. 


Plate 


47 c. 


Plates 48, 48 a. 


Plate 


486. 


Plate 


49. 


Plate 


50. 


Plate 


51. 


Plates 51 a, h, c. 


Plate 


52. 


Plate 


53. 


Plates 54, 55. 


Plate 


55 a. 


Plate 


56. 


Plate 


57. 


Plates 58, 59. 


Plate 


60. 


Plate 


61. 


Plate 


62, 62o. 


Plate 


63. 


Plate 


64. 


Plate 


65. 



Pemphigus Vegetans. 

NsBvus Verrucosus. 

Nsevus Pigmentosus Unilateral is. 

Hyperchromatosus Arsenicalis. 

Lichen Pilaris (Keratosis Pilaris). 

Ichthyosis. 

Hyperkeratosis Palmaris (Callositas). 

Leucoderma (Vitiligo). 

Alopecia Areata (Alopecia Totalis Neurotica). 

Alopecia Areata ; Canities. 

Lupus Erythematosus. 

Lupus Erythematosus. 

Xanthoma Tuberosum. 

Nsevus Vasculosus. 

Nsevus Vasculosus et Verrucosus. 

Lupus Vulgaris Serpiginosus. 

Lupus Vulgaris (Lupus Exulcerans, Lupus Exe- 
dens). 

Chronic Tuberculosis of the Hand, following Ex- 
articulation of Necrosed Middle Finger. 

Chronic Tuberculous Ulcerations on Back of 
Hand. Scrofulogunimata on Forearm. 

Chronic Tuberculosis of the Skin of the Leg (Lupus 
Tumidus). 

Lupus Vulgaris ; Phlegmon. 

Lupus Vulgaris (Lupus Hypertrophicus). 

Tuberculosis Subacuta Mucosae Oris. 

Panaritium Tuberculosum. 

Tuberculosis Cutis. 

Lepra. 

Carcinoma Lenticulare. 

Epithelioma. 

Carcinoma Penis. 

Epithelioma Cicatrisans. 

Tinea Favosa. 

Pityriasis Maculata et Circinata. 

Tinea Trichophytina Corporis (Tinea Circinata)- 

Tinea Versicolor. 

Actinomycosis. 

Scabies. 

MaculiB Cserule® ; Phthiriasis. 

Animal Parasites. 

Vegetable Parasites. 



DISEASES OF THE SKIN. 



INTRODUCTION. 



The successful study of skin-diseases presupposes an 
exact anatomic knowledge of the skin, its appendages, 
physiologic functions, and reciprocal relations to other 
organs. Owing to limited space, we cajinot devote a sec- 
tion to this subject; and this can indeed be studied more 
readily and satisfactorily in the larger works on derma- 
tology, the handbooks on anatomy and physiology, etc., 
which treat of this subject. We would only emphasize 
especially that the skin belongs to the group of the most 
important organs of the body, and participates intimately 
in tiie functions of the entire organism ; consequently, 
morbid changes in the skin may give rise to decided dis- 
turbances in the economy of the organism, and, vice 
versd, diseases of internal organs may lead to pathologic 
clianges in the skin. The general integument, therefore, 
should not be regarded as being solely intended for pro- 
tection ; nor looked upon, according to popular view, as 
an unimportant leathery cover. 

The skin serves, it is true, as an organ of protection in 
the mechanical sense of the word ; but it also possesses an 
im})ortant function in regulating the giving off of heat, 
and is itself an organ of secretion in which ctitaneous 
respiration (the giving off of carbonic acid and water) also 
plays a rdle ; althougli its power of absorption is very 
limited, it may under certain circumstances be not unim- 
])ortant. Finally, the skin serves as an organ of touch, 
through which arise common sensation, the sense of local- 
ity or space. 

2 17 



18 DISEASES OF THE SKIN. 

The etiology of cutaneous diseases, as to be expected 
from the j30sition of the integument in the organism, is 
many-sided and varied, and, owing to the relations ex- 
isting between it and the organism as a whole, fre- 
quently complex. " External " onuses of disease, me- 
wianical and chemical, of the most diverse character, as 
well as parasites, which not infrequently gain access to 
the skin, may have a markedly damaging action. The 
skin is further affected by many noxious influences which 
attack the entire organism, be they infectious diseases, 
the most pronounced clinical group of which (acute ex- 
anthemata) have an especially active effect on the integu- 
ment; or be they intoxication by poisons which have 
developed or have accumulated in the body itself, due 
to deficient elimination of the products of metabolism. 
The skin, therefore, presents a large number of sympto- 
matic diseases : The acute cutaneous exanthemata, syphilis, 
equinia, typhoid fever, cholera, uremia, etc. all usually 
have cutaneous manifestations. Diseases of single organs 
(heart, liver, kidneys, nervous affections) are not uncom- 
monly accompanied by phenomena on the external skin. 

Direct injurious influences to which the skin may be 
subjected give rise tx) the so-called idiopathic skin-diseases. 
These influences, whether they are of an infectious or 
chemicophysical, traumatic character, are the causes of 
many of the acute and chronic inflammatory cutaneous 
diseases. 

As cutaneous lesions are amenable to observation and to 
the sense of touch, they afford a very valuable subject — 
probably not as yet sufficiently appreciated — for theoretic 
and scientific study, w^hich not infrequently can be aided 
and confirmed by microscopic examination. Although it 
would be very interestingtoenter into a discussion relating 
to this subject, and to consider the sequelne and develop- 
ment of granulation-tissue, formation of cicatrices, etc., 
we must, owing to lack of space, pass it by. 

The symptoms of skin-diseases are divided into sub- 
jective and objective. To the former belong the various 



INTRODUCTION. 19 

painful, itching, and burning sensations, etc. ; further, those 
accompanied by a feeling of tension, disturbances of sen- 
sibility, anesthesia, and paresthesia. Of greater importance 
are the visible changes on the surface — objective symp- 
toms — of the skin, the so-called cutaneous lesions or efflo- 
rescences, as they offer the necessary points for diagnosis. 

We distinguish maculcc — macules, spots ; of Mhich the 
erythemata are examples. In the same class belong also 
telangiectases, ncevi vasculosi ; hemorrhages, as petechicB, 
vibices, ecchymoses ; and also chloasmata, lentigines or 
freckles, and na;in pigmentosi, all of which latter are pig- 
mentary spots, usually of a brownish color. Yellow 
plaques or spots, usually somewhat thick and elevated, 
are called xanthoma. We have further papules and 
tubercles, lesions which are elevated above the level of 
the skin ; tumors, circumscribed plastic elevations larger 
than a tubercle ; and wheals, which are elevated above 
the surface ; further, vesicular and bullous elevations 
of the epidermis with varying contents : Vesicular, or 
vesicles, bulke, or blebs, pustuke, or pustules, ecthymata, 
pustules of larger size accompanied by inflammatory 
infiltration of the surrounding parts. Injuries to the 
skin are known as excoriations, rhagades (fissures). Ul- 
cera, ulcers of the skin, are the result of more severe 
inflammatory ])rocesses accom])anied by necrosis. Squama', 
or scales, are the products of morbid desquamation or ex- 
foliation of the epidermis. AVhen the contents of ^he pus- 
tules or ulcers dry up, crusts, scabs, or scurf are formed, 
which cover the diseased or injured places. 

Efflorescences may be solitary (efflorescent ice solitai'ia;) 
or scattered (dispeisce), crowded together (aggregatce), or 
in circles or segments of circles (ejfiorescentice annulares, 
circinatcr). The latter frequently form when the process 
spreads at the periphery and undergoes involution in the 
center. The name iris (herpes, or erythema iris) is 
given to that form in which several circles of efflores- 
cences occur around a primary- focus. Gyri are more or 
less circular lines, which are formed by the confluence of 



20 DISEASES OF THE SKIN. 

several circles and segments of circles. Exanthem desig- 
nates a cutaneous eruption which is distributed over large 
surfaces or over the entire body. 

There remains to be mentioned that certain skin-dis- 
eases have seats of predilection, which are partly de- 
pendent upon external causes (pressure of clothing) ; 
partly upon anatomic conditions — ramifications of nerves, 
vascular areas ; and, finally, upon conditions of the text- 
ure of the skin itself — e. g., the so-called lines of cleavage 
of the skin as described by Voigt and Langer. 

We cannot refrain from making a short reference to 
the classification of skin-diseases. Every system serves 
as a didactic aid, and the endeavor to establish such 
in our eminently empirical science appears natural. 
The rich abundance of etiologic facts which the ex- 
ternal causes of disease aiford us has tended, with 
the inclusion of those found due to bacteriologic fac- 
tors discovered during the last twenty years, to make 
an etiologic system possible. We are, on the other hand, 
not yet united, in many groups of diseases, as to the 
anatomic details, still less on etiology, which frequently 
has not passed beyond the hypothetic stage. W^hat a rdle 
is still played at the present day by tro])hic disturbances 
in the nerve-tracts and by the so-called reflex neuroses ! 

We do not consider it our duty, however, in this ele- 
mentary treatise, to enter at length on such far-reaching 
questions as this of classification ; we also believe that 
Hebra's system, as slightly modified in many recent 
works, is still sufficient for the study of skin-diseases, 
even at the present day. 

GENERAL THERAPEUTICS. 

In dermatology we are as yet far from attaining the 
desired object of our therapeutic endeavors — to treat 
forms of disease according to their etiology. In but few 
skin-diseases has the question relating to the primary or 
essential causative factor or factors of an affection been 



GENERAL THERAPEUTICS. 21 

satisfactorily settled ; the treatment of the greater number 
of diseases is still based upon the symptoms. As these 
are subject to changes during the course of a malady, the 
therapeutic indications also change ; it is accordingly of 
great importance to the physician to recognize each one 
of these several phases or stages, and he will then be en- 
abled to use intelligently the numerous remedies which 
dermatologic therapeutics places at his disposal. 

Internal Treatment. — The older practitioners rec- 
ommended and employed various internal remedies in 
skin-diseases. Nearly all of these have been forgotten at 
the present day ; the ideas, however, of treating skin- 
aifections by placing stress upon dietary rules and internal 
medication are a^ain cominjj more and more to the front. 
In some skin-diseases dietary regulations are not only 
strongly to be advised, but are even indispensable. One 
need, for instance, only recall urticaria, often due to in- 
gestion of certain kinds of food, and which may appear at 
other times when intestinal digestion is imperfect or 
faulty ; and the ervthemata, which occur under similar 
etiologic conditions ; and also the eruptions of eczema in 
diabetic, nephritic, and gouty individuals. 

It is therefore surely an error to practise dermatology 
with the aid of the ointment-pot alone ; just as it would 
be, on the other hand, to endeavor to combat marked 
changes in the cutaneous integument by simply forbidding 
certain articles of food. 

Of the internal remedies we desire to mention the fol- 
lowing : Arsenic, mercury, iodin, carbolic acid, tar-prepa- 
rations, pilocarpin, atropin, quinin, sodium salicylate, 
thyroid preparations, calcium chlorid, menthol, etc. Some 
cases are benefited by a course of treatment with the 
natural minend waters (Carlsbad, Franzensbad, Roncegno, 
Hall, Lipik [and in our own country Richfield Springs, 
Hot Springs of Virginia, Healing Springs, Bedford 
Springs, and many others well known. — Ed.]). 

External Treatment of Skin-diseases. — We em- 
ploy the following means : 



22 DISEASES OF THE SKIN. 

1. Water for ablutions and for partial and full baths; 
the cold water as an astringent and warm water dilating 
the vessels. The continuous water-bath (Hebra's water- 
bed) may be employed in pemphigus foliaceus, decubitus, 
extensive burns, universal psoriasis, lichen rul)er, and 
pityriasis rubra Hebra. Medicated baths are baths con- 
taining alkalies, potassium sulphid, brine, tar, corrosive 
sublimate, etc. 

2. Besides waters, the fats serve materially for the 
purpose of softening morbid accumulations on the skin. 
Mineral, vegetable, and animal fats, in solid and fluid 
form, are employed ; they are used alone or as vehicles 
for medicaments. We mention those most frequently 
used : Petrolatum, vasogene (oxygenated hydrocarbons), 
vasole (Hell), cacao-butter, ol. olivse, ol, amygdalarum 
dulc, ol. lini, ol. rapse (rape-seed oil), ol. ricini, lard, 
spermaceti, oesypus (the natural fat of wool), adeps lanse 
(wool-fat), lanolin [this is not a fat, but consists princi- 
pally of ethereal fatty acids of cholesterin and isocholes- 
terin, which are also found in all tissues containing kera- 
tin and in the human skin and human hairs, and of free 
fatty acids (up to 30 per cent.)], cod-liver oil, and oleum 
physeteris. 

Further : MolHn (an over-fatty soap made of pure 
kidney-fat and the finest Cochin cocoanut-oil, saponified 
by mixing potash- and soda-lye and addition of glycerin), 
myronin (produced from vegetable wax and ol. pl»y- 
seteris), resorbin (made of almond-oil, wax, and addition 
of gelatin, soap, and adeps lanse), glycerinum saponatum 
(H. V. Hebra), epidermin (Kohn), unguentum lanolini 
Paschkis (lanolin, anhydr., G5 (six gr. xxxv) ; paraffin. 
liquid., 30 (sviiss) ; ceresini (mineral wax), 5 (gr. Ixxv) ; 
aq. destill., 30 (sviiss)), vaselinum lanolinatum (Hell), 
and glycerin. 

Ointment-mulls (Salbenmulle) (Beiersdorf) are band- 
ages spread with special sjilve-mass variously medicated, 
which do not adhere to the skin, but must be kept in 
position by suitable bandages. The fatty mass of the 



GENERAL THERAPEUTICS. 23 

omtraent^nmlls consists principally of sebum benzoinatum, 
with addition of more or less wax. 

3. Soaps. — These are combinations of fatty acids with 
alkalies. We distinguish between soft soaps (fat saponi- 
fied by potash-lye) and hard soaps (fat saponified by soda- 
lye). When all of the alkali of the soap is combined 
with fatty acids the soap is neutral. The action of the 
soaps is said to be due to the soluble basic, fatty-acid 
salt. Over-fatted soaps are those which contain along 
with the fatty-acid salts, of which neutral soap consists, 
a certain quantity of unsaponified fat. Unna's over- 
fatted or basis-soap is made of the best beef-tallow and a 
mixture of two parts of soda-lye and one part of potash- 
lye ; sufficient olive-oil is added to the soap-mass so that 
about 4 per cent, will remain unsaponified. Eichhoff has 
produced soaps containing various pulverulent substances. 

We employ, in addition, Hebra's "spiritus saponatus 
kalinus " (tinctura saponis viridis) according to the follow- 
ing directions : 

!^ Saponis viridis, 200 (3I gr. xv). 

Solve leni calore in 
Spirit, vini, 100 (fsxxv gr. viiss). 

Filtra et adde 
Olei lavanduljB, 

Olei bergamottae, da 3 (gtt. xlv). 

Misce et filtra. 

Sig. — Spiritus saponatus kalinus (tinctura saponis 
viridis). 

Finally, a number of medicated soaps (naphtol-sulphur 
soap, sulphur and tar, corrosive sublimate, menthol, thy- 
mol, resorcin, etc.). 

4. Varnishes. — Excipients which, when painted on the 
skin, dry and form a smooth coating. 

a. Varnishes soluble in water : Linimentum exsiccans 
Pick consists of tragacanth, 5 parts ; glycerin, 2 parts ; 
distilled water, 100 parts. 

Unguentum caseini Unna consists of alkali-casein, 



24 DISEASES OF THE SKIN. 

glycerin, vaselin, and water. It is miscible with all sub- 
stances whicli do not coagulate casein. Tar up to 20 per 
cent, may be added to the casein-ointment, although with 
this an addition of 1 part of sapo viridis to 4 parts of 
water is recommendeo, so as to render the product less acid. 
Rubbed on the skin, it dries into an elastic, smooth layer. 

Gelanthum consists substantially of tragacanth, gelatin, 
and water. 

Gelatin-paste, according to Unna^s formula, is as 
follows : 

1^ Gelatinae alb., 30 (sviiss) ; 

Zinci oxid., 30 (.^viiss) ; 

Glycerini, 50 (f^xiiss) ; 

Aquae, 90 (f^xxiiss). 

The gelatin is dissolved in the water over a water-bath, 
the glycerin added, and the zinc oxid well incorporated. 
When desiring to use, melt over water-bath and paint on 
with brush. 

6. Varnishes insoluble in water : Collodion, traumaticin 
(liquor gutta-perchae), liquor adhaesivus Schiff or filmogen 
(cellulose nitrate dissolved in acetone with addition of oil). 

5. Pastes. — These are mixtures of medicaments having 
the consistence of dough. 

6. Plasters. — These consist of lead and soap, or of a 
mixture of turpentine, various resins, and fats, or of 
varying proportions of the two plasters. 

The Unna-Beiersdorf gutta-percha plaster-mulls are 
plasters in which the fabric is first coated with a thin 
layer of gutta-percha. The thickly applied plaster-mass 
consists principally of caoutchouc with addition of adeps 
lanae, and is variously medicated. The " paraplasters " 
have as base a close cotton material of very fine fiber, 
which is saturated with a solution of caoutchouc and vul- 
canized. Collemplastra are plasters in which caoutchouc 
is mixed with the plaster-mass. 

7. Powders. — Starch, talcum, magnesium carbonate, 
and zinc oxid are most usually employed. 



DISORDERS OF THE OLANDS. 25 



DISORDERS OF THE GLANDS. 

Tlie secretory processes in tlie skin consist, in the 
maiu; of tlie ordinary secretions of the sweat- and seba- 
ceous glands. Various substances found in the circula- 
tion are mixed with these secretions, so that they always 
represent a complex mixture. The normal secretions of 
the sudoriparous glands contain fat and the products of 
the so-called materia perspiratoria. This latter comes 
from the blood-vessels and mixes with the sweat, and 
usually consists of volatile fatty acids, which are mixed 
with the glandular secretions, and which may be quite 
abundant and may rapidly undergo change and give 
off a specific odor (osmidrosis, bromidrosis). The 
sweat-secretion is most abundant in the axillae and in the 
genital region, which are rich in glands and which in cer- 
tain individuals gives rise to an especially pungent, pene- 
trating odor. It seems surprising that even pus-cocci 
have been excreted in perspiration of the skin, especially 
when sweating is profuse (Brunner, Eiselsberg). 

The vicarious function of the sweat-glands, between 
which and the renal secretion there exists a relationship, 
is of especial importance. We observe under certain 
physiologic as well as pathologic conditions, when the 
function of the sweat-glands is increased, that the usual 
daily quantity of urine is decreased. We can, further- 
more, frequently demonstrate admixtures of urea in the 
sweat in diseases of the kidneys, and also excretions of 
balsamic remedies, etc. The skin of diabetics, who pass 
large quantities of urine, vice versd, is characterized by 
dryness. 

Pathologic increase of sweat-secretion (hyperidrosis) 
is usually observed in corpulent individuals and those 
who undergo but slight bodily exertion, in psychic ex- 
citement, and also after conditions which lead to hyper- 
emia of the skin. Profuse sweating often occurs in 



26 DISEASES OF THE SKIN. 

cachectic, tubercular, and anemic subjects. Subjective 
symptoms of prickling and slight itching of the skin 
sometimes may precede the sweating. 

Increase in sweat-secretion of certain regions of the 
body, as the palms of the hands and the soles of the feet 
{hyperidrosis palmarum et plantarum), is to the individual 
thus afflicted of considerable importance. It is common 
in anemic subjects, whose hands and feet are cyanotic, 
owing to stasis, and who complain of sensations of cold in 
the extremities. This excessive sweating may exist for 
many years without any change whatever taking place in 
the skin. In rare instances vesicles sometimes may form 
on the fingers, more frequently on the toes ; these rupture 
and lead to excoriations of the epidermis [dysidrosis, 
pompholyx ? — Ed.]. The epidermis between the toes is 
frequently macerated and peels off; painful excoriations 
and fissures occur, which may give rise to troublesome 
inflammation, and exceptionally to the formation of pus. 

Dysidrosis, pompholyx, or cheiropompholyx 
[Hutchinson] occurs on the palms of the hands, on the 
sides of the fingers, and on the soles of the feet, owing, it 
has been believed, to retention of sweat. Vesicles and 
blebs, from the size of a pin's head to that of a pea, or 
larger, develop ; their contents are perfectly clear at first, 
though they become turbid later on. The inflammatory 
symptoms, redness and slight or marked swelling of the 
epidermis, complete the picture of this disease. The affec- 
tion disappears after the vesicles have ruptured spontane- 
ously or have been ruptured by macerating treatment or 
accidentally. As the disease, however, relatively often 
attacks individuals who suffer from sweating feet, its 
recurrence is not uncommon (Plate 1). 

Treatment. — In universal as well as local hyperidrosis 
it is of great importance to consider the possible under- 
lying cause or causes (tuberculosis, anemia, etc.). Of 
internal remedies which have the power of influencing 
excessive secretion of sweat, we mention especially atropin 
and agaricin. 



Or 



DISORDERS OF THE GLANDS. 27 

^i Atropin. sulphat., 0.015 (gr. ^^^) ; 

Extr. taraxaci, 

Pulv. rad. althseae, q. s. 
Ft. pil. Xo. XX. 

Sig. — One pill night and morning. 

^ Atropin. sulphat., 0.01 (gr. ^^) ; 

Aq. menth. pip., 10 (fsiiss). — M. 

Sig. — Five to ten drops t. d. 

^ Pulv. agarici alb., 1 (gr. xv). 

Dtur. tal. dos. No. x. 
Sig. — One powder t. d. 

I^ Agaricini, 0.015 (gr. ^^). 

In pil. No. XXX. 
Consperg. sem. lycopod. 
Sig. — One pill t. d. 

The following are advised in the external treatment: 
Baths, ablutions, and applications of alcoholic solutions, 
such as menthol (1 : 100), carbolic acid (1 : 100), salicylic 
acid (1-2 : 100), naphthol (^3-naphtoli, 1 (gr. xv) ; aqua 
coloniensis, 25 (.^vj gtt. xv) ; spir. vini galL, 175 (^vss)). 
A dusting-powder should be subsequently applied. The 
following is useful for this purpose : 

i;^ Salol., 1 (gr. xv) ; 



Or 



Zinci oxidi. 
Talc, ven., da 45 (,^iss). — M. 

Sig. — Dusting-powder. 

^ Acidi salicyl., 5 (gr. Ixxv) ; 

Acidi tartar., 

Acidi boric, ad 10 (siiss) ; 

Zinci oxidi, 25 (.^vj gr. xv) ; 

Talc, venet., 50 (sxiiss). — M. 
Ft. pulv. 
Sig. — Dusting-powder (EichhoiF). 



28 DISEASES OF THE SKIN. 

In hyperidrosis pedum Hebra's favorite treatment with 
unguentum diachyli is often useful. The feet are daily 
enveloped with bandages spread with ung. diachyli, 
pledgets of lint smeared with this ointment being placed 
between the toes. This proceeding is continued for ten 
to fourteen days, during which period the feet are not to 
be washed. A few days after the dressing has been discon- 
tinued the skin exfoliates, and when desquamation has ceased 
the hyperidrosis is usually noted to have been relieved. 

Applications of a 5 per cent, solution of chromic acid, 
solutions of formalin and corrosive sublimate are to be 
recommended ; also painting with the following : 

!^j. Liq. ferr. sesquichlorati, 30 (f Sviiss) ; 
Glycerini, 10 (fsiiss) ; 

Oh bergamottae, 20 (fsv).— M. 

Sig. — To be applied with a brush to the sole of the 
foot and the regions between the toes (Legoux). 

The sebaceous secretion of the skin is the product of 
the sebaceous glands, whose fat-cells secrete the nascent 
sebum found on the surface. An abnormal increase in the 
amount of sebaceous matter is known as seborrhea, 
which, when it appears in the form of an oil-coating, con- 
stitutes the condition known as sebon'hcea oleosa ; when 
the excessive sebaceous secretion dries up with the loose 
epidermic cells into scales, it gives rise to the type known 
as seborrhoea sicca seu squamosa. 

Oily seborrhea may exist for years on the nose, fore- 
head, and chin of many individuals without demonstrable 
cause ; it may also be seated upon the scalp. Seborrhoea 
sicca is observed most frequently. It may be observed 
at almost any age, but is more common during adoles- 
cence and early adult life. It is also noted on the scalp 
of nursing-infants as a dry, hard crust, which adheres to 
the tender hairs. 

The vernix caseosa is of similar origin, and occurs in 
newly-born infants as smegma, covering the whole body 
and consisting chiefly of detached epithelium. 



DISORDERS OF THE GLANDS. 29 

The same disease is exemplified in collections of 
smegma in the preputial pouch in balanitis and balano- 
posthitis, and on the prepuce of the clitoris and inter- 
labial folds ; these conditions lead to maceration of the 
epidermis and to excoriations, and even to inflammation 
accompanied by secretion of pus. 

When seborrhea has existed for a longer period it gives 
rise to comedones. These formations are also noted 
when there is but a slight oilly or branny seborrheic con- 
dition of the surface of the skin. The fat and loose epi- 
thelium become inspissated in the excretory duct, lanugo- 
hairs and the Demodex folliculorum (Plate 64, Fig. l)are 
mixed with this secretion, and the dilated follicle is filled 
with a greasy mass having a black external covering. 
These plugs are frequently loosened by the accumulating 
secretion beneath in the follicle, and can be readily removed. 
The excretory duct, which has become patulous, can be seen 
as an opening in the skin. Owing to increased accumulation 
of sebum in the cystic, dilated excretory ducts, the come- 
dones may be converted into adenomata from the size of a 
pea to that of a bean {vide Plate 3). 

As a consequence of comedo or blocking of the sebace- 
ous ducts, inflammation of the sebaceous glands — aeue — 
finally results, which will be discussed later on. 

Treatment of Seborrhea. — The accumulated scales 
and crusts should be softened with oils or fats and then 
removed. When this has been done, or to aid in this, the 
scalp is thoroughly washed with soap (tinctura saponis 
viridis) and lukewarm water. The scalp, which may have 
become sensitive and moist, is covered with ointment. 
Zinc oxid, sulphur and sjilicylic acid, sulphur and zinc 
oxid, in ointment-form, and pastes of sulphur and zinc 
oxid are employed 



-M. 



^i Zinci oxidi, 


6 (3iss) ; 


Sulph. praecip.. 


4(3j); 


Terr, silicefe. 


2 (3ss) ; 


Adipis benz., 


20 (3vij).- 


Tt pasta (Unna). 





30 DISEASES OF THE SKIN. 

Ointments of white and red precipitate, 5 to 30 grains 
to the ounce, are preferable if the hair is long or has not 
been cut. [Ointments containing pulverulent substances 
in any quantity are not so well adapted for scalp treatment 
as those just mentioned or those containing salicylic acid, 
resorcin, or sulphur, 5 to 30 grains to the ounce. — Ed.] 

Conjointly or alternately with ointment we use ab- 
lutions containing spirituous solutions of carbolic acid 
(0.35-0.70 (gr. v-gr. x) to the ounce), salicylic acid, 
/9-naphtol, and resorcin ; the last in ointment, 2 to 10 per 
cent, strength, or either in alcoholic or aqueous solution 
of 2 to 4 per cent. 

When the disease is localized on other parts of the body 
treatment based on the same principles is employed, but 
the applications should be weaker. 

PITYRIASIS CAPITIS (SEBORRHEA SICCA). 

[The author, while placing this under sehorrhea, recognizes its 
clinical difference by giving it a special heading for treatment. Most 
writers consider this as belonging to Unna's seborrheic eczema. — Ed.] 

The method of treatment, as recommended by Lassar, 
should be mentioned first. This consists of : 

1. Shampooing with tar-soap for ten to fifteen minutes ; 
this is washed off with warm water, which should be 
gradually cooled. 

2. Washing with 

^ Sol. hydrarg. chlorid. corros., / ^'f ''JP^ (^'; f"^ 
^ J ^ ' [ to 311SS water) ; 

Glycerini, 

Spir. coloniensis, da 50 (f^xiiss). 

3. Shampooing with 

I^ /9-naphtol, 0.25 (gr. iv) ; 



Alcohol, absolut., 200 (f ^vj sij). 

tubbing into scalp 

Acidi salicylici, 2 (gr. xxx) ; 

Ol. olivse, ad 100 (f.^xxv). 



DISORDERS OF THE GLANDS. 31 

In connection witli snap-wa<hing and spirituous appli- 
cations to the scalp, sulphur-ointments will also give good 
results in these cases. Unna recommends : 

1^ Adipis lanse, 
Aq. calcis, 
Aq. chamomillse, 

Ung. zinci oxidi, da 10 (siiss),; 

Sulphur, praecip., 2 (gr. xxx); 

Pyrogalloli oxid., 0.40 (gr. vj). 

The following is also useful, to be gently rubbed in : 

I^ Tinct. cantharid., 10(f3iiss); 

Tinct. benzoini, 20 (fSv) ; 
Hydrarg. chlorid. corros., 0.20 (gr. iij) ; 

Chloral, hydrat., 4 (.^j) ; 

Resorcini, 5(gr. Ixxv); 

Ol. rinini, 10 (f.^iiss) ; 

Alcohol, absolut., 200 (f 5vj sij)— M. 
, Sig. — For local use. 

Recently captol (a product of condensation of tannin 
with chloral) has been recommended by Eichhoff: 

IJj Captoli, 

Chloral, hydrat., 

Acid, tartar., da 1 (gr. xv) ; 

Ol. ricini, 50 (f^xiiss) ; 

Spirit, vini (65 per cent.), 100 (fsxxv). — M. 
Sig. — For external use. 

MILIUM (Plate 2). 

In this condition round grains the size of a millet-seed, 
of a milky-white color, and slightly raised above the level 
of the skin, can be seen shining through the epidermis. 
They are met with chiefly on the eyelids, cheeks, tem- 
poral regi(ms, and male genitalia ; rarely on the labia 
minora. When the epidermis is incised and these small 
bodies have been removed from their bed, they fall to 



32 DISEASES OF THE SKIN. 

pieces on slight pressure. They consist of dry epidermic 
cells and fat. 

Treatment. — The overlying skin is incised with a 
small knife and the contents removed by lateral pressure. 
The ensuing wound, which is insignificant, heals very rap- 
idly. When a large number of small niilia exist a desir- 
able method of treatment is that which produces exfolia- 
tion of the epidermis ; and this may be attained by ex- 
citing a moderate degree of inflammation by stimulating 
the skin with applications of soft soap (Kaposi). 

The names Molhiscum Contagiosum, 3Iolliiscum Verru- 
cosum, Molluscum Epithdiale, are applied to a verrucous 
proliferation on the skin, appearing as a rounded, shining, 
pearly, translucent, slightly elevated growth, and usually 
attaining the size of peas, which project hemispherically 
and show a slight depression at their apex. Lateral 
pressure with the fingers or curetting causes the contained 
whitish mass to be ejected, which is seen to be lobular in 
construction and surrounded by a tiiin covering of con- 
nective tissue ; this sends out processes which converge 
toward the center as septa. The mass often has a firmer 
cover ; it can be easily crushed to pieces, and the contents 
are found to be made up of epidermic cells, fat, crystals 
of fat, and so-called molhiscum bodies. These latter are 
structureless, slightly shiny formations of ovoid siiape, 
smaller than an epithelial cell, and are usually surrounded 
by epithelial cells and cell-debris (Plate 65, 6). 

Molluscum contagiosum has been demonstrated to be 
contagious ; the growths are often found on contiguous 
surfaces of the skin and in individuals who are in close 
contact with one another (children and nurses). The 
most common sites are the face, eyelids, the genitalia, 
scrotum and penis, the external female labia (see Atlas 
of Syphilid, Plate 71), and inner folds of the thighs. 
They also occur on the neck, hands, and forearms, and, 
may even be distributed over the general surface, &i 
observed by Kaposi in small children. 



HYPEREMIA OF THE SKIN. 33 

Treatment. — The contents are usually removed by 
lateral pressure ; when the lesions are numerous or per- 
sistent, removal by surgical means (Volkmann's spoon ; 
excision) is recommended. Puncturing with a pointed 
knife, pressing out the contents, and touching tlie interior 
with carbolic acid or silver nitrate will usually suffice. 

ANEMIA OF THE SKIN. 

Cutaneous anemia is most usually a part or symptom 
of systemic anemia. It is characterized by pallor and 
coldness of the general integument. Anemic conditions 
due to psychic excitement, as anger, or to reflex action 
from the digestive tract, as occurs in malaise, colic, etc., 
also local anemias due to cold or to transitory occlusion of 
larger vessels, are of no importance, as they are only of 
short duration and are not followed by further changes in 
the skin. Of more importance, as far as the final result 
is concerned, are the local and universal anemias of the 
skin, already referred to, when they are long continued or 
exert their influence frequently at short intervals, as they 
lead to interference with secretion and nutrition. The 
skin becomes dry and the epidermis exfoliates in lamellae. 
The skin becomes lax, and atrophic conditions, excoria- 
tions in places, and even deeper necrotic ulcers may result. 

HYPEREMIA OF THE 5KIN. 

Of greater importance are the cutaneous hyperemias. 
They are due either to congestion of blood in an irri- 
tated area of the skin (active hyperemia) or to stasis when 
the return-circulation is interfered with (passive hyper- 
emia or hyperemia due to stasis). 

Active hyperemias {erythema congeMirum) are the result 
of engorgement of the smallest capillaries in the papillary 
layer. Large areas on the surface of the skin are pale 
red or bluish-red. Frequently the redness appears in 
small circumscribed spots and disappears on slight press- 
ure, to return as soon as pressure is withdrawn. 



34 DISEASES OF THE SKIN. 

Sometimes patients feel a slight itching or burning. 
Such hyperemias, of a rapid transitory character, disap- 
pear without causing any change in the skin. When long 
continued or of frequent recurrence, however, they lead to 
desquamation of the epidermis, accumulation of pigment, 
and to increased activity of the sebaceous and sudoripar- 
ous glands. 

These hyperemic conditions arise from mechanical, 
thermic, or chemic irritants which come into direct con- 
tact with the cutaneous^ surface. Peripheral irritation — 
e. g., scratching — may also be conveyed by reflex to other 
central nerve-tracts and give rise to a hyperemic condition 
in remote places of the surface. Finally, psychic disturb- 
ances — e. g., shame and other psychic emotions — may 
cause direct irritation of the vasomotors from the cortex 
of the brain and thus produce hyperemia. 

Livedo belongs to the stasis-hyperemias. It is due to 
interference with the return-circulation by the pressure of 
a bandage or tumor on the returning veins, to cold, or 
dilatation following inflammation of veins ; larger or 
smaller areas of the skin show a bluish discoloration. 

Cyanosis is a more widely distributed bluish discolora- 
tion of the skin, usually associated with dilatation of the 
vessels. It is due to occlusion of the larger veins, or 
directly to cardiac lesions or to stasis in the larger vessels. 
These conditions bring about the permanent changes lead- 
ing to various consecutive processes, as chronic edemas, 
thickening of the skin, etc. 

DERMATITIS. 

Inflammatory processes in the skin are preceded by 
hyperemia. When an irritant is applied to the vasomotor 
nerve-branches, alteration in the vascular capillaries 
occurs and active hyperemia results. This is the pre- 
cursory stage of inflammation. It is but a short step 
from hyperemia to inflammation, at first almost imper- 
ceptible. When exudations and infiltrations and changes 



ERYTHEMA. 35 

in the cellular elements have occurred — for example, pro- 
liferation of the cellular elements — inflammation becomes 
moie decided. Although these fundamental principles of 
inflammation are always present at the same time, the 
clinical picture differs according to one or the other be- 
coming more pronounced. 

ERYTHEMA. 

Under this designation we group those mildly inflam- 
matory conditions of the skin occurring in the most 
superficial layers and accompanied by slight or moderate 
exudation. 

Erythema multiforme (Plate 6) is the type of this class. 
Vascular dilatation, active cell-migration, and an edema- 
tous saturation of the papillary layers, and also moderate 
proliferation of the connective tissue form the substratum 
of the cutaneous inflammation. Proliferation of the 
epidermis-cells in the rete and loosening or bullous eleva- 
tion of the epidermis complete the picture of this inflam- 
matory process. 

Erythema multiforme most usually appears on the 
forearms and upper part of the arms, over the ankle- 
and knee-joints— in fact, over the extensor surfaces of the 
extremities ; further, on the face, neck, nucha, and chest. 
Papules crop out rapidly ; these spread, and in a few 
hours become deep-red patches. In a few days the skin 
is seen to be covered with macules and papules, project- 
ing above the level of the skin ; the older lesions are 
depressed in the center and begin to fade, but extend at 
the periphery with a red margin. Adjacent efflorescences 
{!oalesce and form with the successive crops the type of 
polymorphism. When the condition does not advance 
beyond the first stage of development we have an ery- 
thema papukdum. When papules and macules of the 
same age are principally present and confluence predomi- 
nates they form the so-called erythema gyratum, erythema 
fguratum. 



36 DISEASES OF THE SKIN. 

According to the amount of exudation characterizing 
the process, there occur elevations of the epidermis in 
the form of vesicles, the size of a lentil to that of a pe^, 
which are situated on a red base and are tense and firm 
— erythema vesicidosum, erythema multifonne buUosum 
(Plates 7 and 7, a). 

When these erythematous spots, or the vesicles, are ar- 
ranged in rings — i. e., when a new ring appears around one 
or more of these macules or bullfe — it constitutes respec- 
tively the so-called ei'ythana iris and herjies iris. When the 
older vesicles desiccate in the center and the new periph- 
eral ring alone remains we call this form herpes circinatits. 
These two latter forms occur principally on the backs of 
the hands and feet ; they are usually associated with ery- 
thematous patches and rarely in fact appear independently 
of these. The outbreak lasts for two to several weeks, 
and frequently recurs at the same time the following 
year. 

The course of the efflorescences differs according to the 
amount of exudation ; they may fade in eight to ten 
days, disappearing with accompanying slight desquama- 
tion of the epidermis. They may, however, remain four to 
six weeks ; and especially when they appear in successive 
crops, which is usually characteristic of the disease, they 
may annoy the patients for several months. At times 
the mucous membranes of the oral cavity and genital 
tract participate in the disease. 

In addition to these objective phenomena the process is 
accompanied by moderate itching, at times by a burning 
sensation, languor, and psychic depression. In accord- 
ance with other observeis we could often demonstrate 
troublesome gastric disturbances in our cases. At times 
patients complain of pains in the joints, which may 
develop into aggravated articular affections. Of rare 
occurrence are albuminuria or hemorrhages from the 
kidneys, and inflammatory complications of serous mem- 
branes, conditions which must be regarded as being due 
to a high degree of general intoxication. Usually a slight 



ERYTHEMA. 37 

rise of temperature is noted, sometimes even high fever, 
which, liowever, does not follow any certain type. 

Another type of erythema, which is distinguished from 
the ordinary erythema multiforme only by its external 
form and not by its character, is erythema nodosum. Fre- 
quently botli forms appear side by side. In erythema 
nodosum intensely red and usually somewhat deep-seated 
nodules (Plate 8) appear over the extensor surfaces of the 
tibia, knee- and ankle-joints, more rarely over the articu- 
lations of the hands and on the forearms. The nodules 
increase in size, several may fuse together, and the 
affected parts frequently show a marked increase in 
volume. The nodes are very sensitive to pressure, and 
have a hard, elastic feel. The accompanying general 
disturbances are mutatis Diutamlis the same as in ery- 
thema multiforme : Nausea, feeling of weakness, fever, 
and articular pains. The swelling declines in one 
to two weeks and the entire process is usually over in 
about a month. Hemorrhagic infiltrations not infre- 
quently occur in these nodose swellings along with the 
serous exudation, they turn bluish [erythema coiitusiforme, 
Plate 8), undergo gradual involution and show the Avell- 
known changes of color from green to greenish-yellow. 

As to the causes of erythema and related processes, 
we are up to the present date forced to look to a few em- 
piric facts and more or less theoretic supjx)sitions. Ex- 
perience teaches that certain kinds of fruits — i. e., straw- 
berries, raspberries ; further, oysters, crabs, lobsters, sea- 
fish ; especially fat, stale pork or sausage — may give rise to 
digestive disturbances and to ery themata. According to our 
clinical observations, made years ago, it is not difficult to 
imagine that after a certain cause — /. e., eating of damaged 
food — not only the substances referred to above, but also 
others that are formed in the organism from imperfect di- 
gestion, proiluce various disturbances, especially in the 
digestive tract, to which is adde<l the erythema and the 
clinical picture completed. Our co-laborer in chemistry. 
Dr. Freund, could always in such cases demonstrate a 



38 DISEASES OF THE SKIN. 

considerable number of toxins and ptomains in the ex- 
cretions. Unfortunately, experimental proof is lacking to 
explain these processes thoroughly. 

Treatment. — As erythema multiforme can be demon- 
strated to be, or at least may be supposed to be, of j^roba- 
ble intestinal origin, the diet should be correspondingly 
regulated ; and, when indicated, laxatives and intestinal 
antiseptics should be resorted to. As such, we prescribe 
either menthol (0.2 (gr. iij) per dose in gelatin cap- 
sules, t. d.), or — 

^ Pulv. cort. cinnamomi, 0.20 (gr. iij) ; 

Ol. menth. pip., 

Ol. eucalypti, da gtt. j-ij. 

Ft. capsula. (una). 
Sig. — Four to six capsules daily (Freund). 

General treatment is, in other respects, according to the 
usual rules; rheumatic pains and articular swellings, etc., 
when present, are treated with local applications (ice-water, 
plumb, acet. bas. solut., Burow's solution), and internally 
salol and sodium salicylate are given. 

When there is tendency to itching it is well to have the 
aifected areas painted with spirituous solutions of carbolic 
acid and spirituous solutions of salicylic acid, etc., about 
the same strength as advised in hyperidrosis [q. v.), fol- 
lowed by dusting with starch. 

The same therapeutic remedies will suffice for erythema 
nodosum and purpura rheumatica (Plate 1 1). 

Several similar processes are allied with the typical 
erythemata, which they resemble partly etiologically, 
partly clinically — /. e., as far as their external course is 
concerned. Urticaria comes first ; it is chanicterized by 
the rapid appearance of wheals, elevations which are fre- 
quently pale red, rarely white, and are surrounded by a 
hyperemic halo. As they disappear and reappear rapidly, 
and here and there become confluent, it is scarcely pos- 
sible to state their size, because stable efflorescences are 



ERYTHEMA. 39 

not found frequently. The spots seldom project more than 
1-2 mm. above the level of the skin. Owing to paling 
of the center and peripheral extension of the process, urti- 
caria presents the picture at times of a serpigiuous affec- 
tion. In some instances urticaria is closely allied to ery- 
thema multiforme. In urtictiria as well as in the ery- 
themata the appearance of edematous swellings, the 
cropping out of bullse, and participation of the mucous 
membranes are of not rare occurrence. 

Urticaria is especially characterized by severe itching, 
which is exceedingly troublesome to patients, as it robs 
them of sleep; and if the disease is of any duration, they 
grow weak in consequence of imperfect rest and the ner- 
vous tension. The itching leads to scratching, and this 
gives rise not only to localized new eruptions, but is also 
conveyed by reflex to remote and more extensive cuta- 
neous surfaces. The skin of certain persons who are pre- 
disposed to these erythematous eruptions is so very sen- 
sitive that every local irritation is followed by an eruption 
of wheals {urticaria factitia, autographism, thomme auto- 
graphe of the French). Such individuals are frequently 
nervous and hysterical. 

AVorthy of special note are those forms of urticaria 
which appear in childhood, and which, owing to their 
persistence and frequent recurrence, trouble the patients 
for many years and leave brownish pigmentations behind 
[urticaria pigmentosa). 

If anv one of the erythematous diseases is entitled to 
the term angioneurosis, it is urticaria, because it presup- 
poses a nervous disposition, inasmuch as slight peripheral 
irritations are frequently followed in a very short time by 
urticarial eruptions on remote parts of the body. The 
external irritants may be the bites of fleas, lice, bed- 
bugs, gnats, or stinging-nettles. Urticaria is also met 
with in prurigo, in pemphigus, in pruritus of diabetics 
and jaundice, and likewise in disorders of menstruation 
and puerperal diseiises with more or less pronounced 
participation of the uterus, as flexions, pregnancy, etc 



40 DISEASES OF THE SKIN. 

Further, the ingestion of foods and fruit is to be men- 
tioned, as has ah'eady been done under the head of er}'- 
themata. 

Treatment. — When an urticarial eruption cannot be 
attributed to external irritants (epizoa), the condition of 
the general health, and especially of the intestinal tract 
and the genital system, should be given careful considera- 
tion. In some }>ersistent and recurring cases it Avill be 
necessary to regulate carefully the diet, or, when indicated, 
to combine a bath-cure (Karlsbad), and in other cases to 
treat any existing disorder of the digestive or generative 
organs. 

For internal treatment are recommended : Arsenic, 
atropin, ichthyol (0.2 (gr. iij) per dose, Lang), antipyrin, 
salophen (4-5 (gr. Ix-gr. Ixxx) per day, de Wannemaeker), 
calcium chlorid (0.2-0.3 (gr. iij-gr. ivss) per dose t. d., 
Wright). 

Brocq advises : 

I^ Quinin. muriat., 0.05 (gr. |) ; 

Ergotini, 0.05 (gr. |) ; 

Extr. belladonn., 0.02 (gr. ^) ; 

Glycerini, q. s. ad pil. unam. 

Sig. — Eight to sixteen pills daily. 

Locally : Applications of the spirituous lotions already 
mentioned. The following may also be used : 

I|i Spirit, lavandulae, 100 (f^xxv) ; 

Spirit, vini gallici, 150 (fsxxxviiss) ; 

JEther. sulph., 2.5 (gr. xxxiij) ; 

Aconitini, 1 (gr. xv). — M. 
Sig. — To be painted on. 

^ Acid, salicylici, 1 (gr. xv) ; 

Acid, carbolici, 2 (gr. xxx) ; 

Glycerini, 50 (f^xiiss) ; 

Spirit, vini, 100 (fsxxv).— M. 
Sig. — To be painted on. 



ERYTHEMA. 41 

Further, baths containing starch, ahim, corrosive sub- 
limate, washing witli vinegar, etc. 

Allietl to urticaria is cedema eiitis circumscriptum, 
angioneurotic edema, described by Quincke and others. 
In this somewhat rare disease edematous, cutaneous 
phlegmonous swellings appear, which may be the size 
of the palm of the hand, and which gradually merge 
into the normal skin. They disappear in one place, 
to reappear soon upon some other portion of the 
body. The mucous membranes of the mouth, pharynx, 
and larynx are also frequently implicated. Vomiting 
and local disturbances, due to swelling of the raucous 
membrane, are the most annoying concomitants of this 
affection. Riehl regards this morbid condition as an 
angioneurotic disturbance of the circulation similar to an 
urticaria. 

Another diffuse erythema appearing symmetrically on 
the hands or feet is erythromelalgia. Patients at first 
complain of attacks of burning and pain, which are suc- 
ceeded by erythema of varying intensity, which, however, 
persists for some time. This process is also regarded as 
an angioparalysis. Other observers attribute it to cen- 
tral pathologic processes in the nervous system. 

Evythemata occurring in infectious diseases (toxic ery- 
themata in the stricter sense). In connection with the 
above-mentioned erythematous and slightly inflammatory 
cutaneous diseases we would call attention to those patho- 
logic products on the skin which precede or accompany 
various infectious diseases. In enteric fever, cholera, 
grave pneumonias, septicemia, acute exanthema tii, etc., 
not infrequently small spots of roseola are observed on 
the trunk, most usually on the epigastrium and on the 
flexor surfaces of the extremities, and also extravasations 
of blood in the form of ecchymoses and petechiae. These 
phenomena occasionally may be due directly to micro- 
organisms collecting in the capillaries; the explanation, 
however, attributing them to intoxication affecting the 
nerves of the vessels, is much more plausible. 



42 DISEASES OF THE SKIN. 

PELLAGRA. 

Pellagra, mal rosso, mal del sole, in its early stao;e ap- 
pears as an erythematous malady, which during its further 
progress exhibits the anomalies of pigmentation. Its sup- 
posed cause (an intoxication) associates it closely with the 
erythemata. 

In some regions (as I^ombardy, Venetia, Eastern 
Friaul, Bukowina, Roumania, etc.) pellagra occurs en- 
deraically. It appears in the spring and summer at fiVst 
as an erythematous skin-aifection, which becomes dark 
brown ; the eruption shows itself on those uncovered por- 
tions most exposed to the niys of the sun, as the face, the 
dorsal surfaces of the hands, and, in the peasants who go 
barefooted, on the dorsal surfaces of the feet also. Patients 
feel weak and suifer from a feeling of pressure in the epi- 
gastrium and frequent diarrhea. Desquamation of the 
epidermis occurs. The discoloration of the skin disappears 
in the winter, to reappear the next summer. Later 
the pigment turns darker and bluish-red and the skin 
becomes sensitive. Patients complain of chilly sen- 
sations and cold. Muscular weakness, anemia, despond- 
ency, stupor, and melancholia develop. A fatal issue is 
brought about by aggravated diarrhea, diseases of internal 
organs, and delirium. 

The disease is attributed to an excessive diet of 
maize ; damaged cornmeal especially is said to give rise 
to pellagra. Neusser is of the opinion that the poison- 
ous principle is developed in diseased maize under the 
influence of the Bacteridium maJidis, and that it produces 
the disease in field-laborers who are debilitated by insola- 
tion and gastric derangements. According to this writer, 
pellagra is a chronic systemic disease, characterized by dis- 
turbances of delicate nerves in the domain of the sympa- 
thetic and its central nerves and arterial channels, caused 
by a toxic principle forming in the intestines of individ- 
uals affected and leading to autointoxication. 

Treatment. — This is mainly one of diet. Nourishing 



DRUG-ERUPTIONS. 43 

food, out-door life, and administration of iron-preparations 
are indicated. Advanced cases are not influenced by such 
measures and a fatal result is inevitable. 

DRUG ERUPTIONS. 

In the majority of instances diseases of the skin due to 
the ingestion of drugs belong to the type of erythemata, 
but differ from these prinei[)ally in being polymorphous. 
In common with most erythemata, they are accompanied 
by gsistric disturbance and not infrequently by fever. It 
is of practical importance, however, to study these various 
skin-manifestations separately. 

All drugs do not give rise to cutaneous eruptions ; and 
individuals differ materially in susceptibility, many in- 
deed being free from such influence. Lewin's statements 
(Handbook of Phamnacology) are interesting : Among 402 
drugs he found that 204 — i. c, 50.7 per cent. — might possess 
the proj)erty of irritating the skin. Such action from 
drugs requires a temporary or inherent individual predis- 
position. Some patients have an idiosyncrasy for certain 
drugs and react to the smallest doses ; others can bear 
larger quantities and also a larger application of a drug 
without experiencing unpleasant consequences of any kind. 

The rapid appearance of a generalized eruption from 
drugs in certain individuals is often surprising, which can 
be explained only on the basis of reflex action ; for scarcely 
has the drug reached the digestive tract before tlie exan- 
thema is noticeable on the skin. 

It is somewhat different in those cases due to local ap- 
plication, when the skin is irritated directly by a remedy 
which is taken up by the skin, not only giving rise to irri- 
tation of the area or areas to which it has been applied, 
but also by reflex action leads to similar eruptions on other 
parts (Plates 14, 23, 23, a, 24, 25, 25, a). Exanthemata are 
due more frequently, however, than was formerly thought 
to be the case, to absorption of materials by the blood, 
which are then excreted by the glands of the skin, and 



44 DISEASES OF THE SKJN. 

durino- their passage give rise to the cutaneous erup- 
tion. 

It would be beyond the scope of tliis work to consider 
individually the numberless drugs which may produce irri- 
tation of the skin. 

Erythematous and at times vesicular efflorescences of 
various degree are observed to follow the use of antipyrin, 
atropin, chloral hydrate, balsam of copaiba, opium and its 
derivatives, strychnin, sulphonal, turpentine, etc. 

Arsenic is of special interest, for the reason that it 
undoubtedly has a closer relation in its action to the skin, 
and is, moreover, frequently employed in dermatologic 
therapeutics. It produces erythemata, edema (especially of 
the eyelids), papules, bullous eruptions, zoster, and pig- 
mentary deposits. 

Mercury in all forms and methods of employment may 
irritate the skin. Not to mention the countless cases 
which show a diffuse erythema after the application of a 
mercurial ointment, we meet with erythemata following 
its internal administration and after hypodermic mer- 
curial injections ; even after transitory external use of 
corrosive sublimate — i. e., washing out a furuncle — we 
have noticed the occurrence of erythemata and even of 
eczemas. 

The preparations of iodin, especially potassium iodid, 
and potassium bromid, cause acneiform cutaneous efflores- 
cences to appear, which will be further discussed in the 
section on acne. 



HEMORRHAGIC ERUPTIONS. 

Partial hemorrhages into single nodules have already 
been alluded to when discussing erythema contusiforme 
and septic erythemata. In the following pages those dis- 
eases which are principally or extensively accompanied by 
hemorrhages will be considered (Plates 9, 10, and 11). 

Pelio-sift, or purpura rheunmiica, belongs here. It may 
occur simultaneously with varieties of erythema in the 



HEMORRHAGIC ERUPTIONS. 45 

same individual. It differs from tlie ordinary varieties 
of erythcinata in involving the joints more markedly, 
and the efflorescences over the articulations are more 
numerous. 

Dark-red to blue spots, the size of a lentil to that of a 
pea, develop at first over the joints, later on the rest of 
the body, more especially, however, on the limbs; the 
lesions are situated on a level with the skin and rarely 
project above it ; they do not disappear on pressure and 
soon assume a purple hue, or in very grave cases, owing 
to marked extravasation of blood, they are of a bluish- 
black color. Patients are prostrated and complain of 
pains in the joints. In many cases the joints are de- 
cidaily swollen, the exudation is serous, sometimes hemor- 
rhagic. Moderate rise of temperature in the evening, 
languor, anorexia, and a feeling of thirst are constant 
concomitants. 

The exciting cause of peliosis, despite the numerous 
investigations of late years, still remains unexplained. 
The hemorrhage may be preceded by hyperemia and 
stasis, usually of long duration. The blood escapes 
through the walls of the vessels by diapedesis ; it is rarely 
possible to demonstrate capillary disease. Some observers 
have stated that hyaline degeneration, fatty changes in 
the endothelium, and formation of thrombi during this 
process take place. This state of affairs, however, would 
probably be found to exist only in petechise occurring in 
the course of grave diseases (tuberculosis, Bright's dis- 
ease). 

It is highly probable, however, that toxins and pto- 
mains circulating in the blood either change the latter or 
cause angioparalysis of the smallest branches by influen- 
cing the vasomotors. As far as the changes in the blood 
are concerned, it is certain that the percentage of hemo- 
globin is greatly diminished. Microcytes and poikilocytes 
are found occasionally in fresh blood ; and, further, the 
eosinophilous cells are increased in number. Here and 
there it has been possible to demonstrate microorganisms. 



46 DISEASES OF THE SKIN. 

The older efflorescences undergo the ordinary changes 
of blood-coloring matter and appear greenish-yellow to 
reddish-brown. When hemorrhage into bullae (in ery- 
thema bullosum) has taken place, they dry up into brown 
scabs. The process generally lasts four to six weeks, and 
tends in some instances to recur. 

3Iorbus maculosus Werlhojii, or purpura hccmwrhagica, 
is a disease which is differentiated from peliosis by the 
number and extensive character of the hemorrhages. 

In this affection irregularly generalized, scattered 
petechiae and vibices appear over the entire body. The 
mucous membranes of the mouth and pharynx participate 
more frequently in this process than is observed in pur- 
pura rheumatica. Edematous swellings accompanied by 
hemorrhages occur, and when they involve the larynx 
they may cause dangerous symptoms of suffocation. Still 
graver complications are the occurrence of hematuria 
and endocarditis and pericarditis, conditions which go to 
confirm more fully still the intoxication of the entire 
organism. 

In order to complete the subject of hemorrhages in the 
skin we will briefly refer to scorbutus (scurvy), which 
differs from morbus maculosus only in degree and is char- 
acterized, along with the phenomena peculiar to that dis- 
ease, by involving the gums and the mucous membranes 
of the oral cavity at an early date. The gums are of a 
dirty-gray color, very loose, and undermined in places by 
hemorrhages. 

Owing to necrosis of the mucous membrane of the 
mouth there is very pronounced foetor ex ore. The hemor- 
rhages on the trunk and extremities, the soft parts being 
permeated by larger extravasations of blood and forced 
apart, are of graver importance. 

Scurvy and morbus maculosus Werlhofii, as experience 
teaches, especially the former, result from malnutrition in 
general and lack of fresh meat and vegetables, and occur 
most frequently in convicts and seafaring-men. 



ACNE. 47 

We would mention finally that bleeders' disease (fnvmo- 
ph'd'ui) is a permanent inherited tendency to hemorrhages, 
and is often found to exist in fat, well-nourished individ- 
uals, whereas the affections discussed above are acquire<l 
diseases accompanied by disturbances of nutrition. 

ACNE. 

Eruptions which are situated principally on the face, 
and which upon superficial inspection pi'esent a similar 
appearance, have heretofore been included under the gen- 
eral term of acne. Formerly acne vidgans, acne rosacea, 
and acne menfagra (sycosis) were discussed together, al- 
though each disease depends on a different pathologic 
process. 

At the present day we designate as acne a disease con- 
sisting essentially of an inflammation of the sebaceous 
follicles. 

It may depend upon various causes. In many in- 
stances the irritation of the cutaneous follicle and result- 
ing inflammation are due to external noxious influences. 
Not infrequently we must seek the jiredisposing cause in 
the organism itself — e. g., cachexia, debility. Finally, we 
are acipiainted with sul)stances which during their excre- 
tion from the body through the skin give rise to follicu- 
litis. Some authors would regard staphylococci as the 
cause of some varieties (blepharitis ciliaris, hordeolum). 
Acne corres])ondingly presents different clinical pictures 
and does not always pursue the same course. 

Acne vidgaris, or acne, appears on the face (nose, fore- 
head, chin, and cheeks), on the chest, and on the back 
(Plate 30). Both sexes are attacketl alike. Chlorotic, 
anemic girls are especially predisposed ; also boys, probably 
more than girls, during the period of puberty (sixteen to 
twenty years), when the beard begins to grow. Digestive 
disturbances, such as habitual constipation, indiscretions in 
diet, etc., are frequently mentioned as causes. We cannot 
up to the present time ofier a plausible explanation for this 



48 DISEASES OF THE SKIN. 

frequent complaint. We would, however, not like to be con- 
sidered as regarding the above-named disturbances as en- 
tirely without influence in producing this disease. In such 
individuals the secretory activity of the sebaceous glands 
is noticed to be increased ; very frequently seborrhea oleosa 
is also present. The real cause of acne, however, is inter- 
ference with free excretion by sebaceous plugs or comedones 
forming in the outlets of the sebaceous glands and fol- 
licles; this leads to swelling and inflammation of the fol- 
licles and the neighboring surrounding tissue ; the black 
plugs can be usually seen in tlie middle of the paj)ules 
(acne punctata). Wliere the sebaceous glands are more 
numerous, as on the forehead, the nasolabial folds, and 
chin, acne-papules frequently make their first appearance, 
and are usually more numerous here throughout the 
course of the disease. Aggravated cases, with increased 
swelling and inflammation, take on a reddish-blue color 
and have a pustule in their center (acne pustulosa). 

When the tubercles are hard, tough, and arranged in 
rows or closely bunched, as on the eyelids, it is called 
acne hordeolaris. 

Acne varioliformis, acne necrofisans, is a special variety, 
appearing at the margin of the hair and on the hairy 
s(^lp. In this form the small papules and rapidly-form- 
ing pustules dry into a crust ; after tiiis falls a slightly-de- 
pressed cicatrix remains. This is regarded as character- 
istic of the affection. A further variety, in which the 
subjective symptf)ms consist mainly of burning and itch- 
ing, has been designated acne urticata by Kaposi. 

Finally, there remains to be mentioned that form of 
acne with accumulation of granulation-tissue ; this appears 
principally on the nose, and is known as folliculitis exul- 
cerans serpiginom. 

In this chronic disease, which frequently lasts for years, 
inflammation recurs with more or less intensity, and the 
swelling and pigmented markings may frequently lead to 
considerable disfigurement. In addition to the whitish, 
flat, and sometimes depressed cicatrices we also see raised 



ACNE. 49 

macules and elongate pustules which are still red and in 
various stages of evolution and involution ; and alongside 
of these we also encounter inflamed tubercles of different 
sizes, making it difficult for an inexperienced observer to 
recognize the j)rocess as originating in the follicles. 

The inflammation spreading to the sebaceous glands 
and extending to deeper structures, larger cutaneous 
abscesses frequently occur, which contain fluid and some- 
times inspissated pus. 

Owing to its long duration the disease becomes a great 
trial to patients and repulsive and unpleasant to friends. 
The general health is scarcely affected. 

In so-called acne cachedicorum (Plate 3) the case is 
different. It occurs in debilitated, marasmic individuals ; 
it is usually more extensive, and frequently is found also 
on the body, and especially on the lower extremities. 
Follicular lesions of a livid color make their appearance, 
which exhibit a tendency to necrosis and to be converted 
into small superficial torpid ulcers. Occasionally lichen 
scrofulosorum coexists. Hemorrhagic effusion around the 
follicles and into the inflamed tubercles not infrequently 
makes the picture of cachexia more complete. 

We are, finally, familiar with certain drugs, already 
referred to, which may irritate the cutaneous follicles and 
lead to follicular inflammation on those parts with which 
they come in contact. Such a substance is tar, which when 
used on hairy regions plugs the orifices of the follicles and 
causes acne aiiijicialis (also called tar-acne). A similar con- 
dition is seen on the dorsal surfaces of the hands and fore- 
arms of fiictory-employees who handle dirty paraffin. Ben- 
zin, creosote, etc. are also looked upon as favoring causes. 
The ingestion of iodin and bromid preparations is also 
known to produce acne. Potassium iodid and sodium 
iodid not only cause the well-known catarrhal symptoms, 
occurring on the mucous membranes (coryza due to iodin), 
but also produce irritation while being excreted through the 
sebaceous glands, in consequence of changes in the seba- 
ceous secretion, giving rise to disseminated acne-tubercles, 
4 



60 DISEASES OF THE SKIN. 

not only on the face, but also frequently on the entire 
body. These tubercles and pustules are often accom- 
panied by slight buruing and pain. Extensive swellings 
of the follicles are rare ; usually they are not larger than 
a pea ; they involute without forming cicatrices, if they 
receive proper care and attention. 

In bromid-aene the follicles are more markedly infil- 
trated, and it is less disseminated than iodin-acne ; it is 
usually confined, moreover, to smaller areas of the skin ; 
owing to the infiltration and inflammation becoming more 
extensive, the follicles may be converted into raised, irreg- 
ular plaques, up to the size of the palm of the hand. The 
surface of these plaques seldom disintegrates ; only small 
moist spots situated on a more or less intensely reddened 
and irregular raised base are formed. 

The diagnosis of this last-named type of bromid-acne 
is often very difficult, as it presents few characteristics and 
may readily be confounded with vegetating syphilitic 
ulcers, or even with epithelioma. We have observed an 
instructive case of this kind on the lower extremity. An 
uneven, slightly raised, ulcerating surface covered with 
granulations presented itself for consideration. The 
patient, an aged female, liad been taking large doses of 
potassium bromid in secret. The supposition that we had 
a bromid-acne before us, and not syphilis or epithelioma, 
was strengthened by the absence of symptoms pointing to 
syphilis, the presence of decided inflammatory phenomena, 
and also by the more rapid course than occurs in epi- 
thelioma. 

Treatment. — Internal causes, chlorosis, disturbances 
of the stomach and intestines, and difficulties of menstru- 
ation are to be considered. These must receive their share 
of attention ; and their management must go hand in hand 
with local treatment. The little pustules and abscesses 
are opened first ; tubercles which may exist are punctured. 
When the small incisions and punctures have bet^n healed 
by compresses or indifferent ointments and bandages the 
affected parts are thoroughly washed with soap and warm 



ACNE. 51 

water. Potash-soap, tincture of sapo-viridis, and tlie 
legion of medicated soaps can be used, Tliis treatment 
suffices for many mild cases. Usually in connection 
with the soap- washing, which is to be repeated at least 
nightly, an ointment must be ordered. We mention : 

I|< Sulphur. prjBcip,, 

Potass, carbonat., 

Glycerin i, 

Aq. laurocerasi. 

Spirit, vini gallici, da 10 (^iiss). — M. 
Ft. pasta. 

i;* Sulph. lot., 10 (siiss) ; 

Balsam, peruv., 

Camphorje, da 2 (gr. xxx) ; 

Saponis viridis, 5 (gr. Ixxv) ; 

Adipis, 30 (3viiss). — M. 
Ft. ung. (Eichhoff). 

I^ Bismuth, subnitrat., 

Hydrarg. prsecip. alb., 

Ichthyoli, da 2 (gr. xxx) ; 

Vaselini, 20 (3v).— M 

Ft. unguentum. 

Sig. — To be applied thickly before bedtime (Hebra- 
Ullmann). 

I^ Camphorse, , 

Acid, salicylici, dd 0.3-0.50 (gr. ivss-viiss) ; 

Sulphur, prsecip., 10 (.^iiss) ; 

Zinci oxidi, 2(gr. xxx); 

Saponis viridis, 1 (gr. xv) ; 

Ol, physeteris, 12 (siij). — M. 
Ft. unguentum. 

Sig. — To be used externally every evening (C 
Boeck). 



Or 



62 DISEASES OF THE SKIN. 

Schiitz recommends : 

^ Sulphur, lot., 

Calcii sulphurat., 

Calcii phosphat., da 25 (3vj gr. xv). — M. 

Ft. pulv. subt. 
Sig. — Sulphur powder. 

This is mixed with a little water and allowed to remain 
on during the night. 

Further, lotions of : 

!^ Sulphur, praecip., 15 (siij gr. xlv) ; 

Camphorae, 12(3iij); 

Aq. destill., 250 (f gviij). 

^ Sulphur, praecip., 10 (siiss) ; 

Spir. vini Gall., 50 (ftxiiss) ; 

Spirit, lavand., 10 (ftiiss) ; 

Glycerini 150 (f^iv 3vj). 

!^ Sulphur, praecip., 

Spiritus vini gall., 

Aq. rosae, da 30 (Sviiss) ; 

Mucilag. acaciae., 10-20 (3iiss-3v). 

Sig. — To be used every three hours. 

And other spirituous solutions and mixtures of similar 
composition. 

We note very good results with Lassar's method of 
producing ei^oliation : 

:^ j9-naphtoH, lO^Siiss); 

Sulphur, praecip., 40 (3x) ; 

Vaselini, 

Sapon. viridis, dd 25 (3vj gr. xv). — M. 

Ft. pasta. 

This paste is applied as thick as the back of a knife 
and is allowed to remain for fifteen minutes to one hour, 



SYCOSTS. 53 

when it is wiped off and an indifferent powder is dusted 
on. The patient applies a 10 to 20 per cent, resorcin 
paste, which is aUowed to remain over night. In a 
few days inflammation of the skin, treated in this man- 
ner, results, the epidermis exfoliates and the acne is usu- 
ally much improved or cured [? — Ed.], ^yhen improve- 
ment alone results, this procedure is to be rejieated. 

Unna uses the following paste to bring about exfoliation : 

^ Resorcini, 40 (sx) ; 

Zinci oxidi, 10 (siiss) ; 

Terr, siliceae, 2 (gr. xxx) ; 

Adipis benzoinat, 28 (Svij). — M. 
Ft. pasta. 

SYCOSIS. 

Synonyms : Acne mentagra, FoUmditis barbce, Sycosis 
vulgaris. 

Sycosis is exclusively a disease of the hairy parts of 
the body. The ordinary and most common seats of the 
affection are the hairy portions of the face, as the upper 
lip, the cheeks, the chin. The eyebrows and eyelids, the 
nostrils, axilla, the pubes, even the hairy scalp, may in rare 
instances show a similar follicular inflammation. 

We have to deal with an inflammation of the follicles 
and perifollicular tissue. The first or primary stage of 
the eruption consists of papules, which change into pus- 
tules and are pierced in the center by a hair. These hairs 
when pustulation is advanced and of some duration, are 
loose, and on removal the sheath of the hair-root is seen 
to be yellowish, infiltrated with pus, and swollen. On 
pressure with the finger-nails pus can frequently be made 
to flow from the follicle. AV^hen the pustules are crowded 
together, larger inflammatory infiltrations result, which 
are covered with crusts and scabs (Plate 31). After the 
scabs drop off a cicatrix may remain, the follicle is oblit- 
erated ; as a rule, however, in many cases of sycosis no 



54 DISEASES OF THE SKIN. 

permanent trace is left. In long-continued sycosis, or 
peculiar forms of the affection, and when the disease has 
extended over a larger surface and is of the actively sup- 
purative type, there remain cicatricial areas partially or 
completely devoid of hair (lupoid sycosis, ulerythema 
sycosiforme). 

This affection may persist for years, and as it attacks 
exposed portions, as the face, it is exceedingly annoying 
to patients. The pustules are furthermore sensitive to the 
touch and very painful when the inflammation is exten- 
sive. 

We are unacquainted with the causes of this non- 
parasitic variety of sycosis. We only know that eczemas 
occasionally give rise to folliculitis, and that chronic nasal 
catarrh is sometimes followed by sycosis of the upper lip. 
[In recent years investigations of this disease point to 
pyogenic cocci as the essential etiologic factor, — Ed.] 

In connection with sycosis, it ap}>ears to us the 
proper place to refer briefly to a disease, described by 
Kaposi as dermatitis papillaris capillitii, which other 
authors (Bazin, Rogets) have called aene-keloid. Tubercles 
and tuberculo-pustules form at the margin of the nucha and 
posterior scalp ; these develop into papillomatous vegeta- 
tions, bleed easily, and are covered with crusts, and .some- 
times here and there contain pockets of purulent fluid. 
The process advances upward from the occiput to the ver- 
tex. The hairs are gathered in tufts or are entirely ab- 
sent. New formation of sclerotic connective tissue, 
atrophy, and baldness result. At times tufts of hair pro- 
trude from the sclerosed tissue. In most instances the 
disease tends to limit itself to the lower occipital region. 

Treatment. — It will be possible to retain the beard 
during the period of treatment only in mild cases. In 
aggravated cases the beard is cropped as close as possible 
and the crusts are softened with an emollient ointment. 
The hairs in the mature pustules are then removed witii 
depilation-forceps and the beard is shaved. When the pa- 
tient is very sensitive or when decided inflammatory reac- 



SYCOSIS. 55 

tion exists, it is frequently impossible, at least in the first 
week or two, to shave, and a paste of barium sulphid (de- 
pilatory) is substituted. Barium sulphate, charcoal, and 
linseed oil, according to Lestikow's directions, are stirred 
into a paste and subjected to a very hot coal fire ; barium 
sulphid is thus obtained as a dark-blue powder. The fol- 
lowing is ordered : Barii sulphidi, 10 (siiss) ; zinci oxidi, 
amyli, da 5 (gr. Ixxv). The powder is made into a paste 
with water and is applied pretty thickly to the affected parts 
with a wooden spatula ; in five to ten minutes it is to be 
washed off. Plxisting abscesses are incised and gray plas- 
ter is used to bring about resolution of tubercle-formation. 
Sulphur- paste, sulphur-mixtures, sulphur-soaps, and Wil- 
kinson's ointment are adapted to further treatment. Fur- 
thermore, washing the parts cautiously with spirituous 
solutions of corrosive sublimate (^2 per cent.), resorcin 
(5-10 per cent.), and pyrogallol (2 per cent.) are to be 
recommended. 

Eichhoff has the following solution well rubbed into the 
skin : 

^ Naphtalini, 

Acid, salicyl., da 3 (gr. xlv) ; 

Chloroformi, 

Spirit, vini, 

Glycerini, da 10 (fsiiss). — M. 

Sig. — To be painted on. 

Sycosis of the nasal mucous membrane and of the hairy 
scalp is treated on the same principles. 

Similar methods in the main are employed in the treat- 
ment of parasitic sycosis (tinea sycosis, tinea trichophy- 
tina barbae, q. ^\). Ehrmann treats this variety with 
electric cataphoresis. The electrodes are open in front or 
contain receptacles of hard rubber, into which ichthyol 
(lOj)er cent.) is poured. The electrode is then applied to 
the skin and a current of 15 to 20 milliamp^res is used 
for ten to fifteen minutes. 



56 DISEASES OF THE SKIN. 



ACNE ROSACEA. 



Acne rosacea is characterized by red or bluish discolor- 
ation and hypertrophy of the cutaneous structures of the 
nose, and occasionally extends to, or is seated upon, other 
parts of the face, as the forehead, cheeks, and chin. This 
affection appears usually in adults, more frequently in 
men, but also in women ; in the latter exceptionally during 
the period of puberty, most frequently, however, during 
the climacteric. 

Patients at first complain of a sensation of warmth in 
the nose upon the slightest cause, as when entering a 
warm room, excitement due to psychic irritation or to 
drinking ; at which time especially the nose appears 
flushed, which, however, soon disappears. The nose is 
observed to be frequently moist or oily — seborrheic. 
Sooner or later the redness becomes permanent and 
disappears only on mechanical pressure for a short 
period, to reappear as soon as this is withdrawn. 

This intense redness goes hand in hand with slight or 
more or less pronounced swelling and hypertrophy of the 
nose. Occasionally a few venous vessels become more 
prominent at an early date. These dilated, tortuous 
varicose vessels impart a bluish color to the affected 
parts. The hypertrophy referred to is due to pro- 
liferation of the connective tissue, which begins around 
the vessels and is irregularly distributed. Frequently 
single flat papules develop superficially ; these increase in 
size and number, become confluent, and often form ex- 
crescences the size of a cherry to that of a nut. These 
lobular tumors, which are pedunculated at times, and the 
swelling of the nose may exceptionally increase to the 
size of a small fist, and the distorted organ overhangs the 
mouth (rhinophipna). 

The skin of the enlarged organ is furthermore covered 
with dilated sebaceous follicles and scattered acne-pa])ules 
and -pustules. At times patients also complain of burning 
pain, which is probably due to suppuration and formation 



ACNE ROSACEA. 57 

of the acne-pustules. These enlarged noses retain their 
soft, elastic consistence for a long time, and only rarely 
feel tough and thick to the touch. 

In the early stages the slight swelling of the nose 
may cause acne rosacea to be mistaken for lupus ery- 
thematosus ; careful insj)ection will, however, prevent 
such an error. Soon the vascular alteration becomes 
conspicuous. The shiny, intensely red surface, the ab- 
sence of being sharply defined from the surrounding 
neighborhood, and lack of scar-formation point to acne 
rosacea. The absence of disintegration and ulceration 
distinguishes acne rosacea from lupus vulgaris ; the same 
applies to syphilis. Enlargement of the nose of higher 
degree in this disease, unaccompanied by excrescences, 
reminds us of rhinoscleroma ; it differs from the latter, 
however, principally in being of softer consistence. [In 
the large majority of cases of acne rosacea met with in 
this country the condition consists of either diffused 
redness or additionally of dilated vessels and more or 
less numerous acne-lesions. Connective-tissue hyper- 
trophv, except to a slight degree, is not very common. 
—Ed.] 

Popular opinion attributes the disease to drink. In 
most cases the abuse of alcohol must be recognized as the 
causative factor, sour white wine, whiskies, and brandies 
being regarded as especially injurious. These drinks, 
however, must not be looked upon as the direct cause ; 
the chronic catarrhal conditions of the stomach and intes- 
tines of alcoholics nuist be regarded as the direct essential 
factors. Hence catarrhal diseases of these organs occujrring 
in non-alcoholics may likewise be of similar etiologic im- 
portance. Experience, furthermore, demonstrates that in- 
dividuals who are much exposed to cold — e.g., coachmen, 
hucksters, and sailors — are frequently affecte<l with acne 
rosacea. People of this class, however, are not very care- 
ful in their diet nor in the use of alcohol, and frequently 
resort to the latter for its warmth-giving effect. Ex- 
cessive tea-drinking is also of causative influence. Our 



58 DISEASES OF THE SKIN. 

observation, that such patients not infrequently have a 
pale skin and conjunctiva, appears worthy of mention. 

There are other etiologic factors to be considered. We 
have mentioned that girls develop acne rosacea during 
puberty and women more frequently during the cli- 
macteric period. Such individuals suffering from dis- 
turbances of the genital system are nearly always anemic. 
We therefore may regard it as probable that long-con- 
tinued anemic conditions dispose to this disease, and that 
the anemia is the result, either of digestive disturbances, 
due to malnutrition, or to disorders of the genitalia and 
loss of blood. A very hopeful prognosis therefore cannot 
be given, in many instances, as the underlying causes may 
be either difficult of recognition, or, when they depend on 
the method of living, cannot be removed. The affection 
never reaches a stage dangerous to life. 

General treatment should be directed to the fre- 
quently associated symptoms of uterine disorders, abuse 
of alcohol, disturbances of the stomach and intestines, and 
constipation, which must receive proper consideration. 

Schiitz recommends the following as an intestinal disin- 
fectant : 

I^ Thymoli, ~ 0.4 (gr. vj). 

Solve in spirit, vini rect., 25 (f3\'j gr. xv). 
Aq. destill., 150 (fsiv 3vss).— M. 

Sig. — One tablespoon ful in a glass of water at 10 
and at 5 o'clock. 

To overcome constipation : 

1^ Extr. aloes, 0.50 (gr. viiss) ; 

Ferri snlph., 3 (gr. xlv) ; 

Extr. belladonnae, 0.20 (gr. iij) ; 

Sach. et rad. liq., q. s. ad pil. No. 60. 

Sig. — One pill t. d. after meals. 

Ix)cal treatment, of course, is governed by the stage 
and conditions. In the first stage applications of hot 



HERPES ZOSTER. 59 

water for a short period, coveriug the diseased skin with 
adhesive phister or plaster of salicylic acid soap, and 
mopping with sulphur-lotions, will be productive of good 
results. 

The following will be found serviceable : 

1^ Sulphur, praecip., 

Amnion, muriat., da 1.2 (gr. xviij) ; 

Spirit, camphorae, 2.4 (gr. xxxvj) ; 

Acet. vini, 

Liq. cupr. ammon. mur., da 4 (fsj) ; 
Aq. laurocerasi, 

Aq. rosae, dd 15 (fsiij gr. xlv). — M. 

Sig. — Shake and apply with finger (Schiitz). 

Application of tincture of iodin, iodized glycerin, and 
gray plaster will bring about absorption of hard infiltni- 
tions. 

When numerous tubercles and dilated vessels are 
present it is best to scarify the skin. The choice of the 
instrument, of which there are quite a number, may be 
left to the individual taste ; personally we prefer the 
most simple instruments. Some authors (Hardaway, 
Lassar) employ the electrolytic needle in place of scarifi- 
cations. The treatment of rhinophyma is purely surgical. 

VESICULAR AND BULLOUS ERUPTIONS. 

HERPES ZOSTER. 

The main representative of this group is herpes zoster 
(Plates 12 and 13). Its appearance is frequently an- 
nounced by sensations of pain in the domain of the 
nerves in which the eruption is about to occur ; or patients 
often feel only a burning sensation in the affected area 
shortly before the lesions appear. Slight inflammation 
and swelling of the skin in the region of one or more 
nerves ensue, and papules crop out on the surface, which 
in one to three days become translucent vesicles, varying 



60 DISEASES OF THE SKIN. 

in size from a grain of buckwheat to that of a pea. This 
condition may retrograde and abort. The disease, how- 
ever, often continues to spread ; tlie bullae frequently 
attain the size of a bean and cover the entire affected 
areas of the involved region, with the exception of the 
red borders. 

The contents, at first serous and transparent, gradually 
become turbid, and finally dry up into brown scabs. The 
inflammation declines; the pain becomes less intense or 
ceases, or is limited to atypical recurrent neuralgias, which 
annoy patients once or several times daily. The disease 
usually lasts three to six weeks. 

This typical course differs very materially in some 
cases ; extravasations of blood, accompanied by violent 
neuralgic pains, may impart a blue or dark-red color to 
the bullae [zoster hcemorrhagicus). Not only the bulla?, 
but also the tissue-base (upper layer of the corium) are 
permeated by hemorrhages. The severest variety, known 
as zoster gangrcenosus, is accompanied by high fever and 
pain, and the accompanying dark greenish discoloration 
indicates necrosis of the skin (Plate 12, single groups). 

Zoster of an uncomplicated type, as already re- 
marked, gets well in several weeks and new epidermis 
is formed under the scabs. In zost^ir gangrsenosus the 
gangrenous eschar is separated by suppuration and an 
ulcerated surface results, which cicatrizes slowly and 
leaves keloidal cicatrices behind. After the objective 
phenomena have disappeared, patients frequently, more 
particularly those of advanced years, complain for a long 
time of anesthesia in the affected areas ; more frequently, 
however, of neuralgias, paralyses, and trophic disturb- 
ances, manifested by atrophy of the muscles and some- 
times by falling of the hair. 

This disease, originating solely under the influence of 
the nerves, is usually unilateral and follows the distribu- 
tion of single nerve-branches. Tl^e intervertebral ganglia 
have been found to be diseased, which, as we know, 
receive an anterior motor and a posterior sensitive root 



HERPES ZOSTER. 61 

from the spinal cord. Consequently the most frequent 
form of zoster is one which follows the peripheral dis- 
tribution of a spinal nerve. Of the cephalic nerves it is 
usually the trigeminus, in which the ganglion Gasseri plays 
the same role as the intervertebral ganglia, already men- 
tioned, do in the spinal nerves. Besides this common 
etiologic factor, central diseases of the brain and spinal 
cord, especially diseases of the vasomotor centers, may 
give rise to zoster ; bilateral zoster is attributed to this 
cause. Finally, the nerve-branches may develop a peri- 
neuritis in their peripheral distribution or irritability, 
due to pressure, and in this manner an herpetic eruption 
may ensue without the central part participating. In 
this case the herpetic eruption follows the ramifications 
and anastomoses of the peripheral nerves, and does not 
always adhere to the main trunks; consequently there 
occur completely isolated foci of herpes zoster, which are 
not covered by the main nerve-trunks. 

The clinical pictures of zoster correspond to the locali- 
zation and to the severity with which the nerves have 
been affected by the toxic influence. In thoracic zoster 
we notice the first eruption of vesicles at the greatest 
curve of the ribs, in about the posterior axillary line. 
The anterior pectoral portions usually follow. Vesicles 
in groups, corresponding to a small cutaneous branch, five 
to eight in number, invariably appear, and are developed 
in a certain place contemporaneously and in the same 
manner. The succeeding crops behave likewise, and we 
can frequently demonstrate fresh vesicles at the periphery 
along with central groups which are drying up. It is 
noted that the herpetic vesicles frequently do not ad- 
here strictly to the region which the ramifications of 
the nerves seem to assign to them, and appear on the 
median lines or ascending or descending in the domain of 
neighboring nerves. The anastomoses of the cutaneous 
nerve branches (known to exist) alone can be held ac- 
countable for this. 

Hemorrhages into the ganglia and inflammatory changes 



62 DISEASES OF THE SKIN. 

in them, or when long continued leading to death of the 
nerve-elements, diseases of foci of the brain or of the 
spinal cord, cicatricial formation with remnants of pig- 
ment and preceding hemorrhages, lead to diseases of the 
nerves or nervous system giving rise to zoster. Direct 
causes are frequently traumatic in character, as an injury, 
a blow, pressure on a nerve or ganglion by neighboring 
organs — e. g., exudations, inflammations, diseases of bones 
(periostitis, exostitis), or carcinomata. Sattler has observed 
toxic forms of zoster, especially in the domain of the tri- 
geminus, follow carbonic-oxid poisoning ; and Blaschko 
and others have observed it follow arsenical administra- 
tion. Malaria may also lead to neuralgia and zoster. 

Beside these recognized causes, the etiology of a number 
of cases of zoster is entirely unknown. Its epidemic 
appearance, frequently associated with other acute infec- 
tious symptoms or diseases, appears to point to an infec- 
tious cause, which, however, still remains to be proved. 

Zoster usually attacks adolescents and young adults, 
old individuals less often, children infrequently. 

Herpes zoster faciei et capillitii corresponds to the region 
controlled by the trigeminus. In the domain of the first 
branch of the trigeminus zoster occurs most frequently on 
the eye, upper eyelid (nervus supraorbitalis), angle of the 
eye (n. supraorb. et trochlearis) (Plate 13). Zoster cervi- 
calis corresponds to the domain controlled by the second, 
third, and fourth cervical nerves. The occiput, nucha, 
neck, and region of the shoulders also belong to the cer- 
vical plexus. The region of the upper extremities is sup- 
plied by the brachial plexus and by the first and third in- 
tercostal nerves. The region of the chest is controlled by 
the intercostal nerves. The nates, abdomen, and genitalia, 
and part of the thighs belong to the domain of the lum- 
bar and sacral plexuses. Tiie last supplies the skin of tlie 
perineum, of the genitalia, and of the posterior surfaces 
of the thighs, and the nates downward over the extremi- 
ties to where the crural nerve begins on the thigh. 

Treatment. — The affected areas are to be dusted with 



HERPES FACIALIS ET PROGENITALIS. 63 

an indifferent powder, or mild salves can be used ; when 
the ])ain is severe, extract, opii, extr. belladonna?, or 
orthoform may be added. To control the neuralgic pains 
sodium salicylate (4-6 grams (3j-3iss) per day), antipyrin, 
pyramidon (0.3 per dose (gr. ivss) t. d.), chloral hydrat, 
(juinin, hydrobromat. (Wolff); occasionally hypodermic 
injections of morphin must be employed to relieve the 
tt»rturing neuralgia of some patients. Scharff injects 
Schleich's solution in the intercostal space, close to the 
point of exit of the nerve : 

I^ Cocaini hydrochlor., 0.2-0.4 (gr. iij-gr. vi); 
Potass, chlorat., 0.40 (gr. vj) ; 

Morph. hydrochlorat., 0.05 (gr. |) ; 
Aq. destill., 200 (f^viss).— M. 

Sig. — Liquor ansestheticus Schleich. 

HERPES FACIALIS ET PROGENITALIS. 

The frequent herpetic eruptions on the face and geni- 
talia do not follow the type of zoster. They are preceded 
by slight itching, and appear on the mucous membranes 
and neighboring skin and form groups of vesicles, each 
vesicle the size of a pin-head to that of a lentil, situated 
on a slightly reddened and somewhat raised base. Her- 
petic eruptions around the entire mouth, involving the 
carmine of the lips and extending to the mucous mem- 
brane, are only infrequently met with, and in such in- 
stances only when catarrh of the cavity of the mouth 
exists. Herpes around the nostrils is frequently asso- 
ciated with herpes labialis. This form of herpes occurs 
almost exclusively in young subjects with slight catarrhal 
affections accom})anied by fever, coryza, and bronchitis ; 
also in grave diseases of the respiratory tract, pneumonia, 
and intermittent fever. 

Genital herpes behaves in a similar manner. In men 
it occurs most frequently on the prepuce (herpes prceputi- 
alis), more rarely on the glans. Although of short dura- 



64 DISEASES OF THE SKIN. 

tion, this disease often occasions diagnostic difficulties, and 
is of great importance to tlie physician, inasmuch as ener- 
getic caustics and strong remedies may convert it into a 
chronic, torpid affection, resembling infectious nlcers. 
Very frequently slight swelling and tenderness of the 
inguinal glands accompany herpes progenitalis. In 
women genital herpes is met with on the labia minora and 
majora, which are more or less swollen ; we have repeat- 
edly seen herpes spread over the entire external genitals, 
the perineum, and the inner surfaces of the thighs as a 
very grave and painful disease. 

The exact causes of these forms of herpes are unknown ; 
they are probably of nervous origin. Fright, excitement, 
and slight febrile disturbances at times give rise to herpes 
labialis and facialis. In some individuals herpes prae- 
putialis may be due to persistent erection, and also may 
show itself within two or three days after sexual inter- 
course. 

Treatment of this herpetic disease consists in appli- 
cation of mild dusting-powders or salves. The parts 
should be protected ; caustics should be avoided. 

MILIARIA. 

Miliaria riihra et alba — heat-rash, or prickly heat — an 
eruption of very minute vesicles, accompanied by pro- 
fuse sweats, and appearing on the trunk and extremities, 
at first has a red, later, when the epidermis becomes mace- 
rated and opaque, more of a whitish color (therefore the 
terms rubra et alba). The contents of tlic vesicles have 
an alkaline reaction. We meet such eruptions in field- 
laborers during the summer or in tropical countries, espe- 
cially at the seaside after bathing in salt water, and some- 
times in healthy individuals after long-continued sweat- 
ing ; also frequently in children during the hot weather. 
The general health is not interfered with. Fresh-water 
baths and keeping the skin dry cause the disease soon to 
disappiiar. 



IMPETIGO HERPETIFORMIS. 65 

Miliaria crystaUina, or sudamen, makes its appearance 
in the most diverse infections diseases, on the neck, trnnk, 
abdomen, and the flexor snrfaces of the extremities, in the 
form of perfectly clear minute vesicles, the size of a pin- 
head, and at times the size of a small pea. The affected 
regions are neither hyperemic nor inflamed, and have the 
appearance of being covered with dew-drops. Miliaria 
crystallina occurs during the })uerperal process, in endo- 
carditis, enteric fever, etc. The vesicles do not change 
materially, being finally absorbed, the thin cover simply 
scaling off. Its occurrence and even successive crops 
are of slight importance ; the causative or associated 
febrile systemic disease is mainly to be considered. 

Miliaria epidemica is a rare disease of greater impor- 
tance. It occurs epidemically, and is ushered in by rigors 
and fever ; the patients sweat profusely and are very dull. 
The skin of the neck and rump is covered with tubercles, 
vesicles, or pustules. 

The entire aspect of the disease conveys the impression 
of its being due to general systemic infection, and this 
view gains in importance owing to the individuals devel- 
oping constant fever, dulness, and stupor, and frequently 
perishing. During the epidemic of 1892 observed in 
Carinthia 24 per cent, of the cases proved fatal. 

Conditions of temperature appear to influence the origin 
of this disease ; the epidemics occur principally during 
the spring and summer, when the atmosphere is warm 
and moist. Nothing characteristic is found at post- 
mortem ; it is striking, nowever, that such cadavers de- 
compose very rapidly. 

IMPETIGO HERPETIFORMIS. 

This rare skin-disease has been observed, with but few 
exceptions, only in pregnant women and during the puer- 
perium. The eruption begins on the inner surfaces of the 
thighs and inguinal region, on the umbilicus and breasts, 
spreads over the whole body, and even appears on the 

5 



66 DISEASES OF THE SKTK 

raucous membranes. Innumerable whitish vesicles of 
pin-head size, situated on a reddened, slightly swollen 
base, develop, whose contents become opaque and dry into 
a thin whitish crust. The eruption, which at first is con- 
fined to areas the size of a pea to that of a penny, spreads 
rapidly and in a few days larger regions of skin are in- 
vaded. The eruption extends in tlie following manner : 
A reddened and swollen zone appears at the periphery 
of a desiccating area or border, upon which new lesions 
form. Upon removal of the above-mentioned thin, dirty- 
white crust, newly formed epidermis is either found 
underneath or the skin is moist after the manner of 
eczema rubrum. 

The gravity of the disease is indicated by the condition 
of the general health. The patients have continued or 
remittent fever and rigors; they are prostrated and have 
lost interest in everything ; the tongue is dry ; there are 
vomiting at times, stupor, and even delirium. 

The prognosis is very unfavorable. Of fifteen cases, 
thirteen ended fatally (Kaposi). A pregnant woman, 
who passed through the disease after delivery and devel- 
oped grave symptoms, came under our observation ; she 
recovered so far as to be able to leave her bed ; the fever, 
however, returned, and she perished rapidly, exhibiting 
signs of collapse. Post-mortem findings were negative, 
as in other cases reported. 

The etiology of this disease is unknown. Inferring 
from the course it pursues, it may be regarded as an 
infectious disease allied to some erytheniata and varieties 
of herpes and pemphigus. 

Treatment is wholly symptomatic. In all cases so 
far observed it could not be demonstrated that the disease 
is influenced by any therapeutic remedies. 

PEMPHIGUS ACUTUS. 

As belonging to the bullous eruptions, the rare disease 
acute pemphigus is to be mentioned. Following short 



PEMPHIGUS ACUTUS CONTAGIOSUS. 67 

prodromal disturbances of the general healtli, the temper- 
ature often rises to 40° C, and pea-sized, perfectly clear 
vesicles, which increase rapidly in size and are scattered 
irregularly over the body, make their appearance. These 
rupture, the epidermis becomes dry and desquamates, 
and a slightly pigmented spot remains. 

Similar successive crops occur for two or three weeks ; 
the general symj)toms improve and the disease termi- 
nates. At times gangrene of the skin in defined spots has 
l)een said to occur as a complication. We have only once 
observed a case of this kind, terminating with simple 
desiccation of the bullae. 

This disease appears to be of an infectious nature ; this 
belief is strengthened, by the fact that the entire organism 
participates, the temperature especially rising rapidly, 
when only relatively slight involvement of the skin exists. 

PEMPHIGUS NEONATORUM. 

Pemphigus neonatorum is a disease which appears in 
the first or second week of life ; the main symptom is the 
formation of bullae, inasmuch as important disturbances 
of the general health are absent. The contents of the 
bulla? become opaque in one to two days ; they grow 
flaccid and rupture. New red epidermis, surrounded by 
the remnants of the elevated epidermis, appears at the 
base. The localization of the disease differentiates it 
from pemphigus syphiliticus. The latter occurs on the 
palms and soles along with other evidences of syphilis on 
the rest of the body ; the base and surrounding tissue are 
more infiltrated, this condition being entirely absent in 
the affection acute pemphigus. 

PEMPHIGUS ACUTUS CONTAGIOSUS. 

A disease in children, characterized by a bullous erup- 
tion, which is apt to occur epidemically after vaccination, 
has often been described under the name of acute con- 
tagious pemphigus {dermatitis exfoliativa of Rittershairi). 



68 DISEASES OF THE SKIN. 

This disease appears more as a diffuse inflammatory affec- 
tion of tlie epidermis over large areas of the body. The 
epidermis desquamates or is elevated by serum and dries 
into crusts. Or finally — in cases of higher degrees — the 
epidermis is raised in the form of flat bulhe, branny 
desquamation occurs, or the epidermis is rubbed off. 
Underneath, the general integument appears red. 

Riehl has recently discovered in one case a fungus with 
long mycelial filaments, and also regards this parasite as 
the causative factor in other exfoliative dermatitides. [It 
is generally believed that some cases of " acute contagious 
pemphigus," those in which there are scattered blebs of a 
benign character, are examples of an anomalous type of 
impetigo contagiosa. — Ed.] 

PEMPHIGUS. 

We apply the title pemphigus, in the narrower sense of 
the word, to bullous eruptions wliose course is chanicter- 
ized by an eminently chronic character. We differentiate 
two main types, pemphigus vulgaris and pemphigus foli- 
aceus. 

Pemphigus Vulgaris. 

The far greater number of pemphigus-vulgaris cases 
must be designated as a febrile disease, as they are ushered 
in by rigors, rise of temperature, nausea, and other dis- 
turbances. Usually outbreaks of erythema precede the 
eruptions of bullae, and wheals resembling erythema an- 
nulare, figuratum, and urticatum, appear. Tense blebs 
develop on these wheals or erythematous spots. They 
may, however, occur on apparently normal skin without 
being preceded by other formations. The bullae, which at 
first are the size of a pea, attain the size of a nut ; or when 
numerous and close together they become confluent and 
develop various irregular forms. 

It is not so much the size as the number of bullae ap- 
pearing on the skin at the time of the eruption which 



PEMPHIGUS. 69 

characterizes a case as being of more or less gravity. The 
contents, at first serous and limpid, become opaque in a 
few days, the bulla ruptures, and the covering and exudate 
dry into a scab which is usually of a hemorrhagic character. 
In rare cases blood is in the earliest stage mixed with the 
contents of the bullae. The inflammation is more marked 
where the bullae and, later, the scabs cover large areas. 
The skin becomes hot and painful. Sometimes the disease 
is complicated by lymphangitis and adenitis. 

Subjective symptoms are partly dependent upon impair- 
ment of the general health, Ihirst, anorexia, and maras- 
mus being not infrequently associated; partly upon the 
processes on the skin, as burning, pains, tension, and itch- 
ing, which interfere with sleep. The scabs gradually fall 
ott' and a young bluish-red epidermis appears underneath, 
which later on becomes pigmented and may remain so for 
varying lengths of time. Cases pursuing a benign course 
may terminate completely in two to six months, although 
such individuals may expect recurrences sooner or later. 

There are, however, very mild cases of pemphigus in 
which the disturbances referred to are only observed in a 
minimal degree, and whose course is accompanied by only 
slight formation of bullae. On the other hand, malignant 
cases occur in which numerous lesions appear and in which 
the above-mentioned systemic disturbances are very 
marked. In these latter cases the mucous membranes are 
also usually involved ; and in such we may meet with 
bullae and erosions having a whitish cover on the mucous 
membranes of the oral cavity, of the lips, tongue, palate, 
larynx, and pharynx, which are not only painful, but 
when involving the larynx may give rise to symptoms of 
sutfbeation (Plate 34, a). Pemphigus also attacks the con- 
junctiva and cornea. On the skin the efflorescences fre- 
quently pursue a different course from the one described 
— e. (J., the corium remains exposed after the covering of 
the bulhe has been lifted off or appears to be covered with 
a croupous exudate (pemphigus crouposus). 

Pemphigus pruriginosuSy as the name indicates, is char- 



70 DISEASES OF THE SKIN. 

acterized by severe itching, which interferes with sleep, 
and loss of strength, nervousness, and restlessness result. 
Owing to the lesions being destroyed early by scratching, 
excoriations, pustular eczema, extensive pigmentation of 
the skin, and melanosis result; in short, all the sequelae 
belonging to chronic diseases accompanied by pruritus. 
[Many of these cases are now considered by the majority 
of American writers as belonging to the disease dermatitis 
herpetiformis. — Ed.] 

Neumann has called attention to a particular variety, 
namely, pemphigus vegetans' (Y\diies, 33, 34, and 34, a). 
These verrucous, ulcerating surfaces, depending on prolif- 
eration of the rete and papillary outgrowth, are thus 
formed : After the bullse have broken the moist, oozing 
surface begins to be elevated ; the margins are raised in 
the form of flat, imperfectly raised bullae and connect 
with the neighboring blebs ; in this manner plaques 
the size of the palm of the hand are formed. The 
fungoid vegetations occur on the face, on the alse of 
the nose and lips, on the ends of the joints, the genito- 
crural folds, the female genitalia, cleft of the anus and 
axillae ; they pour out a secretion having a rancid odor 
and show a tendency to spread serpiginously. They seldom 
break down rapidly, but generally remain stationary for 
a long time. 

Formerly this variety was regarded as certainly fatal, 
but owing to the modern method of treatment cases of 
late have remained alive for a longer period, as shown by 
the case depicted on Plate 33, and several others men- 
tioned in the literature on the subject. 

The papillary vegetations become flat when they are 
kept dry and disinfecting treatment is employed, and be- 
come covered with skin and cicatrize. 

Pemphigus Foliaceus. 

Pemphigus foliaceusdiflPers from the pemphigus varieties 
just mentioned by its more severe type and graver course. 



PEMPHIGUS. 71 

This condition develops either after a long duration of 
pemphigus vulgaris, or quite flaccid bullae appear from 
the first, whose cover is macerated and rapidly lifted off, 
leaving the corium denuded and red. 

Owing to very deficient regeneration of the epidermis, 
we meet witii large areas of excoriated epidermic lamellae, 
which are partly covered with remnants of epidermis and 
are dried into thin crusts. Between the lamellae the de- 
nuded corium or an imperfect epidermis appears. The 
scales are loosely adherent to the surface and exfoliate 
very readily (therefore, "foliaceus "). Owing to the 
gradual spread of the diseiise, the entire body-surface be- 
comes affected. Irregular lines of skin denuded of its epi- 
dermic cover extend between the scales and exude serous 
fluid, which causes the clothing and dressings to adhere 
to the body. The hair of the entire integument is loose 
and usually falls out ; the nails are thin and brittle. 

Patients experience great pain with every motion ; 
owing to fever and excessive diarrhea they become 
markedly emaciated and sooner or later succumb. 

One form of pemphigus, as already indicated, may de- 
velop from another type of pemphigus. Usually, how- 
ever, when the condition has lasted for years, we observe 
one form on one part and another on a different part of 
the body ; for instance, pemphigus pruriginosus and pem- 
phigus vegetans (case shown in Plate 33), and pemphigus 
foliaceus, etc. 

We therefore are led to suppose that the several varieties 
of pemphigus are only one disease. 

The etiology of this usually ominous disease (according 
to Kaposi's estimate, 10 per cent, do not recover perma- 
nently) has remained unexplained up to the present. Post- 
mortem investigations have not developed anything tangi- 
ble ; the individuals either succumbed to an intercurrent 
affection or to marasmus. [Comparatively few of the 
cases described in this country under the name dermatitis 
herpotifi)rmis, which Kaposi contends are pemphigus- 
cases, are of a fatal character. — Ed.J 



72 DISEASES OF THE SKIN. 

Bacteriologic examinations of the contents of the blad- 
der and of the products of metabolism (urine) have also 
failed to furnish a positive explanation. As many nervous 
affections are known to be accompanied by skin-diseases 
with formation of bullae, pemphigus has been attributed 
to this cause. 

Occasionally, in some instances, we are enabled by a 
study of the cases to advance hypotheses attributing pem- 
phigus as a symptom of another affection of the organism, 
appearing on the skin. Otherwise the etiology of most 
cases is enveloped in darkness, and such will be the fact 
until we possess a more intimate knowledge of the dis- 
turbances of metabolism and of the associated chemic 
and toxic processes in the organism. 

Treatment. — As the entire organism participates in 
this disease, the general health must receive proper atten- 
tion first. The strength must be improved by tonics, proper 
diet, and alcohol. Of internal remedies, arsenical prepara- 
tions are worthy of most confidence, although their action 
in pemphigus must be said to be unreliable. When itching 
is severe the administration of calcium chlorid (1 gram to 
1^ grams per day (gr. xv to gr. xxiiss)) may be tried. 
Externally, inert dusting-powders, bandages, and oint- 
ments of boric acid and zinc oxid, and Wilson's oint- 
ment, etc., are used. When there is tendency to severe 
itching, painting and rubbing with tar and tar-ointments 
are indicated. When large areas are denuded of epi- 
dermis and considerable serum has been lost, and treat- 
ment with ointments, owing to the general condition of 
the patient, is difficult to carry out (pemphigus foliaceus), 
the use of the continuous water-bath is recommended ; 
patients usually feel quite comfortable in it. 



DERMATITIS. 73 

INFLAMMATORY DERMATOSES. 

DERMATITIS. 

In the section on erythema it was stated that the 
essential element of inflammation of the skin is hyper- 
emia ; and in the beginning is, in fact, the only one. We 
have also referred to the superficial inflammations of the 
skin which are called forth by irritating substances 
(toxins, medicaments), showing the close relationship of, 
and the very slight differences between, hyperemia and 
inflammation. In the following brief summary we shall 
refer to inflammations of higher degree. These are 
caused either by pathologic processes in the organism 
or are the results of direct thermic, chemic, or mechanical 
injuries, to which the skin is often subject. As to the 
inflammations due to traumatic injuries, Ave consider such 
as belonging properly to the province of surgery. 

Experience has taught that diabetics are predisposed to 
various kinds of cutaneous inflammation. Such indi- 
viduals may suffer from anidro.-^is, asteatosis, pruritus 
cutaneus, sometimes erythemas, eczema, furunculosis, 
anthrax, and even diffuse dermatitis. Such dermatitides 
on the extremities occur as a result of slight pressure 
or slight injuries. It may easily happen, therefore, in 
such instances that the subcutaneous tissue of the soles 
of the feet, toes, ball of the foot, and dorsum of foot, 
become the seat of inflammation, which may lead to 
gangrene and bone-necrosis. 

The pathogenesis of these conditions is not entirely 
clear. Kaposi holds the view that the sugar deposited in 
the tissues ferments, and thus gives rise to the inflam- 
mation. We might also call attention to the lessened 
resisting power of the organism as a factor in such 
patients ; especially as it is known that diabetics are not 
equal to much fatigue or to continued mental effort — in 
fact, their power of resistance and recuperation is much 
compromised. Experienced surgeons are well aware of 



74 DISEASES OF THE SKIN. 

this fact, and, if possible, avoid operations of gravity in 
such people. 

Inflammations and even tissue-necrosis are encountered 
in enfeebled individuals after acute diseases, such as 
variola, typhoid, etc. In spite of the greatest care in 
some casea one is not able to prevent the formation of 
beti-sores. 

In this same class, too, belong marasmic subjects and 
old men, in whom the circulation is weak (senile or maras- 
mic gangrene) ; finally, cases in which there is contrac- 
tion or closure of the arteries, as in atheroma of the 
vessels ; in endarteritis obliterans, as sometimes observed 
in the distal arteries after syphilis, which leads to in- 
flammation of the peripheral parts of the extremities and 
to progressive gangrene. 

Finally, multiple cachectic gangrene is to be mentioned, 
which Simon and Kaposi have observed in enfeebled 
children, and thought due to capillary thrombosis. 

In this group of inflammations of the skin are to be 
included these cases which belong to the domain of neu- 
rotic cutaneous disease. Among these the most impor- 
tant is RaynaucVs disease, or symmetric gangrene, which 
has been observed in brain and spinal affections, and, 
according to Hochenegg, signifies a pure vasomotor dis- 
turbance, without primary disease of the vessels. The 
capillary vessels of the skin are contracted by vasomotor 
influence ; there arises a local anemia ; the skin feels cool 
and is pale. If the contraction lessens, there follows a 
congestion of the veins, which is characterized by regional 
cyanosis and swelling. If the circulatory disturbance is 
not equalized, if the trophic impulse is increased, there 
follow, with accompanying severe neuralgic pains and 
vesicle-formation, inflammations, and indeed gangrene, 
of the toes and fingers. 

Paresthesias and anesthesias are observed in cases 
of symmetric gangrene preceded by markedly severe 
nervous disturbances. 

Syringomyelia is also often associated or followed by 



COMBUSTIO. 75 

trophic disturbances of the skin ; it is, however, to be 
distinguished from Raynaud's disease by the asymmetric 
appearance of the ulcerations, as well as by the a})i)ear- 
ance of various other eruptions in consequence of tiie 
dystrophy, as eczema, rliagadcs, panaritis, bleb-formation, 
gangrene, etc. 

Ferforating ulcer of the foot has been considered by 
some authors likewise as a trophoneurosis. It apjwars 
most frequently on the flexor side of the large toe and 
over the ball of the foot. Mostly a callous condition of 
the epidermis or a corn-formation precedes it. This 
accumulation is thrown off by underlying inflammation, 
and leaves an ulcer, which extends deeply and may even 
lead to necrosis of the bone. 

Finally, we may refer to spontaneoiis r/angrene in 
hysteria, of which young females are mostly the subjects. 
Preceded and accompanied with burning sensations, a 
(piartcr-dollar-sized to dollar-sized spot or a wheal-like 
efflorescence develops, which soon takes on a dark-blue 
color and is covered with a dry crust. This is cast off, 
the wound heals from time to time, and new gangrenous 
j)laques appear. After a shorter or longer duration (up 
to two years) the eruptive tendency disappears. 

COMBUSTIO (BURNS). 

Under the term " combustio " are designated those 
cutaneous inflanmiations due to the action of heat or 
caustic chemic substances upon the skin. The tissues re- 
act after such injury in different degrees of inflamma- 
tion, provided vitality has not been completely com- 
promised or destroyed. On account of the frequency 
of this accident the skin inflammations in this group 
are of first importance. The most common cases in 
which burns are observed are from heated bodies or hot 
liquids, as hot pitch, hot water, petroleum, explosive ma- 
terials ; and of the chemic materials, mostly lime, caustic 
acids, etc. The surface of the body is always the seat of 



76 DISEASES OF THE SKIN. 

the first symptoms, although almost immediately there- 
after also disturbances of a constitutional character pre- 
sent themselves. According to the effects produced, it is 
customary to divide burns into three grades, as follows : 

1. Bums of the First Degree. — In this grade (combustio 
erythematosa) a small or large surface of the skin reddens 
with slight swelling, as observed in erythema, but diffused 
and not in wheal or papular form. This slight inflamma- 
tory condition of the skin is followed in a few days by 
a brownish coloration ; , it then gradually returns, with 
slight exfoliation, to the uormal state. Generally, with 
this degree of combustio the general equilibrium is not 
disturbed, and the burning sensation of the skin is readily 
controlled by therapeutic measures. 

2. Biufis of the Second Degree (Combustio Bullosa). — 
The surface involved is the seat of vesicles and blebs from 
pea- to fist-size, tolerably well filled with serous fluid. 
The epidermis is not equally lifted up, as it is, for exam- 
ple, in pemphigus-blebs; and the covering is mostly 
thicker, the base of the blisters being the rete Mal- 
pighii or even the papillary layer. The surrounding skin 
is dark red and shining. The patient experiences a feel- 
ing of burning or heat in the part, which often extends 
beyond the immediate boundary of the burn itself. The 
smaller blisters remain unbroken, their contents becoming 
milky ; the epidermis dries to dark crusts, which drop off 
and disclose the newly-formed epidermis. The larger 
blisters are torn upon removal of the burnt clothing 
or from pressure or contact in lying in bed, so that 
when first observed by the physician they are seen as 
irregular folds of epiderm or bared red areas. These 
are covered with whitish spots or specks, and in a few 
days become quite red, and are followed by an exudation 
and a cell-formation which gradually lead to complete 
over-skinning. 

The subjective symptoms in these cases consist of 
marked pain and burning, which are heightened by the 
pressure in bed and by the removal of dressings or cloth- 



COMBUSTIO. 77 

ing. If a large part of the surface is involved, the life 
of tiie patient is endangered. 

3. Barns of the Third Degree {Comhmtio Eacharotica). 
— In these cases, in addition to "the symptoms of the other 
grades, there is observed, as especially characteristic, a con- 
dition of mortification of the tissues, resulting from the 
intense action of the heat. The soft parts present, at 
least as to extent and depth of the burns, in every 
case all possible degrees. Most frequently the part, 
both skin and tissue, appears as if it had been cooked 
with steam or hot water. Very seldom are to be seen 
on the burned areas bullous elevations; but for the 
most part the skin is observed hanging in shreds. In 
other cases the affected regions present a mortifica- 
tion, in which the skin is whitish, alabaster-like, hard 
and tough to the touch, and lifeless in appearance. 
Worse still are those cases in which the skin and soft 
parts are converted into a dry, leathery, and hard dark- 
brown slough. The sloughs are irregular in area, and 
on the periphery symptoms of burns of the milder de- 
grees are observed. In those unfortunate cases in which 
the body is exposed to direct flame the condition is one of 
carbonization and distortion. The patients are in the high- 
est degree of agitation, and in this severe grade of burn 
succumb often in four to six hours (nerve-shock (Kaposi)). 

More frequently, after a period of excitement there fol- 
low an apathetic condition, yawns, sighs, and gradually 
singultus, and even vomiting of gall. The patients grow 
restless, bewildered, are attacked with cramps and opis- 
thotonos, lose consciousness, become delirious, and fall 
into a stupor. In these cases the bladder is found to con- 
tain but a small quantity of urine. The breathing be- 
comes superficial, the pulse weak, and a fatal result soon 
ensues. If the patient survives the first two or three 
days, there begins a sharply defined inflammation with 
suppuration. The slough contracts and in the course of 
one to three weeks is cast off by the suppurative action. 
On the less-involved areas granulation begins. This 



78 DISEASES OF THE SKIN. 

period is for the })atient also a dangerous one, inasmuch as 
he may suddenly die from heart-failure. Many authors 
consider death in such instances due to a breaking down 
of the red blood-corpuscles ; others, to the formation of 
toxic substances in the organism. 

Irrespective of these direct dangers from the actual 
burn there are other risks to the life of the patient later, 
due to intercurrent disease, as pneumonia, Bright's disease, 
erysipelas, and pyeniia. 

The scars following burns are often keloidal, hyper- 
trophic, and cause in later years more or less difficulty ; 
the blood -circulation may be compromised, as a result of 
which the peripheral part becomes enlarged by edema and 
elephantiasic. Very often the movements of the head are 
hindered by scars on the neck. Contraction of scars on 
the extremities impairs the usefulness of the limbs, and 
the arms are not infrequently drawn into fixed angles or 
drawn to the trunk. 

Treatment. — In bums of the first degree : Dusting 
the parts with an indifferent dusting-powder, or ice- water 
applications frequently clianged, or aluminum acetate. 

In burns of the second degree: Opening the blisters 
and applying mild salves spread upon bandages. The 
bared rete or corium is dusted with iodoform in a thin 
layer, and over this a bandage of boric-acid salve or 
dressings of equal parts of oil and lime-water. Von 
Bardeleben recommends for the burnt areas solutions of 
carbolic acid (3%) or salicylic acid (3^), and then to be 
enveloped with soft gauze bandages which have been 
previously covered with equal parts of bismuth and starch. 
Such a dressing may remain on eight to fourteen days. 

According to the latest experience, treatment with picric- 
acid solutions has been commended. The burnt parts are 
bathed for five to ten minutes with — 

]^ Acidi picrici, 5 (^j gr. xv) ; 

Alcoholis, 80 (.^iiss) ; 

Aquae de-stillatse, 1000 (Oij). 



CONGELATIO. 79 

Immediately following this the wounds are covered with 
wadding or lint if the skin is still intact; or, if this is 
injured, then with sterilized gauze. These dressings are 
renewed every three or four days. In extensive bums 
compresses wet with this solution are kept constantly 
apj)lied. According to our experience, this treatment, 
owing to its painfidness, is not to be recommended. 

In extensive cases the continuous bath, according to 
Hebra, is especially serviceable. Internally alcohol is to 
be given ; and if there is great restlessness, w ith loss of 
sleep, morphin, chloral hydrate, and the bromids. 

Lustgarten reconmiends atropin. and lately Tommasoli 
the subcutaneous injection of artificial serum (that made 
of salt and sodium bicarbonate). 

The management of burns of the third degree is to be 
according to the same general plan. 

CONGELATIO (FROST=BITE). 

Frost-bite arises after more or less prolonged expos- 
ure to low temperature. The time necessary for such 
action differs materially with different persons. Anemic 
individuals or those weakened by wading through snow 
suffer more severely than robust, healthy people. The 
appearances upon the skin are, as in burns, divided into 
the three grades — erythematous, bullous, and escharotic. 

Frost-bite is most common in such parts as the un- 
covered hands, the poorly clad feet, the nose, ears, and 
cheeks. The patient experiences slight burning; soon 
loses, liowever, this feeling, and is only subsequently 
made aware that he has been frost-bitten by the thawing 
out, which is accompanied by sticking pain and intense 
itching. In this manner arises dermatitis erythematosa, 
so-called frost-bites, or pemiones, or chilblain, appearing 
as variously sized, slightly raised spots of livid color. 
The blood-vessels become paretic, to which are diTe the 
bluish color, the serous infiltration, and the slight swell- 
ing. If these inflammatory appearances are followed by 



80 DISEASES OF THE SKIN. 

greater infiltration and exudation, the epidermis will be 
lifted into vesicles or blebs, the contents of which may be 
more or less hemorrhagic. Sometimes these give place 
to torpid ulcerations, which from their exposed situation 
heal slowly and may be troublesome through such com- 
plications as lymphangitis and adenitis. 

As already mentioned, anemic individuals are especially 
exposed to this affection, especially the hands and ears ; 
and in even moderate cold, after having once suffered 
from frost-bite, with its consequent blood-vessel changes, 
may readily be attacked again. 

In extreme cases of frost-bite (congelatio escharotica) 
there always arise hemorrhagic blebs or a bluish, marble- 
ized, cold-feeling and insensitive surface. One cannot at 
first sight gauge the extent and the consequences in such 
cases, inasmuch as experience teaches that the soft parts, 
which may present the appearance of having been frozen, 
may yet recover, since the blood-vessels may remain per- 
meable. In its further course a reactive inflammation 
occurs around the mortified areas ; or after exposure to 
intense cold the mortification may not only extend 
through the soft parts, but even involve tlie bone. 

Necrosis — casting off of the ear-lobes, or phalanges or 
entire fingers — is not infrequent. In these long-contin- 
ued cases there is always the possible danger of absorption 
of putrid material, with consequent phlebitis and septi- 
cemia and death. 

Treatment. — As already stated, anemic individuals 
are the frequent subjects of these accidents, especially of 
the first grade, on ears, nose, hands, or feet; it is there- 
fore evident that in such cases the internal administration 
of iron-preparations is to be advised. Locally, painting 
with tincture of iodin, collodion, or the use of — 

I^ Acidi tannici, 2 (gr. xxx) ; 

« Glycerini sen, 

Spiritus camphorse, q. s. ad 50 (f^iss). — M. 

Sig. — To be rubbed in. 



ERYSIPELAS. 81 

I|i Camphorse tritae, 3 (gr. xlv) ; 

Lanolini, 

Vaselini, ad 15 (3ss) ; 

Acidi hydrochlorici pur., 2 (gr. xxx). — M. 
Ft. unguentum (Carrie). 

I^ Bals. peruviani, 5 (gr. Ixxv) ; 

Misturae oleoso-balsamicae, 
Aquse colonienisis, da 30 (^). — ^M. 

Sig. — For external use (Rust). 

^ Calcis chlorat., 1 (gr. xv) ; 

Unguent, paraffini, 9 (sij gr. xv). — M. 

Ft. unguent. 

Sig. — Rub in a pea- to bean-sized piece five minutes 
and bandage (Binz). 

Besnier and Brocq recommend bathing with a solution 
of walnut-leaves and painting on 

^ Aquae rosse, 

Acidi tannici, M 0.5-1 (gr. viss-xv) ; 

Glycerini, 30 (,lj).. 

Then dust with salicylated bismuth powder (1 : 6). 

In acute cases it is advisable first to place the person in 
a cool room, and to rub the parts with snow and adminis- 
ter the usual analeptica. 

ERYSIPELAS. 

Erysipelas is a disease due to infection, and is always 
accompanied by systemic disturbance. The eruptive 
phenomena may be found upon any part of the botly. 
The affected area is swollen, tense, and smooth, and 
fiery red. The disease not infrequently continues to 
spread peripherally, and in some cases it cannot be deter- 
mined beforehand how far the process will extend. The 
affected parts are tender to touch, and, especially on the 
peripheral zone, painful. 



82 DISEASES OF THE SKIN. 

The disease does not invariably spread regularly from 
all sides, but sometimes shoots out in lines ; or a neigh- 
boring part may be spared and it appear some distance 
from the original infection. Not infrequently it spreads 
along the lymphatics along the entire extent of the 
limb. A peculiarity is noticed in some cases, in that the 
disease heals at the place of first appearance and then 
spreads to the adjoining surface, extending in this way 
peripherally for some time and jx)ssibly involving a con- 
siderable surface (ei'ysipelcis migrans). Sometimes the 
parts already healed again become affected. In severe 
cases vesicle- and bleb-formation is a noticeable feature 
(erysipelas bullosum). In extreme cases the parts may 
even become gangrenous. 

The Streptococcus erj'sipelatis (Fehleisen) is admittedly 
the cause of this disease. Inoculations of pure cultures 
of this microorganism have succeeded in producing true 
erysipelas. 

The most frequent site for the disease is unquestionably 
the face. It often begins at the nasal apertures, in con- 
sequence of some exfoliation or fissure ; or from the corner 
of the eye, or from some other point where there has been 
an injur)' or break in the continuity of the epidermis 
through which the infection gains a foothold, and then 
spreads out over the face, ears, and the hairy scalp, 
sometimes extending down the neck and possibly to the 
trunk. 

Even before the redness appears there may be more or 
less fever and a feeling of being unwell ; the temperature 
rises to 40° C. with every exacerbation. In cases in- 
volving the entire head the patient is sojjorific or often 
violently delirious ; in those who drink freely — alcoholics 
— the disease is almost always accompanied with delirium 
tremens. 

Experience teiiches that recurrences are not uncommon, 
due either to the fact that some of the cocci remain in 
the tissues or that the disease arises from a new infection. 
Such recurrences frequently leave behind thickening of 



ERYSIPELAS. 83 

the connective tissues and elephantiasic enlargement ; as, 
for example, on the lower extremities when in association 
with foot- and leg-ulcers. Falling out of the hair is a 
frequent consequence of erysipelas of the head. 

Erysipelas heals with a lamella-like exfoliation of the 
epidermis or with the gradual dropping off of the crusts — 
the latter resulting from the dried-up blebs and vesicles. 

It is worthy of note that the exanthems, as syphilis, 
psoriasis, and lupus, often disappear during the course 
of the fever in this disease (erysipelas salutaire of the 
French). 

The prognosis depends upon the constitution of the 
individual, upon the severity of the attack, and especially 
upon the duration of the disease. 

With erysipelas the so-called pseudo-erysipelas (phleg^ 
mon) may be confounded. This phlegmonous inflamma- 
tion usually has its origin at the seat of an injury, which 
either by immediate infection or subsequently is inoculated 
by septic material. Accompanied by chilliness and fever 
it may sj)read over an entire extremity — a thick, hard, 
painful, tense, and red swelling. Very seldom is there 
any tendency . to retrogression ; but usually pus-forma- 
tion in the subcutaneous tissues takes place. Sometimes 
the ])rocess results in extensive purulent melting away 
of the tissue. The purulent action involves the fascia and 
muscles, often down to the bone. On opening a pus- 
collection great masses of bad-smelling pus mixed with 
tissue-debris are poured out. The patient, on account of 
the general infection and the severity of the loctd process, 
becomes emaciated and weak ; arid if he does not die in 
the acute stage of pyemia, he is endangered by the long- 
continued cachexia. 

Treatment. — This consists of regulation of the diet, 
antipyretics, and alcohol. In investigating the source 
of inoculation, as, for instance, in facial erysipelas, inspec- 
tion of the mouth and nose should be made, when it will 
often be found that the starting-point has been an abrasion 
from rhinitis or from a tooth-abscess. 



84 DISEASES OF THE SKIN. 

Local poultices of aluminum acetate or lead-water, 
painting of the bordering healthy skin with iodin tincture, 
collodion, or ichthyol-collodiura (10 per cent.), etc. We 
employ preferably the following salve applied on bandages : 



'^ Iodoform!, 


30 (5j); 


Creolini, 


15 (3ss) ; 


Lanolini, 




Vaselini, 


da 30(Sj).— M, 


Ft. unguentum. 





Of the many other remedial applications recommended 
may be mentioned absolute alcohol applied on com- 
presses of lint, and which are wetted every fifteen or 
twenty minutes, over which are placed a dry clotii and 
gutta-percha tissue-paper (von Langsdorf ) ; painting 
with guaiacol and olive oil, equal parts (Maraghano) ; oil- 
of-turpentine treatment after Luecke, in which rectified 
oil of turpentine is rubbed four or five times daily into 
the affected parts with a brush or a piece of lint. 

FURUNCULUS. 

Furuncle, or boil, is frequently observed to have its 
origin in an acne-pustule, or at least in an inflamed 
follicle. In the beginning there is noticed a painful 
inflammatory nodule in the skin. The apex gradually 
shows pustulation, in which sometimes a hair is found 
sticking. This pustule dries to a crust ; after three or 
four days the purulent infiltrated plug may be pressed 
out ; or this may be facilitated after the part has been 
linearly incised, the opening being thus enlarged. The 
cavity left closes gradually by granulation. It is repeated 
experience that boils are rarely seen singly, but that most 
frequently several appear simultaneously, or, what more 
frequently happens, many furuncles appear one after the 
other (funincnlosis). 

Boil-formations are often seen in connection with acne, 



PUSTULA MALIGNA. 85 

scabies, pediculosis, eczema, etc., the excoriations produced 
in these diseases by the scratching presenting favorable 
means of inoculation. The fact that boils appear succes- 
sively on the same individual and close together, and 
also appear on several or more people living together, 
speaks strongly for the conveyance of the disease from 
one point to another and from one person to another 
(Plate 32). 

Staphylococci have been recognized as the active etio- 
logic factor. 

CARBUNCULUS. 

Carbunculus, or anthrax, appears most frequently at 
the nape of the neck, in the face, on the back, and in the 
sacral region. It is distinguished from furuncle by its 
larger size and painfulness. It is nut to small-fist sized, 
hard, very painful connective-tissue inflammation, which, 
after some duration, breaks through the surface at several 
ix)ints. Sometimes the overlying skin necroses to a dry 
leathery slough. The high fever and the intense painfnl- 
ness make this disease one of some severity, and when the 
inflammation extends peripherally to any great extent there 
is grave danger that the patient may die from pyemia. 

PUSTULA MALIGNA. 

This is a disease of the cutiuieous structures due to 
infection by the Bacillus anthracis of splenic fever, which, 
as known, occurs in animals, as horses, sheep, homed 
cattle, etc. 

Inoculation occurs either directly to men who may be 
employed among animals, such as coachman, hostlers, and 
shepherds ; or among those who have to do with the 
products from animals, as it is known that even hair and 
skins may convey the bacilli, esjiecially the spores, which 
have an extremely tenacious vitality. The infection may 
take place through insect-bites, or by direct inoculation ; 
less frequently through inspiring dust containing spores, 
or through the digestive tract from eating diseased flesh. 



86 DISEASES OF THE SKIN. 

The course of such an infection is always dangerous, 
although it sometimes happens that the pustules, accom- 
panied by mild systemic disturbance, finally heal, the infil- 
trated tissue being cast off. 

EQUINIA. 

Equinia, or glanders, arises most frequently through 
direct inoculation from affected horses or mules. The 
cause of the disease is a specific microorganism. It is 
known that remaining in an infected stall or handling 
affected animals exposes to i)0ssible infection. 

The course of the disease is rapid, and frequently, in 
consequence of the chills, fever, pain, edema, suppuration 
of the joints, phlegmon, and gangrene, the individual's life 
becomes endangered. 

Some cases may persist for years. In such instances, 
even when many nodes are present in the subcutaneous 
tissue with subsequent breaking down of the lymphatic 
glands, recovery may finally take place. 



SQUAMOUS DERMATOSES. 

PSORIASIS. 

This disease frequently appears in individuals about 
puberty and early manhood. Children are comparatively 
seldom attacked ; in advanced years it is met with, but 
usually as a recurrence or as a persistent eruption or 
remnant from the disease in earlier life. In the begin- 
ning the eruption consists of red papules, which in a few 
days show scaliness of a somewhat adherent character. 
The lesions increase in size and numbers, so that in the 
course of a few weeks the older efflorescences are to be 
seen as flat rounded scaly patches with a red halo, while 
recent lesions are seen near by. 

According to the predominant form and size of the 
lesions, it is customary to designate the eruption by 



PSOniASLS. 87 

various names. In the early stages, when the lesions are 
mostly of small size, as already mentioned, it is designated 
psoriasis punctata (Plates 15 and 16) ; if the plaques are 
flat with considerable scaliness, it presents the so-called 
psoriasis guttata, from its resemblance to the condition 
which would be produced by sprinkling a handful of 
mortar over the skin. If the eruption consists of moder- 
ate-sized, flat and scaly patches, it constitutes the most 
common clinical variety — psoriasis nummularis (Plates 17 
and 18). 

When there is a marked tendency for the lesions to be- 
come confluent and to melt into each other the result is an 
eruption of various forms, concave and convex lines — 
psoriasis Jigurata. 

Further along in the course of the disease, or in some 
ciises ap})earing early in its course, the central part of the 
patches tends to disappear and the disease spreads periph- 
erally, producing rings of various sizes — psoriasis an- 
nularis, pj^oriasis circinata (Plate 19). In this variety, 
if the circles run together, the meeting borders melt 
away and give rise to irregular, tortuous scaly bands — 
psoriasis gyrata (Plate 20). 

Finally, if the lesions grow to considerable size and 
new outbreaks occur, large confluent areas result, in- 
filtrated and scaly, along with the ordinary, scattered, 
variously sized lesions — psoriasis diffusa universalis. 

Psoriasis involves especially the outer skin. Fre- 
quently the process involves. the nails, which may be- 
come milky, break easily, crack, and from time to time 
may crumble or be cast off" entire. In rare instances, and 
then only after long-continued psoriasis of the hairy scalp, 
the hair may fall out to some extent. 

The pathologic basis of psoriasis is an inflammation in 
the papillary layer. The vessels are hyperemic, the upjier 
corium and stratum papillaris are infiltrated with serum, 
and around the vessels are seen cell-collections. The rete 
is somewhat relaxed and edematous ; to this is due the 
fact that in the matured lesions the accumulated and 



88 DISEASES OF THE SKIN. 

horny epidermis may be rubbed off by light scratcliing, 
and from the underlying hyperemic blood-ves.sels bleeding 
is readily produced. 

To the rapid reproduction of the epidermis-cells is due 
the fact that the scales are silvery and shining, not hav- 
ing time to go through the process of cornification. Old 
patches, on the contrary, show thickening of the skin 
due to hyperplasia in the papillae and connective tis- 
sue, even to the extent of becoming somewhat wart-like 
(Kaposi). 

As a rule, patients are apt to have psoriatic patches on 
the extensor surfaces of the knees and elbows for years, 
and then for some unknown reason eflBorescences show 
themselves on the trunk and limbs. 

The scalp and the bordering forehead rarely remain 
free. The eruption seldom shows itself on the face, and 
still less frequently on the palms and soles. 

In rapidly developed cases the inflammatory characters 
may sometimes, in the course of three or four weeks, show 
considerable retrogression ; the plaques become much flat- 
tened and the scaliness less marked. In most cases, either 
through spontaneous retrogressive changes or as the effect 
of treatment, most of the patches disappear ; but fre- 
quently there remain slightly perceptible remnants on the 
places of predilection — the knees and elbows. AVhen this 
is the case the patient can be almost sure that the disease 
will in some months begin to spread afresiK 

As to subjective symptoms, the most common is itching, 
especially associated with disease in those cases in which 
are marked infiltration and inflammation of the papillary 
layer. In severe cases there may be gastric^ disturbance, 
restless nights, and the aj)pearance of painful fissures 
about the joints and flexures, so that the patient becomes 
incapable of getting about, and is obliged to give up work 
and for a time keep to his bed. 

Several atypical forms of psoriasis have been described 
which were distinguished either by peculiar appearances 
on the skin itself or by complications with joint- or 



PSORTASrS. 89 

organic diseases. As yet, it is not proved whether these 
conijjlications have any relationship to the psoriasis, or 
whethei", as is more probable, they are accidental only. 

We have rej)eatedly observed psoriatics with marked 
disturbances of the general health. The patients feel 
weak, show atypical temperature-changes, and complain 
of unrest, sleeplessness, and loss of appetite. The psori- 
atic patches may be succulent, elevated, covered with 
dirty-white scales, and surrounded by an inflammatory 
halo or band several millimeters in width. Gradually the 
subjective symptoms abate, the psoriatic plaques flatten, 
and there develops the usual picture of psoriasis, in which 
the involution-period is apt to be more rapid than usually 
observed. This peculiar course and condition we do not 
venture to ascribe to the cause responsible for the psori- 
asis ; but it impresses one as being due to some toxic 
agent, as in the erythemata. 

We have pictured a case of this kind with dollar-sized 
and larger plaques with inflammatory appearances (Plates 
17 and 18). It was also remarkable in that on the hairy 
scalp was seated a large and hard scaly or crusted plate- 
formation of a dirty-white color, which we were able to 
loosen in mass, representing a C4ist of the parts. Under 
this the skin was infiltrated, slightly reddened, and cov- 
ered with recent epidermis. 

In other instances we observed eczema in psoriatic 
patients which partly masked the clinical picture of pso- 
riasis ; an unfortunate complication, inasmuch as the 
patients were troubled with constant itching ; and we 
frequently, on account of the presence of the eczema, 
could not treat the psoriasis with the ordinary thera- 
peutic methods. These exceptional cases occurred in 
uric-acid patients, who were constantly troubled with the 
disease. 

In recent years cases of psoriasis complicated with 
joint-affections have been described. Such a case was 
observed in Lang's clinic, and described as psoriofiis 
ostreacea by Dr. Deutsch in Wiener klinische Wochen- 



90 DISEASES OF THE SKIN. 

schrift, 1898, No. 6. This case, owing to its extent 
and the intensity of the process, and the peculiar form 
of the efflorescences and the associated joint-affection, 
is especially interesting. Gassmann published a similar 
case as psoriasis 7-upioides, and Grube several such asso- 
ciated with gout and diabetes. 

We have (Plates 21, 21, a, and 21, 6) pictured a similar 
case, and saw also, on a visit to the City Hospital in 
Ragusa, a second case, which in addition to severe joint- 
affection presented horn-like, heaped-up, pyramidal scales 
and large, dirty-white, mortar-like crusts. As yet we 
are not certain that these cases simply represent a very 
intense process ; but must believe that uric-acid is the 
additional causative element. 

Psoriasis is commonly observed in well-developed, 
strong individuals in the prime of life, so that one cannot 
say that a cachexia or a general disease is the cause. [To 
this statement there are many exceptions. — Ed.] 

It may, however, be stated that a hereditary disposi- 
tion to the disease exists, which is shown in the family 
of the patient, in various branches, as grandparents, 
parents, or brothers and sisters, although by no means 
observed with that regularity and frequency which ob- 
tain with hereditary syphilis. 

The prognosis in psoriasis is usually favorable. 
Spontaneous involution of the psoriatic patches of the 
first attack and the recurrences is not uncommon. Be- 
sides, modern methods of treatment have an influence. 
Severe, complicated cases, such as those mentioned, or 
the accidental infection through the fissures which niay 
occur about the joints of the erysipelas or phlegmon 
microorganism, may threaten the life of the patient. 

Treatment. — Internal Remedies. — 1 . Arse7iic. — {a) 
In the Form of Fowler's Solution. — Six drops are given 
daily, divided into three doses and taken diluted. Every 
day the amount is increased by one drop. One can in 
this manner increase the quantity up to thirty drops 
daily, remaining at the dose at which involution of the 



PSORTASTS. 91 

psoriasis is observed to take place ; not to be discontinued 
suddenly when apparently completely cured, but return- 
ing gradually to a less and less quantity (Kaposi). 
(6) As Asiatic Fills. — 

I^ Arsenici albi, 0.75 (gr. xj) ; 

Pulv. piperis nigri, 6 (iiss) ; 

Pulv. acaciae, 1.5 (gr. xx) ; 

Pulv. althseje, 2 (gr. xxx) ; 

Aqua; fontan., q. s. ut. ft. pil. No. 100. 
Sig. — Three pills to be taken daily. 

Ever}'' fourth day the dose is increased by one pill up to 
ten or twelve })ills daily ; and in the same manner as with 
Fowler's solution, gradually lessening this quantity after 
an apparent cure. The pills are to be taken immediately be- 
fore meals. [Less apt to disturb if taken after meals. — Ed.] 

In addition to these methods of administering this 
remedy, it may be given by subcutaneous injection — of 
Fowler's solution, 0.2 (ITI iij) pro die ; of arseniate of 
sodium, 0.02 (gr. ^) pro die. According to Ziemssen, 
the official solution of arsenite of potassium is inappro- 
priate for subcutaneous injection, owing to the method of 
its preparation and also to the presence of a fungus which 
develops in it. He recommends the following : One 
part of arsenious acid is boiled with five parts of srxla 
solution till complete solution is effected ; it is then 
diluted to make one hundred parts and filtered. For 
use, put some of the solution in a small tube, which is 
stopped with a wad of cotton, and it is then sterilized with 
steam. Of this 1 per cent, solution of arseniate of sodium 
the beginning injection is 0.25 (TTtiv) once daily ; after a 
few days twice daily, and then the quantity of each injec- 
tion is gradually increased and is administered twice daily. 

Danlos and Rille recommend sodium cacodylate for sub- 
cutaneous injection (so<lii cacodylat., 4 (3j) ; aquse destill., 
10 (foiiss) ; daily a syringeful. 

Herxheimer injects 0.001 (gr. -^) arsenious acid (in 
solution) in a skin-vein of the elbow or knee region. 



92 DISEASES OF THE SKIN. 

Every day the dose is increased 0.001 (gr. ^V) till it 
reaches 15 mg. (gr. -^), at which it is kept till complete 
disappearance of the efflorescences. 

2. Potassium iodid (Greve, Haslund) in increasing 
dosage, beginning with 3 to 4 grams (gr. xlv-gr. Ix) pro 
die, increasing every third day about 1 to 2 grams (gr. xv 
-gr. XX x), and may even be increased to 60 to 70 grams 
(.^xv-^xviiss) pro die. Generally, this energetic treatment 
is well borne, but the large doses should be given while 
the patient is under direct observation ; the result in many 
cases is not to be doubted. 

3. Thyroid preparations (Byroni Bramwell) ; especially 
of these, however, the more reliable preparation, iodo- 
thyrin Baumann (Paschkis and Grosz). One begins with 
0.5 (gr. viiss) of the commercial triturate, and increases 
the dose every three or four days by about this same quan- 
tity. Untoward heart-action and psychical symptoms are 
to be guarded against. Should head-pain and heart-palpi- 
tation appear, the dose is to be intermitted ; if no symp- 
toms appear, one may increase the dose to 5 to 6 grams 
(gr. Ixxv-^iss) pro die. The effect in some cases is sur- 
prisingly favorable. 

External Treatment. — First of all, softening prepara- 
tions, as salves, oils, sapo viridis, besides baths and rub- 
ber clothing, are employed in getting rid of the sailiness. 
Only after the scales have been removed is it advisable to 
begin with those special remedies which are commonly used 
in this disease. As such, may be named : 

1. Tar preparations : Ol. cadini (oil of cade), ol. rusci 
(oil of birch), ol. fagi (oil of beech), pix liquida, ol. lith- 
anthracis (coal-tar), tinctura lithanthracis Leistikow (ol. 
lithanthracis, 30 (.?j) ; spiritus, 95 per cent., 20 (ov) ; aether, 
sulph., 10 (.^iiss)), solutio lithanthracis Sack (ol. lithanth- 
racis, 10 (.!5iiss) ; benzol, 20 (.^v) ; aceton, 77 (^iiss)), 
liquor anthracis simplex, liquor anthracis compositus 
(Fischel), liquor carbon is detergens (Wright, Jaddas- 
sohn). 

These may be applied to the psoriatic areas, either as a 



PSORIASIS. 93 

liquid preparation, painting on, or rubbing in, with a 
brush, as, for example : 

^i Olei rusci, 

OI. olivae, da 24 (fSvj). 

Or in salve form : 

I|s Pix liquidae, 

Lanolini, da 50 (siss). — M. 

Ft. unguentum. 

^ Ol. rusci, ^ ^ 20 (f^v) ; 

Saponis viridis, 5 (gr. Ixxv). 

Lanolini, 75 (3ij 3ij) — M. 
Ft. unguentum. 

Of special value is a 10 to 20 per cent, tar-salve with 
unguentum caseini, with the addition of sapo viridis (one 
part of sapo viridis to four parts of tar). Finally, tar is 
sometimes used in tlie form of the so-called tar-baths. 

2. ( 'hri/sarobin, in salve form, 5 to 15 per cent, strength, 
or with a drying vehicle (trauraaticin, collodium, linimen- 
tum exsiccans, filmogen), as, for example : 

I^ Ghrysarobin, 10 (.^iiss) ; 

Traumaticin (liq. gutta-perchse), 90 (f^xxiiss). 

Also as chrysarobin plaster (Beiersdorf ), and a 30 per 
cent. colla?tinum chrvsarobini (Turinsky). 

With the chrysarobin treatment the affected parts be- 
come white and the surrounding skin violet to brown. 
During the application of this remedy and for some days 
afterward baths should be prohibited, as such may tend 
to bring about a slight universjil dermatitis. 

Lately, Kromayer has recommended chrysarobin-tri- 
acetate (eurobin) and chrysarobin tetracetate (lenirobin). 

I^ Eurobin, 2 (gr. xxx) ; 

Eugallol, 10 (5iiss) ; 

Aceton, 10 (siiss). — M. 
Sig. — External use. 



94 DISEASES OF THE SKIN. 

I^ Lenirobin, 5-20 (gr. lxxv-3v) ; 

Pasta zinci oxidi, da 100 (siij). — M. 

Sig. — External use. 

I^ Lenirobin, 

Eugallol, da 6-10 (gr. lxxv-3iiss) ; 

Cbloroformi, 50 (fsxiiss). — M. 

Less valuable is anthrarobin. 

3. Pyrogallic Acid. — -Its method of application is the 
same as with chrysarobin ; the urine is to be watched, as 
absorption may take place when used too extensively. 

Unna recommends " pyrogallolum oxidatum " as a safer 
preparation : 

IJt Pyrogalloli oxidat., 5 (gr. Ixxv) ; 

Vaselini, 

Adipis lanse, da 25 (sviss). — M. 
Ft. unguentum. 

T^ Pyrogalloli oxidat., 5 (gr. Ixxv) ; 

Vitella recentia ovorum duorum misce intime. 

Sig. — To be painted on. 

Kromayer applies pyrogallol triacetate (lenigallol) and 
pyrogallol monoacetate (eugallol). 

^ Eugallol, 

Aceton, a« 10 (siiss). 

I|« Lenigallol, 1-5 (gr. xv-gr. Ixxv) ; 

Pasta zinci oxidi, q. s. ad 100 (oiij)- 

^ Lenigallol, 

Pasta zinci oxidi, dd 10-30 (siiss-.^) ; 

Vaselini, q. s. ad 100 (5iij). — M. 

Ft. unguentum. 

Less valuable appears to be the application of gallanol 
(Cazeneuve and Rollet), and likewise gallacetophenon. 



PITYRIASIS RUBRA. 95 

4. Sulphur. — This in tlie form of the natural spring- 
water baths ; as Vleminekx's solution (liquor calcii sul- 
phui-at.). In using the latter the patient is first thoroughly 
washed with soap and water ; immediately thereafter tlie 
affected areas painted with it, and the patient then gets 
into a warm bath and remains one to two hours. 

Very efficient is the treatment with unguentum Wilk- 
insoni : 

I|i Sulphur sublimat, 

Ol. fagi, da 50 (sxij) ; 

Saponis viridis, 

Adipis, da 100 (.? 



Cret^e albae, 10 (siiss). — M. 

Ft. unguentum. 

Tiiis salve is to be rubbed into the affected spots twice 
daily. After a week exfoliation of the epidermis begins; 
after its completion a bath is ordered. 

PITYRIASIS RUBRA (HEBRA). 

This extremely rare disease attacks in the beginning the 
flexures of the limbs, and may for years be limited to 
those regions. The affected area is vividly red and is the 
seat of a thin, leaf-like epidermal exfoliation. The patient 
feels moderate itciiing, so tiiat the complete picture resem- 
bles that of a squamous eczema. 

Sometimes, however, the disease spreads over the face 
and the rest of the body. Thickening of the skin does 
not ensue, but there is a condition of hyperemia and 
scaliness without any further changes. The patients ex- 
perience, in addition to the itching, a feeling of coldness. 

The skin loses its elasticity and is tense and drawn, so 
that ectropion of the eyelids and hindrances to mova- 
bility of the lips and extremities result. 

Gradually the hy])eremia disapj>ears, and the skin be- 
comes atrophic, paper-thin, and translucent. The sebaceous 
and sweat-gland ducts atrophy, the hair falls out, and the 



96 DISEASES OF THE SKIN. 

nails become fragile. The skin is easily injured, fissures 
occurring frequently about the joints. 

We saw in a case in the atrophic stage, at the end of 
an intercurrent internal affection, bedsores arise in spite 
of the most careful nursing. 

The treatment of this disease is wholly without re- 
sult. It may be mentioned that Kaposi observed, in a 
recent case, cure follow the internal administration of car- 
bolic acid. 

PITYRIASIS RUBRA PILARIS (DEVERQIE). 

Under this name Devergie described some time ago a 
peculiar disease ; since then, C Boeck, Besnier, and many 
others have reported similar cases and have added the 
weight of their opinion to that of Devergie. On tiie 
other hand, Kaposi contends that pityriasis rubra pilaris 
is not a disease sui generis, but is identical with lichen 
ruber acuminatus. Since we do not yet know the features 
and behavior and external differential characteristics of 
these two diseases — and indeed their external symptoms 
are very similar — the question still remains an open one. 

The above-named writei*s base their opinion upon cer- 
tain clinical points which distinguish this disease from 
lichen ruber acuminatus : 

The appearance of whitish-gray or reddish papules, 
which consist of hardened epidermis and project from 
the follicles. 

The extensor surfaces of the hand, fingers, and fore- 
arms, likewise the face, are in the beginning more fre- 
quently the seat of the disease than the trunk. 

The surface of the skin feels rough and uneven, flatten- 
ing out in the further course of the disease as the papules 
become more closely set. When this has occurrea the 
diseased skin, instead of showing pointed papules, is cov- 
ered with small scales (scalp) or with larger lamellae 
(palms and soles). The hairs sometimes break off or fall 
out, and the nails become longitudinally furrowed and 



LICHEN RUBER. 97 

broken ; both, however, do not haj^pen in all cases and 
not in like intensity. 

The atfected skin is somewhat hyperemic. In the 
beginning the skin immediately surrounding the papules 
is reddened ; later the redness spreads over large areas. 
The intiltration of the skin and the hardness to the touch 
do not reach a marked degree. 

The subjective symptoms, as itching and sensitiveness 
to pressure and touch, vary somewhat in different cases. 
The disease occurs in earlier life, spreads only slowly over 
large areas or the entire body, and disaj)pears sometimes 
spontaneously or upon the administration of arsenic. It 
recurs, however, but never leads to a fatal termination. 

LICHEN RUBER. 

According to the external appearances presented by 
this disease, two forms are recognized : Lichen ruber 
acuminatus and lichen ruber lAaiius. It must be acknowl- 
edged, however, that opinion is divided as to the identity 
of these processes. [^lany writers now consider these 
two forms as different diseases ; and, as already observed, 
some observers look upon lichen ruber acuminatus as 
identical with pityriasis rubra pilaris (Devergie). — Ed.] 

Lichen ruber acuminatus appears in the form of millet- 
seed, reddish, irregularly-scattered pa})ules which termi- 
nate in hardened, horny epidermic points. The papules 
increase rapidly in number, and form either lines or bands, 
or cover, in a period of two or three months, large plaques 
of skin ; they are especially thickly set, and contiguous in 
closely-arranged lines or in large crowded areas, on the 
flexor surfaces of the extremities, especially the upper. 

The skin of the affected areas is then uniformly red, 
thickened, and crackled. The surface is uneven, fur- 
rowed, feels dry, rough, and to the hand passing over it 
not unlike the surface of a nutmeg-grater. The crowding 
together of the papules in rows, with linear depressions or 
furrows between, gives it the appearance of shagreen 
leather, to which Hebra has aptly likened it. 

7 



98 DISEASES OF THE SKIN. 

The hairs become atrophic and foil out. The nails lose 
their brilliancy and become fragile. The palms and soles 
are the seats of markedly thickened, hardened epidermic 
accumulations, by which the movability of the hands and 
fingers is compromised. 

The patients, who from the beginning of the disease 
are troubled with severe itching night and day, grow very 
nervous and tend to become emaciated or of impaired 
nutrition. The first-described cases by Hebm ended 
fatally; but after the adoption of arsenical treatment 
which he introduced subsequent cases were cured, leav- 
ing behind atrophic lines and slightly-depressed furrows. 

Lichen ruber planus, or lichen planus (Plates 22 and 
22, a), as it is usually termed, occurs much more fre- 
quently than lichen ruber acuminatus. In this variety the 
papules appear as millet-seed- to hemp-seed-sized, and are 
elevated, flat, and waxy. At first limited to single regions, 
later the papules are found extending over larger areas or 
possibly over the entire surface. In the center of each 
lesion is a slight depression or urabilication. The earlier 
scattered lesions, by new accessions, gradually form band- 
like, linear, or dime- to dollar-sized, more elevated, dark- 
red plaques. Most lesions show firmly adherent whitish 
scales. The increase of the papules and the spread of the 
disease are seldom so rapid as with lichen ruber acumi- 
natus. The groups remain longer stationary. The invo- 
lution of the papules begins va the middle, the center of 
the patch or plaque becoming brownish in color, while 
on the border fresh bright-red lesions continue to ap- 
pear. 

The substratum of the process consists of an inflam- 
matory infiltration in the corium and papillary layer, 
which leads to the above changes in the epidermis. 

According to the degree of hyperemia, and sometimes 
also to increase in the exudation, depend the clinical ap- 
pearances. Whether, however, such varying conditions 
are ever sufficiently marked to influence or change com- 
pletely the ordinary picture of lichen is very question- 



LICHEN RUBER. 99 

able ; at all ev'ents the appearance of vesicles, for exam- 
ple, as has exceptionally been reported, is not a part of 
this disease. It is probable, and as Lassar rightly says, 
that such unusual manifestations are accidental and due 
to the arsenic administered. 

In the beginning the lesions are millet-seed-sized ; but 
they may become hemp-seed- or even pea-sized, and, ac- 
cording to their grouping, may present various pictures 
ui)on the skin. For instance, we may meet with diffused, 
red, slightly-scaly patches on the extremities, and near by 
or on the trunk scattered papules. Sometimes the lesions 
form in bands or branches or garland-like rows {lichen 
moniliformis), arranged apparently along nerve-tracts. 

On the palms and soles the disease causes thickening of 
the epidermis (tylosis palmaris et plantaris), and gives rise 
to the consequences of such accumulations — fissuring, loss 
of movability, etc. 

The mucous membrane of the cheeks and tongue may 
share in the process. We meet with such as epithelial 
accumulations in the form of white, irregularly shaped 
plaques with red, hyperemic edges. Owing to the possi- 
bility of mistaking it with other processes — syphilis, for 
exam])le — it is to be remembered that the disease may also 
a[)pcar on the genitalia. The dark-brown pigmentation, 
surrounded by fresh papules, the troublesome itching, 
and the duration of the process, sufficiently characterize 
lichen. 

The disease appears in the adult, mostly in well-nour- 
ished individuals. It is neither inherited nor contagious. 
Other skin -diseases, as, for example, eczema, may occur 
at the same time, and are sometimes produced indirectly 
by the lichen, by the attempts to gain relief from the 
itching by rubbing and scratching. The course is pro- 
tracted, but not so active or tempestuous as in lichen 
ruber acuminatus. In how far both processes diflPer from 
one another, we are not in position to say. Histologic 
investigations give no conclusion, the slight differences 
found are not sufficiently characteristic, and, moreover. 



100 DISEASES OF THE SKIN. 

we have observed cases iu wliich both forms existed along- 
side of each other. 

The very troublesome itcliing gives rise to various dis- 
comforts, as unrest by day and loss of sleep by nigiit ; the 
appetite is lessened, and when no relief is obtained the 
nutrition suifers. The patients lose their power of resist- 
ance and frequently become the subjects of intercurrent 
disease. 

The diagnosis of lichen ruber is, if a careful consid- 
eration of the above-described symptoms is given, and no 
other skin-disease temporarily masks the symptoms, not 
difficult. 

Many forms of psoriasis, especially when accomjianied 
by itching, may occasionally give rise to some confusion 
in the diagnosis. The more frequent occurrence, the 
greater participation of the extensor surfaces of the elbows 
and knees, the less infiltration of the skin, and the loosely 
adherent silvery-wliite scales, speak for psoriasis. 

Eczema squamosum will usually yield a history of pre-ex- 
isting vesicles, and eventually in its course fresh outbreaks 
of similar lesions point to this disease. Pityriasis rubra 
(Hebra) is distinguished from lichen ruber by the absence 
of infiltration, and also by the thin atrophic skin. 

The so-called psoriasis syphiliticus — papulosquamous 
syphiloderm — and the mucous patches (resembling some- 
what the mouth patches of lichen) of syphilis are associ- 
ated with other characteristic symptoms of this disease. 
The mucous patches have not the characteristic red edge 
of lichen-ruber plaques. Orbicular papules of a syphi- 
litic character about the genitalia, which bear resemblance 
to those of lichen ruber planus, are usually found with a 
history of syphilis and other symptoms of that disorder, such 
as plaques on the mucous membranes, hair-loss, glandular 
swellings, etc. In addition these syphilitic papules are 
seldom dry as are those of lichen ruber. 

Treatment. — The itching is to be treated by local 
douches, baths, and alcoholic lotions of carbolic acid, 
salicylic acid, menthol, etc. Lassar touches the eflflores- 



LICHEN SCROFULOSORUM. 101 

cences with the galvanocautery. To promote involution 
of the lesions Unna advises : 

^ Unort. zinci benzoinat., 30 (.^j) ; 

Acidi earbolici, 1.25 (gr. xx); 

Hydrargyri ehlorid. 

corros., 0.03-0.3 (gr. ss-gr. v). — M. 

Ft. unguentnm. 

Or 

I^ Acidi earbolici, 5-10 (gr. Ixxv-siiss) ; 

Hydrargyri ehlorid. 

corros., 1-5 (gr. xv-gr. Ixxv) ; 

Creosoti, 2 (gr. xxx) ; 

Collcxlii, 50 (fsxiiss). — M. 

Sig. — Al)})ly with a brush. Use with caution. 

Arsenic internally, as in lichen ruber acurainatus, is 
also valuable. 

The other recommended remedies, as potassium chlorate 
( W. Boeck), asafetida and mercurials (T. Fox), do not seem 
to have any appreciable influence upon the disease. 

LICHEN SCROFULOSORUM. 

This disease is met with in young individuals, especi- 
ally between the ages of fourteen and twenty. The skin 
of the extremities or the trunk is beset with grayish rough 
papules, which occur in bunches or scattered over large 
surfaces. It is without subjective symptoms, and the 
])atients, therefore, often carry the rough patches until 
their attention is called to them accidentally. The 
affected skin is rough and greasy to the touch, and in 
])]ace.s almost smeary ; never so dry as in ichthyosis and 
chronic eczema. The seat of the papules is in the folli- 
cles and the perifollicular tissue. The epidermic plugs 
protruding from the follicles of the sebaceous glands 
often contain a hair or are covered with small thin scak'S 
which may be easily brushed off. Not seldom, especially 



102 DISEASES OF THE SKJN. 

in badly-nourished and run-down individuals, the papules 
are brownish from the admixture of blood-pigment ; often, 
however, particularly on the lower extremities, they may 
be bluish- or even brownish-red (lichen lividus). 

In some cases inflammatory action occurs and acne- 
pustules result (acne cachecticorum). 

As already remarked, this disease is met with in pale and 
badly-nourished young persons. They not uncommonly 
show so-called scrofulous swellings in the glands of the 
neck, or may show fistulous purulent tracts. Impover- 
ished circumstances and lack of care lead to other dis- 
eases of the skin, as, for example, to eczema around about 
the suppurating glands or about the genitalia ; further, to 
pustules, ecthyma, and furuncles, which, however, are to 
be considered accidental, and not necessarily part of the 
symptoms of lichen scrofulosorum. 

Treatment. — The chief consideration is the general 
treatment, which has for its object improving the nutrition 
with tonics, such as iron, arsenic, cod-liver oil with phos- 
phorus, iodin, change of scene, etc. Locally, according 
to the practice of Vidal and Hebra, the affected areas are 
rubbed with cod-liver oil. 

KERATOSIS PILARIS (LICHEN PILARIS). 

This is a disease (Plate 38) frequently seen upon the 
extensor surfaces of the lower and upper extremities, 
characterized by the presence of pale-red papules sur- 
mounted with epidermic scales. After removal of the 
epidermic scales a rolled-up lanugo-hair is observed. 
The parts have a goose-flesh appearance, and may be 
considered physiologic in the period of puberty [? — Ed.] ; 
similar papules are also seen in ichthyosis. In this latter 
disease the condition may be more or less universal. 

ECZEMA. 

This widespread and therefore important disease is an 
inflammatory affection of the skin, accompanied by the 



ECZEMA. ' 103 

subjective symptoms of itching and burning. Many dif- 
ferent clinical pictures are presented in eczema, so much 
so that formerly these several varieties or manifestations 
were considered ditferent diseases ; Hebra proved, how- 
ever, that the various phases and clinical pictures really 
expressed but one disease. The disease may be acute or 
chronic. 

Acute ecijema begins with the appearance of irregu- 
larly scattered red pa})ules [eczema papillosum), which 
give rise to troublesome itching. The papules may retro- 
gress, the redness disap[)earing and a superficial epidermal 
exfoliation taking place. Fre(piently, however, through 
intensity of the inflammatory process, these lesions change 
rapidly into vesicles [eczema veaiculosum). 

If the intensity of the process continues, there arise 
numerous millet-seed-sized to lentil-sized vesicles and 
small blebs (the latter rarely). In the beginning or earli- 
est stages these lesions have serous contents, which soon, 
from the admixture of cell-elements, become milky and 
even purulent [eczema pustulosvm). The overlying epi- 
dermis is either broken by scrat* hing or is rubbed off, and 
the red surface exudes a liquid secretion. 

Sometimes the lesions dry to yellowish crusts, which 
when mixed with blood, which sometimes exudes from 
the hyperemic rete or results from scratching, give rise 
to brownish or even blackish crusts (eczema crustomm). 
Very rarely, and then only as a consequence of violent 
scratching, is any loss of substance noticed beneath the 
crusts, so that when the process has run its course and 
healing has taken place by a regeneration of the epider- 
mis, no scarring remains. 

Frequently, also, acute eczema appears as a diffused 
redness and swelling [eczema erythematosum). In many 
of these cases, on passing the finger over such affected 
areas, one may be able to detect slight, scarcely percepti- 
ble elevations or irregularities, from which vesicles may 
develop. 

The patient first feels a sensation of tenseness in the 



104 DISEASES OF THE SKIN. 

affected areas, which soon changes to intense bnrning and 
itching. The vesicles become confluent, new outbreaks 
rapidly taking place ; the part is soon deprived of its epi- 
derra, and there appears a reddened, oozing surface, the 
base of which consists of the rete Malpighii and papil- 
lary layer. The profuse secretion mixes with the epi- 
dermic cast-oif cells and becomes thereby thicker and more 
smeary [eczema madidans, eczema rubnim). If the affected 
areas are not confluent, or if the intensity of the process 
and the consequent secretion subside, the parts become 
covered with extensive yellowish translucent lamellae, 
which crack, and through such fissures underlying col- 
lected liquid oozes out (Plates 23 and 23, a). 

If the hyperemia, and with it the swelling, subsides, 
the secretion likewise correspondingly lessens ; the epi- 
dermis begins to re-form, and the epidermic cells lie upon 
the still reddened, infiltrated skin as loosely attached scales 
(eczema squamosum). This scaly condition may persist for 
some time or rapidly disappear, and a normal condition 
be re-established. 

As already stated, all stages of acute eczema may pass 
directly and rapidly to cure. More frequently, however, 
we observe that the papular or vesicular stages change 
into the squamous stage or variety. Often we meet with a 
squamous type on one part of the body, on another a 
crusted form ; this is especially noticeable in universal 
eczema and in recurrent or relapsing forms. 

As a peculiarity of eczema, it may be mentioned that 
often a long-continued mild eczema, to which the patient 
gives but little thought, without recognizable cause de- 
velops into acute eczema on distant situations. Many 
authors (Kaposi) look upon such as due to vasomotor 
neurosis ; but this itself must have a foundation. Many 
individuals have at certain seasons of the year an unmis- 
takable disposition to eczema, and even after freedom for 
a number of years the old trouble returns. 

Acute eczema, fortunately, is rarely encountered as a 
generalized disease ; but it produces a severe, sometimes 



ECZEMA. 105 

dangerous condition when it involves the whole surface 
in various degrees of severity. Some parts of the body, 
as the face, the genitalia, and the hands, are markedly 
swollen, and the patients experience tension, burning, and 
itching, which, with the accompanying fever and systemic 
disturbance, are very troublesome. The clothing adheres 
to tile oozing places and causes further irritation ; the 
patients find no relief or rest and lose sleep. They com- 
plain of weakness, loss of appetite, and frequently chilli- 
ness ; and these conditions, together with imperfect nour- 
ishment and by loss of the blood-plasma, may lead to a 
grave issue. [Such extreme cases must, however, be rare, 
and it is even questionable in those instances whetiier the 
disease is not complicated or other than eczematous. — Ed.] 

The duration of universal eczema is uncertain, since 
after subsidence of the acute stage it only partly dis- 
appears, remaining on several parts as chronic eczema. 

Of the localized forms of acute eczema, the most 
frequent is eczema of the hands, these parts being the 
most exposed to external irritating agencies. It apj)ears 
with swelling of the back of the hand and fingers, which 
sometimes extends up the forearm. The hard and thick 
epidermis of the palms is slowly cast off. Frequently 
painful fissures (rhagades) arise, and sf>metimes the sur- 
face around the nails becomes raw looking, with at times 
granulation-tissue formation, so that for a considerable 
time the patient is unfitted for using the hands. The 
same appearances and conditions obtain with acute ec- 
zema about the feet, only on these parts the disease is 
much less common. 

The face is a frequent site for acute eczema (Plate 24). 
Marked swelling of the eyelids, cheeks, nose, lips, and 
even the ears is noted, and gives rise to a feeling of 
tenseness. Not infrequently eczema of this part is 
mistaken for erysipelas faciei. This latter, however, is 
wanting in papules, vesicles, and pustules, and consists 
of a diffused firm infiltration, usually with sharply-defined 
borders, with tenderness and continued high fever. It 



106 DISEASES OF THE SKIN. 

is, unfortunately, seldom that the eruption on all parts in 
acute eczema of the face so completely disappears that 
there is but slight prospect of recurrence or relapse; the 
simultaneous involvement of the ear-lobes Avith the face 
is especially unfavorable for such outlook. An uncom- 
fortable result or consequence of acute eczema is the 
dryness and brittleness of the skin, which in spite of 
apparent cure remain and give rise apparently to recur- 
rence. 

Acute eczema of the, genitalia occurs more frequently in 
men, and is accompanied by great edema and swelling of 
the penis and scrotum. It begins with a feeling of weight 
and tenseness, and obliges the patient to seek rest in tiie 
recumbent posture. Soon the skin of the affected parts 
becomes inflamed and fissured ; " there is also abundant 
oozing, which adds to the patient's discomfort, inasmuch 
as crusts form which crack or are more or less torn by 
the scratching and rubbing and cause painful burning. In 
women the disease usually first affects the labia, and then 
rapidly involves the genitocrural folds, and sometimes 
spreads down the thighs. 

Eczema intertrigo is not uncommon, and may involve 
considerable surface; it is accompanied with a scanty 
secretion and with constant casting off of the epidermic 
cells, which together constitute a greasy covering over the 
reddened corium. The process is most frequently ob- 
served on contiguous surfaces, as the anal fold, under 
the breasts, in the flexures of the legs and arms, and in 
many other regions in fat children and corpulent adults. 

Chronic Kczema. — Morphologically chronic eczema 
is but slightly different from acute eczema. Clinically, 
however, there are many points of difference in the course 
of the affection which distinguish the chronic process from 
the acute. Chronic eczema arises either in the wake of 
a rapid incomplete involution of the acute disease, as 
already stated, or an acute eczema gradually becomes less 
and less marked and passes almost imperceptibly into the 
chronic process. 



ECZEMA. 107 

The chief forms of chronic eczema are the oozing 
(eczema madidans, eczema rubrum) and tlie scaly types. 
Although sometimes papules and vesicles of a markedly 
inflammatory character may be noted from time to time, 
the chronic type is characterized essentially by persist- 
ence, frequent recurrences, obstinacy, and rebelliousness. 
To these characteristics may also be added consecu- 
tive changes which are brought about by the chronic 
disease : Brittleuess and vulnerability of the skin, dis- 
position to branny scaliness, scurfiness, and finally the 
painful fissures which usually appear in the flexures and 
about the joints. As a further result of the chronic dis- 
ease may be mentioned an increase in the pigmentation 
of the affected regions, sometimes thickening of the epi- 
dermis, thickening of the corium, and increased connec- 
tive-tissue growtli. These latter may under certain cir- 
cumstances, especially when involving the lower leg, 
almost approach an elephantiasic condition in appear- 
ance. 

Among the subjective symptoms stands, first of all, 
the intense itching, which is the source of so great dis- 
tress to patients that they continually rub and scratch, 
both when clad and unclad. 

It is rare that chronic eczema involves the entire sur- 
face ; as a rule, only certain parts are predisposed to it. 
There are several places of predilection : 

Chronic pustular eczema of the scalp, frequently asso- 
ciated with eczema of the ear-muscles and the face. The 
scalp is covered with broken-up yellowish or yellowish- 
green, frequently brownish crusts. Here and there in the 
hair are found cast-off or rubbed-off fragments of crusts, 
and in some cases also lice and nits. On removing the 
crusts from the underlying skin the latter is seen to be 
red, oozing, and deprived of its epidermal covering. The 
hairs become matted or project irregularly through the 
crusts. This condition is not infrequently seen in women 
and children as a result of pediculosis capitis. These 
parasites may be primary (the eczema resulting) or they 



108 DISEASES OF THE SKIN. 

may be secondary. The children have, moreover, fre- 
quently swelling of the cervical glands, whicli the mother 
is apt to look upon as scrofulous. If this condition of 
pediculosis is neglected, and to it added extraneous dirt 
and filth, the hairs become tangled in masses or into long, 
thin bunches {plica Polonica). 

Chronic eczema of the face seldom involves this whole 
region ; usually only certain parts, such as the mouth, lips, 
ears, eyebrows, and eyelids. 

A special variety of eczema of the face is observed in 
infants, in which the face and ears are covered with crusts 
{crusta lactea). The ears, cheeks, and brow are most com- 
monly the seat of this troublesome and itchy affection. 

Eczema of the lips, which often occurs in association 
with eczema of the nose, leads to thickening of the bor- 
der, and often of the entire lip, with fissuring of the ver- 
milion ; even after complete healing of the lesions the lips 
may remain permanently enlarged, with linear cicatricial 
or atrophic furrows. 

Eczema of the genitalia and anal furrou' leads to many 
consequences, brought about by the itching and scratching : 
Thickening of the skin, growth of the chronically in- 
flamed furrows, etc. 

It remains to mention eczema of the flexures of the ex- 
tremities, of the nipples, of the mamnise, and of the navel, 
which presents symptoms in no respect diflerent from the 
disease in other parts. 

The occupation of many individuals provokes eczema 
of the hands, fingers, and even the finger-nails (trade- 
eczemas). Those eruptions are not only characterized by 
vesicles and pustules, but the epidermis of the palms 
and of the fingers is thickened, brittle, and fissured, so 
that the many places deprived of their epidermis render 
it painful for the patient to work. A similar condition of 
afliiirs, in somewhat less degree, occurs also on the feet. 

We have yet to refer to certain eczematous eruptions 
known as impetixjo faciei contagiosa or par asitaria. Blebs, 
crusts, and scab-formations, either in large confluent areas 



ECZEMA. 109 

or in groups, are noted, whidi may be surrounded with 
scattered red follicular elevations. Although it is not yet 
positively proved, nor the causative fungus found, yet the 
apparent spread of the disease from one to another — its easy 
auto-ino(!ulation — makes its contagiousness probable. We 
have seen such eruptions in young persons, occurring in 
patches and groups on the face and neck, on the breast, 
and even on the forearm (Plates 27, 28, and 28, a). [Many 
of these cases (not those pictured) are considered by nu- 
merous writers as examples of a distinct disease — impetigo 
contagiosa. — Ed.] 

In conclusion, we will make mention of eczema margi- 
natum (Hebra), as a special form of eczema. It appears 
in palm-sized areas, confluent circles, and elli])ses, which 
show vesicles on their borders ; the central parts being 
either covered with scabs and scales, or, if of long dura- 
tion, showing a somewhat dark pigmented skin. The 
sites chiefly aifected are the inner thighs and the genitalia. 
A variety in its beginning or early stage is shown in Plate 
26. [This is again referred to under the head of ring- 
worm. — Ed.] 

The so-called eczema seborrhoicum Unna has considered 
a disease sui (/eneris. This develops, as a rule, from a slight 
and unnoticed seborrhea of the hairy scalp. Marked aggra- 
vations, such as hair-loss, increased collection of scales and 
crusts, intense itching or oozing, lead the patient to seek 
medical aid. From the scalp proper the disease spreads to 
the forehead and temples, with a sharply-defined border 
which is sometimes quite red and is covered with yellow- 
ish, greasy scales ; the disease not infrequently also invades 
the ears and neck. Unna recognizes three varieties of 
eczema seborrhoicum — the scaly, the cnisted, and the 
oozing. 

In addition to the regions already named as the common 
sites of this manifestation (eczema seborrhoicum), the dis- 
ease may also attack independently, or, more commonly, 
conjointly, the sternal region, where roundish or oval 
patches [seborrhoea corporis of Duhring. — Ed.], finger- 



110 DISEASES OF THE SKIN. 

nail in size, appear singly or in gronps, each spot of yel- 
lowish color with a narrow red border ; the axillse, where 
the affection may present a red, serpiginous, advancing 
line; the flexures of the upper extremities, the dorsal 
surfaces of the hands, the buttocks, the hips, the anal 
region, and the genitocrural folds. 

The affection is to be differentiated from other eczemas 
and from psoriasis. Of special value in the differentiation 
are the spread from above down, the history of a pre- 
existing seborrheic affection of the scalp, and the peculiar 
appearances of the individual patches or efflorescences. 

Therapeutically, Unna recommends especially sulphur, 
in combination with zinc oxid in the oozing form ; for the 
crusted and scaly varieties chrysarobin, pyrogidlol, and 
resorcin have proved of value. [These several remedies 
are employed in the manner advised under seborrhea and 
psoriasis, but weaker. Chrysarobin, if employed, should 
be used cautiously. — Ed.] Internal medication in this 
disease seems without influence. 

Diagnosis of Bcijema. — When the symptoms are 
considered, it will be seen that acute eczema is scarcely to 
be confounded with any other skin-disease ; at the most, 
the acute face-eczema with erysipelas already mentioned, 
the differential points of which have been pointed out. 

Chronic eczema, on the contrary, may, when of long 
duration and from its tendency to scaliness, be confounded 
with psoriasis and with lichen ruber planus. It is ^o be 
remembered that chronic eczema often has its beginning in 
the acute type — that is, there is an entirely different his- 
tory from that of the other diseases named ; and that on 
one or more regions outbreaks of an acute character may 
occur from time to time which are quite diagnostic. 
Eczema is, moreover, chiefly an affection of the epidermis 
and rete, and is distinguished from psoriasis in that it 
does not appear in numerous, uniform plaques as does 
the latter. In lichen planus the papules arise from infil- 
tration of the skin, with less scaliness in disaj)pearing, 
and never present an oozing surface. The subjective 



ECZEMA. Ill 

symptom — namely, itcliing — occurs always in eczema, 
seldom in psoriasis, but frequently, however, in lielien. 

Prurigo, ichthyosis, lupus erythematosus, tinea ton- 
surans and circinata, and favus can scarcely be confounded 
with eczema. On the other hand, however, a combina- 
tion of one or several of these diseases with eczema is not 
a rarity. 

The causes are divided into two classes : One com- 
prises those cases in which the disease seems to have been 
excited by external irritants — external causes ; the other, 
those cases which iiave been called forth by some general 
disturbance of the whole organism — internal causes — 
symptomatic eczema. 

By for the more frequent are the first named — mechan- 
ical, thermal, and chemic irritation. By eczema due to 
mechanical irritants we mean those cases brought about by 
pressure or rubbing, especially if the skin had been pre- 
viously subjected to heat or irritated in any way. In 
such instances the constant rubbing of the clothing and 
the pressure and irritation of bandages suffice to call forth 
mild forms of the disease. In this connection also should 
be mentioned those diseases in which itching is a prom- 
inent symptom, and necessarily gives rise to rubbing and 
scratching, and resulting eczema : Lousiness, scabies, pru- 
rigo, pruritus cutaneus, urticaria, lichen ruber, ichthyosis, 
and pemphigus pruriginosus. Among the mechanical 
causes belong also circulatory sluggishness or conges- 
tion due to varicose veins in the lower extremities, 
especially the lower part of the leg, and sometimes 
the scrotum. The itching induce<l by the congestion or 
blood-stagnation causes the ])atient to rub and scratch. 
The epidermis, thinned by frequent hemorrhage or by 
exudation in the cutis, is easily injured. The repeated 
eczematous outbreaks give rise to new inflammations and 
changes ; the subcutaneous tissue grows, is thickened ; 
the blood- and lymph-vessels are in part dilated, partly 
new formation ; many anastomoses of these (varicosities) 
arise anew ; the connective tissue immediately surround- 



112 DISEASES OF THE SKIN. 

ing these becomes thickened and increases ; with time- it 
becomes still more marked, more or less sclerosed ; the 
affected part increases in volume, and we have the picture 
of elephantiasis. 

Thermal irritation, as, for example, in boiler-makers, 
often leads to diffused inflammatory disturbances either 
of the hands, face, or breast-region [eczema ealoricum), in 
which there is marked vesicle- and bleb-formation. The 
heat of the sun {eczema solare), as, for example, in rowers 
and bathers, calls forth, for the most part, papular ec- 
zemas. 

Frequently we see in long-continued sweating a minute 
papular or vesicular eruption (eczema sudamen). The 
profuse sweat-secretion collects either in the ducts of the 
sweat-glands, lifting up the epidermis, or, also in addition 
to this, by serous oozing out of the papillary vessels and 
collecting in the epidermic layer. The rubbing of the 
clothing or the rubbing and maceration of contiguous 
surfaces add to the condition and lead, in the further 
course of the disease, often to true eczema. 

Finally, as to the numerous chemic irritants, as, for 
example, arnica tincture, which is a popular remedy for 
wounds and injuries ; the resins, as turpentine, a constit- 
uent of various plasters, and which is also used by many 
persons in their work, as painters, printers ; many medic- 
inal substances, as croton oil, cantharides, mustard, iodo- 
form, sulphur, carbolic acid, corrosive sublimate, old mer- 
curial salves, potash solutions, lye, soaps (owing to the 
excess of free alkali), particularly in washerwomen ; and 
macerating poultices of cold water, or as a result of cold- 
water cures (the cutaneous irritations formerly looked 
uix)n as "critical" eruptions) (Plates 14, 24, and 25). 

The symptomatic eczemas residt from various diseases 
which involve the organism and engender in the skin a 
state of irritation or vulnerability. It is especially in those 
general states of the health which bring about depressed 
nutrition and reduce the individual power of resistance, 
that the skin is responsive to the slightest irritation. 



ECZEMA. 113 

In this class belong scrofiilosis, racliitis, diabetes, gout, 
excessive corpulence, and the various anemic and dys- 
peptic conditions whi(th especially dispose the peripheral 
parts of the body (head, hands) temporarily to eczematous 
outbreaks. 

Course and Prognosis. — Concerning tlie course of 
acute eczema there is but little to say. The slight, local- 
ized acute forms disappear in two to four weeks. On 
the contrary, generalized acute eczema terminates for the 
most part, at least in certain regions, in the clironic form. 

The course of the chronic form depends upon the 
causes wliich have provoked the disease and upon the 
changes which have been brought about by it, such as 
thickening of the skin, fissures, etc. Chronic eczema is 
not infrequently associated with furunculosis, the latter 
dependent doubtless u[)on the scratching and the con- 
sequent ready inoculation by the cocci. 

As troublesome and obstinate as eczema is, nevertheless 
one can say, in general, to the patient that recovery is 
probable. If the cause disappears or is modified, or if 
the patient avoids the exciting factors, very often slight 
local tiierapy will suffice to remove the disease. 

Eczema heals without leaving any traces worthy of men- 
tion ; at the most, here and there some slight pigmenta- 
tion or insignificant thickening of the skin. As it is par 
excellence a disease of the epidermal layer, no scarring, 
even in the pustular form of the disease, is left ; and 
should sucli be observed, is due to accidental causes. 
Syphilitics, in order to conceal the fact that they have had 
syphilis, occasionally state that they have suffered from 
eczema which had been preceded by nerve or organic dis- 
ease ; such a statement, however, is not to be believed if 
an examination discloses scar-formation occurring in 
groups and pointing to a pre-existing syphilitic manifes- 
tation which had disappeared spontaneously or as the 
result of treatment. 

Internal Treatment. — Especially by the French 
writers, in all cases of acute and chronic eczema extensive 



114 DISEASES OF THE SKIN. 

dietetic directions and a number of internal remedies are 
recommended. Up to the present, however, ])roof is 
wanting that all cases are in reality dependent upon con- 
stitutional causes, diathesis, etc. ; the probabilities, on the 
contrary, are rather against such acceptance. The con- 
stitutional treatment will therefore be limited to those 
cases in which there is some disease or functional dis- 
turbance of some other organ, as the possibility of some 
connection between the skin-disease and such may exist. 
A persistent anemia is to be treated by appropriate reme- 
dies ; and in cases of diabetes, nephritis, uric-acid diathe- 
sis, oxaluria, the proper dietetic directions should bo given 
and alkalies, diuretics, etc. ordered. It must be admitted 
that better results are to be obtained when attention is 
also given to the general health than when treatment is 
directed to the skin alone. In fact, for successful treat- 
ment each individual case demands careful study. 

External Treatment. — (a) Acute Eczema. — In 
eczema intertrigo and papulosum dusting-powders, such 
as starch, talc, or this combination : 

^ Amyli oryzae, 100 (.siij) ; 

Zinci oxidi, 
Pulv. iridis florent., da 5 (gr. Ixxv). — M. 

Sig. — Dusting-powder. 

When the inflammatory symptoms are of high grade 
ice-cold poultices, aluminum acetate, poultices of 2 per 
cent, resorcin solutions, 2 to 5 per cent, tumenol solutions 
(Neisser), and similar applications are to be recommended. 

If itching is troublesome, it can be moderated or con- 
trolled by applications of alcoholic solutions (^2 per 
cent.) of carbolic acid, salicylic acid, with subsequent 
powdering, and finally with weak tar-applications. Most 
authors advise against the application of tar so long as 
oozing is present; but Lassar, on the contrary, sees no 
contraindication to its employment in such cases. 

In the crusted stage or forms of the disease the soften- 



PRURIGO. 115 

ing salves and oils arc especially useful, especially that 
sovereign remedy, the unguentuni diachyli Hebrse. In 
persistent scaly forms salves applied as plasters, such as 
vaselin, unguent, aqua? rosae, unguent, zinci oxidi, ung. 
Wilsoni, Lassar's paste, unguent, caseini, with or without 
other medication, and cooling salves (Unna) : 

Bf, Lanolini, 10(3iiss); 

Adipis benzoinat., 20 (,^v) ; 

Aqua; rosae, 30 (sviiss). — M. 
Ft. ungueutum. 

1^ Lanolini, 

Zinci oxidi, 

Olei olivffi, equal parts (I hie). — M. 

Ft. unguentura. 

I^ Zinci oxidi, 

Amyli, 

Lanolini, 

Ol. olivse, equal parts (Berliner). — M. 

Ft. unguentum. 

(6) Chronic Eczema. — In addition to the various 
local remedies mentioned above are to be commended soft- 
ening salves, salicylated soap-plasters, and rubber fabric. 
In those cases of considerable thickening and epidermic 
accumulation in which tar fails to soften and relieve, 
strengthen the tar by the addition of sapo viridis (equal 
parts) and carbolic acid. Eventually, /?-naphthol salve, 
pyrogallic-acid salve, chrysarobin salve (1 : 10— i : 50 vase- 
lin) ; cauterizations with caustic potash solutions of vary- 
ing proportions, 10 to 50 per cent. 

PRURIGO. 

Prurigo (Plate 29) is a chronic and extremely trouble- 
some disease, persisting, by frequent and repeated recur- 
rences and relapses or continuously with exacerbations, 



116 DISEASES OF THE SKIN. 

throughout life. The accidental secondary lesions of the 
skin are more conspicuous than its own pathologic prod- 
ucts. The disease begins in childhood, in the first or 
second year of life, with outbreaks of intensely itchy 
hives. The wheals and scratch-marks may be made to 
disappear by means of baths and care of the skin ; but 
soon recur. The wheals rej)eatedly make their appear- 
ance, finally resulting in the formation of papules. These 
are pin-head in size, pale or pale red, and itch intensely, 
so that they are not infrequently observed covered with 
blood-crusts. Their sites of predilection are the extensor 
aspect of the lower leg, the thighs, the sacral and gluteal 
regions, and the extensor surface of the arms, both upper 
and lower parts. These prurigo-papules are scarcely ele- 
vatefl above the level of the skin ; only by persistent 
rubbing do they become prominent. When scratched 
open they become depressed and a blood-crust marks the 
site ; this disappears and leaves behind a white scar or 
speck. The flexures of the knees, groins, and elbows, like- 
wise the face, are usually uninvolved, and are soft, white, 
and moist, so long at least as they remain free from 
eczematous manifestations, which in severe cases are often 
associated or result from the persistent irritation and 
scratching. 

The milder grade of prurigo is often without striking 
or urgent subjective annoyances, in consequence of which 
it may lack the resulting secondary phenomena. This 
type may, by frequent baths and great care of the skin, 
in individuals favorably circumstanced, be kept stationary 
and eventually cured. In many such cases outbreaks are 
often limited to the lower leg and thigh, and at the most 
appear only in winter and for a short time. 

These milder types of the disease are usually desig- 
nated prurigo mitts, in contradistinction to the severe 
forms — prurigo agria or prurigo ferox. In the latter 
variety of the disease the outbreaks of prurigo-papules 
are so numerous and the consequent itching so intense 
that the patient is obliged to be constantly rubbing and 



FBUniGO. 117 

scratching. The skin becomes covered with roundish and 
linear, brownish, dry blood-crusts, which may be sur- 
rounded by an inflamed red or purulent areola. Near 
by are also to be seen recent red or older white scars. 
Owing to the repeated cutaneous outbreaks, and the re- 
sulting hyperemia and persistent scratching in trying to 
obtain relief, the skin becomes more or less pigmented, 
is noted to be hard, rough, and board-like, and can 
scarcely be lifted in folds. In severe cases the lanugo- 
hairs are wanting, or here and there are broken off or pulled 
out by the constant scratching. Especially about the 
knees and ankle-joints the skin is thickened and shows 
deep furrows. The intense irritation of the skin, added 
to by the constant scratching, produces infection and leads 
to chronic inflammation of the lymphatic glands, more 
particularly of the femoral, inguinal, and axillary glands. 
The patients are troubled night aud day by the itching, 
look pale and badly nourished, and are often looked 
upon by their associates as suspiciously scabietic and 
are avoided. 

This disease disposes the affected individual to eczema, 
which may attack the few free })laces in the flexures of 
the joints and on the face. Besides, pustules and ecthy- 
mata on the extremities are not uncommon complications 
or additions. 

The diagnosis of prurigo, when the disease is not 
complicated or masked by a coexisting eczema or scabies, 
is not difficult, the characteristic symptoms already de- 
scribed, the localities affected, and its course furnishing 
sufficiently characteristic points : excepting from this state- 
ment the earliest stages, when the disease usually presents 
solely urticarial symptoms. 

Etiologically there can be recognized but one positive 
factor, and that is heredity, inasmuch as it is often ob- 
served that several children in one family are affected. 

Treatment. — Prurigo-patients are, as a rule, weakly, 
and are slow in development and ill-nourished, and for 
these reasons an effort should be made to build up the 



118 DISEASES OF THE SKIN. 

general health. Internal medication (carbolic acid, men- 
thol) is M'ithout direct effect on the skin ; but as support- 
ing and alterative remedies may be mentioned cod-liver 
oil alone or with iodin (iodin, 0.10 (gr. iss) ; cod-liver oil, 
100 (siij), one or two teaspoonfuls, t. d.), and phosphorus, 
as in the following : 

1^ Ol. morrhujB, 30 (f §j) ; 

Phosphori, 0.01 (gr. ■^) ; 

Acacise, 

Sacchar. alb., da 1 5 (sss) ; 

Aq. dest, 40 ( f .^j sij). 

Sig. — One to four teaspoonsful, t. d. 

Of external applications, tar deserves most prominent 
mention, applied thoroughly ; sulphur (Vleminckx's solu- 
tion (liquor calc. sulphuratse), sulphur salves) ; Wilkin- 
son's ointment (a course of ten to twelve rubbings) ; 
^-naphthol (5 per cent, salve in courses of four rubbings, 
and after each course a bath). In addition, sweat-baths 
(hot baths followed by hot pack) ; subcutaneous injections 
of pilocarpin, 0.01 (gr. t^) each dose; internally jaborandi- 
leaves as infusion, 4 : 100 ; and sulphur baths. 

Murray and Hatschek recommend massage of the af- 
fected skin, which is said to have a remarkably favorable 
influence upon the itching. 

NEUROSES. 

In the descriptions of some of the preceding diseases 
reference was made to the fact that they originated from 
or were influenced or modified by irritation of the nerves ; 
diseases which might well be termed trophoneuroses. It 
is our purpose, however, to consider here the cases which 
belong strictly to the neurotic class, in which itching is 
the essential symptom ; those disturbances of sensibility 
which are not associated with any external cause and 
without primary anatomic changes of the skin. This 
may be present in mild or severe degree. 



NEUROSES. 119 

PrtllittlS. — The extreme sensibility or irritability of 
the skin characterizes itself by itching — pruritus cutaneus, 
pruritus. This affection may occur as pruritus universalis 
or pruritus localis. The patient suffers from attacks of 
violent itching of the skin, so extreme in its intensity 
that he cannot withstand the desire to rub and scratch, 
nor usually stop till the skin is reddened or excoriated, 
and some parts scratched open and bleeding. The itch- 
ing is usually then replaced by a feeling of burning, and 
the patient feels weak or exhausted by the effort and the 
suffering. The attacks are most common in the evening, 
especially when undressing, and through the night, so 
that often sleep is broken or fitful. The skin shows dif- 
fuse redness, or at the most urticarial wheals near the 
blood-crusted excoriations ; it is frequently found dry, is 
seldom moist, and after long duration of the disease 
brownish colored. The sweat-secretion is mostly limited 
to the joint-flexures. In young individuals disturbances 
of digestion are noted, and in women disturbances of the 
sexual organs are often associated with the cutaneous 
affection. Mental emotions may also have an influence 
in promoting cutaneous pruritus. 

Of troublesome nature is the pruritus of those advanced 
in years — pruritus cutaneus senilis — which may persist to 
the end of life. Prnritus due to other causes than ad- 
vanced age may be benefited and relieved ; and even the 
pruritus of senility may often be ameliorated and occa- 
sionally temporarily or permanently controlled. 

The diagnosis is not always possible upon first sight. 
One must carefully consider the various dermatoses of 
which pruritus may be a symptom ; also the possible 
presence of parasites must be excluded. 

Treatment. — In the treatment of pruritus the possi- 
bility that certain diseases may through noxious influence 
be causative must be considered : Diabetes, gout, stomach 
and intestinal disease, liver-affections, and disease of the 
genito-urinary apparatus in women. If any one of these 
causes is found to be operative, then the treatment must be 



120 DISEASES OF THE SKIN. 

directed toward its removal ; or, if this is not possible, 
then toward its modification. 

The remedies, both internal and external, which have 
been recommended for the treatment of this disease are 
very numerous. We name as the first in importance in 
the constitutional treatment, sodium salicylate ; also, atro- 
pin, qurnin, pilocarpin, tinctura gelsemii. Externally 
baths and douches are recommended ; in many cases a 
low temperature of the water, in others a high temperature, 
seems to be more valuable. Of the external remedies 
controlling the itching, which may be applied as lotions or 
salves, are the following : Carbolic acid, salicylic acid, 
ichthyol, naphthol, tarj chloral hydrate, camphor, men- 
thol, thymol, etc. 

The following prescriptions may be given : 

T^ Acidi carbolici, 4 (sj) ; 

Aceti aromat., 200 (fsvj). 

Sig. — Two tablespoon sful to a quart of warm water ; to 
be applied daily, and after it dries on the follow- 
ing powder to be dusted over : 

^ Bismuthi salicylat., 20 (sv) ; 

Amyli, * 80 (^iiss). 

Or the following lotion may be used : 

Hydrarg. chloridi corros., 0.03-0.3 (gr. ss-gr. ivss) ; 
Ammonii chlorid., 0.12-0.5 (gr. ij-gr. viiss) • 

Acidi carbolici, 4 (sj) ; 

Glycerin i, 60 (f.^j 3vij); 

Aquse rosae, 120 (f.^iij oN'j). 

Sig. — Apply morning and evening. 

Or the following : 

I|* Chloral, hydrat., 

CamphoRB, 

Acidi carbolici, 

Glycerini, equal parts. 

Sig. — ^Apply morning and evening. Use with caution. 



CALLOSITAS. 121 

The most frequent pruritus limited to a region is pru- 
ritus pudendorum. The external genitalia and fre- 
quently also the vulva? (pruritus vulvae) are attacked 
by intense itching, and the mechanical irritation pro- 
duced by attempts to gain relief results in thickening, 
hypertrophy, and catarrhal affections of the mucous mem- 
brane. 

In men, mostly in those of advancing years, the itching 
may be limited to the scrotum (pruritus scroti) and 
perineum, and leads quickly to eczema and the above- 
mentioned changes. Sometimes the urethral orifice, the 
urethra itself, and the anal crease are also affected. Pru- 
ritus ani is frequently associated with the various diseases 
of the rectum, as hemorrhoids, fissures, etc. 

Treatment. — In these various local forms of pruritus 
attention is always to be given to the possibility of its 
being due to the various diseases named (hemorrhoids, 
Oxyuris vermicularis, fissures, endometritis, malpositions 
of the uterus, etc.). The remedies already mentioned in 
the treatment of general pruritus are also to be advised in 
the treatment of the local forms. 

Anesthesia of the skin we have almost always 
observed circumscribed in character. It results from 
some disturbance of the nerve-branches or from disturb- 
ance of the central nervous system. Two forms are 
recognized — one in which the anesthesia is to temperature 
and the otlier to the touch. Complete disappearance of 
the sensibility of extensive areas is sometimes noticed, as, 
for example, in lepra anaesthetica. 

ANOMALIES OF THE EPIDERMIS. 

CALLOSITAS. 

The epidermis is often produced in excessive quantity, 
and is cast off in small scales or large lamellae ; or the 
horny cells remain and result in thickening and callosities. 
Callositas (tyloma, callus) is a thickening and harden- 
ing of the epidermic layers, which may become several 



122 DISEASES OF THE SfCTN. 

millimeters thick. The form of these thickenings depends 
somewhat upon the character and extent of the pressure 
which has called them into existence. The sensibility in 
the part is more or less lost ; and by continued action of 
the cause the underlying parts may become inflamed in 
the corium, and the mass is cast oif with an undermining 
of serous and sometimes hemorrhagic exudation. In those 
callous accumulations which form on the flexures of the 
joints of the fingers painful cracks often result (Plate 40). 

CLAVUS. 

Clavus, or corn, is a' horny accumulation with a cone- 
shaped core or hard center, which is pressed into the cutis, 
the apex downward. The formation originally consists 
of concentric layers of cells heaped one upon the other, 
lies in a sweat-gland duct, and presses upon the cutis, 
and may thus cause disappearance of the underlying 
papillae. 

CORNU CUTANEUM. 

Cornu cutaneum, or cutaneous horn, takes its origin 
from the surface of the skin, from apparently fibrous 
tissue, and is observed on the scalp, on the brow, and on 
the prepuce ; more frequently in the female sex and in 
advanced years. The horns are for the most part spiral 
and bent, wider at the base, and of a dirty-brown color. 
Treatment consists in operative removal of the growth 
together with the underlying base. 

VERRUCA. 

Verruca, or ipart% are flat, variously elevated, project- 
ing growths of the skin ; they are not sensitive and are sel- 
dom smooth, but mostly have a cleft, rugous, dark-gray 
surface. They con.^ist of considerably enlarged papillae 
and an increased and hardened epidermis. 

The favorite sites are the hands and face, less frequently 
the hairy scalp ; it is not uncommon for several to be in 



ICHTHYOSIS. 123 

lose proximity. It is rarelv possible to assign a cause 
:" >r their appearance ; in some cases a persistent irritation 
>{ the skin seems a possible ^ctor. They sooner or later 
lisappear spontaneously ; or new ones continue to appear, 
-Inirly or more numerously. Sometimes they appear at 
eriphery of a group, the central older grL>\rths under- 
_ involution, and in this manner forming irregularly 
■ircular areas. 

Ordinarily, warts are merely a disfigurement and occa- 
sion no discomfort ; but they may become torn and some- 
times tissure<l, and in this way give rise to various infec- 
tion-possibilities. 

Treatment. — Warts are removed with the ?harp curet 

or curveii scissors, and subsequent cauterization of the 

'ose with nitric acid, chromic acid, liquor ferri sesqui- 

cidoridi, or glacial acetic acid. The grovrths may also be 

removed by the thermocautery or by electrolysis. 

ICHTHYOSIS nSH-SKIN DISEASE . 

Ichthyosis is a disease chiefly of the epidermis, depend- 
ent upon hereditary disposition. It develops eariy in life, 
miistly in the second year. According to type or d^ree 
of the disease, several varieties are encountered. 

lehikytfgU tiaqiUx is observed chiefly on the extensor 
-urlaces of the extremities ; but may also appear upon the 
"unk. The surface of the skin feels rough, and the small 
(>iipular — follicular — elevations are covered with firmly 
adherent scales, upon the removal of which the surface- 
hairs are observed. This mild type causes the patient 
very little annoyance. 

A more marked type of the disease is the so-called 
ichthyogis terpentina, which is characterized by dirty- 
brown, homy scales and scaly plates on the surface of the 
trunk and extremities. Over the elbows and knees the 
ctmdition is often distinctly papillomatous or warty in ap- 
pearance. The skin of the faee is ako dry, scaly, and 
grayish (Plate 39), 



124 DISEASES OF THE SKIN. 

The most pronounced grade of ichthyosis is the so- 
called ichthyosis hystrix, in which the aiFected epider- 
mis consists of polyhedral plates and accumulations, 
papules, or spines, apparently made up of lamellar and 
fibrous tissue. There are also numerous markedly en- 
larged papillse. The under surface of these spines is un- 
even, projecting from which are seen hardened papillae. Not 
only are these various formations of a dark color, but the 
skin as a whole also assumes a dirty -gray or brownish hue, 
so that the patient presents a remarkable appearance (hys- 
tricisraus). A family of such extreme cases (the Lam- 
berts, father and two sons) was exhibited and described 
in the last century as "porcupine men." 

Unfortunately, ichthyosis is a disease Avhich remains 
incurable, and in the more severe cases at least, owing to 
its recognized hereditary tendency, is, with properly- 
minded people, a hindrance to marriage. The mildest 
types practically disappear during the heated season, and 
the more severe cases are also favorably influenced by a 
warm temperature. 

Treatment. — The removal of the scales and horny 
formations is attained by rubbings and washings with 
sapo viridis, Wilkinson's ointment, /9-naphthol sjilve, and 
salicylic-acid-resorcin-tar salves, in combination with 
baths and prolonged wet packs. In average cases the 
skin is made smooth and flexible by these measures, and 
it can be kept in this favorable condition by applications 
of fat, glycerin-baths, starch-baths, and sweat-baths daily 
or occasionally, according to the type of disease and the 
season of the year. 

The horny papillomatous outgrowths in ichthyosis hys- 
trix are to be removed by caustics or by operation. 

Internal treatment has, up to the present time, proved 
of no value. 



PSOROSPER.}fOSIS FOLLICULARIS VEGETANS. Vlb 

ACANTHOSIS NIGRICANS (KERATOSIS NIGRICANS (KA- 
POSI) ; DYSTROPHIE PAPILLAIRE ET PIGMENTAIRE 
OF THE FRENCH). 

This rare disease is characterized by two peculiarities — 
the pigmentation and the papillomatous growths in the 
skin. Generally the first symptom is the intense dark 
pigmentation ; it is usually only later that the papillom- 
atous growths are added. Tiie sites of predilection are 
the neck, the axilhe, the breast, the navel, anal and gen- 
itocrural regions, and the poplitea. In isolated cases the 
mucous membrane of the mouth and the tongue also share 
in the process. This condition of the skin ciiuses no 
special trouble beyond the fact of its presence and the 
disfigurement caused ; but as the disease is usually on cov- 
ered parts, this latter is of comparative insignificance. 

It is worthy of note that in the majority of the cases so 
far reported carcinomatous disease of the stomach or of 
the uterus was present, so that the skin-conditions were 
overshadowed by the symptoms produced by this latter 
disease. In a case reported by Spietschka there was a 
deciduoma malignum, after operation for which the skin- 
affection disappeared. 

Histologically, one finds pigmentation, papillary growth, 
and thickening of the stratum corneum. The pigment is 
chiefly seated in the basal cylinder-cells, in stratum papil- 
lare and subpapillare, and in the lymph-channels of the 
glands. Changes in the cutis are of an unimportant 
nature. 

The treatment is to be based upon ordinary hygienic 
rules, modified by circumstances ; the character of the 
concomitant basic disease indicates that the eventual ter- 
mination is unfavorable. 

PSOROSPERMOSIS FOLLICULARIS VEGETANS 
(DARIER). 

Darier has described an independent disease in which 
there are growth and hardening of the epidermis, an 



126 DISEASES OF THE SKIN. 

affection in which apparently the cutis has no share. 
Tliere appear small horny formations due to hyperplasia 
in the stratum corneum, which are pointed toward their 
lower part and project from the epidermis. 

These small papules are not only found in the sebaceous 
gland outlets, but also can be found everywhere in the 
epidermis. The stratum Malpighii underlying the forma- 
tions is here and there thinned. Neck, brow, inguinal re- 
gion, axillae, and backs of the hands are attacked. The 
psorosperms which Darier found are not now believed to 
be in reality these bodies, but arise, according to the latest 
investigations, through concentric cornification of the epi- 
dermis-cells. They are met with in two forms — as 
rounded little bodies the size of an epidermis-cell, with 
a nucleus, most abundant in the granular layer ; and as an 
irregular formation, without nucleus, in the upper epi- 
dermis-layers. The acceptance of a parasitic cause for 
this peculiar dermatosis is, therefore, still an open question. 

The disease described by Paget — " Paffcfs dUcane " — 
and likewise that reported by White as keratosis follicu- 
laris, are looked upon as identical with Darier's disease. 
Kaposi has remarked that these keratoses remind him of 
lichen ruber acuminatus. 

ANOMALIES OF THE HAIR. 

Alopecia. — Congenital alopecia is observed mostly as 
an insufficient hair-growth with lanugo-hairs, which may 
sometimes be replaced by normal or increased hair-pro- 
duction. 

Alopecia senilis is the alopecia coming almost invariably 
with advancing years, which begins from the brow, extend- 
ing toward the occiput, the hair still remaining on the sides. 

Acquired hair-loss — alopecia prcematura — appears be- 
tween the twentieth and thirtieth years, as a result usually 
of hereditary predisposition. Frequently this form of alo- 
pecia is met with in several members of the same family. 
As also in the senile form, the hair-loss on the involved 



ANOMALIES OF THE HAIR. 127 

region in these cases, with tlie exception of insignificant 
hinugo, is complete and permanent. The skin is smooth 
and shiny, and the follicles are atrophic. 

The loss of hair during or following acute disease, as, 
for example, typhus and typhoid fevers, puerperal fever, 
syphilis, and inflammatory and parasitic diseases, is, as a 
rule, temporary. 

Alopecia Totalis Praimatura Neurotica (Plate 41, a). — 
Sometimes the hair falls out in young individuals inside 
of a few days or weeks, without any recognizable disease 
of the hair. At times it is noticed to be dry, and with a 
tendency to split or break. The most conspicuous loss is 
of tile hair on the sealp ; but the eyebrows and eyelashes 
also fall out, and frequently the pubic and axillary hair, 
and, in fact, the surface-hairs of the entire integument. 

The hair that sometimes grows after such loss is thin 
and atrophic, and soon falls out. The skin shows no 
changes worth mentioning. It is to be noted that fre- 
quently the nails share in the disease, and are milky and 
fragile. Almost always nervous symptoms are associated, 
such as nervous disturbances, migraine, and psychoses. The 
hair-fall in these cases is considered to be a trophoneurosis. 

Alopecia Areata (Plate 41, 6). — Without apparent skin- 
changes bald spots ajipear on the scalp, which peri])herally 
enlarge ; frequently only one or several at a time. The 
hairs seem of normal appearance. Those which are at the 
immediate periphery of the patches, as a rule, may be easily 
pulled out. The skin is pale, but without change in the 
sensibility. Frequently contiguous bald spots become con- 
fluent, and there then arise larger hairless areas ; seldom, 
however, complete baldness of the entire scalp. Alter some 
months lanugo begin to appear, which later are replaced 
by normal hair. Such regrowth usually takes place in 
from one to two years, sometimes in a shorter period. In 
spite of the fact that distinguished dermatologists have 
given the etiology of this disease considerable study, as 
yet there is no uniform view as to its cause. Some con- 
sider the disease a trophoneurosis, others believe it to be 



128 DISEASES OF THE Sk'IN. 

parasitic. Since for both these views there is much evi- 
dence, the opinion of Lassar seems the correct one — that 
there are etiologically several processes with the same 
clinical picture. 

Treatment of alopecia naturally should be based upon 
what seems to be the possible etiologic factors in the case 
under consideration. It must, however, be remarked 
that this theoretic division in the treatment is not closely 
followed, but that substantially all therapeutic efforts have 
in view a local irritation, and the various local remedies 
employed to produce this are of stimulating and antipara- 
sitic character. For the neurotic type internal tonics arc 
especially recommended, such as iron, arsenical prepara- 
tions, pilocarpin, local massage, application of the faradic 
and galvanic currents. Of the local remedies, may be 
named the application of salt solutions, acetic acid, tinct- 
ure of cantharides, tar tincture, oil of mace, chrysarobin, 
resorcin, etc. If seborrhea is associated, it must be treated 
according to approved methods, as this condition lias an 
important etiologic bearing in such cases. 

Trichorrhexis nodosa occurs more commonly on 
the bearded region, as nodular excrescences on the hairs. 
On the hair-shaft may be seen one or several such swell- 
ings. The hairs break easily at these points, and there 
remains a brush-like extremity (Plate 64). Hodara' 
states that he has found a microorganism in this disease 
and has cultivated it ; he was able to produce on sound 
hairs the same disease. Spiegler has also had a like 
experience. 

Treatment. — Treatment is usually fruitless. Besnier 
advises depilation of the diseased hairs and the applica- 
tion of tincture of cantharides. Eichhoff advises keeping 
the hair closely cut and the rubbing in of 

^i Vanillini, 0.20 (gr. iij) ; 

Adipis, 10 (siiss). — M. 

Ft. unguent. 

* Archivfiir Dermaioloffie und SyphUis, Bd. 41, L 



ANOMALIES OF THE NAILS. Vl\) 

Tar-sulphur salves, aqua ammonia, etc. have also been 
recommended. 

Sometimes apparently normal hairs are seen with the 
ends split (trichoptilosis). For this condition dryness 
of the hair has been considered responsible. 

The term h3^ertrichosis (excessive hair-growth) 
signifies not only that hairs may appear on unusual situa- 
tions, but also that hairs in normal regions may be un- 
usually long and thick. Thickness and length of the 
individual hairs are often associated with luxuriant 
growth. 

The hair in albinismtlS is absolutely without pig- 
ment, yellowish-white, soft, thin, and of silky appearance. 
As acquired, we frequently see whitening of the hair on 
colorless skin-areas ; frequently, however, also without 
the loss of ])ignient in the skin (Plate 41). 

Graying of the hair depends (Ehrmann) upon the 
want of pigment-bearing cells in rete and in the hair- 
bulb. One finds hairs which may have a dark end-por- 
tion and an already whitish, grayish shaft. Sudden gray- 
ing of the hair, which is stated to occur from fright, and 
which is said to be due to the formation of gas in the 
hair-shaft, needs scientific confirmation. 

ANOMALIES OF THE NAILS. 

Irregular formation and shapes of the nails arise from 
excessive growth, by thickening and malformation in 
consequence of hypertrophy of the nail-bed. The nails 
become claw- or talon-like, and twisted like a horn 
(onychogryphosis). The latter arises from the fact that 
the nail-l)ody is lifted up from the nail-bed by the ac- 
cumulation of hardened masses beneath (Plate 40) ; or 
such growth and accumulation may take place at the for- 
ward part of the nail-bed only. The borders are hyper- 
trophied and the lamellar masses show a structure similar 
to that of cutaneous horns. 

Absence of the nails is observed after paronychia, in 
9 



130 DISEASES OF THE SKIN. 

atro])hic conditions of the end-phalanges, and possibly in 
disease of the neighboring epidermis (psoriasis, etc.). 

Digestive disturbance and chronic intoxications, acute 
infections with recurrences, as erysipelas, local irritations 
(ill-fitting shoes), and inflammation of the surrounding 
parts may act as causes of hypertrophy of the nails. 
Diseases of the skin, as chronic eczema, psoriasis, lichen 
ruber, elephantiasis, syphilis, ichthyosis — in short, all 
those which are attended with cell-infiltration of the 
papillary layer and a hyperplasia of the epidermis may 
act as factors in the production of onychogryphosis ; and 
also the parasitic diseases of the nails, as favus and tinea 
trichophytina. 

PIGMENT-ANOMALIES OF THE SKIN. 

Paleness or whitening of the skin occurs in ane- 
mic states, in consequence of lack of blood after hemor- 
rhages, after depressing diseases, and in chlorosis and 
dropsy. 

Congenital want of pigment (albinismus univei'salift) oc- 
curs as a hereditary anomaly. The otherwise normal skin 
of such individuals {albinos) is completely without pig- 
ment, white, pinkish, or reddish in color. In consequence 
of the blood-vessels shining through the iris the eye 
appears red. Albinos, as a result of the lack of ]>ig- 
ment, are sensitive to light and have nystagmus. The 
hairs are fine, silky, shining, and completely white. 

Also after certain diseases of the skin the pigment nor- 
mally present disappears completely. 

Albinismus partialis occurs as congenital loss of pigment 
in circumscribed regions of the skin. Its distribution fre- 
quently corresponds to the domain of a nerve, and, unlike 
acquired pigment-atrophy, the areas are surrounded by 
normally pigmented skin. The hairs in such pigmentloss 
regions may also remain white ; this, however, is not in- 
variably the case. 

The acquired form of pigment-loss (vitiligo, leucoderma, 



PIOMENT-AJ^OMALIES OF THE SKIN. 131 

leucodenna acqumtum) (Plate 41) begins at first as small 
white spots, which spread slowly and irregularly ; the 
bordering skin is overpigmented. There is no text- 
ural change in the skin of such areas beyond the loss 
of coloring-matter, the integument being otherwise atia- 
tomically normal ; moreover, there are no functional dis- 
turbances. The disease may in the course of years in- 
volve almost the entire surface, a few dark stripes or areas 
being left. The hairs become white with the skin. In- 
nervation-disturbances have been looked upon as respon- 
sible for this variety. It is only occasionally that an ex- 
ternal factor may be productive of these spots, as, for 
example, pressure of bandages or constriction of scars. 
It is known that after certain acute diseases, as, for exam- 
ple, typhus, scarlatina, etc., vitiligo has been observed to 
occur. In most cases, however, the affection is seen be- 
tween the tenth and thirtieth years in individuals appar- 
ently otherwise in normal heidth. The investigations of 
Ehrmann, Jarisch, Riehl, and others have shown how the 
displacement of pigment takes place by means of cells, 
without, however, throwing light on the actual causes of 
the process. 

Increase in pigmentation may occur as a congen- 
ital condition ; it is, however, more frequently an acquired 
affection. 

Brownish, brown, and black discoloration of the skin, 
in variously-sized areas, is observed as a congenital affec- 
tion — pigmentary moles ()ueims pigmentostis) (Plates 35 
and 36). Small moles may also be an acquired blemish. 

On several regions of the body are observed circum- 
scribefl pigment-spots, such as frecldes {lentigo, ephilides). 
They are, as well known, millet-seed-sized to pea-sized, 
or possibly larger, yellowish-brown or brownish in color, 
which are met with in summer on the face and on the 
hands, but occasionally also on parts covered with clothing, 
disappearing partly or completely in winter-time. 

Of other varieties of pigmentation, there remains to 



132 DISEASES OF THE SKIN. 

be mentioned that which sometimes occurs in association 
with diseases of tlie female sexual organs — the so-called 
chloasma uterinum, a yellowish and grayish or brownish 
discoloration on the face, on the areola of the nipple, and 
in the linea alba. Discoloration of the buttocks, trunk, 
and extremities was observed in cystic degeneration of 
both ovaries (Neusser) ; after double ovariectomy tlie dis- 
coloration rapidly disappeared. 

Treatment. — Of prophylactic importance in lentigo 
is avoidance of the sun's rays during the summer season. 
In persistent freckles and also in chloasma and other dis- 
colorations the application of corrosive-sublimate solution, 
alcoholic or aqueous, -^ to 1 per cent, strength, is to be 
recommended. Covering the aflPected areas with com- 
presses wet with the solution is useful ; its action should 
be carefully watched if the stronger solutions are em- 
ployed. Also the application of the following : 

!l^ Bismuthi subnitratis, , 

Hydrarg. prsecip. alb., aa 5 (gr. Ixxv) ; 
Adipis, 50 (giss). — M. 

Ft. unguentum. 

Or salves of /9-naphthol or resorcin, already referred to. 

In addition to these several methods for the removal 
of freckles and chloasma, may also be mentioned the 
application of: 

!]^ Adipis lanse, 5 (gr. Ixxv) ; 

Vaselini, 10(3iiss); 

Hydrog. peroxid., 20 (f^v) ; 

Hydrarg. chlorid. corros., 0.05 (gr. f ) ; 

Bismuthi oxychlorid., 0.5 (gr. viiss). — M. 

Ft. unguentum (Unna). 

Leloir advises washing the parts with sapo viridis or 
alcohol, and then painting on a 15 per cent, solution of 
chrysarobin in chloroform ; the spots, after this dries on, 



PIGMENT-ANOMALIES OF THE SKIN. 133 

are painted with a solution of gutta-percha. Hardy 
recommends the application of: 

I^ Hydrarg. chlorid. corros., 1 (gr. xv) ; 
Zinci sulphat,, 

Plumb, acetat., aa 2 (gr. xxx) ; 

Aquffi destillat., 250 (f 5viij). — M. 
Sig. — For external use. 

In many of the cases of acquired pigmentation large 
areas, or indeed the entire surface, may be more or less 
pigmented. The pigment often arises from hyperemia, 
and this usually from some direct irritation of the skin. 
On the other hand, in some cases pigmentation results as 
a consequence of diseases of one or more organs ; in such 
the pigment may also be deposited within the viscera as 
well as in the skin. The several diseases or conditions 
which lead to pigmentation are : 

Melasma is a discoloration of large areas, frequently on 
the lower extremities, widespread, brownish in color, fol- 
lowing chronic inflammations and congestions in cachec- 
tic and emaciated individuals of impaired nutrition. A 
like condition, consisting of a general darkening of the 
skin, is observed in consequence of neglect in individuals 
with flabby panniculus (chloasma cachecticorum), as, for 
example, in phthisics, in whom the skin appears greasy, 
smeary, and discolored. 

Va(/abon<Js' dm^ase (Vogt) is a melanosis observed in 
tramps, which arises from neglect of the skin, lice, and 
heat. 

A dirty-gray discoloration of the skin is observed in 
malarial cachexias. 

The discoloration in pellagra, a disease which has been 
descriiied in connection with the erythemas, may also be 
mentioned here. 

Further, melanoicterus of the skin is observed in cir- 
rhosis of the liver and in chronic forms of icterus gravis. 
It may assume on some regions of the body a peculiar 
bronze color. 



134 DISEASES OF THE SKTN. 

In diabetes mellitus melanodermic conditions (diabete 
bronze of the French) are likewise observed. Also in 
those cases with which are associated polydipsia, poly- 
phagia, polyuria, and glycosuria, the pigment-accumu- 
lation being present in the various organs and lymph- 
glands as well as in the skin. This pigment contains 
iron, and is to be looked upon as a derivative of hemo- 
globin. 

In this group belong also the melanodermata observed 
in affections of the pancreas, with or without associated 
glycosuria. 

Morbus Addisonii.^This disease, described by Addison, 
associated with disease of the suprarenal capsules, occurs 
as a bronzing of the skin, expressing itself also in 
disturbances of the digestive tract and nervous system, 
and almost always ending fatally. According to Lewin, 
disease of the suprarenal capsules is observed in 88 per 
cent, of the typical cases. The discoloration appears 
some time after the patient has been complaining of 
feelings of weakness, depression, and the sensation of 
pressure in the stomach, often pain in the entire abdomen, 
increased thirst, nausea, etc. 

At first the color is a dirty-yellow, yellowish-brown, or 
smoke-gray, and by gradual darkening it becomes that of 
bronze, and may even become black. The uncovered 
parts and parts which are subjected to pressure of the 
clothing are most conspicuously involved ; sometimes also 
the mucous membranes of the lips and mouth. 

The discoloration is either spread over larger areas, in 
which clear- white spots are irregularly scattered, or it may 
appear in the form of single irregular patches. The hairy 

Earts may also be discolored; the hair itself does not, 
owever, usually share in the process. The skin of the 
face is, as a rule, the darkest ; the nails and the nail-beds 
are seldom pigmented. 

The skin is smooth and elastic to the touch, and in- 
clined to sweat, but shows no other changes worthy of 
mention. 



PIGMENT-ANOMALIES OF THE SKIN. 135 

The pigmentation arises, according to Nensser,^ through 
the medium of the genenil and local sympathetic nerves; 
the impairment or abolition of the function of the supra- 
renal capsules being the underlying factor. 

To the general weakness are added depression of spirits, 
ill temper, and impairment of the intelligence. Emacia- 
tion, cachexia, weakness of heart-action, palpitation, and 
dyspnea are symptoms of the early stiiges. Death results, 
with gradual and increasing prostration, in consequence 
of heart-weakness ; sometimes the end comes with high 
fever, diarrhea, persistent vomiting, delirium, and finally 
collapse and coma. The duration of the disease varies, 
the extremes being months and years. Often the end 
comes suddenly, without the patient having gone through 
the several stages or symptoms mentioned. 

In the preceding remarks processes have been de- 
scribed in which the pigment arises from organic con- 
stituents within the patient himself, in consequence of 
some pathologic process. There are, however, other pig- 
ment-deposits observed in the skin, composed of cer- 
tain mineral substances which have been introduced into 
the system or skin from without. We will refer to the 
most important representatives of this group — the 
pigmentations arising from the use of silver nitrate and 
arsenic. 

The discoloration of the skin from arsenic — arsenicdl 
melanosis, arsenicwnus — occurs after its continued ad- 
ministration or from the fact that the patient's occupation 
brings him in contact with it (Plate 37). 

Arsenic is introduced by the mouth as medicine or 
is taken unconsciously in drinking-water; or, as already 
stated, the patient is engaged in some occupation in which 
arsenic is used. It may also be introduced through the 
lungs and skin from arsenic-containing carpets, wall- 
pa jjer, etc. 

' Neusser, article on "Morbus Addisonii" in Nothnagel's Path- 
ology. 



136 DISEASES OF THE SKIN. 

The discoloration appears upon the skin, the mucous 
membranes remaining free. 

The pathogenesis of the pigment-formation is not yet 
understood. It has been assumed that the poison through 
its affinity for certain substances breaks up the blood-cor- 
puscles, the blood-coloring-matter protlucing the skin- 
pigmentation. The pigment is found in the lowest basal 
c^lls of the rete and in the cutis. The fact however, 
as clinical observation teaches, that the pigment is de- 
posited, or often more markedly at least, at the sites of 
former diseased areas of the skin (eczema, psoriasis, etc.), 
is not readily explained. 

The quantity of arsenic which may give rise to pig- 
mentation of the skin differs materially in different indi- 
viduals. In the case depicted it appeared after the ad- 
ministration of 0.26 (gr. iv) of arsenious acid ; in other 
cases only 0.216 (gr. iij +) of arsenious acid had been 
taken ; and in one case in Schrotter's clinic 0.125 (gr. j ^) 
was sufficient. 

As regards the time required, it has appeared in some 
cases after six months' administration of Fowler's solu- 
tion, in others not before three years, after doses of five 
to ten drops three times daily. 

The pigmentation appears gradually, and especially on 
those regions which are normally hyperpigmented. In 
most cases the skin is noted to have a bronze tint ; not 
infrequently, however, a graphite color. 

As soon as the arsenic has been discontinued the skin 
begins to resume its normal hue, especially if other 
damaging effects upon it by the drug (to be referred to) 
have not been observed. The more intense the pig- 
mentation and the older the patient the more slowly does 
it disappear. 

As a further effect of the administration of arsenic on 
the skin we have arsenical hyperkeratosis (Wilson). In 
addition to the uniform hyperkeratosis on certain parts, 
as the hands and feet, corn-like horny formations appear 
with central depressions, which correspond to the hardened 



NEW GROWTHS. 137 

outlets of the sweat-glands. Arsenical hyperkeratosis is 
said to lead sometimes to the formation of epithelial 
growths. 

Argyria. — By the deposition of reduced silver in the 
skin from the ingestion of silver nitrate the integu- 
ment becomes discolored. The silver is found outside of 
the cells in the finest subdivision. The face is the part 
most frequently and markedly pigmented ; also the con- 
junctivae bulbi become gray, and likewise the nail-bed. 
In the beginning the skin is pale gray ; after continued 
administration of the drug it becomes dark blue or cyanotic 
in color. 

As in cases of arsenical pigmentation, the examination 
of the urine is an important diagnostic help in this dis- 
order ; the presence of silver can be readily demonstrated. 



NEW GROWTHS (NEOPLASMATA). 

Congenital and acquired connective-tissue new growths 
are the most numerous of the benign tumors of the skin. 
They occur as small circumscribed cutaneous excrescences, 
or as more or less extensive thickenings of the skin. 

Verrucous growths belong to the former class. They 
are hypertroj)hies of the corium covered wnth pigmented 
epidermis. They are either smooth or notched, are often 
covered with hairs and dilated sebaceous follicles, and are 
either sessile, provided with a broad base, or pedunculated 
(Plate 35). 

Nevus. — The so-called ruevics mollnseifoiinis or ncevus 
Upomatodfii is another example, differing in being rarely 
sessile and occurring as pendulous, pedunculated small 
tumors on the skin of the neck and eyelids. 

N(eviis spihis occurs in the form of elevated lesions, 
the size of a lentil or bean, but may occasionally be dis- 
tributed over large cutaneous areas in the form of hyper- 
trophy of the skin and papillae, accompanied by black or 



138 DISEASES OF THE SKIN. 

dark-brown pigmentation, which often extends even into 
the cutis. Njcvus spiUis is very frequently covered with 
stiif hairs. 

Treatment. — In the smaller lesions the application of 
caustics, such as trichloracetic acid, lactic acid, and nitric 
acid, or sublimated collodium (5-10 per cent.), is recom- 
mended for the removal of flat nevi ; if not successful, 
electrolysis or excision is to be advised. 

When the growths are of larger size and removal by 
surgical means is contraindicated or objected to, recourse 
may be had to electrolysis (Voltolini, Hardaway, Fox) 
or the galvanocautery. 

Cicatrix or Scar. — Losses of substance of the skin 
extending into the corium, or at least into the papillary 
layer, are replaced by cicatricial formation. Scars are 
likely to occur after burns, suppuration, and caustic ap- 
plications, and after diseases leading to purulent destruc- 
tion of tissue, as lupus, scrofulosis, and various der- 
matitides, or extensive hemorrhages and gangrene of 
skin. After the necrotic mass has come away the granu- 
lation-tissue to replace the defect begins to form. The 
proliferation of the granulation-tissue commences in 
the deeper parts, and is gradually converted into con- 
nective tissue, which becomes covered with an imper- 
fect epidermis. The numerous islands of epithelium 
which can be seen in extensive wounds after burns prob- 
ably originate from the epidermis of the sebaceous and 
swejit-glands. Fresh cicatrices are rich in cells and con- 
tain numerous blood-vessels ; the older ones, however, 
contract, the blood-vessels become occluded, and fibrous 
connective tissue forms. Cicatricial formation is frequently 
of great significance, according to its extent and location, 
as it frequently leads to contraction and fixation of the 
articulations. When involving the face, the orifice of the 
mouth is distorted or contracted, ectropion of the eyelids 
results, and finally, owing to constriction, circulatory dis- 
turbances frequently supervene, which lead — especially on 



NEW GROWTHS. 139 

the extremities — to secondary edematous stases and over- 
growth of the tissue, elephantiasis. 

Keloid is a flat, elevated, white or bluish-red, firm, 
tumefied, cicatricial hypertrophy, which frequently sends 
out claw-like processes. It is covered with a thin, shining 
epidermis, and consists of accumulated embryonic con- 
nective-tissue elements embedded in dense fibrous tissue. 

Elephantiasis Arabum; Pachydermia. — This 
disease represents a hyperplasia of the corium and hyper- 
trophy of the papillje. The enormous size of the affected 
part sometimes reached is due to marked hypertrophy of 
the subcutaneous cellular tissue ; this condition occurs 
most frequently on the lower limbs. Higher degrees, 
with irregular hypertrophy and sclerosis of the subcu- 
taneous conne(;tive tissue, and various, even verrucous, 
vegetations of the papillary layer, are met with ; occa- 
sionally, thickened tuberosities and firm linear infiltration 
are at first noted beneath the skin. The integument and 
subcutaneous tissues are permeated with serum, and in 
very advanced .stages the muscles down to the periosteum 
and subcutaneous tissue are degenerated and indurated 
{elephantiasis Arabum). Eczematous, erj^sipelatous out- 
breaks, with inflammation of the connective tissue asso- 
ciated with phlebitis and lymphangitis, is the direct cause 
of these deformities. Hardening and obliteration of the 
veins and lymphatic vessels lead to these consecutive 
phenomena, which may occur not only on the lower, but 
also on the upper extremities, and on the scrotum and 
labia. Necrosis of the epidermis overlying these sclerotic 
masses of connective tissue often occurs, and there result 
large, sinuous ulcers with perpendicular, callous edges, 
surrounded by cicatricial tissue, papillomatous vegetations, 
and eczematous skin. 

Scleroderma. — This chronic disease is characterized 
by board-like consistence and rigidity of the skin. It 
usually occui-s in circumscribed patches on the upper half 
of the body or diffused over larger areas. It is met with 
on the face, neck, and upper parts of the chest and back^ 



140 DISEASES OF THE SKIN. 

on the upper extremities, more rarely on the abdomen 
and lower extremities. The affected skin is firm and 
hard, and cannot be pinched up. Extension occurs either 
in irregular patches or in the form of streaks or bands, or 
diffused over larger areas. The surface is either shiny or 
of a dull brown-red color ; whitish areas alternating with 
irregular dark-brown pigmented spots. The hands grow 
livid and of a cyanotic hue. Owing to the skin being 
bound down firmly and the underlying muscles and joints 
being tightly encircled, their movements are interfered 
with. When the skin of the face is involved it has a 
rigid expression, the mobility of the lips and eyelids is 
impaired, the nose is contracted, and the whole face— to 
quote a classical expression of Kaposi's — appears as if 
petrified and hewn in marble. The articulations of af- 
fected extremities ciin only be slightly moved or not at 
all ; the fingers are semiflexed and rigid. Any attempt 
to extend the joints and pressure on the skin give rise to 
pain. Tactile sensation and also the function of the 
cutaneous secretion are not materially altered ; the tem- 
perature is somewhat lowered. The disease frequently 
extends irregularly ; it has, however, also been noticed to 
follow the distribution of the peripheral nerves. Uni- 
lateral localization, as in eruptions of zoster, along the 
various nerves has been described. 

The commencement of the disease is often so slight 
that the patient's attention is only attracted to it by a 
sensation of tension. Occasionally the process is pre- 
ceded by muscular and articular pains, or by intense 
erythema accompanied by edema, which may exist for 
weeks before the skin becomes sclerosed. In these stages 
the skin may sooner or later return to the normal condition 
and the sclerotic foci undergo resolution. The disease at 
times recurs, the foci increase in extent, and the condition 
lapses into the so-called atrophic stage of scleroderma, 
which is not susceptible of improvement. The skin be- 
comes thin and resembles parchment, the follicles become 
obliterated, and the glands atrophy. The discoloration, 



NEW GROWTHS. 141 

tlie shiny appearance, and the hidebound condition re- 
main unchanged. Owing to pressure, the subcutaneous 
fat shrinks, and even the muscles atrophy (atrophy of in- 
activity). These atrophic conditions at times result in 
disease of the joints and of tlie periosteum and bones. 

The irritation of the skin frequently leads to ulcera- 
tions on ])rojecting parts, and even to gangrene. 

After the disease has continued for years emaciation 
and aggravated marasmus ensue. The fatal issue is usu- 
ally due to intercurrent diseases. 

The diagnosis of scleroderma offers no difficulty, for 
the characteristic changes an<l the hard, smooth, cool-feel- 
ing skin are significant. It might be mistaken for pigmen- 
tation of the skin occurring in Addison's disease — in this 
affection, however, the skin is not sclerotic ; or for xero- 
derma pigmentosum, but in the latter the appearance of 
carcinoma is characteristic. 

The etiology is as yet unexplained. The disease is 
more common in women. Its origin is frequently at- 
tributed to disturbances in the domain of the peripheral 
nerves; this view has some support, as certain forms, 
already mentioned, follow the distribution of nerves. 
Vascular changes, especially compression of the vessels in 
places, have been described, which circumstance has led 
to the conclusion that scleroderma is possibly to be re- 
ganled as the result of an inflammation. 

Treatment, — Nourishing diet, tonics, plain or medi- 
cated baths, and the internal administration of potassium 
iodid and sodium salicylate have been advised. Locally 
massaging of the diseased parts with an indifferent fat or 
salicylic-acid ointment is j)robably the most efficient pro- 
cedure. Some authors laud the action of the constant 
electric current. 

Scleroderma Neonatortim. — Induration of cellular 
ti&sue in new-born infants usually appears during the first 
months of life ; it begins with edema and sclerosis of the 
feet and lower extremities, and gradually spreads in a few 
days over the rest of the body. The temperature declines 



142 DISEASES OF THE SKfK 

steadily, and death usually results in two to ten days. 
The affection is frequently associated with cardiac lesions 
and diseases of the respiratory and digestive tracts in weak 
or debilitated children. 

Myxedema. — This disfiguring affection occurs princi- 
pally in females, and consists of increase in volume of the 
affe(!ted cutaneous parts, which appear swollen, thickened, 
and hardened. It is met with on the face, on the trunk 
and extremities, and also on the tongue and velum palati. 
The hands and fingers also appear more or less deformed, 
owing to thickening. 

The mental and physical faculties of such individuals 
are also impaired ; mental hebetude ensues, the senses of 
taste and smell are lost, and they are incapable of physical 
or mental labor. They frequently perish of cardiac and 
renal disease. 

The affection is due to proliferation and deposit of 
mucin in the skin, in the muscles, and also in the internal 
organs. 

CExlema cutis, or anasarca, due to circulatory disturb- 
ances, is allied to this process. It represents a secondary 
phenomenon, and not an individual skin-disease. 

PARTIAL ATROPHY AND THINNING OF THE SKIN. 

This condition occurs most usually during middle life 
in hydrops, anasarca, pregnancy, and rapid accumulation 
of fat, owing to tension and stretching of the skin ; the 
deeper tissue-layers are spread apart and the skin becomes 
very thin (strice gravidai-um). The streaks at first are 
bluish-red ; later they turn white and shiny, and resemble 
cicatrices [tttrice atrophica;). 

Pressure from a bandage or from an internal tumor 
causes the skin to become hyperemic for a time ; the 
macerated epidermis desquamates freely, and finally the 
skin may atrophy, and after persistent pressure cutaneous 
necrosis or ulceration and disintegration may result. 



XERODERMA, PARCHMENT-SKIN. 143 

GENERAL ATROPHY OF THE SKIN. 

This occurs during advanced age as a degenerative in- 
volution of the skin and its appendages. Diifuse pro- 
gressive atrophy of the skin is furthermore induced by 
many as yet unexphiined pathologic processes. The atro- 
phic skin is exceedingly thin and wrinkled, resembling 
cigarette-paper. It is inelastic, and when pinched into 
folds returns slowly to its original shape. The veins are 
dilated, and can be seen as bluish lines shining through 
the thin, translucent epidermis. Tlie secretion of the 
sweat-glands continues in but few places, as the genitalia, 
face, and axillfe. The hairs are lost ; only a lanugo-hair 
here and there is still visible. The process must be re- 
garded clinically as an atrophy. The progressive form 
of atrophy of the skin has been demonstrated histolog- 
ically to be preceded by a chronic inflammatory process, 
which takes place principally in the layers of the cutis. 
The sequelffi are shrinking and atrophy of the papillary 
layer and of the sebaceous and sudoriparous glands and 
hair, and increase of connective tissue in the deeper parts 
of the cutis. 



XERODERMA PIGMENTOSUM (XERODERMA, 
PARCHMENT-SKIN). 

Kaposi was the first to describe this malady and to call 
attention to its malignant character. The disease develops 
in consequence of congenital predisposition in early child- 
hood, rarely later, and the main characteristics are yel- 
lowish-brown pigmented spots, resembling freckles; 
interspersed among these are small telangiectases and 
slightly-depressed whitish areas, frequently resembling 
tiie scars of small-pox. The skin appears atrophic and 
dried up, resembling parchment, and is tense and can 
only be pinched into folds with difficulty. The telan- 
giectases are either punctiform or linear. The dilated 
vessels and pigmentation, and the whitish cicatrices, im- 
part a spotted color to the skin. 



144 DISEASES OF THE SKIN. 

The integument of the face, neck, dorsal surfaces of 
the hands, the forearms, shoulders, and trunk, more 
rarely the lower extremities and dorsal surfaces of the feet, 
are involved. 

During the further progress of the disease the small 
vessels are obliterated, and white, shiny, atrophic little 
depressions and later diffuse shrinking of the skin are to 
be noticed. As the epidermis also atrophies and ex- 
foliates in the form of lamellae and becomes fissured, 
much disfigurement ensues, such as superficial rhagades 
and ulcers, narrowing of the nasal and oral cavities, 
and eversion of the lower eyelids. 

The rapid spread and continuous atrophic transforma- 
tion of tissue distinguish tliis disease from ordinary 
freckles and pigmented nevi. The vascular changes, con- 
sisting of new growth and obliteration, overgrowth of the 
endothelium, the pigmentary deposit, and projection of the 
rete downward, and the atrophic processes, are the precur- 
sory stages, which stamp this as a peculiar disease subse- 
quently developing into carcinomata and sarcomata. 

These malignant new growths may occur in the course 
of a few months in various places, as the face and ex- 
ternal parts of the ears. When this takes place the doom 
of such patients is sealed, as a fatal termination is in- 
evitable. The epithelial carcinomata appear as warty 
formations ; they increase in size, disintegrate, and soon 
lead to cachexia and death. The early appearance of 
xeroderma in childhood and in several members of one 
family seems to point to heredity. 

The treatment of xeroderma has not as yet given 
positive results. It is usually restricted to symptomatic 
measures, as may seem necessary, or to operative proced- 
ures; without, however, being able to promise much to 
patients. 

Kaposi mentions, as a second form of xero<lerma, an 
atrophy of the skin of the extremities, which is said to 
begin in earliest infancy and is only distinguished from 
atrophic scleroderma by its early appearance. 



LUPUS ERYTHEMATOSUS. 145 

LUPUS ERYTHEMATOSUS. 

This chronic, inflammatory disease appears at first 
principally as small, raised, dark-red sjx)ts, which are 
usually shiny, and the center covered with a thin, ad- 
herent, small scale. In the primary stage the spots 
extend peripherdlly, and this extension leads to the 
so-called lupus eriifhematosus discotdes (Plate 42). 

These discs, the size of a dime to that of a dollar or 
the palm of the hand, usually occur at first on the bridge 
and tip of the nose, the alaj, and cheeks. The shape 
of the discs varies according as the peripheral exten- 
sion is regular or irregular. One of the most usual 
varieties is the so-called butterfly-form, which spreads 
from the bridge of the nose to the alse and even to the 
cheeks. The center of the fully-developed patches is 
depressed, shiny, and cicatricial, and is either red or 
traversed by dilated vessels. The margin is redder, 
elevated, more succulent, and is often covered with scales 
or crusts ; these latter are the result of marked exuda- 
tion from the dilated vessels, the exudation and epidermis 
drying upon the surface. The inflammation begins prin- 
cipally in the follicles and sweat-glands and spreads in 
the cutis, and extends downward to the subcutaneous 
cellular tissue as well as upward to the epidermis. The 
exudation loosens the epidermis, and the latter exfoliates 
in the shape of small scales, which are adherent at first. 
Involution takes place in this manner: The newly-formed 
connective tissue shrinks, atrophic scarring results, the 
affected areas are depressed and contract, and the cuta- 
neous follicles are obliterated ; the sebaceous and sweat- 
glands disappear. 

Another form of lupus erj'thematosus is known as 
lupus erythematosus disseminatus (Plate 43). In this variety 
the efflorescences are more numerous and make their ap- 
pearance about the sjime time. Numerous patches or 
areas are scattered over the entire face and ears. The 
spots are dark red, slightly elevated, firm and elastic, and 

10 



146 DISEASES OF THE SKIN. 

the overlying epidermis is fissured, exfoliates, and is 
studded witli dilated follicular openings. When these 
eflBorescences occur over the fingers and forearms the color 
is apt to be darker and they are firmer than those on 
the face. In a few instances the hairy scalp and the 
mucous membrane of the mouth have been found to be 
involved. According to our experience, such extensive 
spread of the disease must be regarded as rare. 

The course of lupus erythematosus in botii forms is 
exceedingly chronic, the afl'ected areas remaining long 
unchanged, sometimes for years. 

Although the prognosis, even under such conditions, 
cannot be regarded as absolutely unfavorable, as lupus 
erythematosus may either undergo rapid involution or 
may terminate in cicatricial formation and slight vascular 
dilatation, experience teaches that many of these cases 
eventually die of pneumonia and tuberculosis. [As ob- 
served in this country, in some cases the patches may 
retrogress and disappear without leaving a trace, new 
areas usually appearing from time to time. — Ed.] 

According to Kaposi's observation, which is not to be 
underestimated, the greatest number of patients are fe- 
males, who suffer not infrequently from chlorosis, dys- 
menorrhea, catarrh of the apices of the lungs, and in- 
cipient tuberculosis; male patients, however, appear to 
enjoy better health. 

We have seen a case of disseminated lupus of rather 
acute character spread rapidly, accompanied by pro- 
nounced disturbances of the general health, and the 
patient, a female, died six months later of an acute pul- 
monary affection. 

Treatment. — In mild cases washing with soft soap 
or tinctura saponis viridis will at times be sufficient to 
cause the efflorescences to disappear. The application of 
salicylic-acid plaster or gray plaster to the diseased areas 
is also to be recommended. Schiitz recommends painting 
with: 



LUFUS ERYTHEMATOSUS. 147 

I^ Liq. potass, arsenit., 4 (f 3j) ; 

Aq. destillatae, 30 (fsviiss); 

Chloroform i, (gtt. ij). — M. 
Sig. — For external use. 

In obstinate cases recourse must be had to reducing (de- 
oxidizing) remedies — resorcin, salicylic acid, pyrogallol, 
etc. — to bring about results. We have had especially good 
effects witli Lassar's method of producing exfoliation, 
described under acne {vide p. 52). Galvanocautery and 
thermocautery have also been warmly recommended. 
Multiple scarification followed by dusting with iodoform 
gives good results (Veiel). 

Growths of the connective tissue, in the narrower sense 
of the word, have a more projecting character than the 
diseases just described, partaking of the nature of tumors. 
They are : 

Fibroma Molluscum seu Pendulum (Fibroma). 
— Fibromata consist of rounded, usually pendulous tumors, 
rarely flat, and provided with a broad base ; they feel 
doughy, lobulated, soft, or somewhat firm to the touch, and 
are invested with normal skin. They generally occur on 
the head and rump, but in some cases hundreds of varying 
size may be scattered over the entire body. The larger 
growths prove annoying owing to tension, interference 
with motion, and occasionally the occurrence of inflam- 
mation or even gangrene of the overlying integument. 
They are regarded as hyperplasias of the connective 
tissue taking origin in the deeper layers of the corium or 
nerve-sheaths (neurofibromata), and consist at first of 
gelatinoid, later on of fibrous connective tissue. The 
vessels arc contained in the pedicle. The skin adheres to 
the distal end of the growth, and consequently represents 
a pouch in which the tumor is suspended. 

According to the tension and distortion which may 
exist, various changes in the glands and epithelial invest- 
ment occasionally result, and owing to consequent inflam- 



148 DISEASES OF THE SKIN. 

mation, ulceration, and gangrene the tumor falls off. 
Spontaneous involution has also been observed. 

Hereditary predisposition is regarded as a causative 
factor, inasmuch as the tumors are frequently observed 
during early life. Hebra has pointed out that the 
patients usually are degenerates in body and mind. 

Treatment is exclusively surgical. 

I/ipoma. — Lipomata, or fatty growths, do not appear 
before advanced life, and form lobulated, soft, elastic 
tumors. They are usually multiple, and either have a 
broad base or are provided with a pedicle and are pendu- 
lous. The overlying skin is normal in appearance, and 
is seldom changed by distortion and traction, as is the 
ease with fibromata. 

The treatment of lipomata is surgical. 

Xanthoma ; Xanthelasma ; Vitiligoidea. — 
Xanthomata are sharply-defined, flat, slightly-raised or 
tuberous small plates, projecting from tlie skin. The 
former (xanthoma planum) are spots of a yello\v or 
chamois-leather-yellow color ; they are of soft consistence 
and usually occur on the internal or external canthi ; the 
ears, nose, and even the mucous membrane of the mouth 
may also be the seat of the growths. They appear in 
women about the climacteric, but also in men of more 
advanced years, without causing annoyance apart from the 
disfigurement. 

The second variety, xanthoma tuberosum, occurs 
in the form of tumors the size of a pin-head to that 
of a hazel-nut. They are of firmer consistence and of 
irregular, lobulated construction. The lesions are red at 
the base and yellowish at the apex. The tumors occur 
on the extensor surfaces of the joints, the fingers, elbows, 
knees, on the nape of the neck, and in the sacral and 
gluteal regions. They have also been found on the 
mucous membranes and even in the internal organs 
(endocardium, wall of the aorta, etc.). 

Xanthoma represents anatomically a connective-tissue 
tumor with interspersed specific xanthoma-cells. The 



ANGIOMATA. 149 

etiology of xanthomatosis is as yet not known. Fre- 
quently jaundice, disease of the liver, or diabetes co- 
exists. The latter disease especially appears to predis- 
pose to xanthoma tuberosum. In our case (Plates 44 
and 44, «) striking involution of xanthoma-tubercles 
occurred twice after the disappearance of diabetes had 
been brought about by a bath-course at Carlsbad. The 
disease relapsed simultaneously with the appearance of 
sugar in the urine, and at both times the small tuber- 
cles involuted when sugtir cetised to appear in the urine. 



anum is most readily re- 
also by electrolysis — Ed.]. 
loma the general condition 



Treatment. — Xanthoma pU 
moved by siu'gical procedures 
In multiple eruptions of xant 

must be carefully looked into ; patients must be examined 
for diseases of the liver, gout, diabetes, glycosuria, and 
nephritis. The xanthoma-tubercles have been repeatedly 
observed to retrograde under j)roper general treatment. 
Brocq recommends the internal use of phosphorated oil 
and oil of turpentine. 

Dermatomyomata. — Myomata are rare skin-lesions. 
They occur around the nipples, on the scrotum and ex- 
tensor surface of the arms ; are firm pea-sized tumors, 
which are movable with the skin. The overlying skin 
is more pigmented than usual ; otherwise it remains un- 
changed. 

The tumors are not, as a rule, painful on pressure, 
although some have been described as being sponta- 
neously painful. They develop from the smooth mus- 
cular libel's or from the enveloping or immediately adja- 
cent connective tissue. They start from the arrectores 
pilorum. In a few cases numerous vascular coils and 
nerves have been found along with the hyperj)lasia of the 
cells of the muscles, and such cases possibly represent the 
especially painful little tumors. 

ANGIOMATA. 

A. Naevus vasculosus is most commonly a congenital 
dilatation of the capillaries and smaller cutaneous blood- 



150 DISEASES OF TEE SKIN. 

vessels, and is usually on a level with the skin. The 
color of the vascular nevus is mostly dark red or bluish- 
red, and depends on the predominance of the dilatation 
of large vessels or small capillaries. Dilatiitions the size 
of a split pea are frequently seen scattered irregularly 
over the trunk ; larger naevi vasculosi occur on the face 
(temporal region), hairy margin, nape of neck (Plate 45, a), 
and even scattered over larger portions of the body- 
surface (Plate 45). The larger vascular nevi occur uni- 
laterally and may increase in breadth. The anxiety of 
mothers, therefore, to have the small vascular nevi in 
newly-born children removed as soon as possible is not 
without foundation. Telangiectases are acquired blood- 
vessel new formations, usually consisting of enlarged 
capillaries or a pin-head to pea-sized dilatation, with 
or without enlarged capillaries extending from it. Vas- 
cular dilatations resulting from venous stasis due to 
interference with the return-circulation have been con- 
sidered in their proper place. Venous dilatations often 
form plexuses the size of an egg to that of a fist, which 
are very troublesome, as they frequently lead to inflam- 
mation. They occur on the lower extremities, in the 
spermatic plexus, and in hemorrhoidal veins, and must 
be removed by operation (Dittel's elastic ligature, hot- 
wire loop, or excision). 

B. I<yinphaiig^oma. — The capillary lymphatic ves- 
sels of the skin are dilated owing to interference with the 
flow of lymph either by infiltration and occlusion of the 
larger vessels or by swelling of the lymphatic glands in 
whose domain the lymphatic vessels are situated. Should 
any of these small lymphatic vessels rupture the lymphatic 
fluid oozes forth continuously. Pressure of a bandage 
may also lead to decided dilatations of the lymphatic 
vessels. 

More extensive dilatations of the lymphatics are ob- 
served as nodular formations in a swollen area of the 
skin, and exhibit not only varicosities and dilatations, 
but many new vessels form in the corium. We 



RHINOSCLEROMA. 151 

have observed such swellings on the scrotum and penis. 
Finally, dilatations of the lymphatic vessels, accompanied 
by swelling and hypertrophy of the skin, often over a 
whole region of the body, occur, especially on the lower 
extremities ; these are known as elephantiasis lymphan- 
giedodes, and, with accompanying blood-vessel hyper- 
trophy, closely resemble ordinary elephantiasis. 

iymphangioma Tuberosum Multiplex. — Ka- 
posi and others have described numerous, partly round, 
partly elongate, brown-red nodules lying in and movable 
with the skin, situated on the trunk and region of the 
neck. Not having any personal experience with this 
rare skin-disease, we refer the reader to Kaposi's treatise 
on skin-diseases. 



RHINOSCLEROMA. 

The peculiar disease called rhinoscleroma was de- 
scribed by Hebra and Kaposi in 1870. The affection 
attacks the nose and spreads \Qvy slowly over the skin 
and cartilages of this organ and neighboring parts. It 
may further involve the posterior part of the soft palate, 
the isthmus, larynx, and trachea. The disease spreads 
only by contiguity from the starting-point. Rhinoscle- 
roma attacks individuals about the period of puberty. 
The patients are usually not robust. Although it cannot 
be regarded as a specific hereditary disease, a certain 
predisposition is generally thought to exist. One of 
the alfe or the septum is attacked by the disease and 
the shape of the nose changes gradually without exhibit- 
ing decided signs of inflammation. The nose widens and 
feels rigid and immobile to the touch, ^wing to hyper- 
trophy of the inner walls, stenoses and even complete 
occlusion of the nares occur. After months the whole 
organ, anteriorly as far as the lips and posteriorly as far as 
the choanae, becomes involved. The external picture 
varies, and depends on the presence of tuberosities project- 
ing over the level of the skin or on the presence of uni- 



152 DISEASES OF THE SKIN. 

form hypertrophy of the skin and cartilages, resembling 
plaques. The color may be of various shades of red, 
but is usually brownisii- or bluish-red. Blood-vessels are 
seen running over the surface, which is smooth or finely 
wrinkled, and shiny. In the same manner as stenosis of 
the nasal cavity results, the functions of the lips are also 
interfered with. We also meet with various distortions 
and constrictions in the isthmus faucium, which not infre- 
quently remind one of syphilitic sequelae. 

The patient's appearance suffers considerably, and the 
resulting occlusion of the nose and stenosis of the entrance 
to the larynx and mouth are a source of great annoyance. 
The diseased areas are sensitive to pressure. The affection 
is chronic, extending over years, without necessarily any 
change in the general health. 

Most observers regard the disease as inflammatory, in 
which the infiltration is partly absorbed and partly con- 
verted into connective tissue. 

Specific bacilli have always been found in the tissue of 
rhinoscleroma since Frisch called attention to their pres- 
ence. Paltauf and Eiselsberg found capsulated bacilli in 
protoplasmic masses, which correspond to the cells of 
rhinoscleroma or degenerated nuclei, first described by 
Mikulicz. The rhinoscleroma-microorganisms appear as 
2-3 /i long bacilli, or as ovoid, nearly round, capsulated 
cocci, occurring usually as diplococci, which can scarcely 
be distinguished from pneumonia-cocci. 

The prognosis is unfavorable ; it is impossible to stop 
the process by any treatment. Surgical procedure is 
indicated when adhesions and hypertrophy have ad- 
vanced so far as to interfere with the functions of the 
parts. • 

TUBERCULOUS DISEASES OF THE SKIN. 

In this section we embrace those pathologic changes in 
the skin {inde Plates 46 to 51) due to the tubercle-bacil- 
lus ; they show great variety in appearance, course, struct- 



TUBERCULOUS DISEASES OF THE SKIN. 153 

ure, and pathogenesis. To avoid repetitions, we will 
follow in this section the classical work of Jadassohn 
(Luharsch and Ostertag, 1896); we will, however, first 
briefly touch on a few general points. 

The bacillus may gain entrance to the skin in various 
ways. External tuberculous material may be either 
implanted (exogenous inoculation-tuberculosis) or the 
material originates from an already diseased body — e. g., 
sputum, saliva, feces, and urine (tuberculosis due to auto- 
inoculation). Certain external predisjx)sing calises, how- 
ever, are necessary for the tubercle-bacillus to establish 
itself, inasmuch as the skin does not appear to be favor- 
ably disposed to tuberculous disease. The tubercle-ba- 
cillus may find such points of attack where the skin is 
injured or where cutaneous disease exists — briefly, when 
wounds of the integument are present. On the other 
hand, tuberculosis may find its way from a neighboring 
organ into the skin (tuberculosis due to contiguity) — e. g., 
from a primarily-diseased testicle to the scrotum, or from 
bone to the overlying soft parts. Finally, the bacillus 
may gain access to the skin from a diseased organ by 
metastasis. 

We differentiate clinically five forms of cutaneous 
tuberculosis : 

A. Lupus ; 

B. Scrofuloderma; 

C. The tuberculous ulcer ; 

D. Tuberculosis verrucosa cutis ; 

E. Tuberculosis fungosa. 

Although it would be gratifying if the clinical symp- 
toms of the above-named forms of cutaneous tuberculosis 
were always distinctive, the fact must be emphasized 
that several varieties may exist alongside of one another, 
and that frequently one develops from another. Thus, for 
instance, tuberculosis verrucosa may change into lupus; 
lupus may develop from a scrofuloderma which has already 
cicatrized (Riehl). Along with tuberculous ulcers subcu- 
taneous nodules of scrofuloderma, etc. develop. Taken as 



164 DISEASES OF THE SKIN. 

a whole, however, this, as with other nuiltiforni diseases, 
usually presents in different individuals a distinct type or 
variety. 

All these varieties may terminate spontaneously [excep- 
tional. — Ed.]. The cicatricial formation which in such 
cases, as in all ulcerative processes, denotes a cure, is, 
according to the duration and intensity of the disease, at 
one time slight, at another time more marked, and may 
lead to shrinking and other consecutive changes. Various 
authors h'ave called attention to a temporary lull in the 
course of lupus, and have connected it w ith possible con- 
ditions in the organism itself (pregnancy) or with external 
influences of temperature and weather. 

A. LUPUS. 

Lupus is the most frequent form of cutaneous tubercu- 
losis, and occurs principally on the uncovered parts of 
the body, as the face and hands ; and to a less extent on 
the scalp. It begins in many cases during infancy or 
early childhood, and is met with more frequently in fe- 
males. 

It has been established that its origin in the greatest 
number of cases is due to external inoculation ; but it 
may also be conveyed from tuberculosis of the glands and 
bones, or from diseases of the mucous membrane to the 
skin. In general, the tubercle-bacilli in lupus are very 
scanty ; usually several are capsulated in the giant cells. 
The tubercle in the skin consists of round, epithelioid, 
and giant cells and of a reticulum and vessels. The 
lupus-nodule represents a conglomeration of such tuber- 
cles. 

Lupus begins clinically with the appearance of pinhead- 
to hemp-see<l-sized nodules, which are yellowish-gray or 
brownish-red in color. At first, they are embedded in the 
skin and project only after they have persisted for some 
time, and are covered with a smwith, shiny epidermis. The 
typical nodules at first are also flat and isolated ; the vari- 



LVPVS. 155 

oils clinical pictures of the disease are due to the changes 
which take place — to the lesions becoming contiguous and 
confluent, etc. 

The disease soon begins to spread in areas ; the isolated 
foci are usually sharply defined at the periphery and are 
surrounded by inflammatory infiltrated cutaneous tissue ; 
the round-cell accumulation and infiltration follow the 
vessels. This massed cellular infiltration involves all the 
cutaneous parts. The elastic fibers, hair-follicles, seba- 
ceous and sudoriparous glands are either destroyed or 
only their d6bris remains. The changes in the epidermis 
are connected with the processes in the cutis ; once we 
sjiw rapid death of the epithelium tiike place ; but usually 
the inflammation and irritation lead to hypertrophy of 
the epithelium, especially of the epithelial cones extend- 
ing toward the cutis. The surface of the lupus-foci is 
either smooth or covered with scales ; or hyperkeratosis 
is noted, giving rise to superficial verrucosities. 

We usually meet with sclerosis of the inflammatory 
infiltrate around tiie lupus-tissue, which leads to absorp- 
tion accompanied by cicatricial formation. Less fre- 
quently, and only on account of special causes (spread of 
inflammation, secondary infection), do breaking-down and 
ulceration of the lupus-tissue result. Dry caseation is 
rare in lupus. 

Owing to these anatomic changes, to which we have 
briefly alluded, and especially to the extension — already 
mentioned — of the lupus-growths, we differentiate clini- 
cally lupus tuberculosus, when shiny nodules are either 
disseminated or irregularly grouped ; or when arranged in 
rows or closely crowded, and continuing to spread ser- 
piginously {lupus serpiginosus) and protruding over the 
level of the skin ; lupus fumidus, when the lupus-growths 
take on the form of tumor-formations ; lupus verrucosuSy 
lupus papillomafosus, when the surface appears papil- 
lomatous or wartv ; and finally lupus exulcerans (Plates 
46, 47, 47, c). 

The lupus-ulcers are usually covered with dark-colored 



156 DISEASES OF THE SKIN. 

crusts, the ulcerating surface UDclerneatli, on a level with 
the skin, appears red and moist, bleeds readily, and re- 
sembles granulating wounds. 

The mucous membranes of the nose and oral cavity 
may be the seat of lupus-nodules for a long time without 
giving the patient especial annoyance. They are met 
with on the gums, palate, tongue, and larynx, as brown- 
red, usually ulcerating and readily-bleeding nodules, the 
size of a pinhead to that of a split pea. AVhen they 
coalesce and form large plaques the surface is irregular 
and covered with gray, proliferating epithelium ; or if 
breaking down and disintegrating, form flat or Assured 
deep ulcers. 

As already mentioned, lupus extends from the mucous 
membrane upon the external skin, and vice versd. Defects 
of the palate, due to ulceration and shrinking, and also 
depressed contractions of the tongue — the latter are fre- 
quently associated with firm nodular swelling in the 
neighborhood — are of not unusual occurrence. We have 
often found polypoid vegetations in the nasal cavity along 
with ulceration and crust-formation, completely closing 
the affected half of the nose. These are distinguished 
from translucent mucoid polypi by their granulating sur- 
face and by their tendency to bleed ; mucoid polypi are 
covered with a smooth mucous membrane. Perforation 
of the septum, cicatricial contraction, and distortion are 
the sequelae which frequently follow after the disease has 
existed for years. 

The exterior of the nose, and especially the alte, are 
frequently the points first attacked by lupus. 

The disease spreads gradually from the tip to the root 
of the nose. Papillary elevations at the margin of the 
ulcers, which are continually disintegrating, become cov- 
ered with brown crusts and gradually lead to destruction 
of the entire cartilaginous and exceptionally of the osseous 
structure. Lupus also extends to the cheeks and often to 
the margin of the lower jaw and to the neck ; the sub- 
maxillary glands are not infrequently diseased at the 



LUPUS. 167 

same time and consequently suppurate. Lupus tumidus 
is frequently met with on the lobes of the ears. 

Lupus of the eyelids leads to ectropion and consecutive 
diseases of the bulbus. It is occasionally primary — 
although rare — on the conjunctiva of the bulbus and ex- 
tends to the cornea. On the trunk, especially on the 
nates, we often meet with the papillary, verrucous forms ; 
and w4th the serpiginous varieties on the extremities. 
Owing to cicatricial contraction, the articulations become 
fixed and the parts are deformed and become useless. 
Deformities of the hands, especially unsightly hyper- 
trophies, are attributable to disease of the Ivmphatic 
vessels (Plates 48, 48, «, 48, 6). 

Lupus pursues an exceedingly chronic course. Begin- 
ning usually between the ages of ten and twenty years, it 
extends very slowly, retrogressing on one side, and spread- 
ing serpiginously at the periphery ; undergoes involution — 
i. €., cicatrizes — often completely to recur again. Owing to 
mechanical damage or irritation or intercurrent affections, 
erysipelas, etc. inflammation, disintegration, and ulcera- 
tion result, which frequently lead to very great destruc- 
tion of the face, nose, the soft and hard palates, etc. We 
would add that in lupus erysipelas is especially prone to 
recurrence. 

The cicatricial constrictions interfere with the circula- 
tion, and especially when the disease is upon the extrem- 
ities lead to chronic edema and elephantiasis of the sub- 
jacent or peripheral parts. The spread of the tuberculous 
process along the lymphatic interstices and vessels, owing 
to the attending inflammation, leads to elephantiasic trans- 
formation, which may involve the soft parts and even the 
bones. 

Syphilitic lesions occurring in lupus-infiltration or in a 
resulting cicatrix may occasionally complicate the disease. 
This complication, however, does not justify the use of such 
a term as " lupus syphiliticus," and it should be dropped 
from terminology as meaningless. 

Syphilitic ulcers may, vice versd, owing to infection 



168 DISEASES OF THE SKIN. 

m 

with tuberculous material, be converted into tuberculous 
ulcerations. 

Finally, we will briefly refer to the coexistence of car- 
cinoma and tuberculosis. Carcinoma appears more fre- 
quently in a lupus-cicatrix than in fresh lupus-tissue. 
It starts from the rete or from the glandular organs of 
the skin, and does not originate, as many authors have 
thought, from transformation of lupus-tissue into car- 
cinoma. 

Treatment of I^upus Vulgaris. — Internal treat- 
ment must be directed to improving the general con- 
dition ; any direct influence on the skin-atfection from 
the remedies recommended is not to be expected. 
Success can only result from local treatment carefully 
planned. For the purpose of producing destruction of 
the diseased foci and areas the following methods are 
used : Volkraann's spoon, thorough scarification of the 
affected patches (Balmanno-Squire, Vidal), cauterization 
with Paquelin's cautery, galvanocautery, thermocautery ; 
excision followed by transplantation — a procedure which 
in expert hands leads to good results (Lang). 

For the purpose of producing destruction by chemical 
means the caitdic pokes are employed, as the Vienna 
paste (quicklime, 4 parts ; dried caustic potash, 5 parts), 
zinc-chlorid pencils (obtained by fusing zinc chlorid and 
potassium nitrate, or zinc chlorid and potassium chlorid, 
with a cover of tinfoil), Canquoin's paste (zinc chlorid 
and rye flour, equal parts), Landolfi's paste (zinc chlorid, 
3 parts ; bromin chlorid, 5 parts ; chlorid of antimony, 1 
part). These pastes act on the healthy skin as well as on 
the diseased skin. 

Cosme's paste (arsen. alb., 1 (gr. xv) ; cinnabar, factitiee, 
3 (gr. xlv) ; ung. emollient., 24 (svj)) acts by election — 
i. e., it destroys the lupus-nodules, but leaves the neigh- 
boring healthy skin intact. Elective action can, of course, 
be also obtained with the silver-nitrate stick, and with 
cauterization with carbolic, lactic, and pyrogallic acids. 

We have to note very satisfactory results with a 20-25 



LUPUS. 159 

per cent, ointment of pyrogiillic acid. The pain which 
the application generally produces is not great, and may be 
diminished by adding orthoform. After several days or 
longer the formation of the eschar in the lupus-infiltra- 
tions is complete ; separation and cicatrization are al- 
lowed to terminate under an indifferent ointment (boric- 
acid ointment). 

According to the Unna-Scharf method, sharpened pieces 
of wood (toothpicks, shoemaker's pegs, etc.) which have 
been lying for a few days in the following solution are 
introduced into the lupus-foci : 

^ Hydrarg, chlorid. corros., 1 (gr. xv) ; 
Acidi salicylici, 10 (oiiss) ; 

^ther. sulph., 25 (f 3vj gr. xv) ; 

Ol. olivae, ad 100 (fsiij ,^j). 

All the wooden stumps projecting over the level of the 
skin are then cut off with scissors and the surface thus 
treated is covered with any kind of gutta-percha plaster ; 
the best is Unna's gutta-percha plaster of mercury and 
carbolic acid. After removal of the plaster the sur- 
face is seen to be covered with thin pus. The pieces of . 
woo<l are removed, the surface is cleansed with an alco- 
holic solution of corrosive sublimate or ether, and the fol- 
lowing powder is introduced into the little depressions 
made by the pieces of wood : 

^ Hydrarg. chlorid. corros., 0.10 (gr. iss) ; 

Magnes. carbon., 10 (^iiss) ; 

Acid, salicyl., 5 (.^j gr. xv) ; 

Cocain. muriat., 0.50 (gr.viiss). 

The surface is then again covered with a plaster. 

Schiitz, under an anesthetic, removes all soft tissue with 
the sharp spoon, and very carefully scarifies the floor of 
the wound and about three-fourths to one centimeter of 
the surrounding healthy border. The entire wound 



160 DISEASES OF THE SKIN. 

is then repeatedly painted with a cold saturated alco- 
holic solution of zinc chlorid, to which a little pure 
hydrochloric acid has been added to make it keep and 
remain clear. Very severe pain follows this procedure ; 
the area operated upon and the surrounding tissue swell 
moderately. Compresses of boric-acid solution cause the 
symptoms to disappear gradually, and in one to two days 
the wound is clean. An ointment of pyrogallic acid and 
vaselin (1 : 4) is then applied ; this should be changed 
three times daily. On the fifth day the ointment is 
replaced by compresses of boric-acid solution. After 
the eschar has separated, the parts are again treated with 
the pyrogallic-acid ointment, and after a suitable interval, 
during which compresses of boric-acid solution are again 
applied, the pyrogallic-acid ointment is used for the third 
time. Cicatrization takes place under empl. hydrargyri, 
iodoform bandage, or boric-acid ointment. 

Elsenberg has recommended parachlorphenol as a 
caustic. The other remedies which have been advised, 
such as injections of thiosinamin (H. v. Hebra), can- 
tharidin (Liebreich), tuberculin (Koch), tuberculocidin 
(Klebs), have not stood the test of unbiased criticism. 
Experience with the latest suggestions, such as the hot- 
air treatment (Hollaender, Lang) and illumination with 
X-rays, is not as yet sufficient to warrant an opinion. 

B. SCROFULODERMA (TUBERCULOSIS CUTIS COLLI- 
QUATIVA). 

The primary lesion and clinical feature of this disease 
is the soft nodule. This is characterized by coUiquation 
and formation of a fluctuating tumor. All the pathologic 
processes in scrofuloderma have their starting-point in the 
subcutaneous lymphatic glands and channels ; and in some 
instances even in diseased bone. Inflammation and new 
formation of nodules take place beneath the still movable 
skin. Lat€r the nodular infiltration softens, the overlying 
skin is firmly attached and finally broken through, and an 



THE TUBERCULOUS ULCER, ETC. 161 

indolent, undermined ulcer results. When the process ex- 
tends, new tubercles, tistulse, ulcerations, and cicatrices form. 
Occasionally dispersed tubercles (gommes scrofuleuses of 
the French) are found on parts of the body where we are 
not accustomed to meet with lymphatic glands. We 
have observed numerous abnormally-situated lymphatic 
glands in syphilitic individuals, and agree with Jadassohn 
that subcutaneous tuberculous nodules occurring in such 
localities should be regarded more often as abnormally- 
situated lymphatic glands. 

Such typical cutaneous and subcutaneous tubercles also 
occur in the course of large lymphatic vessels, and are 
subsequent to the skin-affection (Plate 47, 6), or occur 
independently of such a condition. 

Histologically this tuberculous inflammation is charac- 
terized by being more sharply defined than lupus and by 
the greater abundance of pus-corpuscles containing frag- 
mentary granules. The bacilli are few in number; ex- 
perimental inoculation, however, succeeds better than that 
made with lupus-tissue ; and the animals experimented 
upon perish more rapidly of general tuberculosis. 

Treatment. — The general health must be looked after 
with the greatest care and the deteriorated condition of 
the nutrition must be improved as much as possible. 
Locally, surgical methods are especially indicated, and 
the after-treatment is to be conducted on general surgical 
principles. [In superficial conditions the treatment is 
essentially the same as in lupus. — Ed.] 

C. THE TUBERCULOUS ULCER (TUBERCULOSIS 
ULCEROSA CUTIS). 

This form of local tuberculosis, also known as mili- 
ary tuberculosis of the skin, is usually associated with 
grave general tuberculosis, and is due to autoinocula- 
tion or to extension from the mucous membranes. It 
occurs in the cavity of the mouth, on the lips, nostrils, 
anus, and genitalia. The miliary tubercles (formation 
11 



1G2 DISEASES OF THE SKIN. 

of lymphoid cells predominates), the size of a pinhead 
to that of a hemp-seed, show a great tendency to soften- 
ing accompanied by destruction of the diseased tissue of 
the skin. A superficial ulcer with a torpid base results, 
whose margins are serrated, eaten away, and undermined, 
and with outlying new lesions at the border. At the 
periphery depressions may occasionally be seen after the 
miliary tubercles have disappeared, or small whitish-yellow 
nodules are present (Plates 47, a, 47, b, 49, 50, 51). The 
ulcers, especially on the mucous membranes, show a ten- 
dency to papillomatous vegetations. 

Numerous bacilli are found in this form. 

D. TUBERCULOSIS VERRUCOSA CUTIS. 

This form of cutaneous tuberculosis, first described by 
Riehl and Paltauf, is characterized by warty, papillary 
outgrowths on the surface and by the absence of ulcers 
and a dearth of lupus-nodules ; pustules, however, often 
develop. It occurs on the fingers or dorsal surface of the 
hand, and is found in butchers, attendants in morgues, 
and in physicians — in brief, in those having to do with 
manipulation of tuberculous material, and is consequently 
the result of exogenons inoculation. Post-mortem tuber- 
cles, scrofuloderma, or tuberculous ulcers may also result 
from infection of this kind. 

Tuberculosis verrucosa cutis is a localized process. The 
grayish-white, warty papillomata may appear singly or in 
groups, and exhibit a tendency to heal in the center and 
to spread at the periphery. Fully-developed tubercles are 
found in the most superficial layers of the cutis, and 
contain bacilli, with coexisting small-cell, diffuse infiltra- 
tion. The 'pustules mentioned above are minute miliary 
abscesses in the small-cell infiltration, associated with 
collection of pus beneath the epidermis. Cocci have 
been found in the purulent matter of the pustules, which 
the authors already mentioned regard as the pyogenic 
factors. The epidermal involvement, the proliferation of 



LEPRA. 163 

the stratum Malpighii and coriiim, and extension of the 
rete, which is traversed by leukocytes, are the result — as 
is the case in many other diseases — of inflammatory proc- 
esses in the superficial cutis, in which, as has been referred 
to, the deeper layers of the epidermis participate, with 
proliferation and cornification of the upper layers. 
Treatment. — Erasion or excision. 

E. TUBERCULOSIS FUNQOSA (FUNGUS CUTIS). 

Riehl has described a tuberculous infiltration begin- 
ning deep in the bone and periosteum and progressing 
upward toward the soft parts, which leads to formation 
of fistulous tracts and to soft superficial growths, giving 
rise to mushroom-like tumors, which disintegrate de novo 
and form ulcers. We have described such a variety 
on the lower extremity (Plate 47, c). In such a case 
it is quite proper to drop the term lupus, inasmuch 
as in this instance, as in tuberculosis verrucosa, lupus- 
nodules do not occur, tlie disease being characterized 
solely by infiltration and subsequent disintegration, but 
not by colliquation, as is the case in scrofuloderma. 

According to Riehl, bacilli are more numerous in this 
manifestation than in scrofuloderma or lupus. 

LEPRA. 

Leprosy (Plates 51, «, b, c) is a chronic infectious dis- 
ease, due to a specific bacillus, and consists of the forma- 
tion of granulation-tissue growths of varying character 
and extent. 

In Europe it is most common in Norway, the Swedish, 
Finnish, and Russian coasts on the East Sea ; in Asia, in 
India, China, Africa, Egypt, Abyssinia, Morocco ; and in 
America in California and Mexico, in Australia, and 
Sandwich Islands. 

The cause of leprosy is the Bacillus lepne (Hansen, 
Neisser), and its discovery has been the means, contrary 



164 DISEASES OF THE SKIN. 

to the older views, of adding more believers in the con- 
tagious nature of the disease, and that it spreads from 
individual to individual. 

Two chief forms are usually described : lepra tuberosa 
and lepi'a ancesthetiea seu nervosa. As the essential cause 
is the same in both, it can be readily understood that 
mixed forms are frequently encountered. There are cer- 
tain sites of predilection on the general surface, although 
leprous nodules are constantly found in the liver, spleen, 
lymphatic glands, and scrotum in both forms. 

I^epra tuberosa, or tubercular leprosy, attacks 
chiefly the integument and the mucous membranes of the 
nose, palate, roof of the mouth, larynx, and pharynx. 

On the skin the first changes show themselves in the 
form of infiltration ; the skin in one or more places, over 
areas of several centimeters, becomes elevated and assumes 
a brownish-red or dull-red color. In the region of the in- 
filtration the sensibility disappears partly or completely, 
and on hairy parts the hair of the affected area falls 
out. 

After a longer or shorter period (up to several years) 
there develop upon these patches nodular and tubercular 
growths ; they appear as papular lesions, brown to copper- 
brown in color, and gradually increase in size. In the be- 
ginning scattered or discrete, they may later form by conflu- 
ence diffuse masses with a rough, uneven surface. The size 
of the lesions or patches may vary between that of a pea 
and an extensive tumor-like mass. They are hard in con- 
sistence, and the skin-sensibility is reduced or abolished. 
The favorite site for the tuberculous lesions is the face, 
especially the forehead, eyebrows, nose, and lips ; likewise 
the upper and lower extremities, especially the extensor 
aspects. After variable duration the tubercles undergo 
changes, either becoming fibrous with atrophy, or soften- 
ing and breaking down. Ulcerations covered with gray- 
ish coating and with callous borders are the result of this 
disintegration. Direct suppuration of the nodules is 
somewhat rare. The ulcers extend deeply to sinew and 



LEPRA. 165 

bone, the latter being laid bare and necro.sing ; at times 
also the joints are in this manner opened up. 

On the mucous membranes the lesions show themselves 
either as small papules or tubercles, or as round, flat infil- 
trations, which become ulcerated and may heal with cica- 
tricial shrivelling. The results are often conspicuous dis- 
turbances of the affected part — disappearance of the 
cartilaginous nasal septum, the soft palate, and the epi- 
glottis ; stenosis of the larynx is one of the most common 
occurrences. 

Also«on the conjunctiva bulbi, especially at the corneal 
border, characteristic tubercles often develop. 

The disease has a remarkably regular and progressive 
course, inasmuch as new lesions are always presenting 
themselves. The new outbreaks arise, as with the initial 
eruptions, under febrile action ; erythematous reddening 
of the affected parts presenting, which is soon followed by 
the formation of tubercles and nodules. At the sites of 
the older lesions, usually at the time of the fresh out- 
breaks, changes are noted to take place, miliary ab- 
scesses or blebs arising, either of which may end in 
ulceration. 

It is deserving of mention that at the time of these fresh 
outbreaks the lepra bacillus may be demonstrated in the 
blood, in which at other times it is wanting. 

I<epra Anaesthetica sen Nervosa. — Anesthetic lep- 
rosy is characterized by sensibility and trophic disturb- 
ances of the skin and muscles, the new tissue-formation, 
which produces the nodose growths of the tubercular form, 
remaining in the background or entirely wanting. 

The disease begins as a leprous polyneuritis. Its sub- 
stratum is the leprous deposit, with but slight granula- 
tion-tissue formation (leproide) in the peripheral nerves. 
In the early stage rounded spots appear, often confluent, 
and for the most jiart symmetric, of a bright, later dark- 
red color, which in time changes to a brown or dark 
brown. The spots grow by peripheral extension to palm 
size, and usually show a slightly infiltrated edge and 



166 DISEASES OF THE SKJN. 

an atrophic center. The more recent the eruption the 
wider the border of infiltration. With increasing atro- 
phy the color becomes paler and paler, changing to 
a yellowish-brown, the pigment finally disappearing, 
so that the atrophic areas are then lighter in color than 
the surrounding skin. The increase in the atfected area 
takes place by the gradual creeping outward of the infil- 
tration, while the inner portion atrophies. Through this 
manner of spreading and through confluence of neighbor- 
ing patches map-like areas are produced. The attacked 
parts are completely anesthetic. 

The sensibility and atrophic symptoms are the pre- 
dominant characteristics of this type of leprosy. Soon 
follow deep-seated disturbances of sensibility, first thermo- 
anesthesia, later complete anesthesia of the skin, and finally 
anesthesia of the deeper parts, muscles, and bones. 

Among the atrophic disturbances the first are atrophies 
of the muscles, with preference for the thenars (Aran- 
Duchenne type), the interosseals, and the extensor mus- 
cles of the hands. On the lower extremities the first 
muscle to be attacked is usually the extensor of the toes. 
Later there is noted involvement of other nerve-regions, 
especially the face. 

In addition to those already described, the atrophic 
disturbances of the skin are ulcer-formations — pressure- 
ulcers — which are observed most frequently in the form 
of perforating ulcer of the foot. Further, there appear 
in the palm <ieep fissures and rhagades, which may extend 
to the fingers and to the dorsum of the hand. 

One of the most frequent lesions of the skin is bleb-for- 
mation, the so-called pemphigus leprosus. The blebs vary 
in size from a pinhead or pea to a grape or larger, are 
filled with clear liquid, break, and leave livid excoriated 
spots, which by neglect or improper treatment may give 
rise to ulcers. The appearance of the bleb-eruption is 
usually accompanied by general symptoms. Some inves- 
tigators have stated that they were able to find lepra- 
bacilli in the biebs. 



LEPRA. 167 

The deeper parts also show trophic disturbances ; espe- 
cially are the bones of the finger-phalanges so disposed. 
These become necrotic, the phalanx swells, softens, and 
breaks down into a fistule, through wiiich the bone is cast 
off. The result of this recurrent process is a distortion of 
the hand, to which the name of lepra mutilans is given. 

Worthy of mention is the recent conclusion of Sticker, 
which points to the primary effect of lepra as a specific 
lesion of the nasal mucous membrane, especially in the 
form of an ulcer over tiie cartilaginous part of the sep- 
tum. From this primary ulceratine lesion lepra-bacilli 
are being constantly thrown off in enormous numbers. 

The course of the disease is eminently chronic, the 
duration extending between five and eighteen years, the 
anesthetic type being the more prolonged in its course. 
A cure is unknown ; all cases end fatally. [Several al- 
leged cures, or at least a}>parent cures, have been rejwrted 
from time to time. — Ed.] There develops a progressive 
cachexia, due to the persistent ulcerations of the skin and 
to the severe trophic disturbances, and also to visceral 
leprous complications (liver, spleen, kidneys). 

Especially the kidneys show constantly severe paren- 
chymatous changes, without necessarily being the seat of 
the leprous deposits. Visceral leprosy induces severe de- 
rangements of the stomach and intestinal functions, so 
that the patient may succumb to the increasing cachexia 
so caused or to some fatal intercurrent affection. Espe- 
cially is tuberculosis one of the most frequent complica- 
tions which carry off the patient or hasten the fatal end. 

Treatment. — The greatest weight is to be placed 
upon prophylactic measures. In cases in which the dis- 
ease is already established dietetic and hygienic measures 
play a very important part in its management, without 
being sufficient to stay materially the progress of the dis- 
ease. The remedies proposed for the treatment of \e\y- 
rosy, even including the Carrasquilla-serum, have a prob- 
lematical worth. Unna claims that by the administration 
of ichthyol and the local application of ichthyol and pyro- 



168 DISEASES OF THE SKIN. 

gallol to have cured two cases. Also the internal use of 
sodium salicylate and iodid preparations has been praised 
by many. Vidal gives : 

T^ Balsam, gurguni, 

Acacise, da 4 (sj) ; 

Tinct. catechu, 12 (fsiij) ; 

Infus. Valerianae, 60 (f 3xv). 
Sig. — For one day. 

This daily dose is gradually increased 12 (siij) pro die. 

Frequently prescribed is chaulmoogni oil, in the dose 
of 5 to 120 drops three times daily. Locally: 

I|i Ol. cliaulmoogra, 25 (fsvj gr. xv) ; 

Vaselini, 50 (sxiiss) ; 

Paraffin., 10 (siiss). 

Or resorcin salve, 5 to 20 per cent. ; also ichthyol salves. 

MALIGNANT GROWTHS OF THE SKIN. 

The general integument is often the seat of malignant 
new growths, arising spontaneously or through metastasis, 
the cutaneous manifestation being the first evidence of 
the disease. Most of these growths belong essentially to 
the domain of surgery, and are fully treated in works upon 
that subject. It is, however, often the province of the der- 
matologist to see these formations in tiieir earlier stages. 

The most frequent malignant tumors are tiie sarcomata 
and their allied growths, and certain forms of carci- 
nomata. 

In the past several years, on both clinical and histo- 
logic grounds, many growths heretofore classed under 
sarcoma have been recognized as distinct formations. 
Kaposi includes under the name of "sarcoid tumors" 
granuloma fungoides (mycosis fungoides), lymphodermia 
perniciosa, and sarcomatosis cutis, although he recognizes 
the fact that it is difficult to treat of such differently char- 
acterized diseases collectively. 



GRANULOMA FVNGO'JDES. 169 

GRANULOMA FUNGOIDES. 

Gi'anuloTiia fungo'ides is a disease which should be dis- 
cussed separately from the sarcomata (Alibert). This 
chronic skin-disease is distinguished by a progressive 
course and by the formation of infiltrated and tumor-like 
growths which develop rapidly, but which may also 
undergo complete involution. Viewed as a whole, it is 
customary to divide its course into three dififerent stages. 
The disease begins with prodromal erythematous and 
eczematous, intensely itchy plaques on the trunk, on the 
flexors of the extremities, and on the face, especially on 
the forehead. The epiderm in these places exfoliates or 
is covered with thick crusts. [This stage may last from 
several months to several years. — Ed.] 

Owing to the intense itching, the patient is troubled 
with loss of sleep. Gradually individual lesions or patches 
completely' disappear, others heal in the central part and 
spread at the periphery, and there gradually develops 
what Koebner has designated the stage of infiltration — 
second stage. In addition to the infiltrated patches or 
areas, lentil- to bean-sized red protuberances appear, 
which gradually develop into half-rounded tumors of the 
size of a small apple or mandarin orange, and the third 
stage is entered. The color is pale brown to dark red, 
the surface notched or serrated, the center slightly de- 
pressed. At first hard, it gradually becomes softer. 
These tumors also may melt away in the course of sev- 
eral days or a few weeks, leaving nothing but pigmenta- 
tion. More frequently, however, they become necrotic 
and give place to ulcers which bleed readily. The 
patients' general condition, apparently little disturbed in 
the earlier stages, now begins to fall perceptibly ; they 
become marasmic, and the large majority gradually suc- 
cumb to the disease. 

The lymphatic glands are not involved in the process. 
In exceptional cases, at the autopsy, numerous whitish 
bean-sized tumors have been found in the internal organs. 



170 DISEASES OF THE SKIN. 

Histologic investigations of the tumors of granuloma 
fungoides teach that the process consists of cell-growth 
about the vessels, at the bases of the papillfe in the con- 
nective tissue, and about the glands and hair-follicles. 
The cell-growth appears mostly as an infiltration crowd- 
ing out the cutis and the papillary body. The irregular 
collections of round cells are massed in a framework of 
fibrillar connective tissue; and Paltauf intimates that this 
stroma for the most part consists of bundles of cutis-fibers 
pressed asunder. The epidermis in the beginning seems 
thickened ; later, however, it is thin and free from pro- 
liferation-processes. 

Unna calls special attention to the fact that parasites 
can easily localize themselves in the loose, soft tissue, 
and may easily lead to necrotic changes and general 
septic infection. 

The various findings of bacteria and cocci in the 
growths are to be looked upon as belonging to septic 
processes and accidental, and not necessjirily having any 
pathogenic relationship to the disease. 

Most authors are agreed that the tumors of granuloma 
fungoides occupy a middle position between granulation- 
tumors and sarcomata ; in support of such view we have 
the relatively benign character of the disease, the spon- 
taneous involution, and the slight disposition to metasta- 
sis, in addition to the anatomic changes. 

In the external treatment the reducing remedies 
are most commonly employed — resorcin, chrysarobin, and 
pyrogallic acid. 

The best results are promised from arsenical admin- 
istration, along with the external use of the remedies 
named. Surgical treatment is without permanent results. 

The skin-manifestations in leukemia and pseudoleukemia 
consist of various tumors and infiltration-lesions, which, 
judged by external appearances and form, seem to ap- 
proach closely to granuloma fungoides and also to sar- 
comata. Paitsiuf {Transactiorm of the Second International 
Dermatoloffic Congress) calls attention to the existence of 



SARCOMA CUTIS. 171 

the general disease before and at the time of the develop- 
ment of the tumors, and rightly emphasizes that we are 
enabled by the blood-investigation, especially in leukemia, 
very early in the course of the disease to render a diag- 
nosis as to the nature of the tumors and skin-infiltration. 
The blood-investigation dis(!loses a true leukocytosis. 
The number of the red blood-corpuscles is more or less 
diminished and the hemoglobin decreased. Some caution 
is required, however, inasmuch as similar conditions are 
sometimes met with in granuloma fungoides and also in 
sarcomatosis cutis. 

Lyinphodennia perniciosa Kaposi describes as a disease 
characterized by eczematous manifestations and the de- 
velopment of infiltration and nodes, which may be seated 
upon the face, trunk, and extremities. The spread of the 
disease over the forehead, ears, and lips gives the patient 
the apj)earance of facies leonina. 

The disease appears as leukemic tumor-growths or as 
diffused infiltrations in the subcutaneous fat-tissue, over 
which the skin is eczematous. With increase of the gen- 
eral paleness individual growths break down and change 
into ulcers ; swelling of the lymphatic glands also de- 
velops, as well as enlargement of the spleen, the patient 
finally succumbing. At the autopsy leukemic nodes are 
found in the pleura, the lungs, and other internal organs, 
as well as in the skin and glands. 

Similar, if less characteristic, appear the deposits in the 
skin in pseudoleukemia. In this disease also eczematous 
or urticarial manifestations usually go hand in hand or 
precede the node-formation in the subcutis. The sub- 
jective symptoms, as Avell as the further course, are simi- 
lar to those of leukemia, which together with the blood- 
investigation permit a recognition of the disease. 

SARCOMA CUTIS. 

The distinctive sarcomata of the skin appear as the 
typical melanotic sarcoma, sarcoma melanodes. These 



172 DISEASES OF THE SKIN. 

tumors arise from a warty growth or nevus, and witliin a 
few weeks result in pea- to cherry-sized, and also larger, 
painful, dark-blue growths. At first they are hard, but 
later become more succulent. The lymphatic glajids 
become swollen, the nodes break down, and through con- 
fluence there arise larger blue-black plaques. Finally 
metastases take place in the internal organs and the gen- 
eral cachexia leads to a fatal end. 

The melanotic sarcomata are alveolar angiosarcomata 
with pigment-deposit in and between the cells. 

Another form is multiple, hemorrhagic, idiopathic sar- 
coma. Inasmuch as we have had no experience with this 
form, we give a brfef description by Kaposi : " Without 
known cause hazelnut-sized, bluish, firm and elastic, 
rounded, elevated, occasionally grouped or bunched, nodes 
appear having a smooth surface, and being at first ob- 
served on the feet. Later the eruption occurs on the legs, 
arms, and trunk ; and finally swelling of the lymphatic 
glands, and node-formation in the mucous membranes and 
in the internal organs are noted. Individual nodes may 
undergo involution." The pigmentation Kaposi considered 
due to capillary hemorrhages. The duration of the dis- 
ease is from three to eight years, during which time new 
nodes are developing from the peripheral to the central 
parts. The feet and hands are swollen and painful upon 
pressure. The involution of the growths, with formation 
of pigmented cicatricial depression, is the usual course 
with the older nodes ; breaking-down occurs less i're- 
quently. With fever, bloody diarrhea, hemoptysis, and 
marasmus, death finally takes place. At the autopsy are 
found vascular nodes in the lungs, liver, spleen, and in 
the muscles of the heart, and especially in the large 
intestine. 

The treatment of sarcoma is essentially surgical. In 
pigment-sarcoma arsenical treatment should be tried. 
This is the only method which so far has given a good 
result (Koebnei-). 



EPITHELIOMA. 173 



EPITHELIOMA (RODENT ULCER, CANCER, SKIN- 
CANCER). 

The general integument may be primarily the seat of 
epitheliomatous growths, or it may be involved second- 
arily from tumors beneath the skin ; or skin epithelioma 
may finally occur as a metastasis from one or more of 
the internal organs. 

The most frequent primitive form on the skin is the 
epidermic cancer. In the beginning it appears as a flat 
hard papule or tubercle, or as a diffused, uneven, irregular 
growth, or as a subcutaneous nodule involving the skin. 
The chief characteristic of this form of epithelial cancer 
is the so-called pearl-rolls or bodies, the cancroidal 
bodies, which appear as a conglomeration of variously- 
shaped epithelioid cells in the form of waxy, glistening or 
pale-red hard tubercles, which if seated on the surface 
may be readily pressed out. For several years or more a 
flat wart-like growth presents, newer nodules forming on 
the periphery. If the mass breaks down, a flat super- 
ficial ulcer (ulcus rodens) results, secreting scanty fluid, 
which dries to a thin covering or crust. 

Sometimes there results complete exfoliation with cica- 
tricial formation in the center, a new progressive hard, 
waxy-looking edge with contained cancroidal bodies form- 
ing on the borders. Should the scar and the border contain 
pigment, it represents the so-called chimney-sweepers' 
cancer. 

For ten to twenty years such a process upon the skin 
may go on, apparently at times stationary ; sooner or later 
induration, ulceration, contractions, and consequent changes 
in the skin take place, but without the general organism 
being disturbed. 

Some epitheliomata arise out of nodular, more deeply- 
seated tumors, which may reach down to the subcutaneous 
tissue, forming flat growths which break down in the central 
part. These break down earlier than the type first de- 
scribed ; also spread into the peripheral region more 



174 DISEASES OF THE SKIN. 

quickly ; may, however, cicatrize in tlie center, so that 
surrounding a shiny vascular scar-tissue is noted a gar- 
land of fresh epithelial foriuation or tissue. The growth 
may also be papillomatous, which breiiks down more 
quickly, foHowing the course of the more malignant 
form of this variety of cancer. 

The most frequent sites of epithelioma are the eyelids, 
nose, li})s, and less frequently the forehead and cheeks. 
Of importance are the epitheliomas of the eyeliils, which 
gradually destroy the latter, invade the conjunctiva, and 
finally the bulbus (Plate 55, a). 

From the nose and lips the epitheliomatous growth 
may extend to the mucous membrane of these parts. The 
disease may also occur primarily as an independent affec- 
tion on the mucous membranes of the mouth, nose, and 
rectum. The frequent thickenings observed on the mu- 
cous membrane of the cheeks, and especially the tongue, 
are after years' duration oft«u the starting-point of epi- 
thelioma. On the penis, especially about the urethra, 
epithelioma develops, and invades the corpus cavernosum, 
forming small or large ulcers (Plates 54 and 55). The 
lymphatic vessels of the penis and the inguinal glands 
become involved ; at first hard painless tumors form, 
which may break down and become purulent. Epi- 
thelioma of the external genitalia and vagina of women 
behaves the same way, and may frequently be mistaken 
for syphilis (Plate 53). 

Epithelioma occurs generally in advanced years. It 
may appear at the site of slow granulating ulcers or scars 
after syphilis and lupus ; or have its seat, as already 
mentioned, in warts and mucous-membrane thickenings. 
It may exist, as already indicated, ten to twenty years 
without endangering life, till finally, more especially in 
the papillomatous form, more rapid breaking down and 
glandular involvement ensue and the patient dies from 
marasmus. 

Another form of cancer observed in the skin is car- 
cinoma lenticulare, which frequently starts from mammary 



TINEA FAVOSA. 175 

cancer, with redness and hardening; spreads and gives 
rise to an infiltration of the skin, so that the thorax is 
covered with newly-formed masses, as if enveloped in a 
coat of mail (cancer en cuirasse) (Plate 52). 

Treatment. — Surgical methods are of first importance. 
Only when surgical treatment cannot be carried out is 
recourse to be had to other plans. As such, we name the 
destruction of the growth with caustics (lactic acid, acetic 
acid, nitric acid, Vienna paste, zinc chlorid, arsenical 
jiastes), thermocautery, and erasion of the mass with the 
curet. The pyoktanin treatment, as likewise the Adam- 
kiewicz's cancroin treatment, has been abandoned. In 
ulcus rodens, resorcin, pyrogallic acid, in powder or salve 
form (15 per cent, to 30 per cent.), has been recom- 
mended. Lassar recommends subcutaneous arsenical in- 
jections. []\Iany of these cases, and especially in the 
early stages, and those of a superficial ty])e, can be most 
satisfactorily treated with arsenical and ziuc-chlorid 
plasters. — Ed.] 



PARASITIC DISEASES OF THE SKIN. 

The parasites of the skin are of both vegetable and 
animal nature. The diseases induced by their presence 
have naturally a contagious character; such diseases are, 
however, distinct from infectious diseases, which are also 
called forth by parasites (microorganisms), but which, in 
addition to attacking the skin, involve other organs. 

The vegetable parasites of the skin belong collectively 
in the group of pathogenic mould-fungi (hyphomycetes). 

The diseases produced by these parasites are termed 
ilormatohyphomycoses or dermatomycoses. 

Each of the several disease is produced by a special 
fungus. 

TINEA FAVOSA (FAVUS). 

Favus (Plate 56) is due to invasion of the skin by a 
vegetable parasite, the Achorion Schonleinii. This fungus 



176 DISEASES OF THE SKIN. 

consists of numerous wide and branching mycelial threads 
and spores, is found usually on the hairy scalp, and forms 
disc-like yellowish crusts, which show in the center a de- 
pression. The fungus invades the follicles and even the 
sheath of the hair-root, and causes falling of the hair. The 
hairs of the affected spots may be pulled out easily or read- 
ily break off. The color of the discs or crusts is sulphur- 
or straw-yellow. After the crust is removed or falls off 
there is left a smooth atrophic depression. The follicles 
are destroyed and the affected areas are more or less bald. 
Through confluence large masses of crusts are formed. 
The fungus (Plate 65, e) gives out a characteristic mouse- 
urine odor. 

This chronic disease, which usually appears early in 
life and persists through adolescence and manhood, may 
disappear spontaneously, all the follicles having been de- 
stroyed. In such cases the scalp is completely bald, with 
the exception of scattered single hairs or tuf\:s of hair ; 
the skin is thinned, smooth, and atrophic. 

The disease is also met with on other parts of the body, 
although comparatively seldom. The fungus has, in fact, 
been found, in a case of universal favus, even on the mu- 
cous membranes, the patient having died of gastro-enteritis 
(Kundrat). The nails of the hands may also be the seat 
of this vegetable parasite, with the consequent changes ; 
they become opaque, crumble, or break easily, and are 
found permeated with the fungus (Onychomycosis favosa). 

Treatment. — Treatment of the disease on the scalp 
begins with cropping short the hair of the whole region. 
After this the accumulated fungus-masses are removed. 
This is most readily accomplished by softening with oil 
or fats, with or without the addition of carbolic acid or 
naphthol ; and subsequently by thoroughly shampooing. 
When this has been eflPected the diseased areas should be 
depilated, and this should not be limited to the spots, 
but should extend one or two centimeters beyond the 
borders. By gentle traction only the diseased hairs are 
brought away. Lotions of antiseptic solutions and band- 



TINEA FAVOSA. 177 

ages spread with antiparasitic salves may be applied, 
having in view the destruction of the fungus. 

The number of such applications for this disease is a 
very large one. We name the tar preparations, salicylic- 
sulphur salves, alcoholic solutions of corrosive sublimate, 
resorcin, naphthol, creolin, pyrogallie acid, and chrysa- 
robiu : 

^ Chrysarobin, 

Ichthyol, da 5 (gr. Ixxv) ; 

Acidi salicylici, 3 (gr. xlv) ; 

Vaselini, 100 (siij).— M. 
Ft. unguentum (Unna). 

Besnier advises the following salve to be applied at 
night : 

^ Bals. peruviani, 

Acidi salicylici, 

Resorcini, dd 5 (gr. Ixxv) ; 

Sulphur, praecip., 15 (?ss); 

Lanolini, 

Vaselini, 

Adipis lanae, da 30 (^j). — M. 

Pt. unguentum. 

In the morning the scalp is thoroughly washed with 
lukewarm water and soap (tar-naphthol soap), dried, and 
then the following solution painted on : 

I^ Spirit, vini gallici, 100 (.^iij) ; 

Acidi acetici, 0.25-1 (miv-ITlxv) ; 



Acidi borici, 2 (gr. xxx) ; 

Chloroformi, 2 (Htxxx).— M. 

Sig. — External use. 

Pick considers the best method of treatment to cx)nsist 
of daily washing with boric-acid soap, and subsequently 
applying a 5 per cent, to 10 per cent, alcoholic solution 

12 



178 DISEASES OF THE SKTN. 

of boric acid ; in severe cases powdering with boric-acid 
powder, over which is placed moist lint, and then envelop- 
ing the parts with gauze. 

Pirogoff orders the affected parts shaved, and every 
twenty-four hours the following salve to be applied, 
spread as a plaster : 



!^ Potass, carbonat., 


8(3ij); 


Sulphur, sublimat, 


30 (5j); 


Tinct. iodini. 




Picis liq.. 


ad 100 (^iij) ; 


Adipis benzionat., 


200 (5vj).— M. 


Ft. unguentum.' 





Each time before the salve is applied the scalp is to be 
washed with soap and water. 

Zinsser orders the scalp washed with soap and water, 
and shaved ; the scalp is then covered with compresses 
wet with a solution of 3 per cent, carbolic acid or of 
0.25 per cent, corrosive sublimate, over which is placed 
a Leiter coil, through which water of the temperature 
of 52° to 58° C is kept circulating. During the night 
the coil is not employed. 

In carrying out any of the plans mentioned above for 
the treatment of this obstinate disease persistence must be 
enjoined for many months. Culture-tests of the depilated 
hairs must be made the basis of further treatment or its 
discontinuance. 

The treatment of favus on non-hairy surfaces is much 
easier and more satisfactory. The crusts are removed, 
and one of the antimycotic applications already mentioned 
applied to the affected area. 

The treatment of favus of the nails consists in bathing 
the parts in antiseptic solutions, and then applying com- 
presses wet with the solution. Before making the appli- 
cation the nail should be thoroughly scraped with the 
sharp spoon or gently cut away. 



TINEA TRICHOPHYTINA. 179 

TINEA TRICHOPHYTINA (TRICHOPHYTOSIS, RINGWORM, 
HERPES TONSURANS (OF THE GERMANS)). 

The several cutaneous manifestations due to invasion of 
the cutaneous tissues by the trichophyton fungus (Gruby, 
L. Mahnsten), usually designated tinea circinata, tinea 
tonsurans, and tinea sycosis, present externally diverse 
appearances. This vegetable-parasite, consisting of long 
mycelial threads with comparatively few spores, vegetates 
in the upper layers of the epidermis and gives rise to 
greater changes and more diverse clinical pictures than 
does favus. The upper layers of the skin become slightly 
or moderately inflamed, with scaliness and vesicle- or even 
pustule-formation. [It seems now to be established that 
there are two distinct forms of fungus responsible for ring- 
worm — the small-spored fungus (Microsporon Audonini) 
and the large-spored fungus (Trichophyton). Of the latter 
there are several varieties. — Ed.] 

Tinea Circinata (Tinea Trichophytina 
. Corporis). 

In average cases of tinea circinata — ringworm of non- 
hairy parts — one or several pinhead- to pea-sized slightly 
hyperemic spots appear, which soon show slight branny 
scaliness ; the central part begins to clear up, while the 
patch enlarges by spreading peripherally. After several 
days or a week they usually attain the size of a silver 
(juarter. The border is noted to be slightly red and 
scaly, and may even tend to papular and vesicular forma- 
tion, or in exceptional cases small pustules may develop. 
The central part clears up, the skin being there pale red 
or pale brownish, free from scaliness or with trifling 
exfoliation. The outer part of the circle is usually some- 
what more scaly, but this is rarely pronounced. The dis- 
ease may remain stationary, or the patches may extend 
somewhat ; or new spots may show themselves. As com- 
monly met with there are rarely more than three to ten 



180 DISEASES OF THE SKIN. 

areas. The older patches gradually disappear with slight 
scaliness. This frequently takes place after one or two 
weeks ; usually as the result of the application of some 
home-remedy of an antiseptic character, or it may spon- 
taneously disappear. In some cases the areas are per- 
sistent and demand more energetic applications, which 
will be referred to later. 

[Under the name " herpes tonsurans disseminatus," the 
author describes a manifestation, which is considered in 
this country to be independent of the ringworm-fungus, 
and to represent the disease known as pitytiasis maculata 
et eircinaia. At all events, it represents in its clinical 
manifestations the disease here referred to, and the atlas- 
plate (Plate .57), which in the original is put down as 
illustrative of " herpes maculosus et squamosus," has ac- 
cordingly been changed to that of pityriash maculata et 
cireinata. The author's description, somewhat abbreviated, 
will be given in his words and with his title. — Ed.] 
" Herpes tonsurans disseminatus [pityriasis maculata et cir- 
einata — Ed.] presents itself over extended surfaces (abdo- 
men, back, breast) in rapidly successive, small pale-red 
spots with irregular borders, which present in the center 
a small scale. Near by, and especially on the lower parts, 
new spots develop in a few days. The older scales in the 
center extend irregularly toward the peripheral parts, so 
that the center may have entirely recovered and the scali- 
ness be found chiefly on the outer portions. Sometimes 
before this general outbreak an old circumscribed patch 
may be found. The patches often attain the size of coins. 
Owing to the peripheral spread and the central involution 
they are often annular, the central part is finally without 
scaliness and merely pigmented, the peripheral part still 
scaly, reddened, and covered with flat adherent scales." 

Eczema marginatum (Plate 26) is a name originally 
given to a disease involving usually the crurogenital 
region, which was subsequently found to be due to the 
ringworm-fungus. It arises on sweating, superficially- 
macerated regions, which furnish a good soil for the 



TINEA TRICnOPHYTINA. 181 

vegetation of the parasite. The skin becomes infiltrated, 
reddened, and scaly, and shows peripherally a sharply- 
defined, elevated edge beset with vesicles and crusts. 
The nature of the region involved prevent the involu- 
tion which takes place in patches of the disease when 
seated elsewhere ; instead, the skin thickens, and is either 
reddened or pigmented. Through confluence of several 
such areas the disease may involve the whole genital 
region, thighs, scrotum, and extend upward beyond the 
pubes ; it is irregular in outline, and gradually spreads out- 
ward. This disease, owing to heat, moisture, and friction 
of the parts, is very troublesome, itchy, and painful ; 
especially in soldiers after long marches. 

In a similar manner to that just described the regions 
of the axillae, the anal fold, and the under part of large 
loose-hanging breasts in women may be the seat of the 
disease. 

In ringworm, as in favus, the nails may also be In- 
volved, together with the disease on other parts or inde- 
pendently (onychomycosis trichophytina). The fungus 
presses into the nail-substance, and it may in this way 
become opaque in spots or the entire nail may become 
milky and fragile. Less frequently the nails may be 
more severely involved — increased in size, bent, and dis- 
torted (onychogryphosis trichophytina). It is extremely 
persistent, much more so than ringworm of non-hairy 
parts, and may even be more so than the disease upon 
the scalp. 

Tinea Tonsurans (Tinea Trichophytina Capitis). 

Tinea tonsurans, or ringworm of the scalp, presents at 
first a somewhat similar appearance to a patch of the dis- 
ease on other parts. These characters are, however, soon 
lost. The fungus penetrates the hair-substance, between 
the cells of the cortical substance ; the hairs become 
lusterless, break easily, and some fall out. The broken 
ends show brush-like extremities. Some break oil' just at 



182 DISEASES OF THE SKIN. 

the margin of the follicle and appear as black specks in 
the duct-opening. The follicular outlets in the earlier 
stages are somewhat more prominent, like goose-flesh, 
from the crowding of cells and fungus. One or several 
patches may be present, and may attain the size of coins 
or larger ; if two or three are close together, they may 
fuse and an irregularly-shajjed area result. 

The patches vary in size, and are usually covered with 
slight scaliness and occasionally with crusting. The 
fungus tends to press into the hair-follicles, and there 
may develop follicular and perifollicular irritation, with 
suppuration and marked exudation ; in some cases with 
considerable circumscribed swelling (tinea kerion). The 
disease shows no disposition toward spontaneous recov- 
ery, though it may remain stationary. [It rarely persists 
beyond the age of fifteen years, and is only exceptionally 
met with in the adult. — Ed.] 

Tinea sycosis, parasitic sycosis, or barber's itch, is a 
disease of the bearded parts of the face due to the ring- 
worm-fungus. The process may remain a superficial one, 
resembling somewhat ringworm of the scalp; but more 
commonly it develops into the classical type of the dis- 
ea.se, consisting of considerable lumpiness and nodulation, 
with more or less hair-loss and suppuration. 

The trichophyton is conveyed from man to man ; fre- 
quently, however, from domestic animals to man, as, for 
example, from cats and dogs to children, from horses and 
cattle to those whose occupation brings them in contact 
with such. Shaving also oifers a good opportunity for 
conveyance of the disease. 

Treatment. — In the treatment of ringworm of non- 
hairy parts all remedies capable of bringing about active 
exfoliation of the epidermis are useful. The most im- 
portant of this group is sapo viridis, which is to be ap- 
plied to the affected areas as a salve, repeatedly rubbed in 
and permitted to remain till mild exfoliation is set up. A 
combination with naphthol is commended by many der- 
matologists ; but, according to our experience, it does not 



TINEA VERSICOLOR. 183 

seem to be more efficient than the soap alone. Applica- 
tions of tar, chrysarobin (as salve or 5 per cent, chrysa- 
robin solution in liquor gutta perchse), corrosive sublimate 
(1-2 per cent, strength), and iodin tincture are also valu- 
able. 

In treatment of the disease upon the scalp, after re- 
moval of the crusts or scales in the ordinary manner (see 
Favus) the hairs of the affected areas are to be extracted, 
and then one of the antimycotic remedies applied. In 
general, in addition to those already named, the same 
remedies employed in the treatment of favus of the scalp 
may also be used in this disease. Kaposi recommends : 

B^ Ol. rusci, 15(fgss); 

Sulphur, priecip., 10 (siiss); 

Tinct. saponis viridis, 25 (fsvj) ; 

Spirit. lavandultB, 0.5 (UTtviij) ; 

Bals. Peruvian i, 1.5(gr. xx); 

Naphtholi, 0.5 (gr. viij). — M. 
Sig. — External use. 

In ringworm of the bearded region it is also necessary 
that careful depilation should be practised. The reme- 
dies to be employed here, as salves, are chrysarobin (with 
caution), anthrarobin (10-20 per cent.), resorcin, precipi- 
tated sulphur ; corrosive sublimate (in solution"), gray 
plaster, iodin tincture, and acetic acid : 

I^ Acidi acetici, 10 (siiss) ; 

Sulphur, prsecip., 2.5 (gr. xxxv). — M. 

Ft. pasta. (Kaposi). 

The treatment of ringworm involving the nails is the 
same as that employed in favus of these parts. 

TINEA VERSICOLOR. 

Tinea versicolor, pityriasis versicolor, chromophytosis, 
or, as popularly believed, " liver-spots," is due to in- 
vasion of the epidermic tissue by a vegetable parasite, the 



184 DISEASES OF THE SKIN. 

Microsporon furfur (Eichstedt). This fungus is readily 
recognized under the microscope by the bunching of 
large masses of spores with mycelial threads between 
(Plate 65, Fig./). The fungus invades the outer skin ; 
the hairs and nails are not involved. It is to be found 
especially in the uppermost layers of the epidermis. 
With the exception of the face, hands, and feet, the erup- 
tion may be found upon any part of the body. As a rule, 
its chief seat is on the trunk, and especially the upper 
part, particularly on the anterior aspect. It is practically 
never seen elsewhere except in connection with the dis- 
ease on this region. The lower trunk, the axilla?, flexors 
of the arras, the crural fold, and the poplitea are some- 
times involved. [In several instances the lower part of 
the face has also been invaded, extending from the neck. 
—Ed.] 

The eruption consists of variously-sized yellowish, 
brownish, or fawn-colored spots, not elevated, or at least 
not perceptibly so. They may become confluent anil 
form large irregular areas; even the whole upper trunk 
may be uniformly covered. There is usually slight 
branny scaliness, visible upon close examination. The 
disease begins with one or several spots, and then gradu- 
ally spreads and increases. It is usually slow in its 
progress, and lasts for years, practically showing little if 
any tendency to spontaneous disappearance. In sensitive 
skins, especially in women, the eruption may have a pale- 
red tint. It gives rise to no discomfort, except slight 
itching when the patient is heated, although exceptionally 
itching may be quite a factor. 

The transference of the fimgus has been proved ; but it 
apparently requires a peculiar susceptibility of the indi- 
vidual. It is found frequently in phthisical patients ; 
and such persons, as well as others affected, are fre- 
quently subject to recurrences. After long continuance 
the disease may finally disappear in advanced years. 

Treatment. — Soap-and-water baths ; applications of 
tar, chrysarobin, naphthol, iodin tincture. Wolff' recom- 



ACTINOMYCOSIS. 185 

mends alkaline baths, and after the baths the rubbing in 
of an ointment containing corrosive sublimate, one-fourth 
to one grain to the ounce. 

ERYTHRASMA. 

Erythrasma occurs from invasion of the cutaneous tis- 
sue by the Microsporon minutissimum (Burchhardt, v. 
Bjirensprung). This fungus permeates the epidermis, and 
consists of numerous fine threads and conidia ; Dr. Reale 
(Clinic of de Amicis) has succeeded in making cultures. 
The disease is seen especially where two surfaces come 
tf)gether, as on the inner surfaces of the thighs, in the 
axillje, etc. ; and is characterized by slightly-scaly, palm- 
sized, brownish spots. The skin in the involved regions 
is often macerated, presenting intertrigo. The affection 
runs a very chronic course. 

Treatment. — For treatment the reducing remedies 
are recommended, as tar, chrysarobin, anthrarobin, pyro- 
gallic acid, or combinations of tar and pyrogallic acid and 
of tar and naphthol. 

ACTINOMYCOSIS. 

This disease (Plate 61) occurs most frequently pri- 
marily on the jaw or neck. It spreads gradually and 
gives rise to inflammatory symptoms, infiltration, ab- 
scesses, and fistules. In the deeper parts the disease 
spreads as proliferating granulation-tissue, and may even 
involve the bones. 

The cause of the disease is the ray-fungus (Plate 65, a), 
actinomyces ; this fungus is also found in cattle and swine. 

It is probable that the assumption that the disease is 
conveyed to man through vegetable food is correct. 

The duration of the process depends somewhat upon its 
location ; generally, however, long-continued suppuration 
and fever lead to marasmus. 

If early recognized, the disease may be limited by 
energetic cauterization or by surgical measures (thermo- 



186 DISEASES OF THE SKIN. 

cautery). Potassium iodic! has been recommended for 
internal administration. 

THE ANIMAL PARASITES OF THE SKIN. 

The animal parasites of the human skin may be con- 
veniently divided into three classes : 

1. Those which live in the skin or subcutaneous tissue; 

2. Those which persistently or temporarily live on the 
skin and suck blood ; 

3. Those which only accidentally are found upon the 
skin, and give rise to symptoms of cutaneous irritation. 

SCABIES. 

In the first class of greatest importance is the Acarus seii 
sdrcoptes hominiiis (Plate 64, Figs. e,f, </, A), the cause of 
scabies or itch, an affection of the skin attended with in- 
tense itching. The impregnated female mite penetrates 
the upper layers of the epidermis and makes a burrow in 
which she deposits her eggs. After the larvae have been 
hatched out they begin to burrow also, and the irritation 
thus provoked gives rise to irritation of the skin, in- 
creased by the uncontrollable scratching, and to various in- 
flammatory lesions of the skin (Plates 62 and 62, a), such 
as papules, vesicles, pustules, ecthymata, and excoria- 
tions. 

Treatment. — Thorough application of one of the 
salves to be mentioned, with special care for those parts 
of the body which are most favored by the acarus, as 
between the fingers, hands, elbows, axillae, shoulder-region, 
breast-nipples, the waist-region, lower abdomen, genitalia 
(especially in men), nates, knee-region, and ankles. After 
the rubbing the patient is enveloped in a woollen cover 
or puts on woollen underwear. As a rule, this rubbing is 
repeated morning and evening for two days, and on the 
fourth day a bath is to be taken. The patient's bod is to 
be carefully looked after, and disinfected. For inuhctions 
the following are recommended : 



SCABIES. 187 

T^ Naplitholi, 15 (siiiss) ; 

CretsD alb,, 10 T^iiss) ; 

Saponis viridis, 50 (sxiiss) ; 

Adipis benzoinat., 100 (siij)- — M. 
Ft. unguentum (Kaposi). 

Wilkinson's ointment, as modified by Hebra : 
^i Sulphur, sublimat., 

Ol. fagi, 

Saponis viridis, 

A(lipis benzoinat., da 80 (.liiss) ; 

Cretaj alb., 5 (gr. Ixxv).— M. 

Ft. unguentum. 

Or the salve recommended by Weinberg : 
^i Sulphur, sublimat., 

Styracis liq., 

Cretae alb., da 20 (sv) ; 

Saponis viridis, 

Adipis benzoinat., dd 40 (sx). — M, 

Ft. unguentum. 

Or Paltauf's styrax mixture (styracis, 4 parts; ol. 
olivffi, 1 part). 

Or Peruvian balsam, about nine grams (sij) for each 
inunction. 
Or 

^ Potass, carbonat., 25 (svj) ; 

Sulphur, prwcip., 75 (Sxviij) ; 

Ol. lavandulae, 

Ol. caryophylli, dd 1 (gr. xv) ; 

Adipis benzoinat., q. s. ft. unguent. 

Or a 5 to 10 per cent, losophan salve : 

^ Losophani, 5-10 (gr. Ixxv-siiss) ; 

Leni calore solut. in 
Ol. olivffi, 20 (3v); 

Adipis benzoinat., q. s. ad 100 (liij)- — M. 
Ft. unguentum. 



188 DISEASES OF THE SKIN. 

Hardy's method for rapid cure is as follows: The 
patient is thoroughly and vigorously rubbed with sapo 
viridis over the entire surface, after which he takes a luke- 
warm bath. After the bath he is rubbed with Hardy's 
modification of Helrarich's ointment : 

]^ Sulphur, sublimat., 20 (sv) ; 

Potassii carbonat., 10 (siiss) ; 

Adipis benzoinat., 80 (Biiss). 

The salve is permitted to remain on for twenty-four 
hours, and then the patient again takes a bath. 

The irritation brought about by the use of these active 
remedial applications, as well as that which has resulted 
from the scabietic irritation itself, is to be treated accord- 
ing to the rules governing the treatment of eczema. 

The hair-follicle mite, the Acanis folliculorum {Demo- 
dex folliculonim) (Plate 64, Fig. i), is a harmless parasite, 
which is observed frequently in acne-cases in the glandu- 
lar ducts and sebaceous glands, but provokes no irritation 
worthy of mention. 

Cysticercus CeUulmce Cutis. — The larvte of Taenia 
solium, the Oysticercus cellulosce, live in pigs, deer, dogs ; 
and also in man, acquired by swallowing the embryos. 
It is to be found most frequently in the eye and brain, 
but also in other organs, as well as in the subcutaneous 
tissue, giving rise to an oval nodule. In the connective 
tissue the growth reaches about the size of a pea, and 
causes no •discomfort. Owing to its seat in internal or- 
gans, however, the disease is dangerous. The cystioercus 
seldom dies spontaneously ; in such event the nodule slowly 
undergoes calcification. 

A tropical parasite, the Filaria medinenms, the guinea- 
worm, is to be found in the subcnitaneous tissue, especially 
in the neighborhood of the ankle-joint, etc. The larvae 
probably gain access through drinking-water. The pain- 
ful cutaneous symptoms are accomjxinied by fever. There 
arises often a painful tumor or ulcer in which the worm is 



PEDICULOSIS. 189 

to be found ; the disease may, however, disappear without 
these occurrences under the skin. 

Pulex penetrans, the sand-flea, comes from South 
America. It bores into the skin, especially the lower leg 
and toes, where inflammatory lesions with pus-formation, 
and even lymphangitis and necrosis, may be caused. 

CREEPING-DISEASE. 

By this name Crocker has designated a peculiar skin- 
affection which occurs most frequently in children, or 
upon exposed situations in adults. In Vienna Professor 
Neumann, and subsequently Dr. Ehrmann and Dr. Rille, 
and Russian and other English physicians, have also 
observed it. It appears as an itching or burning spot, 
from which a fine red elevated line extends through the 
skin in any direction. This line is either straight, zigzag, 
or bowed, quite irregular, and lengthens from day to day. 
The fresh progressive line is bright red, about 1 mm. 
wide, and slightly elevated ; the older lines are flat and 
pale brown. The progress is not constant, but limits 
itself to a few hours daily, especially in the night. 

It is believed that an animal parasite which bores simi- 
larly to a mole is the cause. Efforts to secure the same 
have up to the present time been fruitless. 

Therapeutically it is advised that the progressive end 
of the line be excised ; according to experience, it is nec- 
essary that considerable surrounding tissue be included. 

PEDICULOSIS. 

To the second class of animal parasites belong the 
pediculi or lice : the Pediculus capitis (Plate 64, 6), 
Pediculus vestimenti seu corporis (Plate 64, c), and Pedic- 
ulus pubis (Plate 64, d). The bite of the louse is attended 
with intense itching, which causes scratching and as a 
further consequence possibly eczema, as we have already 
intimated. 



190 DISEASES OF THE SKIN. 

Pediculosis Capitis seu Capillitii.— In head-lousi- 
ness, in consequence of the exudation and eczematous 
irritation produced on the surface, tangling and matting 
of the hair, and even plica, may result. The scalp of such 
a person has a mouldy smell, and only after removal of the 
hair, which requires much care and trouble, can the scalp 
with its enveloping crusts be seen. I^ice, nits (ova), 
attached to the hairs are to be found, and even maggots 
may be present, and complete the picture in cases of gross 
neglect. [Fortunately such extreme cases are rarely, if 
ever, seen in this country. — Ed.] 

Pediculosis Corporis seu Vestimenti. — In pedic- 
ulosis corporis numerous linear scratch-marks may be 
seen upon the skin ; in neglected cases eczema, furuncles, 
and cutaneous abscesses may be produced. 

Pediculosis Pubis. — Tlie Pediculus pubis, or crab- 
louse, is to be found on all hair-regions except the scalp, 
although its common habitat is the pubic region. The eggs, 
or nits, as with those on the scalp, are found glued to the 
hair-shaft (Plate 64, a). By careful inspection the lice may 
be discovered close to the skin at the root of the hair. 

In addition to the artificial eczema produced by the 
irritation and scratching, we not infrequently notice on 
the trunk and also on the thigh bluish rounded spots 
(maculae cserulese, Plate 63), which, according to Mallet, 
are said to arise from injection of secretion from the 
salivary glands near the middle part of the breast; 
these marks disclose the migration of the crab-louse 
over the skin. 

The bed-bug (Cimex leetularius) lives in the crevices 
of furniture, especially beds, and during the night feeds 
upon man. Its bite gives rise to papules or wheals. 
Similar lesions are provoked by the Fulex irntans, com- 
mon flea, although the central hemorrhage is more dis- 
tinct. The female lays its eggs in the clefts of floors and 
furniture and in dusty places. Such eggs have even been 
found on the body of dirty individuals. 



PEDICULOSIS. 191 

To the third class of animal parasites belong the 
harvest-mite (Leptus autumnalls) and the tick (Ixodes 
ricinus), which bite into the upper skin, and give rise to 
papules, wheals, slight edema, and pain. A similar para- 
site is Dennanyssus avium, which chiefly attacks fowl, 
but may also attack man. 

In this class also belong the several kinds of gnats 
(Oulicid(c) and flies (Stornonyidfe), which suck blood and 
provoke wheals and other symptoms of irritation. 

Also many QJstrkkc (3Tijiasis dermatosa oestrosa, O. 
Nagel) are to be found, chiefly in tropical countries, on the 
skin of man and cause boil-formation. 



PLATE 1. 
Pompholyx. 

S. J., aged 25 years, a laborer, was admitted Jan. 16, 1897. 
The patient had sought hospital-treatment for the relief of 
swelling and tenderness of the feet. Sweating of the feet had 
existed in a mild degree since early childhood. He had pre- 
viously been an inmate of the hospital in 1894, with articular 
rheumatism ; and at that time the soles of the feet were already 
the seat of immerous disseminated and confluent plaques of 
loose epidermic scales and some small vesicles ; the nails were 
thickened and brittle. 

Status Praesens. — The malleolar regions are swollen and 
tender upon pressure. The soles are covered with sweat and are 
studded with pinhead-sized red papules, persistent under press- 
ure ; .similar lesions are seen at the edges of the soles, less abun- 
dantly on the dorsum of the feet and lower instep. In many 
places these lesions have changed into vesicles; and in other 
places, especially the plantar region, these vesicles have become 
confluent and form large bleljs with milky contents. The skin 
of the entire plantar surface, the borders, and dorsum of the 
feet, is red, as if inflamed. 

Jan. 25. — The vesicles, for the most part., have become con- 
fluent and form larger lesions, so that both plantar regions are 
covered with lentil- to bean-sized milky blebs. The borders of 
the soles show numerous minute hard epidermic granules, 
which are seated in the glandular outlets and which can be 
readily pressed out. Under the uplifted epidermic flakes there 
is apparently slight depression covered with new epidermis 
having distinctly visible gland-ducts. In some blebs the secre- 
tion has become white, thick, and cheesy. The epidermis be- 
tween the plaques and more active spots is beset with numer- 
ous minute, hard, deep-lying granules having a yellowish 
aspect. The epidermis of the soles is swollen, sodden-looking, 
and whitish, and in places reddened as if the result of macera- 
tion. The palms are moist. 

Examination of the cheesv contents of the blebs mentioned 
showed epithelium, epidermic flakes, and debris. 

The patient was, after a month's treatment Avith mild and 
softening salves, discharged ; the parts had become covered with 
new epidermis. 

[In the German edition the author describes this plate under 
the heading " hyf)eridrosis of the feet with vesicle- and bleb- 
formation." It pictures to the English and American mind, 
however, what is usually considered pompholyx ; although this 
latter is rarely limited to the feet, as in this instance. In the 
text, however, the author refers to this plate when describing 
pompholyx. — Ed.] 



^ 




\ 



1 



\ 



\ 



PLATE 2. 
Milium. 

I. J., siged 18 years, servant-girl, came under notice July 23, 
1897. 

Status Prsesens.— On the face are to be seen grayish and 
yellowish-white, hard, irregularly scattered, pinhead-sized ele- 
vations. By puncturing the overlying epiderm the contents, 
consisting of lirni white bodies, may be readily scratched or 
pressed out. 





.M^ 




-^^ 



Lith.Anst t: Reidihald Munrhcn 



PLATE 3. 
Adenoma Sebaceum. Comedo. Acne. 

F. G., aged 22 years, workman, admitted Feb. 18, 1896, states 
that when 17 years old the inflammatory acne-nodules first 
appeared ; at this time he also noticed the appearance of black 
points, and the nodular tumors, lentil to pea in size. The dis- 
ease had now lasted five years. 

Status Prsesens. — The man is well developed, pale, with 
moderate amount of flabby panniculus adiposus. The extensor 
surfaces of the extremities show lichen pilaris. On the forehead, 
alae of the nose, especially in the nasolabial folds, on the cheeks, 
more particularly toward the scantily-bearded portion, numer- 
ous comedones are to be seen ; scars from former suppurating 
follicles, acne-nodules, and adenoma in the region of the chin. 
In the clavicular region are sparsely-scattered comedones — in 
great numbers, however, over the sternum ; also adenomata, 
and scars varying in size from a pea to a dime, resulting from 
similar previous growths which had suppurated. 

The back is thickly beset with acne-lesions, brown pigment- 
spots, and comedones. 



Tab.:). 




/Stft^^r 




I 




lith A„,f F Hoirhhnlil U,inrh„ 



PLATE 4. 

Morbilli (Papular Form). 

F. F., aged 19 years, a domestic, wtis under observation from 
May 5 to 12, 1897. Patient wa« taken ill three days previously, 
with sore throat and repeated sweats ; for the last day running 
from the eyes and an eruption on the trunk. 

Status Praesens. — The patient is medium-sized, strongly 
built, and well nourished. The face is thickly beset with pin- 
point-sized reddish papules with a minute dark-red areola. On 
the breast and neck the eruption is similar, except that the 
papules are smaller and flatter and the areola less marked. 
While plentiful upon the breast, the eruption is wanting upon 
the back toward the waist. The eruption is present, but less 
abundantly, upon the abdomen ; more profusely on the thighs 
and the inner sides of the knees. The lower part of the legs is 
entirely free. The upper extremities show the rash, extending 
down to the forearms. Conjunctivae injected. Soft palate 
slightly red ; tonsils considerably enlarged and red in spots. 
Patient is without fever. 

Pulse and respiration normal. No subjective symptoms. 
Specific gravity of urine. 1011; slightly acid; free from albu- 
min. 

The patient remained free from fever, and Wiis discharged 
cured in seven days, during which period the catarrhal symp- 
toms and the eruption gradually disappeared. 



Tab. 




l.iOi . Arist. J-: Heulttwld. Mtiiithen 



PLATE 5. 
Varicella. 

A. S., aged 21 years, a domestic, admitted on Nov. 7, 18%, 
was taken sick three days previously witli fever, headache, 
and sore throat ; for the last two days an eruption had been 
present. 

Status Prsesens. — Tlie eruption is less abundant upon the 
face, neck, and buttocks than upon the trunk and extremities. 
The recent efflorescences are miliary in size, slightly elevated 
above the skin-level, and of a bright-red color. In their further 
development thej- change to rounded vesicles containing serum, 
and have an irregular red border. 

Nov. 12. — The older vesicles show seropurulent and purulent 
contents; the more recent vesicles are still distended with 
serous fluid; all are surrounded with inflammatory areola. 

N(rv. 16. — The vesicles have, for the most part, dried to brown- 
ish crusts. 

Nov. 20. — The pustules have dried up ; most of the crusts 
have fallen off, leaving pale-brown spots. 

Nov. 26. — Patient was discharged cured. During the entire 
course the temperature was not materially elevated. 





Tah.A 



Sa 



C- A^ 



^ -^ » 



CJ 



«*-> 



o 



C 



Lith, Anst H ReicMiold. i4iinchen. 



PLATE 6. 

Erythema Muitlforme Erythematous and Erythemato- 
papulari. 

G. J.. aged 32 years, a waiter, was admitted Apr. 20, 18%. 
Two days previously, following, as the patient believed, the 
eating of roast pork, an eruption appeared on the face and on 
the hands and feet. 

Status PrSBsens. — Patient is strongly built. An eruption 
consisting of bluish-red, slightly-elevated spots, with a bright- 
red areola, becoming pale upon pressure, is to be seen, sym- 
metrically arranged, on the dorsal surface of both hands, the 
extensor aspects of both forearms, and likewise upon the lower 
extremities and the large toes ; also the same characteristic 
eruption upon the forehead. These efflorescences are for the 
most part circular in shape, here and there several running 
together and forming dollar-sized areas. The palms, the soles, 
the mouth, and throat are free. 

Following the internal administration of oil of mint and oil 
of eucalyptus the eruption gradually flattened without any fresh 
exacerbation, and disappeared with very slight desquamation. 
The patient was discharged cured eight days after admission. 



.5r 




. 




/;//; 



l.iih . Anst F. Reichtwid. Miinrhen . 



PLATES 7 and 7a. 
Erythema Multiforme (Vesicular and Bullous). 

S. A., aged 16 years, locksmith's apprentice, admitted Mar. 
18, 1897, noticed tliree days previously, on awakening in the 
morning, an eruption consisting of small translucent vesicles 
seated upon a red base. The first lesions were observed on the 
axillary folds and the flexor surface of both forearms. Itching 
was quite marked. The individual vesicles grew larger, and 
new lesions appeared, in the course of a few days, on the trunks 
and extremities. During this time the patient had feelings of 
heat and chilliness. 

Status Praesens. — Patient small, slender, with very little 
fiit-tissue. No elevation of temperature; pulse 80, and regular. 
The urine contained traces of albumin and nucleoalbumin. 

Efflorescences are to be seen on the face, especially about the 
cliin, on the neck, profusely on the anterior thoi*ax, on the ab- 
domen, back, and upper and lower extremities. They vary in 
size from a pinhead to a .-iilver (juarter; are pale red, rounded, 
and somewhat elevated like wheals. They become somewhat 
paler on pressure, here and there leaving a yellowish tinge. In 
certain regions, as the anterior thorax, the clavicular region, 
and the outer side of the forearms, they have become con- 
fluent, forming large irregularly shaped groups and areas. 
In the center of many of the efflorescences there is a blood- 
crust. Near by these efflorescences, scattered over the entire 
surface, are countless millet-seed- to bean-sized vesicles with 
clear contents, and for the most part well distended. Where 
the vesicles are broken the reddish base is observed to be cov- 
ered with dried yellowish secretion. In the neighborhood of 
the left collar-bone is an accumulation of thick hemorrhagic 
cru.st*. On the back are two or three blebs with hemorrhagic 
contents. In this region also are numerous scratch-marks. 
There are a few blebs on the dorsal surface of the feet. The 
vola' manus, the soles, lower jiart of both legs, and the joints 
are free. The mouth and throat are likewise exempt. 

Mar. 19. — General condition good and no fever. 

Mar. £2. — Numerous blebs filled with pus; some hemor- 
rhagic. No new lesions. 

Mar. ;?.-?. — Erythematous spots have disappeared ; superficial 
abra.sions mark the sites of burst or broken blebs. 



Mar. 25. — Temin'raturo 87.7° C. Many of the abrasions are 
skinning over. 

Mar. 29. — Some fi-esh blebs on forearms and face. Tempera- 
ture 38.3° C. 

Mar. 31. — The abraded areas have skinned over. Highest 
temperature 37.8° C. 

Apr. 1. — The skinned-over abrasions are still somewhat ele- 
vated. Fresh scattered and closely-crowded lentil-sized blebs 
with clear contents have appeared on forehead and cheeks. 
Temperature normal. 

Apr. Jf. — The blebs on forehead and face have become puru- 
lent. 

Apr. 5. — Evening temperature 39.4° C. 

Apr. 20. — The skinning-over process is almost complete; the 
epidermis on the places of fonner blebs is still quite red, but 
there is now no elevation. 

Apr. 26. — Pale reddish-brown pigmentations mark the sites 
of the lesions. 

Apr. 28. — Discharged cured. 



Tab. 7 a. 




PLATE 8. 
Erythema Multiforme (Papular and Nodose). 

G. I., aged 11 years, acljiiitted Apr. 20, 189() ; discharged May 
3, 1896. For two weeks he had noticed the appearance, with- 
out known cause, of an eruption on hoth arms and legs. He 
had previously been quite healthy. 

Status Praesens. — The papules are to be seen on the exten- 
sor surfaces of the upper extremities and upon both anterior 
and posterior aspects of the lower extremities. The trunk is 
free. The eruption consists of millet-seed-sized papules, ex- 
tending into the cutis and somewhat elevated above the skin- 
level ; on their summits is, for the most part, either a minute 
blood-crust or -scale. In some places, and more especially in 
the popliteal spaces and over the patelail, are observed dime- to 
shilling-sized bluish-red nodes (erythema nodosum). 

Treatment. — Sodium citrate. 

In the course of the disease there was slight hemorrhage into 
the disappearing papules, which, however, was rapidly ab- 
sorbed. The nodose lesions gradually disappeared, undergoing 
the usual color-changes. 



7hb. S. 



r: 








\ 



Liih.Anst F Reichhotri, Mtinr.'-ni 



PLATE 9. 
Purpura Haimorrhagica. 

M. M., aged 33 years, coachman, admitted Apr. 23, 1897, 
stated that for the last eight days he had felt exliausted and 
sick, and had ohserved spots in the skin. Similar spots he 
had noticeil several times previously ; but as they had dis- 
appeared without discomfort or medical aid he had never 
considered them of any moment. He sought the hospital this 
time owing to tlie feeling of general weakness and dei>ression. 

Status PrsBsens. — Patient is large, well built, but pale. 
The gums are livid and furrowed, and bleed easily ; conjunc- 
tivae jaundice-colored. The heart-tones are somewhat dull; 
pulse 84, and soft ; spleen not enlarged. There is neither sugar 
nor albumin to be found in the lu-ine. Over both ankles and 
on the dorsal aspect of both hands there was slight edema. On 
the lower extremities, aliout the hair-follicles, are piuhead- to 
lentil-sized recent and old hemorrhages, here and there showing 
a tendency to be closely set together and in rows. In addition 
to these lesions are to be noticed rounded and more or less 
diffused violaceous spots on the lower legs, in the central part 
of which the follicular hemorrhages are more crowded. In 
these latter places the skin has a succulent feel. Scattered 
hemorrhages are also noticed on the trunk. 

Apr. 30. — Urine shows considerable urobilin. In sediment, 
hyaline cylinders and a few blood-corpuscles. 

May 1. — On the inner side of the upper part of both thighs, 
especially the right one, fresh follicular hemorrhages of a red- 
dish-brown color, and bluish, livid spots have appeared; the 
latter are so extensive as to become confluent. 

May 5. — The brownish-red hemorrhages and the livid spots 
begin to change to a yellowish tinge. The patient suffers pain 
in the legs. 

June 1. — The calf-muscles feel hard, and the patient when 
attempting to walk has considerable pain in these parts. The 
gums are still swollen, the inner side showing numerous minute 
hemorrhages. 

/M?i« ^. —There is considerable pain in knees and hips. 
Evening temperature rises to 39.5° C. 

July 1. — The hemorrhagic spots on trunk and thighs have, for 
the most part, been absorbed. The calves are softer to the feel. 

Aug. 19. — The diarrhea, which had existed for some time, 
alternates with constipation. Urine-examination shows con- 
siderable indican and skatoxyl. There is a somewhat painful 
swelling, soft in character, about the knees ; the overlying skin 
unchanged. 

From now on no new lesions in the skin were observed. The 
patient still suffered, however, from effusion about the knee- 
joints, marked debility, and inability to walk any distance. 



PLATE 10. 
Purpura Haemorrhagica. 

S. M., aged IG years, working-girl. 

Status Prsesens. — Patient small and spare ; pallor of skin 
and mucous membranes, and slight enlargement of the heart 
toward the right. No pulse-irregularity. Menstruation is not 
yet established. Hemoglobin, Fleischl, 55 per cent. 

For four days, beginning on 17th, the patient had noticed 
hemorrhages in the lower extremities. She worked in a laun- 
dry, standing'during the whole day. 

On the lower extremities, from the middle of the thighs and 
extending down over the entire lower legs, are lentil- to pea- 
sized, scattered and confluent cutaneous hemorrhages, some of 
which already show a change to a brownish tint. 

2J^h. — Eight days after the beginning of the outbreak the 
general health seems good; the efflorescences yellowish and 
some becoming skin-color. 



PLATE 11. 
Purpura Rheumatica (Fulminans). 

J. M., aged 38 years, clockniaker, admitted Sept. 12, 1897. 

History. — Nine years previously patient luid a pleuritis. 
For the past four years has had attacks of paiu in the large 
toes, lasting four to six weeks. Has been adtlicted to drink. 
His present disease began on Aug. 28 of this year, with sting- 
ing in tlie heels and the appearance of small red macules on the 
lower extremities. The pain and the spots disappeared in the 
course of several days. There soon followed pain in the knees; 
later in the elbows, hands, and tinger-joints, accompanied with 
swelling of the painful parts. At this time the patient noticed 
the api)earance of dark-l)rown macules on both forearms; 
these spots increased rapidly in size, exhibited superficial vesi- 
cle-formation, and gave rise to marked tenderness and pain. 
Patient was debilitated, feverish, and without appetite. 

Status Praesens. — The man is large and strongly built, with 
well-developed panniculus adiposus. Lungs, heart, and abdom- 
inal organs apparently normal. 

The face is decidedly reddened; the left cheek is some- 
what infiltrated; on the latter some lentil- to bean-sized spots, 
violet to blackish in color, without elevation or tenderness on 
pressure. On the left ala nasi is a reddish-brown hemor- 
rhage. The entire outer border of the right ear is hemor- 
rhagic, of a blue-black color, and very painful. The mucous 
membrane of the mouth and throat is normal. The right 
upper extremity is swollen and both at shoulder and elbow 
held in flexed position. On the outer side of the arm is a 
dime- to quarter-dollar-sized patch of dark- violet skin ; the 
overlying epidermis is elevated as in a blister, and the whole 
area is surrounded by a red areola. Besides this, several pain- 
ful, partly pale-red and partly dark-red spots are to be seen 
near by. On the inner side of the arm is a palm-sized dark- 
violet area similar to the large spot just described. Toward the 
axilla is a spot which already has begun to change to a yellowish 
color. 

The joints of the left arm and forearm are also swollen and 
tender, and present similar, but smaller spots. Both knee- 
joints are swollen and tender and the skin reddened. Over 
the ankle-joint are several spots, which had already become 



brownish. The other joints of the leg and foot are not swollen. 
The inguinal glands are unaffected. 

Urinary examination disclosed specific gravity 1020, some 
albumin, but nothing else abnormal. An examination of the 
blood showed a slight leukocytosis. 

Treatment. — Sodium salicylate 4 grams ((50 grains) pro die. 

Sept. 14- — Numerous elevated red spots, with pale-red areola 
and markedly itchy, are to be seen on the outer side of the 
right and anterior aspect of the left thigh. Temperature up to 
38.1° C. 

Sept. 17. — Numerous lentil- to pea-sized, elevated, hemor- 
rhagic, itchy papules have appeared on the thorax. Tempera- 
ture 39.2° C. 

Sept. 20. — Hemorrhage has taken place into the left ear- 
muscle ; the left foot is edematous. Passing large quantity of 
urine. 

Sept. 22. — Tlie joints are again much swollen. Fresh out- 
break of hemorrhages on thorax, abdomen, and thighs. Tem- 
perature 38.7° C. 

Sept. 27. — The flexor muscles of the right forearm, close to 
the elbow-joint, markedly inflated and painful. Fresh hemor- 
rhages in the left loin. On the hemorrhagic patches on the 
upper extremities superficial ulcers have appeared. 

Od. 3. — The hemorrhagic spots are being slowly absorbed. 
The swelling and tenderness of the joints are fast disappearing. 
Temperature normal. The ulcers on the arm are granulating. 
Zinc-oxid salve ordered. 

Oct. 19. — Allnimin no longer in urine. The ulcers on the 
left arm completely healed ; on the right are still two small 
ulcerations covered with abundant granulations. 

Oct. 28. — The affected areas are seen to be slightly pigmented. 
Patient was discharged cured. 



PLATE 12. 

Herpes Zoster (Sacrolumbalis, Hsemorrhagicus et Qan- 
grsenosus). 

S. W., aged 66 years, female, admitted Feb. 29, 1896, stated 
that for two months she had suffered from bronchial catarrh. 
For the past fourteen days she had pain in the back and thigh. 
A few days ago an eruption appeared on the buttock of the 
right side, accompanied with burning pain, and rapidly became 
more and more extensive. 

Status Praesens. — On the right buttock several groups of 
herpetic efflorescences, with hemorrhagic contents and with 
hemorrhagic areola, are to be seen. Some groups have become 
gangrenous and changed into shallow ulcers with hemorrhagic 
base. Over the region of the sacrum are recent vesicles with 
serous, and partly milky, contents. Six days after admission, 
and the twentieth day after the beginning of pain, the lesions, 
began to dry up and the tenderness and pain were much less 
marked. 






* ( 



.^ & 









w 




PLATE 13. 
Herpes Zoster (Supraorbital and Palpebral). 

L. S., aged 16 years, mechanic, came of a good, sound 
family and was himself always healthy. 

In Mar., 1896, the patient had a similar eruption on the same 
region for a period of eight days ; since then he has had no 
sickness; never had headache or other nervous symptoms. 
Five days ago the patient felt unwell, had a chill, and toward 
afternoon felt ohliged to lie down. On the following day the 
left upper eyelid was red and swollen, and on the ne.xt morn- 
ing he noticed some vesicles upon the nose and eyelid toward 
the inner angle. Yesterday, four days after the fii*st symptoms 
presented themselves, vesicles also appeared on the eyehrow ; 
and this morning early the two recent groups which cover the 
outer side of the lid. There is a feeling of distention and hurn- 
ing in the affected lid. 

Status PrSBsens. — The eruption is to be seen on and around 
the inner side of the lid and on the nose, and consists of 
vesicles with reddish base and areola, and beginning to dry. 
The entire U[)per lid is swollen and edematous, inflamed, and 
red. On the brow is to be seen a group of greenish-yellow 
vesicles, tending to become confluent. In the middle of the 
lid and also toward the outer side are two groups of recent, 
yellowish-white vesicles, partly confluent. Toward the edge 
of the lid and upon the border are piuhead-sized scattered 
vesicles. 




j'.Uh.Afist F. ReichhoUi. Mnnrlicn 



PLATE 14. 
Dermatitis (Cantharide^). 

S. M., aged 35 years, drug-clerk, healthy, had from morning 
till mid-afternoon worked with cantharides, sifting it, and per- 
spired freely during this time. Toward evening he felt burning 
sensations ; blebs appeared, which enlarged considerably during 
the night. 

Status Praesens. — On the forearms and on the neck are 
irregular, well-distended blebs with serous contents, and 
having reddish areola. The rest of the body is free. 



e2 




PLATE 15. 
Psoriasis (Punctata et Outtata). 

G. J., aged 17 years, locksmith, was admitted Mar. 23, 1886. 

The patient had his first attack of more or less generalized 
psoriasis two years previously, which, with the exception of a 
few spots on the knees, had entirely disappeared after the use 
of salves. The present eruption was noticed fourteen days 
before admission, first on his arms. 

Status Praesens. — The patient is strongly built, well nour- 
ished, and is apparently in good general health. On the trunk, 
extremities, and face are numerous psoriatic efliorescences, 
varying in size from a mere point to a lentil, having the char- 
acteristic scaliness. On the extensor surfaces of the knees are 
larger lesions, apparently of longer duration. 

The painting was made two weeks after the beginning of the 
present outbreak. A week later the lesions were more numer- 
ous, with a tendency to form confluent patches, and covered 
with silvery scales. The borders of the patches were bright red. 



.5; 



00 



O 



PLATE 16. 
Psoriasis (Diffusa). 

H. C, aged 41 years, shoemaker's helper, admitted Aug. 22, 
1896, stated that four years previously he had been treated for 
the same disease. For the past five months he noticed a reap- 
pearance of the eruption. He had himself made applications 
of petroleum, but with no result, and had then sought the 
hospital. 

Status Praesens. — The entire surface of the patient is cov- 
ered with psoriatic patches. In some places they have become 
confluent, forming large red infiltrated areas, covered with 
scales. This is more especially the case on both lower legs, on 
the outer sides of both thighs, in the lumbar region, and on the 
extensor surfaces of both forearms. On the scalp the eruption 
is extensive and confluent. On the trunk, on the chin, and on 
the forehead are scattered lesions, pinheiwl- to pea-sized. All 
patches are moderately elevated with narrow red border, and 
covered with fine white scales. 

Treatment. — Chrysarobin salve. After ten days' use, owing 
to a conjunctivitis, this was temporarily discontinued. After 
the conjunctival inflammation was relieved treatment with the 
salve was again begun, and the case finally cured. 



m 







PLATES 17 and 18. 
Psoriasis Nummularis [Eczema Seborrhoicum ?— Ed.]. 

S. J., aged 64 years, vine-grower, was admitted Feb. 5, 1896. 
He stated as follows : That he was always healthy ; in 1868, with- 
out any apparent cause he rapidly lost his hair. Is a moderate 
drinker. His present disease was first noticed about a half 
year before admission, and fii-st on the trunk and hands. After 
moderate itching some blisters appeared, which dried to crusts. 
For a longtime he had been in the habit of removing these 
crusts with oil, but they always reappeared. Later the erup- 
tion appeared on scalp and face. 

Status Praesens. — Patient is strongly built, but not well 
nourished. The scalp is covered with brownish-white crusts, 
which when loosened can be made to come off as an ill-defined 
cast. The hairless underlying skin is thin and hypcremic. 

On the face, about the eyelids, are eczematous, weeping 
patches. Chronic conjunctival catarrh, moderate ectropiura 
of the lower lids, and increased tear-flow are noticeable. On 
the breast and upper belly-region and on the extremities the 
eruption is extensive, consisting of scattered half-dollar-sized, 
palm-sized, and larger areas. The scattered spots show in the 
central portion considerable scaliness, more or less heaped up, 
and have a hyperemic border. Vesicular formation cannot be 
seen on any part. 

The paintings show two of the more recent patches on the 
breast (Plate 17), and on the scalp (Plate 18) after partly free- 
ing it from crusts. 

[By many these plates and description would be considered 
to belong to cases partaking of the nature of both eczema and 
psoriasis (psoriatic eczema), and by others as eczema seborrhoi- 
cum — Ed.I 





ldh.Anstf-:i<eichh< 



7'(//>./>s. 





Lith.Anst.J-: ReichJwltl, Miiiirhen. 



PLATES 19 andlOa. 
Psoriasis (Circinate, Annular, Gyrate). 

H. F., aged 21 years, laborer, admitted July 6, 1896, stated 
that for a period of eight years scaly papules had been ob- 
served. Two years ago he was treated elsewhere with tar- 
tincture and drops (arsenic ?), and later, in winter, for tliree 
months with pyrogallol, chrysarobin, and pills (arsenic ?), but 
without result. 

Status Prsesens. — Patient is medium built, with fair bone- 
structure and muscular development. Internal organs normal. 
On the buttocks and on the upper extremities are scaly papules, 
pinhead to lentil in size and with a narrow red border; like- 
wise larger efflorescences, rounded and with infiltrated ba.ses. 
On the abdomen and upper third of the lower extremities are 
patches consisting of an infiltrated, red, scaleless center, sur- 
rounded by an annular border covered with glistening white 
scales. 

Course and Treatment. — Thyroidin was prescribed in cap- 
sules, each containing 0.50 gm. (7J grains), beginning with one 
daily, and increasing one every three days. The pulse was not 
materially affected, and the body-weight varied but several 
pounds (between 52 and 57 kg.). The skin-condition gradually 
improved, so that on Aug. 19 the following status Wius noted : 

On the arms the psoriasis-spots are pale; infiltration and 
scale-formation have disappeared. The circinate and gyrate 
patches on the breast, abdomen, and back exhibit less redness, 
being now pale red or brownish, with retrogressive infiltration 
and scale-formation. Pulse 100, and regular. 

frf/r/i/ S''pt. — On buttocks are still to be seen some slightly 
elevated areas, and some patches which are still somewhat red. 

Sept. 19. — The patient was discharged cured. 




^ 



m 






A 



Tab. 19 a. 




PLATE 20. 
Psoriasis (Gyrate, Annular). 

C. F., aged 21 years, laborer, admitted Mar. 18, 1897, stated 
that he had psoriasis for the first time in 1893, at which period 
the patches appeared on the extensor surfaces of the elbows 
and knees. Under treatment with pyrogallol and chrysarobin 
salves he was much benefited. A year ago he noticed a change 
in the diseased areas — spontaneous disappearance of the cen- 
tral portions and an extension and confluence of the lx)rders. 

Status Praesens. — Patient is of graceful build ; moderately 
nourished. Internal organs normal. On the legs, arms, and 
trunk, in addition to scattered pinhead-, pea-, and coin-sized 
lesions, are to be seen large serpentine or irregularly circinate 
plaques, the peripheral portions being made up of hyperemic, 
elevated, scaly borders, sharply defined, and enclosing areas of 
brownish pigmented skin. Here and there within these bound- 
aries are to be observed lentil- to pea-sized scaly spots. The 
scalp is reddened and covered with thick scales. Body-weight 
(Mar. 17), 54.5 kg. 

Treatment. — lodothyrin. 

Apr. 6.— Weight. 52.1 kg. 

Apr. 16. — Patient was, upon request, discharged, some im- 
provement having taken place. 




A 



\ 




I 




f 



PLATES 21, 21a, and 21b. 

Psoriasis. Cornua Cutanea (with Degenerative (from Uric- 
Acid Diathesis) Changes in Right Hand and Left Foot . 

H. J., aged oS years, an innkeei)er, \vat< admitted May 5, 
1897. The patient stated that his ftither had been a sutierer 
from gout, and that he himself, when in his thirty-tliird year, 
was ill. His illness began with symptoms of general weakness, 
which increased, and was accompanied with swelling of the 
joints of the feet. This condition lasted some months. In 
1883, when about forty-four, he again became sick, and was 
obliged to keep in bed; there were swelling and pain in all 
joints, especially those of the lower extremities, and in the 
loins. Four years later heliad a similar attack. In 1891, there 
developed a tumor or swelling on the head, which was removed 
by operation. In 1889, scaly papules appeared on the right 
shoulder, since which time similar lesions had made their 
appearance on the trunk and extremities. The hands were 
free up to three months before admission, when the eruption 
appeared on these parts; there was pain in the right hand. 
Lately the patient had lost considerable flesh. Appetite was 
good. The bowels were sluggish, sometimes five days elapsing 
between the stools. 

Examination of the urine passed in twenty-four hours showed 
a marked increase in the uric acid and considerable uric-acid 
sediment. Urine was much less actively solvent for the uric 
acid than normally. 

Status PrsBsens. — Patient is large, pale, very much emaci- 
ated, and of delicate bony structure. Pulse Ci^ ; rounded and 
well filled. Temperature normal. Arteries hard. Lungs em- 
physematous, and diriclo.sing many nlles and nuich whistling. 
Heart-sounds apparently normal. Liver and siilcen could not 
be made out. 

The skin in general is dry and easily lifted in folds, the sub- 
cutaneous fat having disappeared. On both forearms the skin 
is parchment-like and in wrinkles and folds; on the thighs the 
folds are thicker and more marked. Over the general surface, 
with the exception of the face, neck, breast, and the back down 
to the sacrum, are to be seen innumerable lentil- to palm- 
sized scaly patches (jisoriasis guttata et nummularis). In cer- 
tain places, as on the buttocks and lower legs, the eruption has 



become confluent and formed festoons. Over the olecranon, 
left arm, is a clicstnut-siy.ed, rounded, closely-adherent, heaped- 
up, sliell-like scale, surrounded hy a red infiltrated border. 
Similar lesions are to be seen, with smaller crust-fornuition, 
heaped up and rounded in form, on the forearms, hands, and 
lower extremities. Upon lifting the shell-like accumulation 
from these lesions, the papilhe are disclosed, the surface bleed- 
ing easily. On the extensor surface of the right elbow the 
eruption is of the usual character. On the extensor surfaces 
of both knees are yellowish crusts seated upon grater-like, raw- 
looking skin. 

On the dorsal aspect of the second joints of the fingers of the 
left hand are also heapetl-up, oyster-shell-like scaly crust-for- 
mations ; in consequence of which the fingers are held in a bent 
position and cannot be extended — the stiffness of the joints of 
this part is, however, paitly responsible. The nails of these 
fingers are thickened, of dirty gray color, fissured lengthwise, 
and lifted up from the matrix by a horny accumulation be- 
neath. The right hand (Plate 21 a) and fingei-s, especially on 
the dorsal aspect, are considerably swollen, reddened, and in- 
filtrated. The palms are the seat of yellowi.sh, tough, hard, 
aorny scales. The nails of the right hand jut out, talon-like, 
over the finger-ends, and rest upon a horny, hypertrojihic nail- 
bed, although less so than with the nails of the other hand. 

The large joints of both big toes are pu.shed forward, and bent, 
valgus-like. and covered with horny masses. Similar horny 
accumulations arc to be observed on the soles. The toe-nails 
are irregular: in part wanting, in part showing horny masses. 

Oours3 and Treatnaent. — In the further course of the dis- 
ease the patii>nt coini)lained of pains in the hand-joints and of 
a troublesome cough. Treatment consisted of Carlsbad cure, 
milk-diet, and baths. Under this treatment most of the crusts 
and scales had in four weeks' time fallen off. 

June H. — The horn-like psoriatic accumulations on the 
elbows, lower legs, and around the ankle have been cast off; 
the borders are still red and slightly scaly. Tlie joint-affection 
has considerably retrogressed ; the nails have hardened, are 
thickened, bent, cracked, and exfoliating. The patient's gen- 
eral apjiearance is materially improved, so that in this im- 
proved condition, at his own request, after a period of six 
weeks' treatment, he was discharged. 



Tab. 21 a. 



^ 


J^ 


m 


1^^^ 


^K ^. ^7 ' "^^^^1 


E^ 


■ 


H^fe 




1 


B 





Tab. 21 b. 





^^^^^H 


pr- :/,4<a|^gH| 




^^^^^1 


i -^^j^H^ 




^^^^^^1 


r ^ l^^H 




^^H 


r ^B 




^V 


^^1 




^^ 


i' J 




^^^^^^^ 


^' ' '^^^H 


^^R^^'.T.i;"' -^' ^'v ' - ^ ''^^^^^^1 


^^^ 


:^«iUi6^^1 


^His^''"-^-''' - "'' '^^Hf^^l 


^^^ 


. ^^jd^^^l 


^■■R> .-..vv, V-'. -"^^^P 


^ 




^^^^^^feTi^^T-. jr.^S'.^Si^ ' -^ 




. /■e|^^>!mJM^^^^^| 




C 










"^^ '•• -tH^m^^JB^^^M 


Hfl^^^R' 


ji 


^»_^^^|^^™ 


^^^^^^H^^^^^i^^ 


^ 





PLATES 22 and 22a. 
Lichen Ruber Planus. 

U. S., aged 41 years, female. 

The eruption is somewhat widespread. Tlie face is free. On 
the upper extrtniiities the flexor surfoces are more especially 
involved, the lesions on the extensor surface heing scanty and 
scattered. On the lower extremities the anterior surfiice of the 
inner side of the thighs and the flexor surface of the lower 
leg are most aftected. On the hack and hreast and the inner 
side of the thighs the individual lesions making up the patches 
and areas are less recognizahle, owing to their being confluent, 
the normal skin between appearing as irregular, narrow spaces. 
On these parts the diseased areas are of an even copper-red 
with a brownish tone, covered here and there with small ad- 
herent white scales. As the sound skin is approached the 
individual character of the lesions making up the confluent 
areas is readily recognized. Such lesions are red, follicular, 
millet-seed-sized, somewhat firm papules, becoiuing paler upon 
pressure. On the top of each is a minute scale of ejjidermal 
exfoliation. In some places the patches are somewhat masked 
by the effects of scratching and covered with hemorrhagic 
crusts, and the eruption rendered somewhat dull and less shin- 
ing in character. The mouth is entirely free. 

Treatment consisted in the administration of Asiatic pills, 
and externally salicylic acid and resorcin si,lves. 




Tah.J. 



LUh, Anst t: Reidihotil. Miinrtirn 



Tab. 22 a. 




PLATES 23 and 23 a. 
Eczema Artificiale Vesiculosum [Dermatitis— Ed.]. 

Ch. K., admitted Jan. 1, 1896. The patient was, when ad- 
mitted, the subject of scabies. On the 16th and 17th he rubbed 
in naphthol-soft-soap. On the 19th he fell sick with fever; 
temperature, 38.2^ C. ; evening, 39.1°, C. The skin became 
eczematous, and of chiefly vesicular character. On the 29th 
the morning temperature was 38° C, and the evening 39° C. 
The vesicular lesions of the eczema persisted. 

The urine-examination disclosed a large quantity of albumin. 
On the 21st the temperature fell to 37.1° C. and the vesicles 
had for the most part dried. On the outer aspects of the 
thighs, where the eruption is less pronounced, are irregu- 
larly-scattered papules, which have partly dried into thin scales 
or crusts, and partly show a cracked epidermic covering. 
The anterior aspect of the leg is covered with yellow vesicles, 
with light-red areola. 

The size of the vesicles varied from that of a pinhead to 
a lentil. On some places they have become confluent and 
form irregular clusters, in some of the lesions and groups 
the epidermal covering being lifted up by the abundant pus. 
On the inner thighs the eruption has dried into yellowish 
crusts of shining aspect and is irregularly divided into areas 
with whitish lines (cracks). 

Jan. 22. — All the pustules have dried up and the inflamma- 
tory symptoms disappeared. Patient feels much better and is 
more comfortable. 

The painting was made from the middle portion of the 
thigh, from both the inner anterior and external aspects. The 
dermatitis evidently resulted from the naphthol. This being 
absorbed, irritated the kidneys, so that in the beginning a large 
quantity of albumin and naphthol could be demonstrated. 



lilt,.. 




if 




liP 



Ltlh. AnsI /■■ Heifhhnld .Uimrhen 



Tab. 2H a. 




PLATE 24. 
Eczema Artificiale Acutum [Dermatitis— Ed.]. 

Sch. J., aged 47 years, worker in the arsenal, was admitted 
Aug. 6, 1896. Patient was burnt on Aug. 5 by a hot piece 
of iron falling on him, producing burns of the neck, hands, 
and thorax. In the beginning he was bandaged with iodoform- 
gauze, and then treated with lime-water and oil. 

Status Praesens. — On the neck and right forearm down 
to the wrist are burns of the first and second degrees. On 
the left side of the chest is a diifused redness. Temperature 
and pulse normal. No constitutional symptoms. Boric-acid 
salve was used. For some inexplicable rejison, at the sug- 
gestion of a hospital-helper, he rubbed some naphthol salve on 
the mucous membrane of the lips, and immediatoly afterward 
an erythema spread over the trunk. At the same time the 
whole face became markedly edematous and swollen, and an 
eczema-like eruption developed over the entire surface, espe- 
cially on the thighs, as numerous pustules. Tlie patient had at 
this time attacks of dyspnea. Morning temperature, 38.5° C. 

Aug. 15. — Tlie eyes are about closed by the swelling of the 
lids, admitting of only slight opening on effort. The mouth 
stands out like .1 proboscis and the lips are markedly swollen. 
On the chin and both cheeks, on the upper lip and in the nasal 
outlets are honej'-yellow crusts; the same on the neck, the 
right upper extremities, and the upper right portion of the 
thorax, the inner surface of both thighs, and in loss degree on 
the left upper extremity. Two days later the swelling of the 
face had markedly subsided ; the eyes could.be readily opened. 
Temperature was normal. General condition good. 

Aug. 25. — The swelling and redness have completely disap- 
peared, and there remain but a few spots that are still slightly 
reddish. 

[The author evidently believes the naphthol responsible for 
the outbreak, but it is possible that iodoform may have been 
the etiological factor. — Ed.] 



Ta{, ^4 



A 



r^ 




Llih.Anst •' nfuiirioiii Muitriirn 



PLATES 25 and 25 a. 
Eczema Pustulosum Artificiale [Dermatitis -Ed.]. 

B. Ph. was admitted for a markedly inflammatory eruption 
about the legs, which he stated had followed the use of a salve 
made up of three parts of diachylon ointment and two parts 
of vaselin. He had applied this to his legs for the relief of an 
alleged eruption which had been itchy, and had rubbed it in 
repeatedly with great vigor. After five days' use of this oint- 
ment the present eruption made its appearance. Three days 
later he was admitted to the hospital. 

Status Praesens. — The extensor surfaces of both legs to 
the lower third, also the posterior surface of the right thigh 
near the knee, are the seat of numerous irregularly-grouped 
large pustules. Out of the center of each pustule emerge one 
or more hairs. The skin ihimediately surrounding the discrete 
lesions is reddened ; where these are in groups this redness 
is confluent. The color is bright red, and may be made to dis- 
appear momentarily by pressure. There is no pronounced 
infiltration. The oldest of the pustules and purulent blebs 
show already hemorrhagic contents. Some have been broken 
and have given place to reddish crusting. The rest of the body 
is entirely free from efflorescences. Here and there are scratch- 
marks, especially on the flexor surfaces and at the axillae. 

The patient remained under observation for two weeks, 
during which period several boils developed ; at the end of 
this time all the pustules had dried up, and from most the 
crusts had already fallen off"; the boils had also practically run 
their course. 

[The case would be classified with us as a follicular pustular 
dermatitis, which is occasionally noted to follow the vigorous 
rubbing-in of ointment (especially if not very fresh) on hairy 
parts. — Ed.J 



n 



/? 



^ 



r^./. 



aO 



??^- 



v 




•--N 



^■""fpr 



Tab. 25 a. 




PLATE 26. 
Eczema Marginatum (Tinea Trichophytina Cruris). 

B. F., aged 15 years, sclioolboy, stated tliat the enij)ti()ii had 
first made its appearance several years before, primarily on the 
anterior surface of the right thigh, and later on the left, in the 
pubic region and about the genitalia. There had been slight 
itching. 

Status Praesens.— The skin of the middle surface of both 
thighs, to the inguinal furrow and up to the pubic region, is 
bright red and hard to the touch. Toward the normal skin 
the affected area is bounded b}" a reddish-brown, slightly- 
scaly, irregular border. The border is elevated and made 
up of a continuous line of confluent papules, pinhead to 
lentil in size; the middle of the area is, for the most part, 
grayish-brown pigmented and slightly rugous. Beyond the 
main area of disease are a number of characteristic ring-shaped 
patches. On scrotum and penis are similar efflorescences, but 
much more recent and ring-shaped. The disease exists in the 
axillary regions, also, as typical, sharply-defined, scah', con- 
fluent areas. 

Treatment. — Lysol lotion (5 per cent.) and wa.>*hings with 
soap, uaphthol-soft-soap, and applications of La,ssar's salve 
sufficed to cure the patient in thirty-one days. 

[It is not now generally believed that all cases similar or 
closely similar to that here described are due to the ring- 
worm-fungus, but that some may be classed us a variety of 
eczema seborrhoicum ; the large majority, however, undoubt- 
edly belong in the ringworm-group, in which the author has 
placed this case. — Ed.] 



7\ 



^. 



i 




PLATE 27. 
Eczema iMycoticum ?). 

N. N., butcher's assistant. 

Status Prsesens. — Beneath the right nipple is a half-palm- 
sized crusted area. The crust is of a yellowish-green color, and 
the border of the patch is red. On this border is seated an 
almost continuous row of white vesicles and blobs; a por- 
tion of the periphery consists of slightly-detached epidermis. 
Close to, but beyond, the patch are scattered small blebs with 
red areola. 

[This would be considered by some dermatologists as an ex- 
ample of so-called " parasitic eczema," and by others as a " pyo- 
dermia" or a "pyogenic dermatitis." — Ed.] 



PLATES 28 and 28a. 

Eczema Madidans et Crustosum Mycoticum ?). 

J. S., aged 28 years, miller, canio under observation Oct. 20, 
1896. The disease had existed since June, without known 
cause. 

Status Praesens. — On the left lower leg is a palm-sized, ir- 
regularly-bounded area, covered with dry yellowish crusts. 
Upon removal of the crusts the oozing corium is brought to 
view. In the immediate neighborhood of this patch are a few 
lentil- to dime-sized pustules. On the left upper extremity, on 
both the arm and forearm, are similar areas, partly oozing and 
partly crusted, of the size of a thimib-nail to a silver quarter. 

Upon the application of diachylon ointment, and later the 
application of Las.sar's paste, a cure resulted. 

[This case is essentially similar to that of Plate 27. — Ed.] 



Tah.'JS. 




/.ifh Xn.lt I' Roi,-hh„l,i U,,,,,h 



Tal). 2Sa. 




PLATE 29. 
Prurigo. 

B. K., aged 13 years, school-girl, admitted Aug. 26, 1897, stated 
that the skin-afTection had existed since earliest childhood. 

Status Praesens. — The skin of the extensor surfaces of the 
extremities, especially the lower in the knee-region, is thick- 
ened, dry, and rough, the folds exaggerated and of a brownish 
color. There are numerous embedded papules, many covered 
with blood-crusts ; between these are reddish and brownish 
pigmented spots, the sites of former lesions. 

Under treatment with macerating baths and the application 
of salves the condition was somewhat improved, and the 
patient left the hospital after twenty-six days' treatment. 



PLATE 30. 
Acne. 

M. A., aged 17 years, somewhat pale, had suffered for several 
years from continued outbreaks of papules and pustules on the 
face, neck, shoulders, and back, having their seat in the seba- 
ceous glands and ducts. The lesions vary in size from a pin- 
head to a lentil, the larger lesions showing in the central part 
purulent contents. 



^ 




PLATE 31. 
Sycosis. 

T. A., aged 54 years, admitted May 7, 1896, stated that in 
1890 he noticed a papula on the upper Hp, which hiter changed 
into an oozing spot, while immediately in the neighborhood 
other papules and oozing patches appeared. In the coui-se of 
four years the process had spread and gradually involved the 
entire upper lip. 

Status Praessns. — The entire moustache-region is inflamed 
and crusted, the crusts mostly confluent and of a greenish color ; 
here and there a small spot covered with horny epidermis, and 
in some places moist spots with a papillomatous (frambesiform) 
tendency. The crusting is quite thick in places, and is irregu- 
larly and scantily pierced by projecting hairs, which are loosely 
embedded and which may be quite easily and painlessly pulled 
out, the root-sheath appearing swollen. In the middle of the 
lip toward the right upper part the skin is free from crust, 
reddened, and infiltrated, and to some extent covered with 
scales. There is no active purulent discharge. From the 
corner of the mouth the process tends to extend downward, 
although the crusting here is not so massive and is ejisily 
detached. 



s^ 



■.A 



PLATE 32. 
Furunculosis [Ecthyma, Impetigo Contagiosa?- Ed.]* 

T. J., aged 36 years, hostler, was admitted Apr. 1, 1897. 
The skin-affection had existed eight days. The first efflores- 
cences appeared in the region of the coccyx and then spread 
toward the sacral region and the lower extremities. In the 
past three days the patient had had several chills. 

Status Praesens. — The patient is large, strongly huilt, and 
well nourished. The buttocks and the outer side of the left 
thigh, and to a much less extent on the remaining parts of the 
lower extremities, except the extensor surfaces, are seen dime- 
to dollar-sized red crusted lesions. The crusts are of a brown- 
ish-yellow color, somewhat heaped up, and are firmly adherent 
to the underlying superficial ulceration. The base is inflam- 
matory and infiltrated, and the areola pronounced and also in- 
flamed and infiltrated. The process is somewhat deep, having 
almost a furuncular nature. Cultures made from the secretion 
show staphylococci and streptococci. 

Under antiseptic applications a cure resulted in sixteen days. 

[These lesions, as here depicted, correspond to the lesions 
usually described under the name of ecthyma. By some ob- 
servers they would also be looked upon as a markedly inflam- 
matory type of impetigo contagiosa. In fact, at the present 
day there is a growing belief that these various diseases are 
the same in etiology (pus-cocci), the differences in the objective 
phenomena being due to individual peculiarity of the skin or 
variation in its resisting power. — Ed.] 



PLATES 33, 34, and 34a. 
Pemphigus Vegetans. 

H. 0., aged 78 years, female, was admitted Feb. 28, 1894. The 
patient was in the hospital three years previously for a pem- 
phigoid eruption. The present attack began three weeks ago. 

Status Praesens. — The nutrition of the patient is poor; tne 
hands and feet slightly edematous. The entire surface is the 
seat of a bleb-eruption ; some of the older lesions covered with 
crusts. Immediately surrounding the anal outlet are some papil- 
lary growths. The skin of the neck, back, axillse, and genital 
region is considerably pigmented, without recognizable cause. 

Cotirse. — Up to August of the next year (1895) the patient 
was upon two occasion.s permitted to leave the hospital, inas- 
much as she was free from blebs and felt much better as to 
general health. Since Aug., 1895, however, she has been con- 
stantly in the hospital. During this whole period it suffices to 
state that the entire body was the seat of recurrent outbreaks, 
of which the following description is a picture : The yellowish- 
brown pigment of the earliest period had, on the neck, upper 
shoulders, lower abdominal region, and axillae, changed to a 
dark-brown or blackish tint. The skin of the hands and inner 
thighs felt leathery and was more or less rugous. In the axillae 
are flat warty and papillomatous thickenings of the skin ; these 
areas had formerly been moist, deeply furrowed, and pai)illoma- 
tous, and coated with a cheesy covering. In the genitocrural 
folds, on the labia, and surrounding the anus are red papilloma- 
tous growths, seated upon broad bases and discharging a cheesy 
secretion. On the dorsal surfaces of the hands are fresh pem- 
phigus-blebs and abraded areas, the seat of recent lesions. The 
skin is furrowed and leatherv, and the border of the blebs red 
and swollen. On the face and lips are smaller broken blebs. On 
other parts of the body may be seen small blebs, associated with 
troublesome itching. The patient is considerably emaciated and 
depressed in general health. Since the beginning of the pres- 
ent year the condition has measurably improved ; the bleb- 
outlsreaks have lessened both in extent and severity, and the 
subjective sensations are not troublesome. 

Treatment. — Great care was taken as to cleanliness ; the 
papillomatous excrescences were treated with drying-powders 
and lotions. Internally, in addition to tonics and nutritious 
food, arsenic was given about two months and " Brown- 
S^quard" for three-quarters of a year. At present writing 
notning is being administered. 






■X- 



Tab. 34 a. 




PLATE 35. 
Nsvus Verrucosus. 

M. H., aged 27 years, female. 

Status Praesens. — The patient had between the shoulders 
an elongated, oval, brown-pigmented patch. The periphery* is 
of a light-brown color and slightly elevated ; the center is 
dark brown, with smooth, rounded, wart-like projections which 
feel somewhat elastic. No pain or tenderness. 



PLATE 36. 
Nsevus Pigmentosus Unilateralis. 

P. C, aged 22 years, male, had shown since infancy pigment- 
marks ; they had not caused any annoyance. 

Status Prsesens. — The skin over the buttock, from the 
anal furrow toward the right and downward on the thigh, ir- 
regularly bounded, is of a yellowish-brown color ; otherwise of 
normal structure and sensation. Further down, beginning at 
the lowest part of the thigh and extending to the posterior and 
inner surface of the lower leg down to the foot was a similar 
blemish. 




I 



PLATE 37. 
Hyperchromatosis Arsenicalis. 

L. F., aged 24 years, male, stated that in July, 1895, for four 
weeks, and from late August into October, for six weeks, he had 
been in the hospital for the treatment of a scaly skin-eruption. 
Both times treatment was begun with the administration of five 
drops of Fowler's solution daily, and reached in the first course 
of treatment twenty drops and in the second period twenty- 
five drops. The scaliness had gradually disappeared and given 
place to extensive pigmentation. 

Status Praesens. — The hairs on the patient are black and 
the skin yellowish-brown. On the extensor aspects of the fore- 
arms, elbows, and knee-regions are numerous scattei'ed psoria- 
sis-efflorescences, partly covered with scales. The skin of the 
entire body, with the exception of the face, neck, hands, and 
feet, is the seat of sepia-colored, reddi.^h-brown spots and areas. 
The most are discrete, pea- to half-dollar-sized, although there 
were many confluent areas of larger size and irregular shape, 
melanotic in character. In most of the discrete spots the cen- 
tral part is less dark, and the borders gradually merge into the 
surrounding normal-colored skin. Neither scaliness nor swell- 
ing of the skin is noticed ; the melanotic spots and areas feel 
normal to the touch and show the normal lines. Tlie patienl= 
had during his two arsenical courses 340 and 570 drops respec- 
tively, or, in all, 900 drops. 



roh.:t7. 



f 



\ 




l2i 



PLATE 38. 
Lichen Pilaris (Keratosis Pilaris). 

J. H., aged 18 years, female, stated that she has had a rough, 
hard skin for some years. Recently she observed the appear- 
ance of numberless minute brownish points. 

Status Praesens. — Patient is strongly built and well nour- 
ished. The entire skin shows want of care. The extensor 
surfaces and the back are the seat, of numerous, irregularly- 
scattered, pinhead-sized, brownish-colored papules, having their 
seat at the hair-follicles. The skin feels rough and dry, more 
noticeable on the extensor surfaces of the extremities. There 
was no itching, nor any symptom of a subjective character. 

[In most cases of keratosis pilaris, as observed in this coun- 
try, the manifestation is most marked on the thighs, especially 
the anterior and outer aspects ; in fact, it is seldom that parts 
other than the thighs and corresponding surfaces of the arms 
and forearms are perceptibly involved. — Ed.] 



PLATE 39. 
Ichthyosis. 

A. K., aged 27 years, female, came under observation Mar. 
29, 1897. 

History. — Tlie roughness and cracked condition of the skin 
had existed since infancy. Her only brother was also the sub- 
ject of the disease. 

Status Praesens.— The patient is medium-sized, and mod- 
erately nourished, but pale. The skin of the entire surface, 
especially the abdomen, back, and lumbar region, is rough and 
covered with epidermic lamellae and plates, the cracks and 
fissures dividing the plates and scales disclosing the reddish 
rete. 

[As a rule, there is less of the red aspect in ichthyosis-cases 
than is here pictured, and in most instances it is entirelj" lack- 
ing. Occasionally, however, especially when an eczema is super- 
added, as sometimes happens, the hyperemic element is con- 
spicuous. — Ed.] 




7ah..Vi. 



\. 



t 



4 




fihold Hunrlirn 



PLATE 40. 
Hyperkeratosis Palmaris (Callositas). 

L. K., aged 36 years, day-laborer, \va^ admitted Nov. 20, 
1896. Patient was a digger, and believed his occupation re- 
sponsible for his complaint; he had at an earlier period had 
the ordinary callous areas in the hand. The present condi- 
tion, it was stated, had lasted two weeks. The patient had 
long suffered from foot- and hand-sweating. 

Status Praesens. — On the palms and flexor surface of the 
fingers of both hands, but more especially the right, the skin is 
much thickened, the epidermic accumulation consisting of 
many layers. The greatest thickness is to be observed on the 
thumb, the ends of the first, second, and third fingers, and on 
those places against which the handle of his shovel had pressed 
most. The joints of the parts showed tolerably deep cracks and 
fissures. The patient held the fingers of the right hand in a 
flexed position, and experienced pain in attempts to straighten 
them out. The nails were likewise much thickened, and between 
the matrix and nail was a mass of hardened epidermic accumu- 
lation. Similar conditions, but in much less degree, were 
noticeable on the soles of the feet. 

Treatment. — Hand-baths, soft soap, and diachylon salve. 
Patient was discharged cured at the end of seven weeks. 



PLATE 41. 
Leucoderma i^ Vitiligo). 

Z. D., aged 21 years, washerwoman, of dark complexion and 
dark hair. 

Status Praesens. — The skin of the inner sides of the thighs, 
the groins, the lahia, and perineum is wanting in pigment-mat- 
ter, being of a dead-white color ; there is increased pigmenta- 
tion in the surrounding skin. The hair on the labia and pubic 
region is, for the most part, also white. With the exception 
of the whitening of the skin and hair there is nothing abnor- 
mal. 




/ 




PLATE 41a. 
Alopecia Areata (Alopecia Totalis Neurotica). 

N. N., aged 22 years, female, unmarried, was admitted Oct. 
13, 1896. 

History. — Patient was of a highly-nervous, excitable family. 
No one had, however, previously suffered from any hair-loss. 
As a child she had varicella, and later, in her fifth year, diph- 
theria. Since that time she had remained anemic and weakly, 
and seemed unable to regain her former condition of health. 
As a young girl she had light-blond, very luxuriant, long 
hair. In early childhood she had suffered from a seborrlieic 
condition of the scalp, but this was not accompanied by any 
hair-loss. From her seventh year she had suffered much frorn 
periodical one-sided headache, which, for the most part, was 
worst toward the occiput and neck. She l)egan to menstruate 
when eleven years old, jit its first onset being under great ner- 
vous perturbation; since then she had menstruated, without 
any special difficulty, regularly every three weeks. Some 
months after the establishment of this function she was subject 
to severe migraine, since which time she had noticed that her 
hair was becoming somewhat lighter in color, hard, brittle, and 
split at the ends, appearing as if without life. After persistent 
headache and recurrent nose-bleed the patient was brought in 
an unconscious condition to the nervous clinic. At that time 
she is said to have been delirious, boisterous, confused in her 
talk, and to have had convulsions. In one night she lost all 
the hair of the scalp, axillae, mons veneris, eyebrows, and eye- 
lashes, and later the downy hairs as well. When the patient 
recovered consciousness and left the hospital, three weeks 
after admission, she was completely bald, and remained so for 
ten years, up to the end of 1894. The nervous symptoms, it 
was stated, disappeared at this time. She noticed that the 
scalp-skin seemecl firmly attached to the underlying tissue. 

In the next six months, up to the spring of 1895, there ap- 
peared in places, first in the occipital region, then on the ver- 
tex, and finally on the parietal regions, a scanty supply of hair. 
This grew in length to the shoulders, although it rem.ained 
sparse in quantity. With return of the severe migraine and 
nervous excitability the hair again fell out as before in two to 
three weeks. In another interval of fieedom from nervous 
symptoms, the past five months, the hair now present had 
grown; the past seven or eight weeks a downy growth had 
also shown itself in the axillae and the genital region. 

Status Prsesens. — By general examination nothing is found 
except a blennorrhagia of the vagina and uterus. The sensi- 
bility, pressure-, pain-, and temperature-sensations .are normal, 
except a slight disturbance in the region of the frontal branch 



of the facial uerve. The skin-, muscle-, and tendon-reflexes are 
present. Urine-examination gives a marked increase in phos- 
phates. The nails are milky and show lines running length- 
wise, and nail-ends tending to be fragile ; they are white-dotted 
here and there. The skin of the scalp is pale, smooth, shining, 
and movable upon the underljing part, although not readily 
lifte<l in folds. The hairs are thin and atrophic, the longest 
being six to eight inches, and the lanugo-hair one or two lines 
long. Some part?!, well defined and tolerably symmetric, are 
almost completely bald, and these, as well a* those now covered 
with hair, agree in their arrangement with the distribution of 
the skin-nerves (ramus prim, trigemini, II. and III. nerv. cer- 
vicalis). A few hairs are on the region of the eyebrows ; the 
lashes are almost completely wanting. The entire skin-cover- 
ing, especially of the extremities, is dry, in spite of the fact that 
the patient for a number of weeks has had considerable sweat- 
ing with the attacks of headache. 

Noteworthy is the coincidence of the rapid hair-fall with the 
psychosis ; the occurrence of nervous symptoms, as migraine, 
congestions, nose-bleed, with the oscillation in growth and fall- 
ing out of the hair; the symmetry of both the hairy and the 
non-hairy areivs, the distribution corresponding to the skin- 
nerves ; the trophoneurotic disturbances of the nails ; and also 
the hereditary nervous tendencies. The entire course of the 
atiection spoke for the nervous origin of the hair-loss, and the 
case is to be placed in the class of alopecia totalis, praematura 
neurotica. 



PLATE 41 b. 
Alopecia Areata ; Canities. 

G. P., aged 17 years, salesman, stated that in Feb., 1895, he 
suffered from alopecia, which by spring was entirely cured. 

The present affection appeared in Jan., 1896; the hair 
changed to a white color in two places in the occipital region 
and then began gradually to fall out. On the borders of the 
circular areas the hairs are easily pulled out. 



PLATE 42. 
Lupus Erythematosus. 

F. H., aged 38 years, female, noticed for a number of weeks 
the appearance of an eruption on the end of her nose. 

Status PrsBsens. — The disease is seated upon the tip and 
left ala of the nose. The area is slightly elevated, and is sharply 
defined from the healthy skin by a red, somewhat raised bor- 
der. There is slight scaliness, the scales being markedly adhe- 
rent and of a grayish and greenish-gray color; upon their re- 
moval the base is noted to be livid red. 

A salicylated mercurial plaster was advised, under which the 
patient was improving, when she failed to continue her visits to 
the dispensary. 



PLATE 43. 
Lupus Erythematosus. 

N. E., aged 40 years, admitted Apr. 15, 1898. The disease 
was first noticed two years ago, appearing on the nose and 
near by on the cheeks. Under treatment improvement then 
ensued. -The present exacerbation patient observed eight weeks 
before admission. 

Status Praesens. — Nose, cheeks, and ear show patches in 
various stages of the disease. The areas are all slightly thick- 
ened and red. In some the surface appears stretched and 
shiny. For the most part, however, the patches are covered 
with lightly-adherent whitish scales, somewhat greasy in char- 
acter. 

Treatment. — Improvement ensued from a salicylated mer- 
curial plaster; the patient was discharged, and subsequently 
treated in the dispensary. 



Tab. 43. 




PLATES 44 and 44a. 
Xanthoma Tuberosum. 

R. P., aged 42 years. 

History. — The father of the patient died of liver-disease ; his 
mother and brothers and sistei-s are living and healthy. About 
ten jeai-s ago the patient began to notice the appearance of 
small tumors on the extensor surface of the upper extremities. 
They gave rise to no discomfort, except when struck or pressed 
upon, when they felt slightly painful. In the course of the 
year similar growths made their appearance on the najie of the 
neck, on the buttocks, and on the extensor surfaces of the lower 
extremities. For the past three years the condition has re- 
mained about stationary. 

Status Praesens. — Patient is of medium size, strong, but 
pale, with considerable panniculus adiposus. The internal 
organs are normal. On the nape of the neck near the border 
of the hair, on the extensor surfaces of the upper extremities, 
the buttocks, and the extensor surfaces of the lower extremi- 
ties, the skin is the seat of numerous growths, lentil to hazelnut 
in size, rounded and prominent; partly smooth and partly 
cleft. The borders are of a bright-red color ; toward the center 
of the growths this becomes of a fat-yellow color. Between the 
closely-crowded and confluent growths are lentil-sized cicatricial 
depressions, with an irregularly-pigmented l>order. 

Urine-examination: Albumin, about 0.067^; sugar, 5%; 
quantity passed in twenty-four hours, 1260 grams; specific 
gravity, 1031 ; color, wine-yellow, clear ; no renal elements in 
sediment. 

Histologic examination of one of the growths shows that the 
tumor consists of fibrous filaments taking origin out of the 
connective tissue of the skin ; the yellow fjit lies in the cells 
of the fibrous filaments. The tumor is not inflammatory in 
origin. 

Treatment. — Patient was advised to take a six weeks' course 
at Carlsbad, with restriction of albuminous foixls and the use of 
abundant vegetable food. During this treatment there was a' 
remarkably rapid involution of the xanthoma-lesions ; in such 
growths the peculiar scar-like depi-essions with pigmented 
areola, above mentioned, remained ; the sugar disappeared 
entirely from the urine. 

The patient presented himself at the end of May, 1898, with 
new nodules; and sugar had reappeared in the urine. 

[This case was published in full by Dr. G. Toepfer, in the 
Archiv fur Dermaiologie und Syphilis, Band 40, 1897.] 



/;//..-> 



\ 




i 



/^ 



\" 



^^i 



Tab. 44 a. 




PLATE 45. 
Nsevus Vasculosus. 

> PLATE 45a. 

Nsevus Vasculosus et Verrucosus. 

The seat of the affection, the left temporal region, is copper- 
red from minute capillary enlargements, and irregular in 
shape. Scattered over it are larger dilated capillaries, and 
small growths or elevations made up of hypertrophic connective 
tissue and blood-vessels. 



TahA.: 




Tab. 4o a. 




PLATE 46. 
Lupus Vulgaris (Lupus Serpiginosus). 

K. A., aged 14 years, female, admitted Mar. 21, 1898, stated 
that the disease had existed since childhood. Several of her 
sisters <lied in infimcy ; she herself v:os always healthy. 

Status PrSBsens. — Patient is large, slenderly built, and pale. 
Apex of left lung infiltrated ; heart normal. In the region of 
the left thigh, involving the upper two-thirds, outer side, is 
observed a wrinkled scar. In this scarred area are numerous 
flat, reddish, irregularly-distributed and -arranged tubercles, in 
greater number and more crowded toward the posterior border. 
Some of these tubercles are covered with a thin crust ; some 
are redder in color and show minute blood-points. The poste- 
rior boundary-line is made up of a thick wall of crust-forma- 
tion. 

Treatment. — Under chloroform, enucleation, Paquelin cau- 
tery', and excision. Healing ensued and patient was discharged 
cured forty-three days after admission. 



Tdh -*■() 




f 



PLATE 47. 
Lupus Vulgaris (Lupus Exulcerans, Lupus Exedens). 

W. A., aged 22 j^ears, shoemaker, was admitted Jan. 6, 1897. 
The patient stated that the skin-affection had existed since he 
was two years old, and that he had been under treatment sev- 
eral times. At present there were some pain and itching. One 
brother and his parents had died of consumption. 

Status Praesens. — On the inner aspect of the left thigh 
there is a palm-sized, bright-red, infiltrated patch, partly scaly 
and the central portion cicatricial. On the borders reddish- 
brown tubercles are to be seen. In addition to this area iso- 
lated patches covered with crusts exist near by. After remov- 
ing the crusts superficial ulcerations are disclosed. On the 
extensor aspect of the thigh, at the same height, is a half-dollar- 
sized area, similar in character. Besides these areas there are 
elongated, atrophic, somewhat depressed scars in the popliteal 
region. 

Treatment. — Under chloroform the patch was excised and 
the skin stretched from the two sides and stitched together; 
later the uncovered wound was covered with transplanted skin. 
The patient was discharged cured four months after admission. 




*ai^ 




<- '"■>■. 

**>*: 




PLATE 47a. 

Chronic Tuberculosis of the Hand, following Exarticulation 
of Necrosed Middle Finger. 

K. J., aged 62 years, day-laborer. 

History. — The patient was taken sick in May, 1891, four 
years previously, with severe pain in the middle tinger of the 
right liand ; in Feb., 1892, it was found necessary to remove it 
by enucleation ; the parts were necrosed. A year and a half 
ago the dorsum manus at the region of enucleation showed 
signs of inflammation and became ulcerated. On the right 
cheek the patient has had for three years a dollar-sized patch 
which has changed but little. Five children of the patient are 
living and healthy. The patient has been in attendance at the 
dispensary for twelve weeks. 

Status Praesens. — Just outside of the right corner of the 
mouth, separated from it by a narrow piece of sound skin, is a 
patch of disease about an inch square. The patch is chiefly 
cicatricial, the scar being white ; toward the angle of 'lie mouth 
the skin is reddened, and in the middle part dep essed and 
slightly ulcerated; papillomatous peripherally. Th3 liase of 
this area is moderately inflamed, infiltrated, and elastic. Toward 
the lower part of the face just below this area is a small patch 
with tubercles and ulceration. 

The right upper extremity, especially the forearm, is, in com- 
parison with the left, emaciated. The hand itself is slightly 
bloated, the thumb free, three fingei-s flexed ; extension of the 
latter is impossible. The middle finger is wanting. Extending 
over the site of the exarticulated finger toward the palm, and 
to a small distance on the dorsum and down the fii"st and 
third fingers, the tissue is of a lived, red color, slightly inflamed 
and infiltrated. The entire surface of this region is beset with 
millet-seed- to lentil-sized ulcerations, many of which are con- 
fluent and form irregular ulcerated islets or areas, extending 
down into the coriura. On the peripheral portion of this area 
can be noticed fresh groups of small tubercles, some of which 
have broken down and formed ulcerations similar to those de- 
scribed. Upward on the hand, beyond this active area, the 
skin is slightly shining and red, with scattered erosions and 
with slight infiltration. At the wrist is another area of active 
tubercles and ulceration. 

Oct. 18. — The suppurative tendency in the tubercles con- 
tinues. 

Dec. 3. — Over the joint the small tubercles have disappeared 
and the ulcerations are nearly healed. 



Tab. 47 a. 




PLATE 47b. 

Chronic Tuberculous Ulcerations on Back of Hand. Scrof= 
ulo^'gummata on Forearm. 

M. M., aged 60 years, female, wus admitted Oct. 18, 1895. 

History. — The patient stated that in her youth she had been 
subject to a cough for a long time, which her physician liad 
declared to be a lung-disease. For some years the symptoms 
of lung-disease had practically disappeared. Ten years ago the 
patient had caries of the right middle finger, which at first im- 
proved, but which two years ago became so much worse that 
enucleation was practised. 

Status Praesens.-^The patient is rather slenderly built, 
but is moderately well nourished. Her muscles are flabby and 
her skin pale. At apex of the right lung there is a somewhat 
shorter percussion-sound; some emphysema. The right upper 
extremity, as to size and nutrition, showed no difference from 
the left, except that the right middle finger is gone. The scar 
from the latter reaches considerabl;j| up the Iiand. The surfiice 
over the metacarpal bones of the second and fourth fingers, 
and extending slightly over that of the little finger, is rugous 
and covered with honey-like crusts, beneath which are shallow 
ulcerations; the surrounding skin is reddened. On both the 
corresponding fingers are small tubercles somewhat scaly. On 
the forearm below the elbow is a livid node about half the size 
of a hazelnut. Above this, separated by a band of sound skin, 
is an infiltrated group of similar, but smaller, lesions. Under 
the olecranon, on the extensor aspect, is a crusted idcer two- 
fifths inch wide and over a half inch long, with moderately- 
inflamed areola, covered with crusts. In the axillse are several 
bean- to walnut-sized infiltrated glands. 

Treatment. — After removal of the crusts various salves 
spread upon bandages were from time to time applied. 

Dec. 12, 1895. — Patient, by her own wish, was discharged ; 
there had been improvement. 



Tab. 47 b. 




PLATE 47c. 

Chronic Tuberculosis of the Skin of the Leg (Lupus 
Tumidus). 

P., aged 69 years, was admitted Dec. 25, 1S94. On the skin 
of the lower leg were numerous warty papillomatous excres- 
cences, furrowed, and with points of ulceration, out of which 
could be squeezed cheesy pus and blood. The development of 
the papillomatous growths was rapid, becoming quite extensive 
over this leg, there being also marked pigmentation. Two 
nodules were excised, examination of which disclosed the 
process to be a typical tubercle-deposit-formation in the granu- 
lation-tissue. 

Treatment. — As the patient refused operative measures, in- 
jections of Koch's tuberculin were tried. Injections were 
made on F'eb. 21 and 26, Mar. 3 and 14, and Apr. 4, each time 
one milligram. Reaction appeared after the first injection; 
temperature rising to 39° C, falling two hours later to 38° C. ; a 
day afterward it had become normal. After the second injec- 
tion the temperature rose to 40° C, and about the same eleva- 
tion followed each of the succeeding injections. The patient 
always felt sick and weak for one or two days after each injec- 
tion, but recovered rapidly. The local changes after the first 
injections consisted in increase of the swelling, congestion of 
the growths and their surroundings, and a melting away of the 
lesions. By the time of the last injection papillomatous growths 
and tumors were merely flat infiltrations ; the local reaction 
showed itself bj' hyperemia of these areas. 

The case is of interest for two rea.sons : First, the appearance 
of tuberculosis of the skin on an unusual site and the peculiar 
appearances and course of the growths ; and secondly, the 
result of the treatment instituted. 



Tab. 47 c. 




PLATES 48 and 48a. 
Lupus Vulgaris; Phlegmon. 

J. A., aged 20 years, trunk-maker, admitted May 0. The 
patient has been sick since early childhood ; the skin-disease is 
of about fourteen years' duration. 

Status Prsesens. — Patient is large, very anemic, and ema- 
ciated. Pulmonary tuberculosis; amyloitlosis hepatis ; ne- 
phritis. The left lower extremity is elephantiasic, thickened, 
and edematous; the dorsinn pedis and the interdigital spaces 
covered with discrete and confluent ulceratimis. Scattered 
groups of lupus-tubercles on the left thigh. On the mucous 
membrane of the cheek are several millet-seed-sized ulcers. 
On the right thigh, starting from a scattered group of lupus- 
tubercles, is a phlegmonous inflammation, with lymphangitis, 
which extends to Poupart's ligament. 

May 15. — Severe pain in the left lower extremity ; at the 
same time there was noted marked increase in the edema and 
the skin became rugous and wrinkled. A bluish-black discol- 
oration of the toes developed, which rapidly spread. Death 
ensued in the night. 

Autopsy. — In the biceps muscle of the thigh was an abscess 
the size of the double fist ; lying between it and the bone was 
the femoral artery. Tuberculosis cutis (lupus verrucosus) ; 
lupus mucosaj oris; hypoplasia arteriarum ; amyloidosis hep- 
atis, lienis, et renum ; nephritis subacuta. 



Tab. 48 a. 




PLATE 48b. 
Lupus Vulgaris (Lupus Hypertrophicus). 

M. C, aged 60 years, was received in the hospital in Sept., 
1897. The patient was much debiUtated and mentally de- 
pressed, and stated that for a year various parts of the face had 
been rapidly and consecutively attacked with considerable in- 
flammatory swelling. He knew nothing of any earlier erup- 
tion, especially as he never had had any pain. 

Status Prsesens. — The fixce is deformed, the right eye 
almost closed, the cheeks and the nose, for the most part, the 
seat of elongated, furrowed scar-tissue; likewise the edematous 
upper lip. Between the eyebrows and root of the nose, over 
the left zygoma, over the right part of the left maxilla, and on 
the right cheek, are ulcerations not very much infiltrated, cov- 
ered with crusts. The neighborhood of the right angle of the 
mouth and the lower lip are edematous and swollen ; small 
points and areas of still greater thickening, in these regions, are 
recognizable by the touch. The mucous membrane of the 
upper lip and cheeks is much reddened, and here and there, 
near the edges, is eroded and even ulcerated. 

The patient was not able to open the mouth and was arti- 
ficially fed. His condition was somewhat improved after two 
weeks in the hospital, but he was then obliged to leave for 
home. 



Tab. 48 b. 




PLATE 49. 
Tuberculosis Subacuta Mucosae Oris. 

K. J., aged 42 years, hotel-keeper, was admitted Feb. 8, 1897. 
The patient stated that for two years he has been sick. His 
trouble began with a swelling of the right lialf of the lower lip, 
which gradually spread superficially. At the same time there 
appeared ulcerations on the mucous membrane of the mouth. 
His disease was considered an actinomycosis, and the ulcers 
were cauterized, partly with the Paquelin cautery and partly 
with acid. There was slight improvement, which did not, how- 
ever, continue, and the past month there has been a positive 
aggravation. 

Status Prsesens. — The patient is of medium size, well 
nourished, and strongly built. The left cheek is swollen, and 
on the inner side, to the extent of a silver quarter, are found 
hemp-seed- to small pea-sized j^apillary growths. The nuicous 
membrane of the lips as well as that of the left cheek near the 
mouth-angle is swollen and the seat of numerous millet-seed- to 
hemp-seed-sized, and several larger, irregularly-shaped ulcers, 
covered with grayish-yellow adherent deposit. The gums of the 
upper and lower jaws show similar changes. 

The lungs, except the apex of the right, are normal ; over 
this latter the percussion-sound is shorter and duller ; ausculta- 
tion gives rMes, whistling, and irregular inspiration and expira- 
tion. 

The plaques in the mouth are very painful, and in them the 
presence of tubercle-bacilli was demonstrated. 

Treatment. — Applications of a 1 per cent, sublimate solu- 
tion, and cauterization with 20 per cent, lactic acid ; both gave 
considerable pain. The disease progressed, showing no disjiosi- 
tion toward improvement, and the patient, at his own retiuest, 
was discharged after a stay of thirteen days. 



'/'tthA.'f 




Llth. AnsI /■' Rfirhholfl Mnnrhen 



PLATE 50. 

Panaritium Tuberculosum. 

W. J., aged 48 years, with advanced pulmonary tuberculosis. 
The patient was of strong bony structure, but cachectic. He 
stated that in 1891 a small ulcer appeared at the nail of the 
middle finger of the right hand, which since that time had per- 
sisted and gradually spread over the third and second phalanges. 
The finger is thickened toward the end, especially at the joint. 
The skin is livid. The nail is in process of being cast off, the 
ba^e being yellowish and to some extent broken off", and lifted 
up from the matrix. The uncovered portion shows ulceration 
covered with crusts. On several places are to be seen small 
pea-sized to bean-sized ulcers covered with granulations; in 
addition there are sf^veral crusted ulcei-s. The movability of 
the finger, except between the first and second phalanges, is 
compromised. The patVnt ha.s boring- and tearing-pains in 
the jiffected parts, at wiwch times the finger always swells and 
breaks out in one or two spots, from which pus exudes ; this 
takes place mostly al>out the nail. This pus-formation has, 
he stated, only been noticeable the past several months ; during 
this period, too, the bones of the part have become involved. 
Formerly the finger was dry, not so swollen, and less painful. 



/■■ Rfieftluil' 



PLATE 51. 
Tuberculosis Cutis. 

F. B., aged 54 years, porter, was treated in the dispensary- 
department. Patient was otherwise healthy and strong, 
although at the time somewhat emaciated. 

Status Prsesens. — The disease occupies the region between 
the index and middle fingers of the left hand ; the affected area 
is elevated, mildly inflammatory, and irregularly furrowed, and 
of the size of a silver half-dollar. To the touch the individual 
nodules are somewhat elastic, and by strong pressure sebaceous- 
looking material in small quantities exudes from the furrows. 
The growth is not painful. The disease began six months pre- 
viously, and had, at first, the appearance of a wart. Patient 
was not aware of any cause for the disease. 



Tab. 51 a. 






PLATE 51a. 

Lepra. 

(Fbom the Clinic of Professor de Amicis, Naples.) 

P. F., from Bisceglia (province of Bari), aged 43 years, 
baker, married, was admitted Jan. 12, 1895, and discharged 
Jan. 18. 

History. — There was no hereditary tendency. In his home- 
region were several lepers. Two brothers had the same disease 
before he had it; neither had been outside of the country. 
Shortly before the disease appeared the patient had married ; 
he has no children ; his wife remains healthy. The disease 
first showed itself when he was twenty-seven years old, with 
the appearance of bullae, at first on the legs and then on the 
upper extremities, with resulting sluggish ulcerations Avhich 
did not heal. Gradually the face began to share in the process, 
becoming considerably disfigured. 

Status Praesens. — Head-hair normal ; everywhere else the 
hair has disappeared, even in the genital region. The skin- 
color of the face is slightly bluish in tinge, and the appearance 
considerably distorted and disfigured. Over the forehead, and 
especially the eyebrows and glabella, the skin exhibits numer- 
ous reddish-brown, more or less confluent, lumpy infiltrations, 
Avith numerous furrows. Over the malar bone there is capil- 
lary enlargement. The appearance of the nose is completely 
changed ; the bridge is flat and sunken, especially at the junc- 
tion of the bone with the cartilage, where a semicircular fur- 
row is noticeable. The alse nasi are somewhat infiltrated, and 
the nasal openings contracted or closed, especially the right 
one ; the bony septum is absent. The lijis are bloated. The 
chin shows infiltration, with many furrows, but less numerous 
and less deeply than the forehead. 

There are many infiltrations and yellowish spots on the 
upper extremities, on which ulcerations, torpid in character, 
are also observed, more especially on the extensor surfaces of 
the right forearm and on the dorsal surfiice of the right hand. 
There are likewise similar conditions on the elbow and dorsal 
surface of the left hand. On the buttocks and lower extremi- 
ties the same lesions are to be observed. The scrotum, the 
skin of the penis, the prepuce, and the glans penis are infil- 
trated. The mucous membrane of the hard and soft palates, 
the tongue, epiglottis, and the arytenoid folds show more or 
less gray diffused infiltration. Everywhere anesthesia. 

Bacteriologic examination of blood from the infiltrations 
showed the Hansen bacilli. 



PLATE 51b. 

Lepra. 

(Fkom the Clinic of Professoe dk Amicis, Naples.) 

D. E. F., of Ischitella (province of Foggia). 

History. — The patient came of a fisherman's family. His 
parents are living and healthy ; his grandfather suffered from 
the same disease. Of the seven brothers and sisters, the patient 
was the third. His four brothers, the second, fourth, sixth, and 
seventh children, have also the same disease ; the remaining 
two are healthy. The affection first appeared in 1880, when he 
W!is twenty years of age ; he came under medical observation 
in May, 1892. 

The disease began with attacks of chilliness, with elevation of 
temperature following, and the appearance of red spots, at first 
on the upper extremities, with subsequent tubercle-infiltration. 
After some months it showed itself in the face, and later also 
on the lower extremities; in this latter region accompanied, 
for a time, with severe muscular pain. Infiltration followed 
soon after the macular lesions or stage, especially in the face, 
of which a considerable part is involved and much disfigured. 
On the trunk the disease spread in the fonii of spots and tuber- 
cles. Recently the voice has been hoarse and weak. 

Status Prsesens. — An examination shows that there are 
numerous tubercle-infiltrations, scattered and confluent, sepa- 
rated by more or less deep furrows, anesthetic, reddish, and 
brick-red in color, covering the forehead, the alopecic eyebrows, 
cheeks, lips, and chin, so that the foce has lost its original ap- 
pearance and is now suggestive of leontiasis. Also on the 
upper extremities are to be seen similar changes, tubercles and 
spots, more or less confluent, especially on the elbows and dor- 
sal surfiices of the hands and fingers, where also some sluggish 
ulcerations are to be observed. On the trunk and lower ex- 
tremities similar lesions are also to be seen, but are less abun- 
dant and less confluent. 

The mucous membranes of the mouth and of the hard and 
soft palates are covered with grayish papular infiltration ; like- 
wise the epiglottis and vocal cords. There is everywhere anes- 
thesia. 

Bacteriolngic examination of blood from the infiltrations 
gave the Hansen bacilli. 



PLATE 51 c. 
Lepra. 

(From the Clinic of Peofessor de Amicis, Naples,) 

D. S., from Marsala, lumberman, unmarried. 

History. — Patient is of robust constitution and of good growth 
and size. His parents and the relatives of the family are 
liealthy. At his home some cases of the disesise are observ(>d. 
The patient had never travelled. Toward the end of May, 
1878, in his nineteenth year, he noticed the gradual appearance 
of scattered spots, of varying size, of reddish-brown color; at 
first on the lower extremities and then on the upper extremi- 
ties. Soon afterward these were followed by similarly-colored 
milletseed- to lentil-sized papular elevations, which from the 
beginning were accompanied by a burning sensation, and later 
by itching. Finally on the affected parts the sensibility wjis 
lessened. After one and a half years he observed falling 
out of his eyebrows and eyelashes. In Nov., 1880, the disease 
having been gradually jjrogressing, he appeared for the first 
time at the clinic ; then again in 1881, 1886, and 1888, where 
he at the last time presented the following lesions and symp- 
toms. 

Status Praesens. — Head. — Striking tubercle- and nodular 
infiltration of the forehead, the region of the eyebrow.*, glabella, 
the nosG, the lips, cheeks, and chin, of the size of a silver 
quarter or smaller; many superficially ulcerated and covered 
with blood-crusts. Complete losvs of hair of the face. An 
almond-sized nodule on the left upper lid and several smaller, 
millet-seed-sized, on the right lid; an almost completely pedun- 
culated nodule on the conjunctiva bulbi of the left eye, with 
accompanying keratitis ; the same on the right eye. Nodular 
infiltration of the ear-muscles. The hairy .««calp is normal. 

Trunk. — On the breast disseminated reddish-brown spots with 
small papular elevations, especially in the neighborhood of the 
nipples'. Some larger, diffused, brick-red spots with symmetric 
papulotubercular elevations on the shoulders and loins. 

Neck. — Two nutmeg-sized, half-rounded nodes with smooth 
surface, one on the left side on the upper third of the sterno- 
cleido-mastoideus muscle, the other on the right side over the 
mastoid process. Several smaller nodes on the nape of the neck. 

Upper Ert remit ies. — Almost the entire surface is reddish- 
brown, with the exception of some disseminated places where 



Tab. 51 b. 




the skin is normal. From the shoulder-joint down to the 
elbow-groove can be seen, on the extensor surface, nodular, 
lupus-like elevations; these are. on the upper part confluent, 
and on the left side give rise to nut-sized ulcerated nodes. On 
the forearms are numerous nodules, nodes, and tubercles, some 
somewhat pedunculated, smooth, and with shining surface ; 
others closely ribbed and covered with bran-like scales. They 
are irregularly distributed, with the greater number upon the 
extensor side. In the wrist-region are large confluent tubercles 
bunched closely together ; traversed with furrows and scars and 
beset with ulcerating nodules. Owing to a deep infiltration 
of the dorsal aspect the hands are much maimed, and the 
fourth and fifth fingers are held in a flexed position. Atrophy 
of the interosseous, thenar, and antithenar muscles. 

Lower Extremities. — As on the upper extremities, the eruption 
is here widespread, extending from the gluteal region to the 
feet. In addition to numerous spots, numerous elevations and 
tubercles are to be seen. Some are pedunculated, others ul- 
cerated and crateriform ; the largest being over the tendon 
Achilles, along the anterior border of the tibia, and on the front 
part of the knee. The skin on the posterior surface of the legs 
is irregularly infiltrated. From the dorsal surface of the feet to 
the ends of the toes are exceedingly numerous elevations and 
tubercles, crowded closely together ; on the right foot is an iso- 
lated giant tubercle the size of a silver quarter. Also on the 
soles are bunched tubercles. 

Genitalia. — Tubercles on the skin of the penis and the 
scrotum. Extensive, almost almond-sized infiltrations in the 
right epididymis ; in the left epididymis still larger nodes and 
numerous smaller tubercles on the surface of the testicles. 

Mucous Memhrarn's. — The entire hard palate is covered with 
an ulcerated, grayish covered granuloma. There are also 
ulcerations and scars on the soft palate and tonsils. The uvula 
and nasal mucous membrane, especially on the septum, are the 
seat of extensive infiltrations. 

Lymphatic System. — The glands in the neck and in the groin 
are markedly enlarged, the latter almost as large as a fist. 

Sensibility. — Sensations of touch, heat, and pain very much 
diminished and in some places entirely wanting. 

Urine. — The urine is ropy and rich in mucin. 

Microscopic examination of blood from the diseased nodes 
disclosed numerous lepra-bacilli. 



Tab. 51 c. 




PLATE 52. 
Carcinoma Lenticulare. 

S. A., aged 74 years, admitted July 0, 1896, stated that one 
year previously the left breast began to harden. 

Status Praesens. — The head is tlirected toward the left, and 
it can be turned only to a moderate degree, and that with diffi- 
culty. The skin of the left breast, of the neck-region, and ex- 
tending to the back and to the face, is the seat of a yellowish- 
red to violet-colored, tough, hard, in part cicatricial-looking 
growth or tumor. The border is, especially at the lower part, 
sharply defined against the healthy skin and slightly elevated. 
Toward the face and back its junction with the normal skin is 
not so clearly recognizable. The left side of the face is edem- 
atous. The submaxillary, supraclavicular, and infraclavicular 
glands are hard, iutiltrated, and enlarged. The opening of the 
mouth is somewhat hindered, owing to lack of complete mova- 
bility of the lower jaw. Swallowing is likewise less easy than 
normally. 

In the following two months no material change ensued. 
The face and shoulder varied somewhat as to the amount of 
edema. 

On Sept. 2, two months after admission, the patient died with 
symptoms of collapse. 

Autopsy. — DifTused and lenticular sarcoma of the skin over 
the left breast, arising from a carcinomatous mammary gland; 
sarcomatosis of the pleura?, peritoneum, and uterus. 



-%:.^;^ 





PLATE 53. 
Epithelioma. 

W. M., aged 60 years, cook, came under treatment May 5, 
1897. The patient first noticed the disease about five months 
previously. It had given rise to no pain. She had always 
enjoyed good health, except having, when aged 40, a peritonitis, 
from which she made a good recovery. She has given birth to 
one child. Menstruation ceased five years ago. 

Status Praesens.— The patient is of moderately strong build 
and fiiirh' nourished. On the lower part of the left labia majnra 
is a dollar-sized ulceration with an infiltrated and elevated base. 
The surface is irregular, red, and uneven, with here and there 
whitish spots. The secretion is scanty. There is no enlarge- 
ment of the inguinal glands. The opposite lip is not involved. 
Above the growth, on the same side, toward the vagina, is a 
bean-sized nodule with epithelial proliferation and beginning 
central destruction. 

Treatment. — Under chloroform the diseased area was excised 
and the patient was discharged cured on June 5. 

In May, 1898, about a year later, there was a recurrence with 
involvement of the inguinal glands. Another operation fol- 
lowed, healing taking place in six weeks. 



PLATE 54. 
Carcinoma Penis. 

(Case from Prof. Ai,bkrt's Clinic.) 

X. X., acjed 51 years, admitted July 9, 1890. 

History. — Fifteen yeai^s previously patient met with an acci- 
dent, suffering an injury to scrotum and penis. The wound 
healed ; subsequently a growth began between the scrotum and 
base of the penis. Two years ago an ulcer appeared on the 
penis, which gradually enlarged and gave rise to considerable 
pain. Lately the patient has lost a good deal of flesh. 

Status Praesens. — ^Tl ? penis is hard, misshapen, and the 
seat of fissures and ulcers ; is a little less than five inches long, 
and four inches in circumurence. On lifting the organ a palm- 
sized ulcer is seen, with hard borders and covered with irregular 
sluggish granulations. The inguinal glands of both sides are 
enlarged. 

Treatment. — Amputation of penis; removal of inguinal 
glands. The urethra was dissected out and stitched to the 
perineum. 



I 



/ 



-"^^''-C. 




l.ah 



PLATE 55. 

Carcinoma Penis. 

(From Pbof. Albert's Clinic.) 

According to the statement of the patient, the disease had 
existed six months. 

Status Praesens. — The patient is strongly built, but emaci- 
ated. The skin of the penis is covered with scars, partly pig- 
mented and partly changed into thick, tough infiltration ; a 
high degree of phimosis exists. On the under half the infiltra- 
tion is continuous and the base irregularly excavated and ulcer- 
ated, and the whole mass is hard and dense. The lymphatics 
on the dorsal side of the penis, and the inguinal glands, are 
swollen and hard. 

Treatment. — Partial amputation of the penis, with plastic 
operation for urethra. 




■■? 't 



^r ^ 




I 



Tab. oo a. 




» 



PLATE 55a. 
Epithelioma Cicatrisans. 

J. J., aged 55 years, day-laborer, admitted Sept. 28, 1892. The 
disease began six years previously, on the right temple, as a 
small nodule, from which point it spread as a continuous ulcer 
on to the cheek and to the right eyelid. 

Status Praesens. — The right cheek is, from the ear-muscle 
posteriorly to the nasolabial fold anteriorly, upward toward the 
attachment of the masseter muscle, and downward to the in- 
ferior maxilla, changed into a smooth whitish scar. The border 
of this area consists of an almost continuous ulcer, somewhat 
elevated, with a base showing but slight infiltration. The base 
seems made up of anemic granulation-tissue. The disease has 
eaten through the upper eyelid, and the lid is somewhat drawn 
outward by the scar-tissue. The patient complained of sting- 
ing-pain occasionally in the ulcerated part. 

At intervals the proliferation was curetted, and in this way 
for a time destructive action or progress was stayed. On 
Dec. 15 the growth was investigated histologically and the 
diagnosis of epithelial carcinoma confirmed. 

Under anesthesia the ulcerated surfsice was thoroughly 
curetted and then cauterized with the Paquelin cautery, so 
that all, with the exception of a linear ulcer at the corner of 
the mouth, healed and scarred over. 

Scarcely four weeks had elapsed after this operation before 
the remainder of the eyelid at the inner canthus broke down ; 
a new destructive action was also observed over the zygoma, 
and the epithelial masses at the corner of the mouth began 
to grow considerably. Tlie patient's weight, with slight fluc- 
tuation, remained at 54 kg. The ulcerated surfaces extended 
and involved the scar-tissue. The eyeball was attacked, and 
lay in the orbital cavity suiTounded by epithelial necrotic 
ma.sses. The patient complained of increasing pain, which 
could only be relieved by constant use of morphin. 

Dec. 22. — In the center of the extended ulcers small islets of 
scar-tissue are again to be seen, although the disease has now 
spread over the entire chin and also over the middle of the 
nose. 

The patient was finally obliged to return to his home, and 



left the hospital on Sept. 21, 1894. The cjvse was under obser- 
vation for two yeai-s. 

The cjisc is remarkable in that in the entire eight years of its 
existence there had been no tendency to change its character. 
Further to be noted were the slow course and the tendency to 
cicatricial formation in the central parts. Later, however, not 
only did the ulcerated parts advance, but the already formed 
scar-tissue again gave away. This disposition to cicatricial 
formation was shown again and again, but the disease slowly 
progressed. The patient, from constant pain, became more 
and more emaciated. 



PLATE 56. 
Tinea Favosa. 

S. L., aged 25 years, admitted Aug. 18, 1896. For a number 
of years scalp-eruption and hair-loss had existed. 

Status PraBsens. — The scalp-hair, with the exception of a 
narrow fringe posteriorly, has entirely disappeared. The scalp- 
skin is covered in many places with sulphur-yellow, kidney- 
shaped crusts. Between these larger crusted areas are scat- 
tered pinhead- to small pea-sized straw-yellow lesions ; the 
same also on the shoulder. 

After three months' treatment the scalp is clean, and no new 
lesions or crusts have appeared. It remained in same condition 
when discharged Jan. 5, 1897. 



f2 




4 




\ 



o 



V 



PLATE 57. 
Pityriasis Maculata et Circinata. 

S. F., aged 18 years, adiuitted Feb. 13, 1896. One day before 
admission the patient noticed that the spots had appeared. 
His attention was first called to them by the itching. 

Status Praesens. — The thorax, abdomen, and the flexor sur- 
faces of the extremities are the seat of numerous efflorescences. 
On the lower belly and pubic region the spots are pale red, the 
larger of which show a central whitish epidermic scale. The 
larger number have already paled in the central portions, 
showing peripherally faintly- wrinkled epidermis, and here and 
there partly-detached scales. The border of the patches is 
slightly elevated, the epidermis of which is smooth and red- 
dened. Similar features are presented by the patches on other 
parts. 

[In the German edition this plate is described under the 
heading of " herpes tonsurans maculosus et squamosus," a 
variety of ringworm. American and English observers, how- 
ever, consider the disease as here pictured as pityriasis macu- 
lata et circinata, a disease entirely independent of the ring- 
worm-lungus. — Ed.J 




:;»♦ 



PLATE 58. 
Tinea Trichophytina Corporis (Tinea Circinata). 

L. W. admitted Nov. 16, 1895; discharged cured Nov. 23. 
Eight days previously patient noticed the central part of patch ; 
since that time it had gradually enlarged to its present dimen- 
sions. 

Status Praesens. — Upon examination is found on the right 
breast a half-dollar-sized efflorescence, the center of which is 
yellowish-red and slightly scaly. The peripheral part of the 
patch is somewhat elevated, slightly crusted and scaly, and red- 
dish in color. The outermost edge is sharply defined against 
the sound skin and is of a bright-red hue. There is itching, Init 
not to a troublesome degree. 



■^ 



^^ri'hT^^ 



PLATE 59. 
Tinea Trichophytina Corporis (Tinea Circinata). 

S. F., ajred IS j-ears, looksmith. lender observation from May 
19 to 28. Fourteen days previously the disease had appeared 
on the face, and during the past week on the left upper ex- 
tremity. Horses were kept in the house in which patient lived. 

Status Prassens. — On the face, and especially on the left 
side, are numerous pustular efflorescences, varying in size from 
a pinhead to a pea, many covered with a yellow-brown crust. 
On the flexor side of the left forearm, close to the hand, is a 
large, rounded, infiltrated, reddish patch with an elevated 
periphery ; inside the border are a number of papules and 
vesicles. Cultures were made with the contents of the vesicles 
and the trichophyton demonstrated. 

Treatment. — La-^isar's paste for the face ; naphthol-sulphur 
paste with resorcin for the patch on forearm. Complete cure 
in eight daj's. 



la ft .'iff. 



'■'- "^. 





\ 



lah, Anst f Reutthold. i/ttnrhei' 



PLATE 60. 
Tinea Versicolor. 

J. N., aged 20 years, workwoman, admitted Aug. 18, 1897. 

Status Praesens. — Over the breast are to be seen numerous, 
variously-shaped and -sized, yellowish-brown patches. Slight 
branny scaliness is observable in some, and the epidermal 
covering is readily scratched off. The color is pale yellowish- 
brown to a darker brown — the darker color being more pro- 
nounced at the edges. 

Treatment. — Naphthol-sulphur soap, sapo viridis, and dust- 
ing-powder of rice-flour. Cure. 



/ 




PLATE 61. 
Actinomycosis. 

D. A., aged 42 years. Tlie patient was in the hospital in 
Aug., 1892, but returned to his home. As his condition had 
gradually grown worse, he was on request again admitted on 
Oct. 28, 1892. 

Status Praesens. — The patient is very pale, emaciated, and 
complains of difficulty in breathing and swallowing. Lungs 
and heart normal. The entire left side of the neck, from the 
lower jaw down over the supraclavicular fossa, is made up of 
numerous elevations and depressions. The whole area is hard. 
Between these depressions the skin is infiltrated and corre- 
spondingly raised, and the seat of numerous fistulous tracts of 
varying depths ; out of which there oozes thick pus containing 
the fungus, appearing as minute grayish-white or yellowish 
granules. The skin over the lower part of this infiltrated area 
is of a dirty violet-gray color. Immediately over the left 
collar-bone is a nut-sized fluctuating tumor covered with pale 
violet-colored skin; also on the right side of the neck, in the 
supraclavicular fossa, is a similar growth. 

Treatment. — Patient was treated by incisions and the injec- 
tion of J per cent, corrosive-sublimate solutions, and the parts 
kept covered with antiseptic bandages. Some improvement 
ensued. The patient insisted upon leaving the hospital three 
weeks after admission. 







1' >^ 



PLATES 62 and 62 a. 
Scabies. 

H. M., female, admitted Aug. 12, 1897. The patient stated 
that itching, especially at night, became noticeable six weeks 
previously, although most of the pustular lesions had appeared 
more recently. 

Status Praesens. — The whole surface is the seat of irregu- 
larly-scattered scratch-marks and excoriations ; and the ex- 
tremities are covered with numerous discrete pustules, mostly 
crusted. The dorsal surface of l)oth hands is studded with well- 
filled pustules and pus-containing blebs; in some places, more 
particularly on the fingers, they have been scratched away and 
given place to raw-looking abrasions. 

Treatment. — Wilkinson's ointment; cure. 



Tab. 62 a. 




PLATE 63. 
Maculae Cseruleae; Phthiriasis. 

0. F., aged 33 years, baker's helper, adi)iitted Aug. 21, 1897. 

In the pubic and axillary regions numerous Pediculi pubis 
(crab-lice) are present, and ova may be observed attached to 
the hair-shafts. In addition, in the inguinal region, from the 
effects of scratching and from applications of mercurial oint- 
ment, are to be seen minute excoriations. The body is covered 
with bluish, rounded and linear, elongated spots up to the size 
of a pea ; the overlying epiderm is uninjured. 



PLATE 64. 

a. Nits (louse-eggs, ova), attached to the hair-shaft. 

b. Head-louse. 

c. Body-louse, clothing-louse. 

d. Crab-louse. 

e. A burrow (cuniculus). 
/. Itch-mite egg. 

g. Itch-mite, from beneath. 

h. Itch-mite, from above. 

i. Hair-follicle mite (Acarus foUiculorum). 



Tab. 6i 







PliATE 65. 

a. Ray-tungus. 

b. Molluscum epitheliale corpuscle ; " molluscum boclJ^" 

c. Trichophyton (ringworm-fungus) in scalp, hair- and outer 
root-sheath. 

d. Microscopic picture of a hair in trichorrhexis nodosa. 

e. Achorion Schonleinii (favus-fungus), from a favus-crust. 
/. Microsporon furfur (tinea-versicolor fungus). 




Tab. 65. 










PLATE 64. 

a. Nits (louse-eggs, ova), attached to the hair-shaft. 
h. Head-louse. 

c. Body-louse, clothing-louse. 

d. Crab-louse. 

e. A burrow (cuniculus). 
/. Itch-mite egg. 

g. Itch-mite, from beneath. 

h. Itch-mite, from above. 

i. Hair-follicle mite (Acarus folliculorum). 



Tab. 64 







INDEX. 



Absence of tlic nails, 129 
Acanthosis nigricans, 125 
Acarus foliiculorum, 188; PI. 64 1 

hominis, 186 
Acliorion Schonleinii, 175 ; PI. 65 e 
Acne, 47 

artificialis, 49 

bromid-, 50 

cachccticorum, 49, 102 

drug-, 49 

follicularis, PI. 3 

hordeolaris, 48 

keloid, 54 

mcntagra, 53 

necrotisans, 48 

punctata, 48 

piistulo.sa, 48 

rosacea, 56 
treatment of, 58 

tar-. 49 

treatment of, 50 

urticuta, 48 

varioliformis, 48 

vulgaris, 47 ; PI. 30 
Actinomyces, 185 
Actinomycosis, 185; PI. 61 
Addison's disease, 134 
Adenoma sebaceum, PI. 3 
Albinism, hair in, 129 
Albinisraus partialis, 130 

universalis, 130 
Albinos, 130 
Alopecia, 126 

areatii, 127 ; Pis. 41 a and 41 b 

congenital, 126 

prsematura, 126 

senilis, 126 

totalis neurotica, PI. 41a 
pnematura neurotica, 127 

treatment, of, 128 
Ana.sarca, 142 
Anemia of the skin, 33 
Anesthesia of the skin, 121 

13 



Anesthetic leprosy, 165 
Angiomata, 149 
Angioneurotic edema, 41 
Animal i)arasites, 186 
Anomalies of the hair, 126 

of the nails, 129 
Anthrax, 85 
Argyria, 137 

Arsenic, eruptions from, 44 
Arsenical hyperkeratosis, 136 

melanosis, 135 
Arsenicismus, 135 
Asiatic pills, 91 

Atrophy of the .skin, general, 143 
Autographism, 39 

Bacillus leprse, 163 
Bacteridium maidis, 42 
Baldness, 126 (see Alopecia) 
Bed-bug, 190 
Body-louse, PI. 64 c 
Boil, 84 

Bromid-acne, 50 
Bromidrosis, 25 
Btillffi, 19 
Burns, 75 

of the first degree, 76 

of the second degree, 76 

of the third degree, 77 

treatment of, 78 

Callositas, 121 ; PI. 40 

Callus, 121 

Cancer, skin, 173 

Canities, PI. 41 6 

Canquoin's past«, 158 

Captol, 31 

Carbuncle, 85 

Carcinoma lenticulare, 174 ; PI. 52 

penis. PI. 55 
Ce resin, 22 
Clieiropompholyx, 26 
Chloasiha cachccticorum, 133 

193 



194 



INDEX. 



Chloasma uterinum, 132 
Chromopliytosis, 183 
Chrysarobin iu psoriasis, 93 
Cicatrix, 138 
Cimex lectularius, 190 
Clavus, 122 
Collemplastra, 24 
Combustio, 75 

bullosa, 7t) 

erythematosa, 76 

escharotica, 77 
Comedo, PI. 3 
Comedones, 29 
C-ongelatio, 79 
Congenital alopecia, 126 
Corn, 122 
Cornu cutaueum, 122 ; Pis. 21, 21 a, 

216 
Cosme's paste, 158 
Crab-louse, 190; Pis. 63, 64 a 
Creeping-disease, 189 
Crusta lactea, 108 
Culieidai, 191 
Cutaneous horn, 122 
Cyanosis, 34 
C^sticercus cellnlossB cutis, 188 

Daeieb's disease, 125 
Demodex foUiculorum, 188 
Dermanvssus avium, 191 
Dermatitis, 34, 73; Pis. 23, 23 a, 24, 
25, 25 a 

cantharides, PI. 14 

exfoliativa of Ritterskin, 67 

papillaris capillitii, 54 
Dermatomyomata, 149 
Drug-acne, 49 

-eruptions, 43 
Dysidrosis, 26 

Dystrophic papillaire et pigmen- 
taire, 125 

Ecthyma, 19 
Eczema, 102 

acute, 103 

artificiale acutum, PI. 24 
vesiculosum. Pis. 23, 23 a 

caloricum, 112 

causes of. 111 

chronic, 106 

course of, 113 

crustosum, 103 

diagnosis of, 110 

erythematosum, 103 

external treatment of, 114 



Eczema, internal treatment of, 113 

intertrigo, 106 

madidans, 104, 107 

et crustosum, Pis. 28, 28 a 

marginatum, 109, 180 ; Pi. 26 

mycoticum, PI. 27 

of face, acute, 105 
chronic, 108 

of hands, acute, 105 
chronic, 108 

of lips, 108 

of scalp, 107 

papulosum, 103 

prognosis of, 113 

pustulosum, 103 

artificiale, Pis. 25, 25 a 

rubrum, 104, 107 

sebovrhoicum, 109 ; Pis. 17, 18 

solare. 112 

squamosum, 104 

sudamen, 112 

trade-, 108 

vesiculosum, 103 
Efflorescences, 19 
Elephantiasis Arabum. 139 

lymphangiectodes, 151 
Ephilides, 131 
Epithelioma, 173, PI. 53 

cicatrisans, PI. 55 a 

treatment of, 175 
Equinia, 86 
Eruptions, drug-, 43 

hemorrhagic, 44 
Erysipelas, 81 

bullosum, 82 

migrans, 82 

prognosis of, 83 

treatment of, 83 
Erythema, 35 

cause of, 37 

congestivum, 33 

contusiforme, 37 

figuratum, 35 

gyratum, 35 

iris, 36 

multiforme, 35 ; PI. 6 

multiforme bullosum, 36; Pis. 7 
and 7 n 
erythematous and erythemato- 

papular, PI. 6 
papular and nodose, PI. 8 

nodosum, 37 

papulatum, 35 

treatment of, 38 

vesiculosum, 86 



INDEX. 



195 



Erythemata occurring in infectious 

diseases, 41 
Erythrasnia, 185 
Erytliromelalgia, 41 
Kiigallol, 94 
Exantheni, 20 
Excoriations, 19 
External treatment, 21 

Face, eczema of, acute, 105 

chronic, 108 
Fats in slcin-diseases, 22 
Favus, 175 

fungus, PI. 65 e 

treatment of, 176 
Fibroma, 147 

molluscura sen pendulum, 147 
Filaria medinensis, 188 
Filmogen, 24 
Fisli-sliin disease, 123 
Flies, 191 
Folliculitis barbae, 53 

exulcerans serpiginosa, 48 
Freckles, 131 

treatment of, 1,32 
Frost-bite, 79 

treatment of, 80 
Fungus cutis, 163 
Furnnculosis, 84 
Furunculus, 84 

Oanorenk, multiple cachectic, 74 

senile, 74 

spontaneous, 75 

symmetric, 74 
Gelanthum,24 
Gelatin paste, 24 
General therapeutics, 20 
Genitals, acute eczema of, 10<) 

chronic eczema of. 108 
Glands, disorders of, 25 
Gnats, 191 

Gommes scropbuleuses. 161 
(Jranuloma fungoi'des. 169 

treatment of, 170 
Graying of the hair, 129 
Guinea-Morm, 188 
Gyri, 19 

Hair, anomalies of, 126 

graving of, 129 
Hair-follicle mite. 188 
Hands, acute eczema of, 105 

chronic eczema of, 108 
Hard soaps, 23 



Harvest-mit«, 191 

Head-louse, PI. 64/ 

Heat rash, 64 

Hebra's spiritus saponatus kaliuas, 

23 
Hemorrhagic eruptions, 44 
Herpes circinatus, 36 
facialis, 63 
iris, 46 

prseputialis, 63 
progenitalis, 63 
tonsurans, 179 

disseminatus, 180 
zoster, 59 
faciei et capillitii, 62 
sacrolumbal is, hsemorrhagicus 

et gangi-jenosus, PI. 12 
supraorbital and palpebnil, PI. 

13 
treatment of, 62 
Hyperchromatosis arsenicalis, PI. 37 
Hyperemia of the skin, 33 
Hyperidrosis, 25 
palmarum et plantarum, 26 
pedum, 28 
Hyperkeratosis, arsenical, 136 

palmaris, PI. 40 
Hypertrichosis, 129 

Ichthyosis, 123 ; PI. 39 

hystrix, 124 

serpentina, 123 

simplex, 123 

treatment of, 124 
Idiopathic skin -diseases, 18 
Impetigo, PI. 32 

faciei contagiosa, 108 

herpetiformis, 65 
Inflammatory dermatosis, 73 
Internal treatment, 21 
lodin, eruptions from, 44 
Itch, 186 

Itcli-mite eggs, PI. 64 / 
Ixodes ricjnus, 191 

Kaposi's disease, 125 
Keloid, 139 

Keratosis nigricans. 125 
pilaris, 102 ; PI. 38 

Landolf's paste, 1.58 
I>anolin, 22 
Lenigallol, 94 
Lentigo. 131 
treatment of, 132 



196 



INDEX. 



Lepra, 163: PI. 51 a, 51 h. 51 c 
ansesthetica sen nervosa, 164, 165 
course of, 167 
mutilans, 167 
treatment of, 167 
tuberosa, 164 
Leproide, 165 
Leprosy. 163 (see Lepra) 

tubercular, 164 
Leptus autumualis, 191 
Leucoderma, 130 ; PI. 41 

acquisitnm, 130 
Leukemia, skin-symptoms in, 170 
Lice, 1S9 

Lichen lividus, 102 
moniliformis, 99 
pilaris, 102; PI. 38 
planus, 93 
ruber, 97 
acuminatus, 97 
diagnosis of, 100 
planus, 98 ; Pis. 22, 22 a 
treatment of, 100 
scrofulosum, 101 
treatment of, 102 
Linimentum es:siccans Pick, 23 
Lipoma, 148 
Lips, eczema of, 108 
Liquor adhseslTUS, 24 
Livedo, 34 
Liver-spots, 183 
Lupoid sycosis, 54 
Lupus, 154 
erythematosus, 145 ; Pis. 42, 43 
discoides, 145 
disseraiuatus, 145 
treatment of, 146 
exulcerans, 155 
papillomatosus, 155 
serpiginosus, 155 
treatment of, 158 
tuberculosus, 155 
tuniidu.-«. 155; PI. 47 c 
verrucosus, 155 

vulgaris hypertrophicus, PI. 48 e 
phlegmon. Pis. 48. 48 a 
serpiginosus, PI. 46 
exulcerans, PI. 47 
Lymphangioma, 150 

tuberosum multiplex. 151 
Lyniphodermia perniciosa, 171 

M\cxTL«, 19 

oemlese, PI. 63 
Mai del sole, 42 



Malignant growths of the skiii, 168 

pustule, 85 
Mai rosa, 42 
Marasmic gangrene. 74 
Melanoicterus, 133 
Melasma, 133 

Mercury, eruptions from, 44 
Microsporon Audouini, 179 
• furfur, 184 : PI. (>5/ 

minutissimum, 185 
Miliaria. 64 

crystallina, 65 

epidemica. 65 

rubra et alba, 64 
Milium, 31 ; PI. 2 

treatment of, 32 
Mollin, 22 
MoUuscum contagiosum, 32 

epitheliale. 32 
corpuscles, PI. 65 h 

verrucosura, 32 
Morbilli, PI. 4 
Morbus Addisonii. 134 

maculosus Werlhofii. 46 
Multiple cachectic gangrene, 74 
Myiasis dermatosa oestrosa, 191 
Myroniu, 22 
Myxedema, 142 

NiEVTTS. 137 

lipomatodes, 137 

mollusciformis, 137 

pigmentosus, 131 
uuilateralis, PI. 36 

spilus, 1.T7 

treatment of, 128 

vascularis. PI. 45 
et verrucosus, PI. 45 a 

vasculosus, 149 

verrucosus, PI. 35 
Nails, absence of. 129 

anomalies of. 129 
Neoplasm at a, 137 
Neurofibromata, 147 
Neuroses, 118 
Xentral soap, 23 
New growths, 137 
Nits, PI. 64 a 

(Edema cutis. 142 

circumscriptum. 41 
CEsypus, 22 
Ointment-mulls. 22 
Onychogryphosis, 129 
trichophytiua, 181 



INDEX. 



197 



Onycboiiiycosis trichoi)liytiiui, 181 
Osmidrosis, 25 
Over-fatted soaps, 23 

Pachydermia, 139 

Paget's disease, 12(i 

Paleaess of the skin, 130 

Paltauf 's styrax mixture, 187 

Panaritium tuberculosum, PI. 50 

Papules, 19 

Paraplasters, 24 

Parasitic diseases of the skin, 175 

Parchment-skin, 143 

Pastes, 24 

Pediculosis, 189 

eapillitii, 190 

capitis, 190 

corporis seu vestimenti, 190 

pubis, 190 
Pediculus capitis, 189 

pubis, 189 

vestimenti seu corporis, 189 
Peliosis, 44 
Pellagra, 42, 133 
Pemphigus, 68 

acutus, 6(3 

contagiosus, 67 

crouposus, 69 

foliaceus, 70 

nconatoruni, 67 

pruriginosus, 69 

treatment of, 72 

vegetans, 70 ; Pis. 33, 34, 34 a 

vulgaris, 68 
Perforating ulcer of the foot, 75 
Phthiriasis, PI. 63 
Pigment-anomalies of the .skin, 130 
Pigmentation of the skin, increase 

in, 131 
Pityriasis capitis, treatment of, 30 

maculata et circinata, 180 ; PI. 57 

rubra, 95 
pilaris, 96 

versicolor, 183 
Plasters, 24 
Plica polonies, 108 
Pompholyx, 26; PI. 1 
Porcupine men, 124 
Potassium iodid in psoriasis, 92 
Powders, 24 
Pricklv-heat, 64 
Prurigo, 115; PI. 29 

agria, 116 

diagnosis of, 117 

-ferox, 116 



Prurigo mitis, 116 

treatment of, 117 
Pruritus, 118 

ani, 121 

cutaneus senilis, 119 

localis, 119 
• pudendorum, 121 

scroti, 121 

treatment of, 119, 1^1 

univei-salis, 119 

VUlViE, 121 
Pseudo-erysipelas, 83 
Pseudoleukemia, skiii-symptomism, 

170, 171 
Psoriasis, 86 ; Pis. 17, 18, 21, 21 a, 
216 

annularis, 87 ; Pis. 19, 19 o, 20 

circinata, 87; Pis. 19, 19 a 

diffusa, PI. 16 
universalis, 87 

figurata, 87 

guttata, 87 

gyrata, 87; PI. 20 

nummularis, 87 

ostreacea, 69 

prognosis of, 90 

punctata, 87 
et guttata, PI. 15 

rupioides, JK) 

treatment of, 90 
Psorospermosis follicularis vege- 
tans, 125 
Pulex irritans, 190 

penetrans, 189 
Purpura hsemorrhagica, 46 ; Pis. 9, 
10 

rheumatica, 44 
(fulminans), PI. 11 
Pustula maligna, 85 
Pustular, 19 
Pyrogallolum oxidatuni, 94 

Ray-funous, 185; PI. 65 a 
Raynaud's disease, 74 
Resorbin, 22 
Rhagades, 105 
Rhinophyma, 56 
Rhinoscleronia, 151 
Ringworm, 179 
fungus, PI. 65 c 
treatment of, 182 
Bodent ulcer, 173 

Sand-flea, 189 
Sarcoma cutis, 171 



198 



INDEX. 



Sarcoma cutis, treatment of, 172 

luelaiiodes, 171 
Sarcoptes lioniiiiis, 186 
Scabies, 186 ; Pis. 62, 62 a 
Scalp, chronic pustulareczema of, 107 
Scar, 138 
Scleroderma, 139 

diagnosis of, 141 

etiology of, 141 

neonatorum, 141 

treatment of, 141 
Scorbutus, 46 
Scrofuloderma, 160 

treatment of, 161 
Scurvy, 46 
Seborrhea, 28 

treatment of, 29 
Seborrhcea corporis, 109 

oleosa, 28 

sicca seu squamosa, 28 
treatment of, 30 
Senile gangrene, 74 
Skin, anemia of, 33 

anesthesia of, 121 

animal parasites of, 186 

callosity of, 121 

epithelioma of, 173 

functions of, 17 

general atrophy of, 143 

hyperemia of, 33 

inflammation of (see Dermatilis) 

lesions of, 19 

malignant growths of, 168 

paleness of, 130 

parasitic diseases of, 175 

partial atrophy of, 142 

pigment-anomalies of, 130 

sarcoma of, 171 

thinning of, 142 

tuberculous diseases of, 152 

whitening of, 130 
Skin-cancer, 173 

internal treatment of, 21 

symptoms of, 18 
Skin-diseases, causes of, 18 
Soaps in treatment of skin-diseases, 

23 
Soft soaps, 23 
Spontaneous gangrene, 75 
Squamse, 19 

Squamous dermatoses, 86 
Stomonyidse, 191 
Striae atrophicie, 142 

gravidarum, 142 
Sudamen, 65 



! Sweating of the feet, 26 
j treatment of, 28 

Sweat-secretion, 25 
Sycosis, 53 ; PI. 31 

lupoid, 54 

treatment of, 54 

vulgaris, 53 
Symmetric gangrene, 74 
Symptomatic skin-diseases, 18 
Syringomyelia, 74 

TAR-acne, 49 

preparations in psoriasis, 92 
Telangiectases, 150 
Therapeutics, general, 20 
Thyroid preparations in psoriasis, 

92 
Ticks, 191 

Tinctura saponis viridis, 23 
Tinea circinata, 179; Pis. 58,59 
favosa, 175 ; PI. 56 
kerion, 182 
sycosis, 182 
tonsurans, 181 
trichophytina, 179 
capitis, 181 
corporis, 179 ; PI. 58 
cruris, PI. 26 
treatment of, 182 
vei-sicolor, 183 ; PI. 60 
treatment of, 184 
Trade-eczemas, 108 
Traumaticin, 24 
Treatment, external, 21 

internal, 21 
Trichophyton, 170; PI. 65 c 
Trichophytosis, 129 
Trichoptilosis, 129 
Trichorrhexis nodosa, 128 
Tubercles, 19 
Tubercular leprosy, 164 
Tuberculosis cutis, Pis. 47 a, 47 6, 
47 c, 50,51 
coUiquativa, 160 
fungosji, 163 

snbacnta mucosa' oris, PI. 49 
ulcerosa cutis, 161 
verrucosa cutis, 162 
Tuberculous diseases of the skin, 
152 
ulcer, 161 
T^'loma, 121 

Ulcer, perforating, of the foot 75 
rodeut, 173 



L\i)i:x. 



199 



Ulerythema sycosiformc, 54 
Unguentmn castini Uniia, 23 

laiiolini Piuschkis, 22 

Wilkinsoni, 95 
Unna-Beiersdorf gutta-percha plas- 
ter-mulls, 24 
Uiina's hasis-soap, 23 
Urticaria, 38 

fiictitia, 39 

pigmentosa, 39 

treatment of, 40 

Vagabond's disease, 133 
Varicella, PI. 5 
Varnishes, 23 
Vasogene, 22 
Vernix caseosa, 28 
Verruca, 122 
Verrucous growths, 137 
Vesiculpp, 19 
Vienna paste, 158 
Vitiligo, 130; PI. 41 



Vitiligoidea, 148 

Warts, 122 

treatment of, 123 
Water, 22 
Wheals, 19 
Whitening of the skin, 130 

Xanthelasma, 148 
Xanthoma, 19, 148 

planum, 148 

treatment of, 149 

tuberosum, 148 ; Pis. 44, 44 o 
Xeroderma, 143 

pigmentosum, 143 

treatment of, 144 

Zoster, 59 (see also Herpes Zoster) 
bilateral, 61 
cervical is, 62 
gangnenosus, 60 
bffimorrhagicus, 60 



Catalogue tt Medical Publications 



OF 



W. B. SAUNDERS & COMPANY 

PHILADELPHIA jt .< Jt j» ,< LONDON 

925 Walnut Street Jt jt jt ^4 ^* 161 Strand, W. C. 

Arranged Alphabetically and Classified under Subjects 

See page 18 for a List of Contents classified according to subjects 

THFl books advertised in this Catalogue as being sold by tubscrifitioH are usually to be 
obtained from travelling solicitors, but they will be sent direct from the office of pub- 
lication icharges of shipment prepaid) upon receipt of the prices given. All the other 
books advertised are commonly for sale by booksellers in all parts of the United States ; but 
books will be sent to any address, carriage prepaid, on receipt of the published price. 

Money may be sent at the risk of the publisher in either of the following ways : A postal 
money or^er, an express money order, a bank check, and in a registered letter. Money 
sent in any other way is at the risk of the sender. 

SPECIAL To physicians of approved credit books will be sent, post-paid, on the following 
OFFER terms : f 5.00 cash upon delivery of books, and monthly p>ayments of I5.00 there- 
after until full amount is paid. Any one or two volumes will be sent on thirty days' time 
to those who do not care to make a larger purchase. 



AN AMERICAN TEXT-BOOK OF APPLIED THERAPEUTICS. 

Edited by James C. Wilson, M. D., Professor of Practice of Medicine and 
of Clinical Medicine, Jefferson Medical College, Philadelphia. Handsome 
imperial octavo volume of 1326 pages. Illustrated. Cloth, $7.00 net; 
Sheep or Half Morocco, $8.00 net. Sold by Subscription. 

AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL- 
DREN. Second Edition, Revised. 

Edited by Louis Starr. M. D.. Consulting Pediatrist to the Maternity Hos- 
pital, etc. : assisted by THOMSON S. Westcott. M. D., .Attending Physi- 
cian to the Dispensary for Diseases of Children, Hospital of the University 
of Pennsylvania. Handsome imperial octavo volume of 1244 pages, pro- 
fusely illustrated. Cloth, J7.00 net ; Sheep or Half Morocco, ^.00 net. 
Sold by Subscription. 

AN AMERICAN TEXT-BOOK OF DISEASES OF THE EYE, 

EAR, NOSE, AND THROAT. 

Edited bv G. E. DE SCHWEIMTZ. M. D., Professor of Ophthalmology. 
Jefferson Medical College, Philadelphia; and B. ALEXANDER Randall. 
M. D, Clinical Professor of Diseases of the Ear, University of Pennsylvania. 
Imperial octavo, 1251 pages; 766 illustrations. 59 of them in colors. Cloth, 
JJ7.00 net ; Sheep or Ha.f Morocco, J8.00 net. Sold by Subscription. 



MEDICAL PUBLICATIONS 



AN AMERICAN TEXT=BOOK OF GENITO=URINARY AND 
SKIN DISEASES. 

Edited by L. Boi.i'ON Hangs, M. D., Professor oi* Gcnito-Urinary Surgery, 
University and Bellevue Hospital Medical College, New York ; and W. A. 
Hakuawav, M. D., Professor of Diseases of tlie Skin, Missouri Medical 
College. Imperial octavo volume of 1229 pages, with 300 engravings and 
20 full-page colored plates. Cloth, ^7.00 net ; Sheep or Half Morocco, 
$8.00 net. Sold by Subscription. 

AN AMERICAN TEXT=BOOK OF GYNECOLOGY, MEDICAL 
AND SURGICAL. Second Edition, Revised. 

Edited by J. M. Baldy, M. D., Professor of Gynecology, Philadelphia 
Polyclinic, etc. Handsome imperial octavo volume of 718 pages ; 341 illus- 
trations in the text, and 38 colored and half-tone plates. Cloth, ;^6.oo net ; 
Sheep or Half Morocco, $7.00 net. Sold by Subscription. 

AN AMERICAN TEXT=BOOK OF LEGAL MEDICINE AND 
TOXICOLOGY. 

Edited by Frederick Peterson, M. D., Chief of Clinic, Nervous Depart- 
ment, College of Physicians and Surgeons, New York ; and Walter S. 
Haines, M. D., Professor of Chemistry, Pharmacy, and To.xicology, Rush 
Medical College, Chicago. In Preparation. 

AN AMERICAN TEXT-BOOK OF OBSTETRICS. 

Edited by RICHARD C. Norris, M. D. ; Art Editor, Rohert L. DICKINSON, 
M. D. Handsome imperial octavo volume of 1014 pages ; nearly 900 beau- 
tiful colored and half-tone illustrations. Cloth, 5700 net ; Sheep or Half 
Morocco, $8.00 net. Sold by Subscription. 

AN AMERICAN TEXT-BOOK OF PATHOLOGY. 

Edited by LUDWIG Hektoen, M. D., Professor of Pathology in Rush 
Medical College, Chicago ; and David Riesman, M. D., Demoi'istrator of 
Pathologic Histology in the University of Pennsylvania. Handsome im- 
perial octavo, over 1200 pages, profusely illustrated. By Subscription. 

AN AMERICAN TEXT-BOOK OF PHYSIOLOGY Second Edi- 
tion, Revised, in Two Volumes. 

Edited by WILI.IAM H. HoWEi.L, Ph. D., M. D., Professor of Physiology, 
Johns Hopkins University, Baltimore, Md. Two royal octavo volumes of 
about 600 pages each. Fully illustiated. Per volume: Cloth, $2>oo net; 
Sheep or Half Morocco, 53-75 "'-'t- 

AN AMERICAN TEXT-BOOK OF SURGERY. Third Edition. 

Edited by WlI.I.IAM W. Keen, M. D., LED., F. R.C. S. (Hon.); and 
J. William White, M. D., Ph. D. Handsome octavo volume of 1230 
pages ; 496 wood-cuts and 37 colored and half-tone plates. Thoroughly 
revised and enlarged, with a section devoted to "The Use of the Ront- 
gen Rays in Surgery." Cloth, #7.00 net ; Sheep or Half Morocco, 
£8.00 net, 



OF \V. B. SAUNDERS b' CO. 



THE NEW STANDARD THE NEW STANDARD 

THE AMERICAN ILLUSTRATED MEDICAL DICTIONARY. 
Second Edition, Revised. 

For Practitioners and Students. A CJomplitc Dictionary of the Terms used 
in Medicine, Surgery, Dentistry, Pharmacy, Chemistry, and the kindred 
branches, including much collateral information of an encyclopedic character, 
together with new and elaborate tables of Arteries, Muscles, Nerves, Veins. 
- etc. ; of Bacilli, Bacteria, Micrococci, Streptococci ; Eponymic Tables of 
Diseases, Operations, Signs and Symptoms, Stains, Tests, Methods of Treat- 
ment, etc.. etc. By W. A. Newma.n Dorland, A. M., M. D.. Editor 
of the " American Pocket Medical Dictionary." Handsome large octavo, 
nearly 800 pages, bound in full flexible leather. Price, $4.50 net; with 
thumb index, §5.00 net. 

Gives a Maximum Amount of Matter in a Minimum Space and at the Lowest 

Possible Cost. 

This Revised Edition contains ail the Latest Terms. 

" I must acknowledge my astonishment at seeing how much he has condensed within 
relatively small space. I find nothing to criticise, very much to commend, and was in- 
terested in finding some of the new words which are not in other recent dictionaries." — 
RoswHLL Park, Professor 0/ Principles and Practice 0/ Surgery and Clinical Surgery, 
L'nii'ersity of Buffalo. 

" I congratulate you upon giving to the profession a dictionary so compact in its structure, 
and so replete with information required by liie busy practitioner and student. It is m 
necessity as well as an informed companion to every doctor. It should be upoa the desk 
of every practitioner and student of medicine." — John B. Murphy, Professor ef Surgery 
and Clinical Surgery, Norlhtvestern University Medical School, Chicago. 

THE AMERICAN POCKET MEDICAL DICTIONARY. Third 
Edition, Revised. 

Edited by W. .A. Newman Dori.AND., M. D.. Assistant Obstetrician to the 
Hospital of the University of Pennsylvania; Fellow of the .American Acad- 
emy of Medicine. Containing the pronunciation and definition of the prin- 
cipal words used in medicine and kindred sciences, with 64 extensive tables. 
Handsomely bound in flexible leather, with gold edges. Price $1.00 net; 
with thumb index, $1.25 net. 

THE AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. 

.V Yearly Digest of Scientific Progress and .Authoritative Opinion in all 
branches of Medicine and Surgery, drawn from journals, monographs, and 
text-books of the leading American and Foreign authors and investigators. 
Arranged with editorial comments, by eminent American specialists, under 
the editorial charge of GEORGE M.GoULD, M. D. Year-Book of 1901 
in two volumes— Vol. I. including General Mediciiu ; Vol. U.. General Sur- 
gery. Per volume : Cloth, fe.oo net ; Half Morocco, fe.75 net. Sold by Sub- 
scription. 

ABBOTT ON TRANSMISSIBLE DISEASES. Second Edition, 
Revised. 

The HycrJene of Transmissible Diseases: their Causation, Modesof Dissem- 
ination', and Methods of Prevention. By A. C. ABBOTT, M. D., Professor 
of Hvgiene and Bacteriology. University of Pennsylvania. Octavo, 351 
pages, with numerous illustrations. Cloth. $2.50 net. 



MEDICAL PCBLICA TIOXS 



ANDERS' PRACTICE OF MEDICINE. Rfth Revised Edition. 

A Text-Book of the Practice of Medicine. By Iames M. Anpeks, M. D.. 
Ph. D.. LL. D.. Professor of the Practice of Nledicine and of Clinical Med- 
icine, Medico-Chinirgical College. Philadelphia. Handsome octavo volume 
of 1292 pages, fiilly illustrated. Cloth, $5.50 net; Sheep or Half Morocco, 
<S6.50 net. 

BASTIN'S BOTANY. 

Laboratory Elxercises in Botany. By Edson S. B.\stin. M. A., late Pro- 
fessor of Materia Medica and Botany. Philadelphia College of Pharmacy. 
Octavo, 536 pages, with 87 plates. Cloth, ^.00 net. 

BECK ON FRACTURES. 

Fractures, By Carl Beck. M. D., Surgeon to St. Marks Hospital and 
the New York German Poliklinik, etc. With an appendix on the Practical 
Use of the Rontgen Rays. 355 pages. 170 illustrations. Cloth, JI3.50 net. 

BECK'S SURGICAL ASEPSIS. 

.\ Manual of Surgical Asepsis. By Carl Beck, M. D., Surgeon to St. 
Mark's Hospital and the New York German Poliklinik, etc. 306 pages ; 65 
text-iUustiatioDS and 12 full-page plates. Cloth. $1.25 net. 

BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, 
AND OPERATIONS. 

Obstetric Accidents, Emergencies, and Operations. By L. Ch. Boislin- 
l^RE, M. D., late Emeritus Professor of Obstetrics, St. Louis Medical Col- 
lege. 381 pages, handsomely illustrated. Cloth. $2.00 net. 

BOHM, DAVIDOFF, AND HUBER'S HISTOLOGY. 

A Text-Book of Human Histology. Including Microscopic Technic. By 
Dr. .\. h.. BOHM and DR. M. VON DaVIDOFF, of Munich, and G. Carl 
HlBER, M. D.. Junior Professor of Anatomy and Director of Histological 
Laborator\-. University of .Michigan. Handsome octavo of 501 pages, with 
351 beautiful original illustrations. Cloth, $3.50 net. 

BUTLER'S MATERIA MEDICA, THERAPELTICS, AND 
PHARMACOLOGY. Third Edition, Revised. 

.\ Text-Book of Materia Medica. Therapeutics, and Pharmacology. By 
George F. Bittler, Ph.G., M. D., Professor of Materia Medica and of 
Clinical Medicine. College of Physicians and Surgeons. Chicago. Octavo, 
874 pages, illustrated. Ooth, $4.00 net ; Sheep or Half Morocco, $5.00 net. 

CERNA ON THE NEWER REMEDIES. Second Edition, 

Revised. 

Notes on the Newer Remedies, their Therapeutic .Applications and Modes 
of Administration. By David Cerna, M. D.. Ph. D., Demonstrator of 
Physiology, Medical Department, University of Texas. Rewritten and 
greatly eiilaiged. Post-octavo, 253 pages. Cloth, Ji.oo net 



OF W. B. SAUNDERS <&• CO. 



CHAPIN ON INSANITY. 

A Compendium of Insanity. By JOHN B. Chapin, M. D., LL.D.. Phy- 
sician-in-Chief, Pennsylvania Hospital for the Insane; Honorary Member 
of the Medico- Psychological Society of Great Britain, of the Society of 
Mental Medicine of Belgium, etc. i2mo, 234 pages, illustrated. Cloth. 
S1.25 net. 

CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. 
Second Edition, Revised. 

Medical Jurisprudence and To.\icology. By Henry C. ChaI'Man. M. D., 
Professor of Institutes of Medicine and Medical Jurisprudence, Jefferson 
Medical College of Philadelphia. 254 pages, with 55 illustnttions and 3 
full-page plates in colors. Cloth, %\.^o net. 

CHURCH AND PETERSON'S NERVOUS AND MENTAL DIS- 
EASES. Third Edition, Revised and Enlarged. 

Nervous and Mental Diseases. By Akchikai.I) CHLRch. M. D., Pro- 
fessor of Nervous and Mental Diseases, and Head of the Neurological 
Department, Northwestern University Medical School, Chicago ; and 
Frederick Peterson, M. D., Chief of Clinic. Ner\'ous Department. Col- 
lege of Physicians and Surgeons, New York. Handsome octavo volume of 
875 pages, profusely illustrated. Cloth. |5s.oo net ; Sheep or Half Morocco. 
go.oo net. 

CLARKSON'S HISTOLOGY. 

A Text-Book of Histology, Descriptive and Practical. By ARTHUR CLARK- 
SON, M. B., C. M. Edin., formerly Demonstrator of Physiology in the Owen's 
College, Manchester; late Demonstrator of Physiology in Yorkshire College, 
Leeds. Large octavo, 554 pages ; 22 engravings and 174 beautifully colored 
original illustrations. Cloth, $4.00 net. 

CORWIN'S PHYSICAL DIAGNOSIS. Third Edition, Revised. 

Essentials of Physical Diagnosis of the Thora.x. By ARTHIR M. CoRWiN, 
A. M., M. D., Instructor in Physical Diagnosis in Rush Medical College. 
Chicago. 219 pages, illustrated. Cloth, $1.35 net. 

CROOKSHANK'S BACTERIOLOGY. Fourth Edition, Revised. 

.\ Te.\t-Book of Bacteriology. By Edgar M. Croukshank. M. B.. Pro- 
fessor of Comparative Pathology and Bacteriology, Kings College. London. 
Octavo, 700 pages, 273 engravings and 22 original colored plates. Cloth, 
$6.50 net ; Half Morocco, $7.50 net. 

DACOSTA'S SURGERY. Third Edition, Revised. 

Modern Surgery, (Jeneral and Operative. By JoHN CHALMERS DaCosta, 
M. D., Professor of Principles of Surgery and C'linical Surgery, Jefferson 
Medical College. Philadelphia ; Surgeon to the Philadelphia Hospital, etc. 
Handsome octavo volume of 1 117 pages, profusely illustrated. Cloth. SS-oo 
net ; Sheep or Half Morocco, $6.00 net. 

Enlarged by over 200 Pages, with more than 100 New Illus- 
trations. 



MEDICAL PUBLICATIONS 



DAVIS'S OBSTETRIC NURSING. 

Obstetric and Gynecologic Nursing. By Edward P. Davis, A. M., M. D., 
Professor of Obstetrics in JetTerson Medical College and the Philadelphia 
Polyclinic ; Obstetrician and Gynecologist to the Philadelphia Hospital. 
i2mo volume of 400 pages, fully illustrated. Crushed buckram, $1.75 net. 

DE SCHWEINITZ ON DISEASES OF THE EYE. Third Edi- 
tion, Revised. 

Diseases of the Eye. A Handbook of Ophthalmic Practice. By G. E. 
DE SCHWEINITZ, M. D., Professor of Ophthalmology, Jefferson Medical 
College, Philadelphia, etc. Handsome royal octavo volume of 696 pages ; 
256 fine illustrations and 2 chromo-lithographic plates. Cloth, $4.00 net ; 
Sheep or Half Morocco, $5.00 net. 

DORLAND'S DICTIONARIES. 

[See American Illustrated Medical Dictionary and American 
Pocket Medical Dictionary on page 3.] 

DORLAND'S OBSTETRICS. Second Edition, Revised and 
Greatly Enlarged. 

Modern Obstetrics. By W. A. Newman Dorland, M. D., Assistant 
Demonstrator of Obstetrics, University of Pennsylvania ; Associate in Gyne- 
cology, Philadelphia Polyclinic. Octavo volume of 797 pages, with 201 
illustrations. Cloth, ;554.oo net. 

EICHHORST'S PRACTICE OF MEDICINE. 

A Text-Book of the Practice of Medicine. By Dr. HERMAN ElCHHORST, 
Professor of Special Pathology and Therapeutics and Director of the Medi- 
cal Clinic, University of Zurich. Translated and edited by AroiiSTUS A. 
ESHNER, M. D., Professor of Clinical Medicine, Philadelphia Polyclinic. 
Two royal octavo volumes, 600 pages each, 150 illustrations. Per set : 
Cloth, $6.00 net; Sheep or Half Morocco, $7.50 net. 

FRIEDRICH AND CURTIS ON THE NOSE, THROAT, AND 
EAR. 

Rhinology, Laryngology, and Otology, and their Signiiicance in General 
Medicine! By DR. E. P. FRIEDRICH, of Leipzig. Edited by H. HOLBROOK 
Curtis, M. D., Consulting Surgeon to the New York Nose and Throat Hos- 
pital. Octavo, 348 pages. Cloth, $2.^0 net. 

FROTHINGHAM'S GUIDE FOR THE BACTERIOLOGIST. 

Laboratory Guide for the Bacteriologist. By Langdon Frothingham, 
M. D. v.. Assistant in Bacteriology and Veterinary Science, Sheffield Scien- 
tific School, Yale University. Illustrated. Cloth, 75 cts. net. 

GARRIGUES' DISEASES OF WOMEN. Third Edition, Re- 
vised. 

Diseases of Women. By HENRY J. Garrigues, A. M., M. D., Gynecolo- 
gist to St. Mark's Hospital and to the German Dispensary, New York City. 
Octavo, 756 pages, with 367 engravings and colored plates. Cloth, ^$4.50 
net ; Sheep or Half Morocco, $5.50 net. 



OF IV. B. SAUNDERS or- CO. 



GOULD AND PYLE'S CURIOSITIES OF MEDICINE. 

Anomalies and Curios ties of Medicine. Bv Geokgk M. Gould M D 
and VValter L. PVLt. M. D. An encyclopedic collection of rare and ex- 
traordinary cases and of the most striking instances of abnormality in all 
branches of Medicine and Surgery, derived from an exhaustive research of 
medical literature from its origin to the present day. abstracted, classified, 
annotated, and indexed. Handsome octavo volume of 968 pages; 295 en- 
gravings and 12 full-page plates. Popular lidition. Cloth, $3.00 net ; Sheen 
or Half Morocco, $4.-00 net. 

QRAFSTROM'S MECHANO-THERAPY. 

.A Text-Book of -Mechano-Therapv (Massage and Medical Gymnastics). 
By Axel V. GRAtvrRoM. B. Sc.. M. D., late House Physician. City Hos- 
pital, Blickwells Island, New York. i2mo, 139 pages, illustrated. Cloth, 
$1.00 net. 

GRIFFITH ON THE BABY. Second Edition, Revised. 

The Care of the Baby. By J. P. Crozer Grikhtu. M. D., Clinical Pro- 
fessor of Diseases of Children, University of Pennsylvania ; Physician to the 
Children's Hospital, Philadelphia, etc. i2mo, 404 pages, 67 illustrations 
and 5 plates. Cloth, §1.50 net. 

GRIFFITH'S WEIGHT CHART. 

Infant's Weight Chart. Designed by J. P. Crozer GRIFFITH, M. D., 
Clinical Professor of Diseases of Children, University of Pennsvlvania. 25 
charts in each pad. Per pad, 50 cts. net. 

HART'S DIET IN SICKNESS AND IN HEALTH. 

Diet in Sickness and Health. By Mrs. Krnf^T H.\Rr, formerly Student 
of the Faculty of Medicine of Paris and of the Lx)ndon School of Medicine 
for Women ; with an Introduction by SIR HENRY Thompson, F. R. C. S.. 
M. D., Ix)ndon. 220 jxiges. Cloth. $1.50 net. 

HAYNES' ANATOMY. 

A Manual of .Anatomy. By IRVING S. HaynES, M. D., Professor of Prac- 
tical .Anatomy in Cornell University Medical College. 680 pages ; 42 dia- 
grams and 134 full-page half-tone illustrations from original photographs of 
the author's dissections. Cloth, J2.50 net. 

HEISLER'S EMBRYOLOGY. Second Edition, Revised. 

A Text- Book of Embryolog)-. By John C. Hei.sler, M. D.. Professor of 
Anatomy, Medico-Chirurgical College. Phil.idelphia. Octavo volume of 405 
pages, handsomely illustrated. Cloth, ^.50 net. 

HIRST'S OBSTETRICS. Third Edition, Revised and Enlarged. 

A Text-Book of Obstetrics. By ll.\KroN CooKE H1R.-.T, M.D.. Professor 
of Obstetrics. University of Pennsylvani.i. Handsome octavo volume of 
873 pages, 704 illustrations. 36 of them in colors. Cloth, {5.00 net ; Sheep 
or Half Morocco, ^.00 net. 



MEDICAL PUBLICATIONS 



HYDE & MONTGOMERY ON SYPHILIS AND THE VENEREAL 
DISEASES. 2d Edition, Revised and Greatly Enlarged. 

Syphilis and the Venereal Diseases. By James Nevins Hyde, M. D., Pro- 
fessor of Skin and Venereal Diseases, and Frank H. Montgomery, M. D., 
Associate Professor of Skin, Genito-Urinary, and Venereal Diseases in Rush 
Medical College, Chicago, 111. Octavo, 594 pages, profusely illustrated. 
Cloth, $4.00 net. 

THE INTERNATIONAL TEXT=BOOK OF SURGERY. In Two 
Volumes. 

By American and Britisli Authors. Edited by J. Collins Warren, M. D., 

LL. D., F. R.C. S. (Hon.), Professor of Surgery, Harvard Medical School, 

Boston; and A. Pearce Gould, M. S., F. R. C. S., lecturer on Practical 

Surgery and Teacher of Operative Surgery, Middlese.x Hospital Medical 

School, London, Eng. Vol. I. General Surgery. — Handsome octavo, 947 

pages, with 458 beautiful illustrations and 9 lithographic plates. Vol. H. 

Special or Regional Surgery. — Handsome octavo, 1072 pages, with 471 

beautiful illustrations and 8 lithographic plates. Sold fiy Subscription. 

Prices per volume : Cloth, $5.00 net : Sheep or Half Morocco, $6.00 net. 

" It is the most valuable work on the subject that has appeared in some years. The 

clinician and the pathologist have joined hands in its production, and the result must be a 

satisfaction to the editors as it is a gratification to the conscientious reader." — Annals 0/ 

Surgery. 

" This is a work which comes to us on its own intrinsic merits. Of the latter it has 
very many. The arrangement of subjects is excellent, and their treatment by the different 
authors is equally so. What is especially to be recommended is the painstaking endeavor 
of each writer to make his subject clear and to the point. To this end particularly is the 
technique of operations lucidly described in all necessary detail. And withal the work is up 
to date in a very remarkable degree, many of the latest operations in the different regional 
parts of the body being given in full details. There is not a chapter in the work from which 
the reader may not learn something new." — Medical Record, New York. 

JACKSON'S DISEASES OF THE EYE. 

A Manual of Diseases of the Eye. By Edward Jackson, A.M., M. D., 
Emeritus Professor of Diseases of the Eye, Philadelphia Polyclinic and Col- 
lege for Graduates in Medicine. i2mo, volume of 535 pages, with 178 illus- 
trations, mostly from drawings by the author. Cloth, $2.50 net. 

KEATING'S LIFE INSURANCE. 

How to Examine for Life Insurance. By JOHN M. KEATING, M. D., Fellow 
of the College of Physicians of Philadelphia ; Ex-President of the .Association 
of Life Insurance Medical Directors. Royal octavo, 2I1 pages. With 
numerous illustrations. Cloth, $2.00 net. 

KEEN ON THE SURGERY OF TYPHOID FEVER. 

The Surgical Complications and Sequels of Tvphoid Fever. By Wm. W. 
Keen, M.D., LL.D.. F, R. C. S. (Hon.), Professor of the Principles of Sur- 
gery and of Clinical Surgery, JefTerson Medical College. Philadelphia, etc. 
Octavo volume of 386 pages, illustrated. Cloth, $3.00 net. 

KEEN'S OPERATION BLANK. Second Edition, Revised Form. 

An Operation Blank, with Lists of Instruments, etc. Required in Various 
Operations. Prepared by W. W. Keen, M. D.. LL.D.. F. R. C. S. (Hon.). 
Professor of the Principles of Surgery and of Clinical Surgery, Jefferson 
Medical College, Philadelphia. Price per pad, of 50 blanks, 50 cts. net. 



OF W. B. SAUNDERS <S- CO. 



KYLE ON THE NOSE AND THROAT. Second Edition. 

Diseases of the Nose and Ihroat. By D. Bkadkn Kvle, M. D., Clinical 
Professor of Laryngology and Rhinolo'gy, Jeflffrson Medical College, Phila- 
delphia. Octavo, 646 pages ; over 150 illustrations and 6 lithographic plates. 
Cloth, $4.00 net ; Sheep or Half Morocco, S5.00 net. 

LAINE'S TEMPERATURE CHART. 

Temperature Ciiart. Prepared by U. T. LAINfe, M. D. Size 8 x 13;^ 
inches. A conveniently arranged Chart for recording Temperature, with 
columns for daily amounts of Urinary and Fecal Excretions, Food, Re- 
marks, etc. On the back of each chart is given the Brand treatment of 
Typhoid Fever. Price, per pad of 25 charts, 50 cts. net. 

LEVY, KLEMPERER, AND ESHNER'S CLINICAL BACTERI- 
OLOGY. 

The Elements of Clinical Bacteriology. By Dr. Ernst Levy. Professor 
in the University of Strasburg, and Dr. Felix Klemperer, Privatdocent 
in the University of Strasburg. Translated and edited by AUGUSTUS A. 
EsUNER, M. D., Professor of Clinical Medicine, Philadelphia Polyclinic. 

Octavo, 440 pages, fully illustrated. Cloth, $2.50 net. 

LOCKWOOD'S PRACTICE OF MEDICINE. Second Edition, 
Revised and Enlarged. 

A Manual of the Practice of Medicine. By GEORGE ROE LocKWOoD. 
M. D., Professor of Practice in the Women's Medical College of the New 
York Infirmary, etc. 

LONG'S SYLLABUS OF GYNECOLOGY. 

A Syllabus of (jynecology, arranged in Conformity with "An .American 
Text-Book of Gynecology." By J. W. LoNG, M. D., Professor of Dis- 
eases of Women and Ciiildren. Medical College of Virginia, etc. Cloth, 
interleaved, ;f!i.oo net. 

MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. 

Surgical Diagnosis and Treatment. By J. W. Macir)NAI,I). M.D. Edin., 
F. R. C. S. Edin., Professor of Practice of Surgery and Clinical Surgery, 
Hamline University. Handsome octavo, 800 pages, fully illustrated. Cloth, 
$5.00 net; Sheep or Half Morocco, $6.00 net. 

MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. 
Second Edition, Revised and Enlarged. 

Pathological Technique. A Practical Manual for I^tboratory Work in 
Pathology, Bacteriology, and .Morbid .\natomy, with chapters on Posl- 
Mortem Technique and the Performance of .Autopsies. By Frank B. 
Mallory, a. M., M. D.. .Assist.int Professor of Pathology, Harv.ird Uni- 
versity Medical School, Boston; and JAMKs H. WricHT, A. M., M.D.. 
Instructor in Pathology, Harvard University Medical School, Boston. 

McFARLAND'S PATHOGENIC BACTERIA. Third Edition, 
increased in size by over 100 Pages. 

Text-Book upon the Pathogenic Bacteria. By Joseph McFARLAND, 
M. D., Professor of Pathology and Bacteriology, Nfedico-Chirurgical Col- 
lege of Philadelphia, etc. Octavo volume of 621 pages, finely illustrated. 
Cloth, $3.25 net. 



lo MEDICAL PUBLICATIONS 

MEIGS ON FEEDING IN INFANCY. 

Feeding in Early Infancy. By ARTHUR V. MEIGS, M. D. Bound in limp 
cloth, flush edges, 25 cts. net. 

MOORE'S ORTHOPEDIC SURGERY. 

A Manual of Orthopedic Surgery. By James E. Moore, M. D., Professor 
of Orthopedics and Adjunct Professor of Clinical Surgery, University of 
Minnesota, College of Medicine and surgery. Octavo volume of 356 pages, 
handsomely illustrated. Cloth, ^2.50 net. 

MORTEN'S NURSES' DICTIONARY. 

Nurses' Dictionary of Medical Terms and Nursing Treatment. Containing 
Definitions of the Principal Medical and Nursing Terms and Abbreviations ; 
of the Instruments, Drugs, Diseases, Accidents, Treatments, Operations, 
Foods, Appliances, etc. encountered in the ward or in the sick-room. By 
HONNOR Morten, author of '"How to Become a Nurse," etc. i6mo, 140 
pages. Cloth, $i.oo net. 

NANCREDE'S ANATOMY AND DISSECTION. Fourth Edition. 

Essentials of Anatomy and Manual of Practical Dissection. By CHARLES 
B. NaNCREDE. M. D., LL.D., Professor of Surgery and of Clinical Surgery, 
University of Michigan, Ann Arbor. Post-octavo, 500 pages, with full-page 
lithographic plates in colors and nearly 200 illustrations. Extra Cloth (or 
Oilcloth for dissection-room), ;^2.oo net. 

NANCREDE'S PRINCIPLES OF SURGERY. 

Lectures on the Principles of Surgery. By CHARLES B. Nancr'EDE, M. D., 
LL.D,, Professor of Surgery and of Clinical Surgery, University of Michigan, 
Ann Arbor. Octavo, 398 pages, illustrated. Cloth, ^JSa.So net. 

NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, 
Revised. 

Syllabus of Obstetrical Lectures in the Medical Department of the University 
of Pennsylvania. By RICHARD C. NoRRlS, A. M., M. D., Instructor in 
Obstetrics and Lecturer on Clinical and Operative Obstetrics, University 
of Pennsylvania. Crown octavo, 222 pages. Cloth, interleaved for notes, 
$2.00 net. 

OGDEN ON THE URINE. 

Clinical Examination of the Urine and Urinary Diagnosis. A Clinical Guide 
for the Use of Practitioners and Students of Medicine and Surgery. By J. 
Bergen Ogden, ^f. D., Instructor in Chemistry, Harvard University Med- 
ical School. Handsome octavo, 416 pages, with 54 illustrations, and a num- 
ber of colored plates. Cloth, JJt3.oo net. 

PENROSE'S DISEASES OF WOMEN. Fourth Edition, Revised. 

A Text-Book of Diseases of Women. By Charles B. Penrose, M. D., 
Ph. D., formerly Professor of Gynecology in the University of Pennsylvania. 
Octavo volume of 538 pages, handsomely illustrated. Cloth, S3.75 net. 



OF W. B. SAUNDERS Ss- CO. u 



PRYOR-PELVIC INFLAMMATIONS. 

The Treatment of Pelvic Inflammations through the Vagina. By W. R. 
Pryor, M. D., Professor of Gynecology. New York Polyclinic, lamo, 248 
pages, handsomely illustrated. Cloth, $2.00 net. 

PYE'S BANDAGING. 

Elementary liandaging and Surgical Dressing. With Directions concerning 
the Immediate Treatment of Cases of Emergency. By WALTER PYE, 
F. R. C. S., late Surgeon to St. Mary's Hospital. London. Small i2mo, 
over 80 illustrations. Cloth, fle.vible covers, 75 cts. net. 

PYLE'S PERSONAL HYGIENE. 

A Manual of Personal Hygiene. Proper Living upon a Physiologic Basis. 
Edited by WALTER L. Pyle, M. D., Assistant Surgeon to the Wills Eye 
Hospital, Piiiladelphia. Octavo volume of 344 pages, fully illustrated. 

Clotli, $1.50 net. 

RAYMOND'S PHYSIOLOGY. Second Edition, Revised and 
Greatly Enlarged. 

A Text-Book of Physiology. By JOSEPH H. RAYMOND. A. M.. M. D.. Pro- 
fessor of Physiology and Hygiene and Lecturer on Gynecology in the Long 
Island College Hospital. 

SALINGER AND KALTEYER'S MODERN MEDICINE. 

. Modern Medicine. By JLLH S L. SALINGER, M. D., Demonstrator of 
Clinical Medicine, Jefferson Medical College ; and F. J. Kalteyer, M. D., 
Assistant Demonstrator of Clinical Medicine, Jefferson Medical College. 
Handsome octavo, 801 pages, illustrated. Cloth, S4.00 net. 

SAUNDBY'S RENAL AND URINARY DISEASES. 

Lectures on Renal and Urinary Diseases. By RoBKRT Saundby, M. D. 
Edin., Fellow of the Royal College of Physicians, London, and of the Royal 
Medico-Chirurgical Society ; Professor of Medicine in Mason College. Bir- 
mingham, etc. Octavo, 434 pages, with numerous illustrations and 4 colored 

plates. Cloth, $2.50 net. 

SAUNDERS' MEDICAL HAND-ATLASES. See pp. 16 and 17. 

SAUNDERS' POCKET MEDICAL FORMULARY. Sixth Edi- 
tion, Revised. 

By Wu-MAM M. Powell, M. D., author of "Essentials of Diseases of 
Children " ; Member of Philadelphia Pathological Society. Containing 1844 
formulne from the best-known authorities. With an Appendix containing 
Posological Table, Formuhe and Doses for Hypodermic Medication. 
Poisons and their Antidotes. Diameters of the Female Pelvis and Fetal 
Head, Obstetrical Table, Diet List for Various Diseases. Materials and 
Drugs used in Antiseptic Surgery. Treatment of Asphyxia from Drowning, 
Surgical Remembrancer. Tables' of Incompatibles. Eruptive Fevers, etc.. 
etc. Handsomely bound in flexible morocco, with side index, wallet, and 
flap. $2.00 net. 

SAUNDERS' QUESTION-COMPENDS. See pages 14 and 15. 



12 MEDICAL PUBLICATIONS 

SCUDDER'S FRACTURES. Second Edition, Revised. 

The Treatment of Fractures. By Chas L. ScCDDER, M. D., Assistant in 
Clinical and Operative Surgery, Harvard University Medical School. Oc- 
tavo, 433 pages, with nearly 600 original illustrations. Polished Buckram, 
$4.50 net ; Half Morocco, $5.50 net. 

SENN'S QENITO-URINARY TUBERCULOSIS. 

Tuberculosis of the Genito-Urinary Organs, Male and Female. By NICH- 
OLAS Senn, M. D., Ph. D., LL.D., Professor of the Practice of Surgery and 
of Clinical Surgery, Rush Medical College, Chicago. Handsome octavo 
volume of 320 pages, illustrated. Cloth, $3.00 net. 

SENN'S PRACTICAL SURGERY. 

Practical Surgery. By NICHOLAS SENN, M. D., Ph.D., LL.D., Professor 
of the Practice of Surgery and of Clinical Surgery, Rush Medical College, 
Chicago. Handsome octavo volume of 1200 pages, profusely illustrated. 
Cloth, $6.00 net ; Sheep or Half Morocco, $7.00 net. By Subscription. 

SENN'S SYLLABUS OF SURGERY. 

A Syllabus of Lectures on the Practice of Surgery, arranged in conformity 
with " An American Text-Book of Surgery." By Nicholas Senn, M. D., 
Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery. 
Rush Medical College, Chicago. Cloth, $1.50 net. 

SENN'S TUMORS. Second Edition, Revised. 

Pathology and Surgical Treatment of Tumors. By NICHOLAS Senn, M. D., 
Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, 
Rush Medical College, Chicago. Octavo volume of 718 pages, with 478 
illustrations, includidg 12 full-page plates in colors. Cloth, $5.00 net ; Sheep 
or Half Morocco, ^6.00 net. 

STARR'S DIETS FOR INFANTS AND CHILDREN. 

Diets for Infants and Children in Health and in Disease. By LOUIS STARR, 
M.D., Editor of " An American Text-Book of the Diseases of Children." 
230 blanks (pocket-book size), perforated and neatly bound in flexible 
morocco. $1.25 net. 

STENGEL'S PATHOLOGY. Third Edition, Thoroughly Revised. 

A Text-Book of Pathology. By ALFRED STENGEL. M. D., Professor of 
Clinical Medicine, University of Pennsylvania ; Visiting Physician to the 
Pennsylvania Hospital. Handsome octavo, 873 pages, nearly 400 illustra- 
tions, many of them in colors. Cloth, $5.00 net ; Sheep or Half Morocco, 
$6.00 net. 

STENGEL AND WHITE ON THE BLOOD. 

The Blood in its Clinical and Pathological Relations. By ALFRED STEN- 
GEL. M. D., Professor of Clinical Medicine, University of Pennsylvania; and 
C.Y.White, Jr., M.D., Instructor in Clinical Medicine, University of 
Pennsylvania. In Press. 



OF H: B. S.IUNDEKS &' CO. 



13 



STEVENS' MATERIA MEDICA AND THERAPEUTICS. Third 
Edition, Revised and Greatly Enlarged. 

A lext-Book of Modern Therapeutics. By A. A. Stkvkns, A. M., M. U., 
Lecturer on Pliysical Diagnosis in the University of Pennsylvania. 

STEVENS' PRACTICE OF MEDICINE. Fifth Edition, Revised. 

A Manual of the Practice of Medicine. By A. A. Stevens. A. M,, M. iJ., 
Lecturer on Physical Diagnosis in the University of Pennsylvania. Spe- 
cially intended for students preparing for graduation and hospital examina- 
tions. Post-octavo, 519 pages ; illustrated. Flexible Leather, 53.00 net. 

STEWART'S PHYSIOLOGY. Fourth Edition, Revised. 

A Manual of Physiology, with Practical Exercises. For .Students and Prac- 
titioners. By G. N. SfEW.VRT, M. A., M. D., D. Sc. Professor of Physiol- 
ogy in the Western Reserve University, Cleveland, Ohio. Octavo volume 
of 891 |)ages ; 336 illustrations and 5 colored plates. Cloth, 53-75 "«*• 

STONEY'S MATERIA MEDICA FOR NURSES. 

Materia Medica for Nurses. By Emily .A. M. STONEV, late Superintend- 
ent of the Training-School for Nurses. Carney Hospital, South Boston, 
Mass. Handsome octavo volume of 306 pages. Cloth, 5i-SO net. 

STONEY'S NURSING. Second Edition, Revised. 

Practical Points in Nuising. For Nurses in Private Practice. By EMILY 
A. M. Sto.NEY, late Superintendent of the Training-School for Nurses, 
Carney Hospital, South Boston, Mass. 456 pages, with 73 engravings and 
8 colored and halftone plates. Cloth, $1.75 net. 

STONEY'S SURGICAL TECHNIC FOR NURSES. 

Bacteriology and Surgical Technic for Nurses. By KMILV A. M. STONF.Y, 
late Superintendent of the Training-School for Nurses, Carney Hospital, 
South Boston, Mass. i2mo volume, fully illustrated. Cloth, $1.25 net. 

THOMAS'S DIET LISTS. Second Edition, Revised. 

Diet Lists and Sick-Room Dietary. By jEROME B. Thomas, M.D., In- 
structor in Materia Medica, Long Island Hospital ; Assistant Bacteriologist 
to the Hoagland Laboratory. Cloth, $1.25 net. Send for sample sheet. 

THORNTON'S DOSE-BOOK AND PRESCRIPTION-WRITING. 

Second Edition, Revised and Enlarged. 

Dose-Book and Manual of Prescription-Writing. By K. Q. Thornton, 
M. D., Demonstrator of Therapeutics, Jefferson Medical College, I'hiladcl- 
phia. 

VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. 

Diseases of the Stom.nch. By Wil.LLXM W. Van Valzah, M. D., Pro- 
fessor of General Medicine and Diseases of the Digestive System and the 
Blood, New York Polyclinic; and J. DOUGLAS Nisbet, M. D., Adjunct 
Professor of General Medicine and Diseases of the Digestive System and 
the Blood, New York Polyclinic. Octavo volume of 674 pages, illustrated. 
Cloth, 53-5° n^t- 



14 MEDICAL PUBLICATIONS. 



VECKI'S SEXUAL IMPOTENCE. Second Edition, Revised. 

The I'alhology and Treatment ot Sexual Impotence. By VICTOR G. Vecki, 
M. D. From the second German edition, revised and enlarged. Demi- 
octavo, 291 pages. Cloth, 32.00 net. 

VIERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Re- 
vised. 

Medical Diagnosis. By Dr. OSWALD VierorDT, Professor of Medicine, 
University of Heidelberg. Translated, with additions, from the fifth en- 
larged German edition, with the author's permission, by FRANCIS H. 
Stuart, A. M., M. D. Handsome octavo volume, 603 pages; 194 wood- 
cuts, many of them in colors. Cloth, 4.00 net ; Sheep or Half-Morocco, 
;5!5.oo net. 

WATSON'S HANDBOOK FOR NURSES. 

\ Handbook for Nurses. Bv J. K. WATSt)N, M. D. Edin. American 
Edition, under supervision of A> A. Stkvens, A. M., M. D., Lecturer on 
Physical Diagnosis, University of Pennsylvania. i2mo, 413 pages, 73 illus- 
trations. Cloth, ;^i.5o net. 

WARREN'S SURGICAL PATHOLOGY. Second Edition. 

Surgical Pathology and Therapeutics. By JOHN COLLINS Warren, M. D., 
LL.D., F. R. C. S. (Hon.), Professor of Surgery, Harvard Medical School. 
Handsome octavo, 873 pages ; 136 relief and lithographic illustrations, 33 in 
colors. With an Appendix on Scientific Aids to Surgical Diagnosis, and a 
series of articles on Regional Bacteriology. Cloth, ^5.00 net ; Sheep or 
Half Morocco, *6.oo net. 



SAUNDERS' 
QUESTION = COMPENDS. 



ARRANQED IN QUESTION AND ANSWER FORM. 



The Most Complete and Best Illustrated Series of Compends Ever Issued. 



NOW THE STANDARD AUTHORITIES IN MEDICAL LITERATURE 

WITH 

Students and Practitioners in every City of the United States and Canada. 



Since the issue of the first volume of the Saunders Question-Compends, 

OVER 200,000 COPIES 

of these unrivalled publications have been sold. This enormous sale is indisputabU 
evidence of the value of these self-helps to students and physicians. 

SEE NEXT PAGE FOR LIST. 



Sau nders' 
Question = Compend Series 

Price, Cloth, Si.oo net per copy, except when otherwise noted. 



Where the work of preparing students' manuals is to end we cannot say, but the Sauaders 
Series, in our opinion, bears off the palm at present."— AVw y'ork Mtdical Record. 



1. Essentials of Physiology. By Sidnby Budcett, M. D. Ah tntirtty nrm 

2. Essentials of Surgery. By Edward Martin, M. D. Seventh edition, revised 

with an Appendix and a chapter on Appendicitis. ' ' 

3. Essentials of Anatomy. By Charles B Nancreue, M. D. Sixth edition 

th(.ir<iui;hly rt;vi?.L-il and enlarged. ' 

4. Essentials of Medical Chemistry, Organic and Inorganic. By Lawrbncb 

WoLhF, M. L). Filth edition, revised. 

5. Essentials of Obstetrics. By W. Easterly Ashton, M. D. Fourth edition, 

revised and enlarged. 

6. Essentials of Pathology and Morbid Anatomy. By F. j. Kaltkvbr, m. d. 

In p> fpii ration. 

7. Essentials of Materia Medica, Therapeutics, and Prescription- Writing. 

By HiiSKY -MiiKKls, .M. D. Kifth edition, revised. 

8. 9. Essentials of Practice of Medicine. By Henry Morris. M. D. An Ap- 

pendix on Urine Examination. By Lawrence Wolff, M. D. Third edition, 
enlarged by some 300 Essential Formulae, selected from eminent authorities, by 
Wm. M. Powell. M. I). (Double number, {1.50 net.) 

10. Essentials of Gynecology. By Edwin B. Cragin, M. D. Fifth edition, 

revised. 

11. Essentials of Diseases of the Skin. By Henry w. Stelwagon, M. D. 

Fourth edition, revised and enlarged. 

12. Essentials of Minor Surgery, Bandaging, and Venereal Diseases. By 

KinvAHi) Martin, M. O. Second editii'ii. revised and enlarged. 

13. Essentials of Legal Medicine, Toxicology, and Hygiene. This volume is 

at present out of print. 

14. Essentials of Diseases of the Eye. By Edward Jackson, M. D. Third 

edition, revised and enlarged. 

18. Essentials of Diseases of Children. By William M. Powell, M. D. Third 

16. Essentials of Examination Of Urine. By Lawrence Wolff, M. D. Colored 

" VoGEL Scale." (75 cents net.) 

17. Essentials of Diagnosis. By S. Solis-Cohen, M. D., and A. A. Eshner, M. D. 

Second edition, thoroughly revised. 

18. Essentials of Practice of Pharmacy. By Lucius E. Sayhb. Second edition, 

revised and enlarged. 

19. Essentials of Diseases of the Nose and Throat. By E. B. Glbason. M. D 

Third edition, revised and enlarged. 

20. Essentials Of Bacteriology. By M. v. Ball, M. D. Fourth edition, revised. 

21. Essentials Of Nervous Diseases and Insanity. By John C. Shaw, M.D. 

Third edition, revised. 

22. Essentials Of Medical Physics. By Fred J. Brockway, M. D. Second edi- 

lion, revised. 

23. Essentials of Medical Electricity. By Hkw^ D. Stewart, M. D., «nd Ed- 

ward S. Lawkanck, M. D. 

24. Essentials OfDiseases Of the Ear. By E.B.Gleason,M. D. Second edition, 

revised and greatly enlarged. 

25. Essentials Of Histology. By Louis Lbroy, M. D. With 73 original illustration.. 



Pamphlet containing specimen pages, etc., sent free upon application. 

IS 



Saunders' Medical Hand= Atlases. 

VOLUMES NOW READY. 

ATLAS AND EPITOME OF INTERNAL MEDICINE AND 
CLINICAL DIAGNOSIS. 

By Dr. Chk. Jakoh, of Erlangen. Edited by AUGUSTUS A. ESHNER. 
M. D., Professor of Clinical Medicine, Philadelphia Polyclinic. With 179 
colored figures on 68 plates, 64 text-illustrations, 259 pages of text. Cloth, 
;53.oo net. 

ATLAS OF LEGAL MEDICINE. 

By Dr. E. R. von Hofkm.vn, of Vienna. Edited by Frederick Peter- 
son, M. D., Chief of Clinic, Nervous Department, College of Physicians and 
Surgeons, New York. With 120 colored figures on 56 plates and 193 beau- 
tiful half-tone illustrations. Cloth, $3.50 net. 

ATLAS AND EPITOME OF DISEASES OF THE LARYNX. 

By Dr. L. Grunwald, ofMunich. Edited by Charles P. Grayson, 
M. D., Physician-in-Charge, Throat and Nose Department, Hospital of the 
University of Pennsylvania. With X07 colored figures on 44 plates, 25 text- 
illustrations, and 103 pages of text. Cloth, $2.50 net. 

ATLAS AND EPITOME OF OPERATIVE SURGERY. 

By Dr. O. Zuckerkandl, of Vienna. Edited by J. Chalmers DaCosta, 
M. D., Professor of Principles of Surgery and Clinical Surgery, Jefferson 
Medical College, Philadelphia. With 24 colored plates, 214 text-illustra- 
tions, and 395 pages of text. Cloth, |!3.oo net. 

ATLAS AND EPITOME OF SYPHILIS AND THE VENEREAL 
DISEASES. 

By Prof. Dr. Franz Mracek, of Vienna. Edited by L. Bolton Bangs, 
M. D., Professor of Genito-Urinary Surgery, University and Bellevue Hos- 
pital Medical College, New York. With 71 colored plates, 16 illustrations, 
and 122 pages of text. Cloth, §3.50 net. 

ATLAS AND EPITOME OF EXTERNAL DISEASES OF THE 
EYE. 

By Dr. O. Haab, of Zurich. P:dited by G. E. DE Schweinitz, M. D., 
Professor of Ophthalmology, Jefferson Medical College, Philadelphia. With 
76 colored illustrations on 40 plates and 228 pages of text. Cloth, 53-oo net. 

ATLAS AND EPITOME OF SKIN DISEASES. 

By Prof. Dr. Franz Mracek, of Vienna. Edited by Henry W. Stel- 
WAGON. M. D., Clinical Professor of Dermatology, Jefferson Medical Col- 
lege, Philadelphia. With 63 colored plates, 39 half-tone illustrations, and 
200 pages of text. Cloth, ^^3.50 net. 

ATLAS AND EPITOME OF SPECIAL PATHOLOGICAL HIS- 
TOLOGY. 

By Dr. H. Durck, of Munich. Edited by Ludwig Hektoen, M. D., 
Professor of Pathology, Rush Medical College, Chicago. In Two Parts. 
Part I. Ready, including Circulatory. Respiratory, and Gastro-intestinal 
Tract, 120 colored figures on 62 plates, 158 pages of text. Part II. Ready 
Shortly. Price of Part I., fo.oo net. 

16 



Saunders' Medical Hand= Atlases. 



VOLUMES JUST ISSUED. 

ATLAS AND EPITOME OF DISEASES CAUSED BY ACCI- 
DENTS. 

By Dr. Eu. GuLEBIEWski, of Berlin. Translated and edited with addi- 
tions by Pe.vrce Bailey, M. D., Attending Physician to the Department 
of Corrections and to the Ahnshouse and Incurable iiospiials. New York. 
With 40 colored plates, 143 te.xt illustrations, and 600 p.iges of text. Cloth, 
S4.00 net. 

ATLAS AND EPITOME OF QYNECOLOGY. 

By Dr. O. Shaefker, of Heidelberg. From the Second Revised Germuit 
Edition. Edited by RICHARD C. NoRRlS. A. M., M.D.. Gynecologist to 
the Methodist Episcop.il and the Philadelphia Hospitals; Surgeon-in-Charge 
of Preston Retreat, Philadelphia. With 90 colored plates, 65 text-illustra- 
tions, and 308 pages of text. Cloth, $3. 50 net. 

ATLAS AND EPITOME OF THE NERVOUS SYSTEM AND 

ITS DISEASES. 

By Professor Dr. Cur. Jakob, of Erlangcn. From the Second Revised 
and Enlarged German Edition. Edited by EDWARD D. FiSHER. M.D., 
Professor of Diseases of the Nervous Sybleni, University and Uellcvuc Hos- 
pital Medical College, New York. With 83 plates and a copious text. 
$3 50 net. 

ATLAS AND EPITOME OF LABOR AND OPERATIVE OB- 
STETRICS. 

Bv Dr. O. Shaefker, of Heidelberg. From the Fifth Revised and Enlarged 
German Edition. Edited by J. Clikton Edoar. M. D.. Professor of Ob- 
stetrics and Clinical Midwifery, Cornell University Medical School. W<th 
126 colored illustrations. $2.00 net. 

ATLAS AND EPITOME OF OBSTETRICAL DIAGNOSIS AND 

TREATMENT. 

Bv Dr. O. Shaefker, of Heidelberg. From the Second Revised and En- 
larged German Edition. Edited by J. ClIFTON Edgar, M. D.. Professor 
of Obstetrics and Clinical Midwifery, Cornell University Medical School. 
72 colored plates, numerous text-illustrations, and copious text. $300 net. 

ATLAS AND EPITOME OF OPHTHALMOSCOPY AND OPH- 
THALMOSCOPIC DIAGNOSIS. 

By Dr. O. Haah. of Zurich. From the Third Revised and Enlarged Ger- 
man Edition. Edited bv G. E. DE SCHWEINITZ, M. D., Professor of Oph- 
thalmology, Jefferson Medical College. Philadelphia. With 152 colored 
figures and 82 pages of text. Cloth. <53.oo net. 

ATLAS AND EPITOME OF BACTERIOLOGY. 

Including a Hand-Book of .Special Bacteriologic Diagnosis. By PROF. Dr. 
K. B. Lehmann and Dr. R. O. Neumann, of Wurzburg. From the Second 
Revised German Edition. Edited by GEORGE H. Weaver, M. D., As-istant 
Professor of Pathology and Bacteriology, Rush Medical College, Chicago. 
Two volumes, with over 600 colored lithographic figures, numerous text- 
illustrations, and 500 pages of text. 



ADDITIONAL VOLUMES IN PREPARATION. 



NothnagePs Encyclopedia 

OF 

PRACTICAL MEDICINE. 

Edited by ALFRED STENGEL, M.D., 

Professor of Clinical Medicine in the University of Pennsylvania ; Visiting 
Physician to the Pennsylvania Hospital. 

IT is universally acknowledged that the Germans lead the world in Internal Medicine ; 
and of all the German works on this subject, Nothnagel's " Special Pathology and 
Therapeutics " is conceded by scholars to be without question the best System of 
Medicine in escistence. So necessary is this book in the study of Internal Medicine 
that it comes largely to this country ift the original German. In view of these facts, 
Messrs. W. B. Saunders & Company have arranged with the publishers to issue at once 
an authorized edition of this great encyclopedia of medicine in English. 

For the present a set of some ten or twelve volumes, representing the most practical 
part of this encyclopedia, and selected with especial thought of the needs of the practical 
physician, will be published. These volumes will contain the real essence of the entire 
work, and the purchaser will therefore obtain at less than half the cost the cream of the origi- 
nal. Later the special and more strictly scientific volumes will be offered from time to time. 

The work will be translated by men possessing thorough knowledge of both English and 
German, and each volume will be edited by a prominent specialist on the subject to 
which it is devoted. It will thus be brought thoroughly up to date, and the American edition 
will be more than a mere translation of the German; for, in addition to the matter contained 
in the original, it will represent the very latest views of the leading American special- 
ists in the various departments of Internal Medicine. The whole System will be under the 
editorial supervision of Dr. Alfred Stengel, who will select the subjects for the American 
edition, and will choose the editors of the different volumes. 

Unlike most encyclopedias, the publication of this work \win not be extended over a 
number of years, but five or six volumes will be issued during the coming year, and the 
remainder of the series at the same rate. Moreover, each volume will be revised to the 
date of its publication by the American editor. This will obviate the objection that has 
heretofore existed to systems published in a number of volumes, since the subscriber will 
receive the completed work while the earlier volumes are still fresh. 

The usual method of publishers, when issuing a work of this kind, has been to compel 
physicians to take the entire System. This seems to us in many cases to be undesirable. 
Therefore, in purchasing this encyclopedia, physicians will be given the opportunity of 
subscribing for the entire System at one time; but any single volume or any number of 
volumes may be obtained by those who do not desire the complete series. This latter 
method, while not so profitable to the publisher, offers to the purchaser many advan- 
tages which will be appreciated by those who do not care to subscribe for the entire work 
at one time. 

This American edition of Nothnagel's Encyclopedia will, withotit question, form the 
greatest System of Medicine ever pioduced, and the publishers feel confident that it 
will meet with general favor in the medical profession. 



NOTHNAGEL'S ENCYCLOPEDIA 

VOLUMES JUST ISSUED AND IN PRESS 



VOLUME I 

Editor, William Osier, M. D., 

F.R.CP. 

Professor c/ MeJicine in Johns Hop kit:. 
University 

CONTENTS 

Typhoid Fever. By I)k. H. (Jurschmann, 

of Leipsic, Typhus Fever. By Dr. H. 

CuRSCHMANN.of Leipsic. 

Handsome octavo volume of about 600 pages. 

Just lssu<\i 



VOLUME n 

Editor, Sir J. W. Moore, B. A^ M. D., 

F.R.CP.L, of DabUn 

ProJ'i-ssor 0/ Practice 0/ McJicine, Royal 
College of Surgeons in Ireland 

CONTENTS 

Erysipelas and Erysipeloid. By Dr. H 
Lenhaktz, III Hamburg. Cholera Asi 
atica and Cholera Nostras. Hy Dk 
K. VON I.IEUERMEISTEK, of '1 iibingen 
AVhooping Cough and Hay Fever. By 
Dr. (i. Stick i;r, of Giesseii. Varicella 
By Dr. Th. von JI'rgensen, of Tubingen 
Variola (including Vaccination). By 
Dr. H. Immermann, of Basle. 

Handsome octavo volume of over 700 pages. 
Just Issued 



VOLUME vn 

Editor, John H. Musser, M. D. 

Professor of Clinical Medicine, i nixtrsity 
of J'tnnsyiviiiiia 

CONTENTS 
Diseases of the Bronchi. By Dr. F. \ 
Hmffmann, of leipsic. Diseases of the 
Hleura. By Dii. Kosenbach, of Berlin 
Pneumonia. By Dk. E. Aupkecht. oI 
Magdeburg. 



VOLUME VIII 
Editor, Charles G. Stockton, M. D. 

I'r.fssor of Medicine. I 'niversity of BnffiiU 



CONTENTS 
Diseases of the Stomach. By 
RiKc.EL, of (iiesscn. 



Dr. F. 



VOLUME DC 
Editor, Frederick A. Packard, M. D. 

Physician to the Pennsylvania Hospital and 
to the Children's Hospital, Philadelphia 

CONTENTS 

Diseases of the Liver. By Drs. H. 
yt'iNCKE and G. Hoppb-Sbvler, of Kiel. 



VOLUME ffl 
Editor, William P. Northrop, M. D. 

Professor of Pediatrics, University and 
Bellevue Medical College 

CONTENTS 
Measles. By Dr. Th. von JUrgensbn, of 
Tiibingen. Scarlet Fever. By the same 
author. Rotheln. Bt the same- author. 



VOLUME X 
Editor, Reginald H. Fitz, A. M., MJ). 

Hcrsey Professor of the Theory and I'tai.- 
tict of Physic, Hat~\tr,i University 

CONTENTS 

Diseas:s of the Pancreas. By Dr. I.. 
User, of Vienna. Diseases of the Supra- 
renals. By Dr. E. Nh':>->ei', of \ icnna. 



VOLUME VI 
Editor, Alfred Stengel, M. D. 

Professor of Clinical Medicine, University 
of Pennsylvania 

CONTENTS 
Anemia. By Dr. P. F.hrlich, of Frank- 
fo^t-on-the-^Iain, and Dr. A. Lazari'S, of 
Charlottenburg. Chlorosis. By Dr. K. 
VON Noorden, of Frankfurton-thc-.Main. 
Diseases of the Spleen and Hemor- 
rhagic Diathesis. By Dr. M. Litten, 
of Berlin. 



VOLUMES IV, V, and XI 
Editors announced later 

Vol. IV.— Influenza and Dengue. Bv D«. 
O. Lekhtenstein, of Cologne. Malarial 
Diseases. By Dr. J MANNARERt;, of 
Vienna. 

Vol. v.— Tuberculosis and Acute General 
Miliary Tuberculosis. By 1»k. G. Cor- 
net, of Berlin. 

Vol. XI.— Diseases of the Intestines and 
Peritoneum. By Dk. H. Nothnaobl, 
of Vienna. 



19 



CLASSIFIED LIST 

OF THE 

MEDICAL PUBLICATIONS 



OF 



W. B. SAUNDERS & COMPANY 



ANATOMY, EMBRYOLOGY, HIS- 
TOLOGY. 

Bohm, Davidoff, and Hubcr— A Text- 
Book of Histology, 4 

Clarkson — A Text-Book of Histology, . 5 

Haynes — A Manual of Anatomy, ... 7 

Heisler — A Text-Book of Embryology, . 7 

Leroy — Kssentials of Histology, .... 15 

Nancrede — Essentials of Anatomy, ... 15 
Nancrede — Essentials of .•\natoray and 

Manual of Practical Dissection, .... 10 

BACTERIOLOGY. 

Ball — Essentials of Bacteriology '15 

Krothingham — Laboratory Guide, . . . 6 

Gorham — Laboratory Course in Bacte- 
riology 22 

Lehmann and Neumann — Atlas of 
Bacteriology 17 

Levy and Klemperer's Clinical Bacte- 
riology, 9 

Mallory and Wright — Pathological 
Technique, 9 

McFarland — Pathogenic Bacteria, ... 9 

CHARTS, DIET-LISTS, ETC. 

Griffith — Infaat's Weight Chart 7 

Hart — Diet in Sickness and in Health, . 7 

Keen — Operation Blank 8 

Laine — Temperature Chart, 9 

Meigs — Feeding in Early Infancy, ... 10 

Starr — Diets for Infants and Children, . 12 

Thomas — Diet-Lists, 13 

CHEMISTRY AND PHYSICS. 
Brock way — Essentials of Medical 

Physics 15 

Wolff — Essentials of Medical Chemistry, 15 

CHILDREN. 
An American Text-Book of Diseases 

of Children i 

Griffith— Care of the Baby 7 

Griffith— Infant's Weight Chart 7 

Meigs — Feeding in Early Infancy, ... 10 
Powell — Essentials of Diseases of Chil- 
dren, 15 

Starr — Diets for Infants and Children, . 12 

DIAGNOSIS. 

Cohen and Eshner — Essentials of Diag- 
nosis, 15 

Corwin — Physical Diagnosis, 5 

Vierordt — Medical Diagnosis, 14 

DICTIONARIES. 

The American Illustrated Medical 
Dictionary 3 

The American Pocket Medical Dic- 
tionary, 3 

Morton — Nurses' Dictionary, lo 



EYE, EAR. NOSE. AND THROAT. 

An American Text-Book of Diseases 

of the Eye, Ear, Nose, and Throat, . . 1 
De Schweinitz — Diseases of the Eye, . 6 
Friedrich and Curtis — Rhinology, Lar- 
yngology and Otology, 6 

Gleason — Essentials of the Ear 15 

Gleason — Essentials of Xose and Throat, 15 
Cradle — Ear, Nose, and Throat, .... 22 
Grunwald and Grayson— .Atlas of Dis- 
eases of the Larynx, 16 

Haab and de Schweinitz— .-Vtlas of Ex- 
ternal Diseases of the Eye, i6 

Jackson— Manual of Diseases of the Eye, 8 
I Jackson — Essentials Diseases of Eye, . 15 
Kyle — Diseases of the Nose and Throat, 9 

GENITO-URINARY. 

An American Text-Book of Genito- 
urinary and Skin Diseases, a 

Hyde and Montgomery— Syphilis and 
the Venereal Diseases, 8 

Martin — Essentials of Minor Surgery, 
Bandaging, and Venereal Diseases, . . 15 

Mracek and Bangs— .Atlas of Syphilis 
and the Venereal Diseases, 16 

Saundby— Renal and Urinary Diseases, ix 

Senn — Oenito-Urinary Tuberculosis, . . la 

Vecki — Sexual Impotence, i^ 

GYNECOLOGY. 
American Text-Book of Gynecology, 
Cragin— Essentials of Gynecology, ... 15 
Garrigues- Diseases of Women, . ... 6 
Long — Syllabus of Gynecology, . . 
Penrose— Diseases of Women, . . . 

Pryor— Pelvic Inflammations, 

Schaeffer and Norris— Atlas of Gyne^ 
cology, ij 

HYGIENE. 
Abbott — Hygiene of Transmissible Dis- 
eases 3 

Bergey^Principles of Hygiene 2a 

Pyle — Personal Hygiene, 11 

MATERIA MEDICA. PHARMA- 
COLOGY, and THERAPEUTICS. 
An American Text-Book of Applied 

Therapeutics, t 

Butler — Text-Book of Materia Medica, 

Therapeutics, and Pharmacology, . . 4 
Morris — Ess. of .M. M. and Therapeutics, 15 
Saunders' Pocket Medical Formulary, . ii 

Sayre — Kssentials of Pharmacy 15 

Sollmann — Text-Book of Pharmacology, 22 

Stevens — Modern Therapeutics 13 

Stoney — Materia Medica for Nurses, . . 13 
Thornton — Prescription-Writing, ... 13 



MEDICAL PUBLICATIONS 



MEDICAL JURISPRUDENCE AND I 

TOXICOLOGY. 
Chapman — Medical Jurisprudence and 

Toxirology 5 

Golebiewski and Bailey— Atlas of Uis- 

eascs Caused by Accidents 17 

Hofmannand Peterson— Atlas of Legal 

Medicine, 16 

NERVOUS AND MENTAL DIS- 
EASES. ETC. 

Brower — Manual of Insanity 22 ' 

Chapin — Compendium of Insanity. . . . 5' 
Church and Peterson — Nervous and 5 

Menial l)isea5es, S 

Jakob and Fisher— Atlas of Nervous 

System, 17 

Shaw — Essentiab of Nervous Diseases 

and Insanity, 15 

NURSING. 
Davis — Obstetric and Gynecolog;ic Nurs- 
ing 6 

Griffith— The Care of the Baby, .... 7 

Hart — Diet in Sickness and in Health, . . 7 

Meigs — Feeding in Early Infancy, ... 10 

Morten — Nurses' Dictionary 10 

Stoney — Materia Medica for Nurses, . . 13 

Stoney — Practical Points in Nursing, . . 13 

Stoney — Surgical Technic for Nurses, . 13 

Watson — Handbook for Nurses, .... 14 

OBSTETRICS. 

An Atnerican Text-Book of Obstetrics, 2 

Ashton — Essentials of Obstetrics 15 

Boisliniere — Obstetric Accidents, ... 4 

Dorland — Modern Obstetrics, 6 

Hirst— Text-Book of Obstetrics 7 

Norris — Syllabus of Obstetrics 10 

Schaeffer and Edgar- Atlas of Obstet- 
rical Diagnosis and Treatment, .... 17 

PATHOLOGY. 
An American Text-Book of Pathology, a 
Durck and Hektoen— Atlas of Patho- 
logic Histology, 16 

Kalteyer — Essentials of Pathology, . . 15 
Mallory and Wright— Pathological 

Technique, 9 

Senn — Pathology, and Surgical Treat- 
ment of Tumors, la 

Stengel— Text-Book of Pathology, . . . la 
Warren— Surgical Pathology, .... 14 

PHYSIOLOGY. 

American Text-Book of Physiology, . 2 

Budgelt— Essentials of Physiology, . . 15 

Raymond— Text-Book of Physiology, . ii 

Stewart— Manual of Physiology, . . 13 

PRACTICE OF MEDICINE. 

An American Year-Book of Medicine 

and Surgery- 3 

Anders — Practice of Medicine 4 

Eichhorst— Practice of Medicine, ... 6 

Lockwood—Pr.icti.e of Medicine. . . . 9 

Morris— Ess. of Practice of Medicine, . 15 

Salinger & Kalteyer— Mod. Medicine, 11 

Stevens— Practice of Medicine 13 



SKIN AND VENEREAL. 
An American Text-Book of Genito- 

Uiinary and Skin l)i»casi-s, 2 

Hyde and Montgomery— Syphilis and 
the Venereal Diseases, g 

Martin — Essentials of Minor Surgery, 
BandaKing. and Venereal Diseases. . . 15 

Mracek and Stelwagon— Atlas of Dis- 
eases of the Skin, 16 

Stelwagon — Essentials of Diseases of 
the Skin, ij 

SURGERY. 

An American Text-Book of Surgery, a 
An American Year-Book of Medicine 

and Surgery 3 

Beck — Fractures 4 

Beck — Manual of Surgical .\scpsis, ... 4 

Da Costa — Manual of Surgery 5 

International Text-Book c^ Surgery, . 8 

Keen— (Operation Blank 8 

Keen— The Surgical Complications and 

Setjuels of Typhoid Fever 8 

Macdonald — Surgical Diagnosis and 

Treatment 9 

Martin— F.ssentials of Minor Surgery. 

Bandaging, and Venereal Diseases, . . 15 

Martin— Essentials of Surgery 1$ 

Moore— Orthopedic Surgerj- 10 

Nancrede — Principles of Surgery, ... 10 

Pye— Bandaging and Surgical Dressing, 11 

Scudder — Treatment of Fractures, . . . la 

Senn— Genito-Urinary Tuberculosis, . . 11 

Senn— Practical Surger>' la 

Senn— Syllabus of Surgery la 

Senn — Pathology and Surgical Treat- 
ment of Tumors la 

Warren— Surgical Pathology and Ther- 
apeutics 14 

Zuckerkandl and Da Costa— Atlas of 

Operative Surgery, 16 

URINE AND URINARY DISEASES. 

Ogden— Clinical Examination of the 

Urine, to 

Saundby— Renal and Urinary Diseases, 11 
Wolf— Handbook of Urine Examination, 2a 
WolST- Examination of Urine 15 

MISCELLANEOUS. 
Abbott— Hygiene of Transmissible Dis- 
eases, 3 

Bastin— Laboratory Exercises in Bot- 
any 4 

Golebiewski and Bailey-Atlas of Dis- 
eases Caused by Accidents, . . . . 17 
Gould and Pyle — Anomalies and Curi- 
osities of Medicine 7 

Grafstrom— Massage, 7 

Keating— Examination for Life Insur- 
ance, ■ 

Pyle-A Manual of Personal Hygiene, . 11 
Saunders' Medical Hand Atlases, . t6, 17 
Saunders" Pim ket Medical Formulary, . it 
Saunders' Onestion-Comjiends, . . 14.15 
Stewart and Lawrence— Essentials of 

Medical Electricity, • «S 

Thornton— Dose-Book and Manual of 

I Prescription-Writing - »J 

, Van Valzah and Nisbet— Diseases of 
1 the Stomach, *J 



THE LATEST BOOKS. 



Bergey^s Principles of Hygiene. 

The Principles of Hygiene : A Practical Manual for Students, 
Physicians, and Health Officers. By D. H. Bergey, A.M.. M. D.. 
First Assistant, Laboratory of Hygiene, University of Pennsyl- 
vania. Handsome octavo volume of about 500 pages, illus- 
trated. 

Brower^s Manual of Insanity. 

A Practical Manual of Insanity. By Daniel R. Brower, M.D., 
Professor of Nervous and Mental Diseases, Rush Medical Col- 
lege, Chicago. i2mo volume of 425 pages, illustrated. 

Gorham^s Bacteriology. 

A Laboratory Course in Bacteriology. By F. P. Gorham, 
M.A., Assistant Professor in Biology, Brown University. i2mo 
volume of about 160 pages, fully illustrated. 

Gradle on the Nose, Throat, and Ear. 

Diseases of the Nose, Throat, and Ear. By Henry Gradle, 
M. D., Professor of Ophthalmology and Otology, Northwestern 
University Medical School, Chicago. Handsome octavo volume 
of 800 pages, profusely illustrated. 

SoIImann^s Pharmacology. 

A Text-Book of Pharmacology. By Tokald Sollmann, M. D.. 
Lecturer on Pharmacology, Western Reserve University, Cleve- 
land, Ohio. Royal octavo volume of about 700 pages. 

Wolfs Examination of Urine. 

A Handbook of Physiologic Chemistry and Urine Examination. 
By Charles G. L. Wolf, M. D., Instructor in Physiologic Chem- 
istry, Cornell University Medical College. i2mo volume of about 

160 pages. 

22 





Date Due 




































































































































(■•5 '^^T. NO ?3 233 PRINTED IN U.S.A. 



WRlUo 
M939a 
1899 
Mracek, Franz. 

Atlas of diseases of the skin. 



ISSUED TO 



WRlUo 
Nf939a 

1899 
Mracek, Franz. 

Atlar of diseases of the skin< 



MEDICAL SCIENCES LIBRARY 

UNIVERSITY OF CALIFORNIA, IRVINE 

IRVINE, CALIFORNIA 92664 




VOLUMES NOW READY. 

Atlas and Epitome of Internal Medicine and Clinical DiagnosU. By Dr Chr 

Jakob, of Erlangen. Edited by .-' ■ \ 'mi m k, M.D., Troicssor of Clinicai 
Medicine in the Philadelphia I'ol' ' '^-••■■■'^ i.n '.s plates and 

259 pages of text. Cloth, $3.00 ne """ ■. •• 

Atlas of Legal Medicine. Ry D 

ERiCK Pkterson, M.D., Chief of 

and Surgeons, New York. Wit! „ _ • ■. . ■ 1 

illustrations. Cloth, I3.50 net. M OOQ 421 7Q 1 

Atlas and Epitome of Diseases of the Larynx. By uk. i^. ..... ^ nich. 

Edited by Chari ks P. Ck.wso.v, M.D., Physician-in-Charge. Throat anu Nose 
Department, Hospital of the Iniversity of Pennsylvania. With 107 colored figures 
on 44 plates, 25 text-illustrations, and 103 pages of text. Clolh, Jj.50 net. 

Atlas and Epitome of Operative Surgery. By Dr. O. Zuckerkandl, of Vienna. 
Edited by J. Chalmers DaCosta, M.U., Professor of the i'ractice of Surgery and 
Clinical Surgery, Jefferson Medical College, Philadelphia. With 24 colored plates. 
217 illustrations in the text, and 395 papes nf text. Cloth, 53.00 net. 

Atlas and Epitome of Syphilis and 1 ' ^ " - nl Diseases. By Prof. Dr. Franz 

Mracek, of Vienna. Edited by 1 \v..s. MI).. Professor of Genito- 
urinary Surgery. University and 1 iiital Medical College, New York. 
With 71 colored plates and 122 pagcb ol iv ,. Cloth, $3.50 net. 

Atlas and Epil of External Diseases . . the Eye. By Dr. O Maab, of Zurich. 

Edited by 'E Schwkinitz, M.U., Professor of Ophtlial .gy, Jefferson 

Medical Coi (iladelphia. With 76 colored illustrations on plates and rA 

pages of text. iih, I3.00 net. 



■/ 



Atlas and Epitome of Sk 

Editetl by Hk.nry W. ST^ 
son Medical College, Phil; 
and 200 pages of text. 



Oiseases. By Prof. Dr 
.GoN, .M.n., C'linical Pro. 
ihi'v. W"ilh63coloret.l plai, 
ft net. 



t .Mracek, of X'lenna. 

f Dermatology, Jefier- 

^9 half-tone illustrations, 



Atlas and Epitome 1 ^ii Patholoeic Histology. By Dr. H. DOrck, of 

Munich. Edited h DVIC ! iCTOen, M.D., I'rofessor of PatMogy, Rush Medical 

College, Chicago. 1 w .is. Part I. just rc-aWv, including the CircuLitor>-, 
Respiratory, and Gas .0-' .nal Tracts, with lit cufured fig'- ' on 62 plates and 

158 pages of text. CIC x) net. 

Atlas and Epitome of u.seases Caused by Accidents. u. Golebiewski, 

of Berlin. Trauslatc-<1 and edited, with additions, i.y ^f. Bailey, M.D., 

Attending PI- ' —»n to the Almshouse and Incurable Ho^p.. Is, New Yorlc. With 
71 colored il -jns on 40 plates, 143 text-illustrations, and 549 pages of text. 

Cloth, $4.00 T 

Atlas and Epiv . >f Oyneco 

the Second Rfv J and liiil, 
Ris, A.M., M.D., Gynecologi 
tals. With 207 colored illusi 
of text. Cloth, I3.50 net. 



i 
I 

00 

23 



By Dr. O. ScMAFFKR.of Heidelberg. /•> 
man Edition. Edit" >y Richard C. N 



<>thodist Episcopa' 
90 plates, 65 text-i 



Philadelphia HosI 
lions, and 308 p; 



Atlas and Epitome of Labor and Operative Obstetrics. B' 

" 11 // J-i/th Revised GerymiH Edition. Editei 



Heidelberg 
M. D., 
School. 



Atlaf 

of 
Euo 
ical Sci. 
of text. 



ome 

. /•"'•< 

., Professoi 

With 122 ■:■ 

Cloth, ^13.00 net. 



•a 
tetrics and Clinical .Midwifer)', Corm 
llic s in colors and 139 other illustrai 

' 'agnosis and Treatment. 

-'ii,d (iitiMiiH Edition. 
.tikI Clitiiial Midwiferv, \ 
, on 50 pUiles, 38 oth' 'lui 




;. O. SCHAPFER, 

by J. Clifti>n 

University Med 

oos, and 317 pages 



, vous System and its Dis. 



Atlas and Epitome of the 

Jakob, of Erlangen. From the Seccnd Ke^'isid _t- 
D. Kisher. M. D., Professor of Diseases of the N' : 
Hospital Medical College, New York. With 83 ; 
$3.50 net. 



«. By Prop. Dr. Chr. 
• >;. F!diled ky RowARb 
University and Belle vue 
5 pages oir text. Cloth, 



Atlas and Epitome of Ophthalmoscopy and Ophthalmoscopic DiagnosU. By 

Dr. O. Haa^, of Zurich. From the Third hnUrced German Ed,t,oH Edited byO. 
F DE ScHWBlJnTZ, .M.D., Professor of Ophthalmology, Jefferson Medical College. 
Philadelphia. 152 colored figures and 82 pages of text. Cloth, fj.oo net. 

Atlas of Bacteriology and Text-Book of Special Bacteriologk 1 — I?v 

Prof. Dr. K. H. Lehmann and Dk. R. O. Ne< mann. of W »r/t"rK ■ 

Revised German Edition. Edited by ('.forge H. \\ e.aver. M. D..^ -r 

of Pathology and Bacteriology. Rush Medical College, Chicago, luu wiuui^i. »itli 
over 600 colored lithographic figures, and 500 pages of text. 

ADDITIONAL VOLUMES IN PREPARATION. 

W. B. SAUNDERS & CO., Publishers, 



C/> 



a 



PHE-ADELPHIA. 



LONDON.