Skip to main content

Full text of "Dieseases of the skin and the eruptive fevers"

See other formats 


Google 


This  is  a  digital  copy  of  a  book  lhal  w;ls  preserved  for  general  ions  on  library  shelves  before  il  was  carefully  scanned  by  Google  as  pari  of  a  project 

to  make  the  world's  books  discoverable  online. 

Il  has  survived  long  enough  for  the  copyright  to  expire  and  the  book  to  enter  the  public  domain.  A  public  domain  book  is  one  thai  was  never  subject 

to  copy  right  or  whose  legal  copyright  term  has  expired.  Whether  a  book  is  in  the  public  domain  may  vary  country  to  country.  Public  domain  books 

are  our  gateways  to  the  past,  representing  a  wealth  of  history,  culture  and  knowledge  that's  often  dillicull  lo  discover. 

Marks,  notations  and  other  marginalia  present  in  the  original  volume  will  appear  in  this  file  -  a  reminder  of  this  book's  long  journey  from  the 

publisher  lo  a  library  and  linally  lo  you. 

Usage  guidelines 

Google  is  proud  lo  partner  with  libraries  lo  digili/e  public  domain  materials  and  make  them  widely  accessible.  Public  domain  books  belong  to  the 
public  and  we  are  merely  their  custodians.  Nevertheless,  this  work  is  expensive,  so  in  order  lo  keep  providing  this  resource,  we  have  taken  steps  to 
prevent  abuse  by  commercial  panics,  including  placing  Icchnical  restrictions  on  automated  querying. 
We  also  ask  that  you: 

+  Make  n  on -commercial  use  of  the  files  We  designed  Google  Book  Search  for  use  by  individuals,  and  we  request  thai  you  use  these  files  for 
personal,  non -commercial  purposes. 

+  Refrain  from  automated  querying  Do  not  send  automated  queries  of  any  sort  lo  Google's  system:  If  you  are  conducting  research  on  machine 
translation,  optical  character  recognition  or  other  areas  where  access  to  a  large  amount  of  text  is  helpful,  please  contact  us.  We  encourage  the 
use  of  public  domain  materials  for  these  purposes  and  may  be  able  to  help. 

+  Maintain  attribution  The  Google  "watermark"  you  see  on  each  lile  is  essential  for  informing  people  about  this  project  and  helping  them  find 
additional  materials  through  Google  Book  Search.  Please  do  not  remove  it. 

+  Keep  it  legal  Whatever  your  use.  remember  that  you  are  responsible  for  ensuring  that  what  you  are  doing  is  legal.  Do  not  assume  that  just 
because  we  believe  a  book  is  in  the  public  domain  for  users  in  the  United  States,  that  the  work  is  also  in  the  public  domain  for  users  in  other 

countries.  Whether  a  book  is  slill  in  copyright  varies  from  country  lo  country,  and  we  can'l  offer  guidance  on  whether  any  specific  use  of 
any  specific  book  is  allowed.  Please  do  not  assume  that  a  book's  appearance  in  Google  Book  Search  means  it  can  be  used  in  any  manner 
anywhere  in  the  world.  Copyright  infringement  liability  can  be  quite  severe. 

About  Google  Book  Search 

Google's  mission  is  to  organize  the  world's  information  and  to  make  it  universally  accessible  and  useful.  Google  Book  Search  helps  readers 
discover  the  world's  books  while  helping  authors  and  publishers  reach  new  audiences.  You  can  search  through  I  lie  lull  lexl  of  1 1  us  book  on  I  lie  web 
al|_-.:. :.-.-::  /  /  books  .  qooqle  .  com/| 


DISEASES  OF  THE  SKIN 


AND   THE 


ERUPTIVE  FEVERS 


BY 

JAY  FRANK  SCHAMBERG,  A.  B.,  M.  D. 

Professor  of    Dermatology  and  Infectious  Eruptive  Diseases  in  the  Philadelphia 

Polyclinic  and  College  for  Graduates  in  Medicine  ;  Diagnostician  to  the  Bureau 

of   Health    and   Consulting    Physician     to    the    Municipal     Hospital    of 

Philadelphia;   Fellow  of    the  College  of  Physicians  of  Philadelphia; 

Member   of    the    American    Dermatological    Association 


Fully   Illustrated 


SECOND  EDITION.  THOROUGHLY  REVISED 


PHILADELPHIA   AND    LONDON 

W.    B.    SAUNDERS    COMPANY 

1911 


PREFACE 


The  study  of  dermatology  in  its  broadest  sense  embraces  the 
consideration  of  all  morbid  processes  that  are  characterized 
by  cutaneous  manifestations.  This  conception  of  the  subject, 
which  follows  that  of  the  old  Vienna  school,  lends  to  derma- 
tology greater  dignity  and  gives  to  it  a  more  important  mission. 
The  specialist  in  diseases  of  the  skin  should  be  skilled  in  the  diag- 
nosis not  only  of  the  ordinary  dermatoses,  but  of  the  rashes  of  the 
various  eruptive  fevers.  The  two  classes  of  affections  frequently 
resemble  each  other  to  such  a  degree  as  to  require  for  their 
differentiation  a  broad  experience  in  both.  The  striking  man- 
ner in  which  syphilis  may  simulate  small-pox  is  well  known. 
The  eruption  of  syphilis  is,  properly  considered,  no  more  en- 
titled to  be  included  among  skin  diseases  than  is  that  of  small- 
pox; the  former  constitutes  the  most  conspicuous  symptom  of 
a  chronic  infectious  process,  while  the  exanthem  of  variola  rep- 
resents the  most  striking  feature  of  an  acute  infectious  process. 

In  the  present  volume  the  exanthemata  are  treated  in  a 
separate  chapter,  and,  owing  to  the  importance  attaching  to 
their  diagnosis,  are  given  greater  space  than  is  usually  accorded 
to  them  in  books  on  skin  diseases.  The  general  symptoms  are 
described  briefly,  but  all  that  relates  to  the  skin  manifestations 
is  exhaustively  treated.  In  addition  to  a  consideration  of  the 
diseases  ordinarily  included  among  the  exanthemata,  there 
are  described  the  usual  and  the  accidental  eruptions  occur- 
ring in  the  course  of  such  diseases  as  typhoid  fever,  typhus 
fever,  epidemic  cerebrospinal  meningitis,  influenza,  malaria, 
rheumatic  fever,  dengue,  miliary  fever,  angina,  and  tonsillitis. 
Space  does  not  permit  of  the  description  of  the  general  symp- 
toms of  these  diseases,  but  merely  of  the  eruptive  phenomena. 

The  part  devoted  to  diseases  of  the  skin  is  designed  to 
present  the  subject  in  a  brief  and  practical  manner:  special 
attention  is  devoted  to  symptomatology,  diagnosis,  and  treat- 


IO  PREFACE 

ment.     It  is  hoped  that  the  numerous  photographic  illustrations 
will  helpfully  supplement  the  text. 

The  author  has  availed  himself  of  the  privilege  of  consulting 
the  well-known  treatises  on  dermatology  of  Kaposi,  Brocq,  Duh- 
ring,  Hyde  and  Montgomery,  Stelwagon,  and  others. 

The  author  has  freely  abstracted  from  the  chapters  written  by 
him  in  Welch  and  Schamberg's  "Acute  Contagious  Diseases," 
and  has  drawn  upon  the  illustrations  therein  contained,  and 
acknowledgment  of  the  courtesy  extended  by  Lea  and  Febiger, 
the  publishers  of  this  work,  is  gratefully  made.  The  author 
likewise  acknowledges  his  obligation  to  P.  Blakiston's  Son  and 
Company  for  the  granting  of  similar  privileges  with  reference 
to  his   "Compend  of  Skin  Diseases." 

In  conclusion,  the  author  wishes  to  express  his  appreciation 
of  the  unfailing  courtesy  and  helpful  cooperation  of  the  pub- 
lishers, the  W.  B.  Saunders  Companv. 

J.  F.  S. 


CONTENTS 


DISEASES  OF  THE  SKIN 

PACE 

■ 

Anatomy  and  Physiology 17 

Embryonic  Development  of  the  Skin 17 

Anatomy  of  the  Skin 17 

Physiology  of  the  Skin 25 

Symptomatology 26 

Objective  Symptoms 26 

Subjective  Symptoms 27 

CLASS  I.     ANAEMIAE— ANEMIAS 

Transient  Anemia 28 

Persistent  Anemia 28 

CLASS  II.    HYPERAEMIAE— HYPEREMIAS 

Erythema  Hyperamicum 29 

Erythema  Intertrigo 30 

CLASS   III.     EXSUDATIONES— INFLAMMATIONS 

Erythema  Exsudativum 31 

Erythema  Multiforme 31 

Erythema  Nodosum 36 

Erythema  Scarlatinoides 38 

Erythema  Induratum 41 

Erythema  Elevatum  Diutinum 41 

Pellagra 42 

Acrodynia .  .  .• 45 

Urticaria 46 

Urticaria  Pigmentosa 51 

Angioneurotic  Edema 52 

Eczema 53 

Eczema  Seborrhoicum  (Dermatitis  Seborrhoica) 76 

Dermatitis  Repens 81 

Impetigo  Contagiosa 81 

Impetigo  Herpetiformis 87 

Ecthyma 87 

Dermatitis  Herpetiformis 89 

Pemphigus 92 

Epidermolysis  Bullosa  Hereditaria 96 

Pompholyx 98 

Hydroa  Vacciniforme  (Hydroa  ^stivale) 99 

Herpes  Simplex 101 

Herpes  Zoster 103 

Lichen  Planus 108 

11 


12  CONTENTS 

PAGB 

Lichen  Ruber  Acuminatus  (Pityriasis  Rubra  Pilaris) 112 

Resistant  Scaly  Erythrodermias. 115 

Progressive  Pigmentary  Dermatosis 116 

Prurigo 1 17 

Lichen  Scrofulosus  Seu  Scrofulosorum 119 

Acne 119 

Acne  Rosacea 128 

Acne  Varioliformis 132 

Dermatitis  Papillaris  Capillitii 133 

Sycosis  Vulgaris 134 

Sycosis  Lupoides 138 

Psoriasis 139 

Dermatitis  Exfoliativa 151 

Pityriasis  Rosea 153 

Erysipelas 156 

Erysipeloid 159 

Dermatitis 160 

Dermatitis  Traumatica 160 

Dermatitis  Calorica 160 

Dermatitis  Venenata 161 

Dermatitis  Medicamentosa 163 

Dermatitis  Gangrenosa 167 

Dermatitis  Gangrenosum  Infantum 168 

Symmetric  Gangrene 169 

Diabetic  Gangrene 170 

Feigned  Eruptions  (Dermatitis  Factitia)   170 

Furunculus 171 

Carbunculus 1 74 

Equinia 1 76 

Anthrax 1 77 

Postmortem  Pustule 1 78 

Tinea  Trichophytina : . .  1 79 

Tinea  Circinatr. 1 79 

Tinea  Tonsurans 183 

Tinea  Sycosis 189 

Tinea  Favosa 191 

Tinea  Versicolor 195 

Erythrasma 198 

Pinta 199 

Craw-craw   199 

Scabies 200 

Grain  Itch 204 

Pediculosis 209 

Pediculosis  Capitis 209 

Pediculosis  Corporis 212 

Pediculosis  Pubis 213 

Cysticercus  Cellulosae  Cutis 214 

Dracunculosis 215 

Ixodes 215 

Leptus 215 

CEstrus 216 

Pulex  Penetrans 216 

Pulex  Irritans 216 

Cimex  Lectularius 216 

Culex 216 


CONTENTS  !^ 

_  PAGB 

CLASS  IV.    HAEMORRHAGIAE— HEMORRHAGES 

Purpura *. 217 

CLASS  V.    HYPERTROPHIAE— HYPERTROPHIES 

Lentigo 220 

Chloasma 222 

Naevus  Pigmentosus 223 

Callositas 225 

Clavus 225 

Cornu  Cutaneum 226 

Acanthosis  Nigricans 228 

Ichthyosis 228 

Verruca 232 

Porokeratosis 235 

Comedo 236 

Milium 238 

Cystis  Sebacea 238 

Molluscum  Epitheliale 239 

Keratosis  Pilaris 241 

Keratosis  Follicularis 242 

Hypertrichosis 243 

Elephantiasis 247 

Dermatolysis 249 

Onychauxis 250 

Acromegaly 250 

CLASS  VI.  ATROPHIAE— ATROPHIES 

Albinismus 25 1 

Vitiligo 252 

Atrophia  Cutis 255 

Atrophia  Senilis  (Senile  Atrophy) 255 

Atrophoderma  Neuriticum  (Glossy  Skin) 255 

General  or  Diffuse  Idiopathic  Atrophy 256 

Striae  et  Macula'  Atrophica?  (Atrophic  Lines  and  Spots) 256 

Acrodermatitis  Chronica  Atrophicans 256 

Xeroderma  Pigmentosum 256 

Sclerema  Neonatorum 258 

CEdema  Neonatorum 259 

Scleroderma 260 

Morphea 262 

Kraurosis  Vulvae 264 

Canities 264 

Alopecia 266 

Alopecia  Areata 269 

Folliculitis  Decalvans 275 

Atrophia  Pilorum  Propria 275 

Fragilitas  Crinium 275 

Trichorrhexis  Nodosa 276 

Monilethrix 277 

Leptothrix 277 

Piedra 277 

Tinea  Nodosa 278 

Plica  Polonica 278 

Atrophia  Unguium 278 

Ainhum 279 

Morvan's  Disease  (Syringomyelia) 279 


14  CONTENTS 

PACK 

CLASS  VII.    NEOPLASMATA— NEW  GROWTHS 

Keloid 280 

Fibroma 281 

Neuroma 283 

Xanthelasma 283 

Xanthoma  Tuberosum 284 

Xanthoma  Diabeticorum > 285 

Myoma 285 

Naevus  Vasculosus 286 

Port -wine  Mark  (Naevus  Flammeus;  Angioma  Simplex)   286 

Angioma  Cavernosum  (Naevus  Tuberosus) 287 

Angioma  Serpiginosum 287 

Telangiectasis 288 

Angiokeratoma 289 

Lymphangioma 289 

Colloid  Degeneration  of  the  Skin 291 

Adenoma  Sebaceum 291 

Rhinoscleroma 292 

Multiple  Cutaneous  Tumors  Associated  with  Itching 293 

Lupus  Erythematosus 294 

Tuberculosis  Cutis 301 

Lupus  Vulgaris 301 

Tuberculosis  Verrucosa  Cutis 308 

Tuberculosis  Cutis  Orificialis 311 

Scrofuloderma 311 

Miliary  Tuberculosis  of  the  Skin 313 

Dermatoses  Assumed  to  be  Related  to  Tuberculosis 313 

Acnitis 313 

Folliclis 314 

Blastomycosis  Cutis 315 

Actinomycosis 317 

Mycetoma 318 

Sporotrichosis 319 

Verruga  Peruana 321 

Syphilodenna 321 

Syphilis 32 1 

Wassermann  Reaction 327 

Syphiloderma  Erythematosum  (Macular  Syphiloderm;  Roseola)  . .  329 

Syphiloderma  Papulosum 330 

Syphiloderma  Vesiculosum 336 

Syphiloderma  Pustulosum 336 

Syphiloderma  Tuberculosum  (Tubercular  Syphilid) 340 

Syphiloderma  Gummosum  (Gummatous  Syphilid) 342 

Syphiloderma  Bullosum  (Bullous  Syphilid;  Pemphigus  Syphiliti- 
cus)    344 

Hereditary  or  Congenital  Syphilis 344 

Lepra 354 

Frambesia 363 

Epithelioma 364 

Multiple  Benign  Cystic  Epithelioma 372 

Paget's  Disease  of  the  Nipple 373 

Sarcoma 374 

Granuloma  Fungoides 376 


CONTENTS  15 

CLASS  VIII.    ANOMALIES  OF  SECRETIONS  OF  GLANDS 

PAGE 

Hyperidrosis 378 

Bromidrosis 379 

Anidrosis 380 

Chromidrosis 381 

Uridrosis 381 

Hematidrosis 381 

Phosphoridrosis 382 

Granulosis  Rubra  Nasi 382 

Hydrocystoma  .* 382 

Sudamen   383 

Miliaria  384 

Seborrhea 386 

Asteatosis 390 

CLASS  IX.    NEUROSES  OF  THE  SKIN 

Hyperesthesia  390 

Dermatalgia 390 

Pruritus 391 

Anesthesia 396 

DISEASES  OF  THE  MUCOUS  MEMBRANES 
Leukokeratosis  Buccal  is 397 

ACTINOTHERAPY,   RADIOTHERAPY,   OPSONOTHERAPY,  AND 

REFRIGERATION 

Actinotherapy 399 

The  Rontgen  or  *-Rays 404 

Action  of  the  x-Rays  in  Cutaneous  Diseases 405 

Radium 409 

Bacterial  Vaccines;  Opsonotherapy 413 

Treatment  by  Refrigeration 414 

Liquid  Air 414 

Carbon  Dioxid 414 

Therapeutic  Indications 415 

ACUTE  ERUPTIVE  FEVERS 

Small-pox 417 

Varieties  of  Small-pox 438 

Vaccination  and  Cutaneous  Diseases 460 

Chicken-pox 477 

Scarlet  Fever 492 

Measles 512 

Rubella 527 

Acute  Infectious  Diseases  Accompanied  at  Times  by  Eruptions 536 

Typhoid  Fever 536 

Typhus  Fever 541 

Innuenza 544 

Dengue 545 

Malaria 546 

Epidemic  Cerebrospinal  Meningitis 547 

Miliary  Fever 549 

Angina  and  Tonsillitis 550 

Rheumatic  Fever 55 1 

Serum  Eruptions 552 

INDEX 557 


Diseases  of  the  Skin 


AND 


Eruptive  Fevers 


DISEASES  OF  THE  SKIN 


ANATOMY  AND  PHYSIOLOGY 

EMBRYONIC  DEVELOPMENT  OF  THE  SKIN 

Embryologically  speaking,  but  two  layers  of  the  skin  are 
recognized — the  epidermis  and  the  corium. 

The  corium  represents  the  foundation  of  the  skin,  and  is 
derived  from  the  superficial  layer  of  the  mesoderm,  called  the 
"skin-plate."  At  the  end  of  the  fourth  week  the  cutis  is  made 
up  of  embryonic  corpuscles,  which  develop  into  spindle-shaped 
protoplasmic  bodies  of  a  fibromyxomatous  nature  between 
the  second  and  third  month.  About  the  fifth  month  the 
myxomatous  tissue  is  replaced  by  a  collagenous  basic  substance. 
Blood-vessels  are  first  formed  about  the  third  month. 

The  epidermis  is  a  distinct  layer,  having  its  origin  in  the 
ectoderm.  It  is  represented  at  the  end  of  the  first  month  by  a 
single  layer  of  epithelial  cells  upon  the  surface  of  the  body. 
From  the  fifth  to  the  eighth  month  the  mucous  layer  takes  on 
great  activity  and,  through  cellular  growth,  forms  the  cutaneous 
glands  and  hair. 

ANATOMY  OF  THE  SKIN 

The  skin  may  be  said  to  be  composed  of  three  distinct  layers : 
the  epidermis,  the  corium,  and  the  subcutaneous  tissue. 

The  epidermis,  or  cuticle,  consists  of  four  layers:  (a) 
Stratum  corneum;  (b)  stratum  lucidum;  (c)  stratum  granu- 
a  17 


DISEASES   OF   THE   SKIN 


losum;  (ii)  stratum  mucosum.  The  stratum  corneum  and  the 
stratum  mucosum  are  of  far  greater  importance  than  the 
stratum  lucidum  and  stratum  granulosum,  so  that  some  writers 
speak  of  the  epidermis  being  made  up  mainly  of  two  portions — - 
the  mucous  and  the  horny  layer. 


(a)  The  stratum  corneum  {horny  layer)  is  composed  of  super- 
imposed rows  of  elongated  horny  cells.     This  layer  forms 
protective   surface   for  the  softer  strata  beneath. 

(6)  The  stratum  lucidum  (clear  layer)  consists  of  from  two 


ANATOMY    OF    THE    SKIN 


19 


to  four  rows  of  bright,  transparent,  homogeneous,  elongated 
cells.  This  layer  is  of  minor  importance,  and  is  considered 
by  many  the  basal  layer  of  the  stratum  corneum. 

(c)  The  stratum  granulosum 
(granular  layer)  is  made  up  of 
several  rows  of  flattened  granu- 
lar cells.  These  granules  contain 
a  substance  called  keratohyalin. 
An  allied  substance,  eleidin,  is 
also  present.  The  granular  layer 
may  be  regarded  as  the  superficial 
stratum  of  the  mucous  layer. 

(d)  The  stratum  mucosum  (mu- 
cous layer,  rete  Malpighii)  is  the 
deepest  and  most  important  layer 
of  the  epidermis.  The  basal  layer 
consists  of  columnar  epithelial 
cells  (sometimes  spoken  of  as  the 
palisade  layer),  which  contain  the 
skin-pigment.  These  cells  lie  in 
contact  with  the  papilla?  of  the 
corium.  Above  the  columnar 
layer  are  irregular  layers  of  poly- 
gonal nucleated  cells  with  ser- 
rated borders  (prickle-cells).  As 
the  granular  layer  is  approached, 
the  cells  become  more  fusiform 
in  shape  and  exhibit  a  stratified 
arrangement.  There  are  no  blood- 
vessels in  the  epidermis,  but  there 
exist  intercellular  spaces  which 
contain  a  nutrient  fluid. 

The  corium  (derma,  cutis  vera,  or  true  skin)  is  a  dense, 
thick  structure  made  up  of  white  fibrous  tissue  interspersed 
here  and  there  with  yellow  elastic  tissue.  It  contains  blood- 
vessels, nerves,  lymphatics,  nerve -corpuscles,  hair,  sweat-  and 
sebaceous  glands,  muscle-  and  fat-cells.  It  consists  of  two 
layers:  (a)  pars  papillaris  (papillary  layer) ;  (b)  pars  reticularis 
(reticular  layer). 

(a)  The  papillary  layer  is  made  up  of  finger-like  prominences 
which  dovetail  into  the  rete  prolongations.  The  papillae  are 
supplied  with  blood-vessels,  n*™—    Ivtnohatics,  and   nerve- 


.  a.— The    epidermis:       t, 

is  (homy)  layer;  g,  granular 

layer:  m,  mucous  layer  (rele  Mai- 
pighii);  the  stratum  lucidum  is 
the  layer  just  above  the  granular 
layer;  d,  corium.  Nerve  termina- 
tions: B,  Afferent  nerve;  b,  ter- 
minal nerve-bulbs;  1,  cell  of  Lan- 
gerhans  (Ranvier). 


20  DISEASES   OP  THE    SKIN 

corpuscles.  According  to  Sappey,  there  are  100  papillae  to  the 
square  millimeter;  it  is  estimated  that  the  entire  cutaneous 
surface  contains  about  150,000,000  papilla;.  There  are  two 
kinds  of  papillae,  "  vascular  "  and  "  sensory."  The  former  are 
richly  supplied  with  blood-vessels,  while  the  latter  are  poor  in 
vascular  tissue,  but  contain  medullated  nerves  and  connective 
tissue. 

(6)  The  reticular  layer  is  made  up  of  loosely  arranged  bundles 
of  connective  tissue.  This  layer  merges  into  the  papillary 
layer  without  a  line  of  demarcation.  It  differs  from  the 
papillary  layer  in  the  arrangement  of  the  connective- tissue 
fibers. 


Fig-  }■— Section  of  negro  skin,  including  epidermis  (a)  and  papillary  layer  (ft) 
of  the  conum.     The  pigment  is  contained  in  the  deepest  layer  (<-)  of  the  epidermis 

The  subcutaneous  tissue  (stratum  subcutaneum)  is  made 
up  of  a  loosely  arranged  network  of  connective  tissue  between 
the  meshes  of  which  are  contained  fat-globules  (panniculus 
adiposus).  The  deeper  hair- follicles  and  sweat-glands  also 
find  lodgment  in  this  layer. 


ANATOMY   OF   THE    SKIN  21 

Blood-vessels. — Two  horizontal  plexuses  exist  in  the  skin — 
a  superficial  and  a  deep  one.  The  former  occupies  the  papillary 
layer;  the  latter,  the  subcutaneous  tissue.  The  deep  plexus 
sends  branches  to  the  sweat-  and  sebaceous  glands  and  to  the 
hair -follicles.      The   superficial    plexus    sends   vessels   to   the 


—The   Mood  rcmetsi    C.   Fpidermi 


*l  or  pai>illaiy  pier...,   . 

nf  ■■„   -:  -■!■- .< ■-■    vs,  an  ililrr- 

Mipph/ing  iwrai  glands  and 


papilliE,  where  capillary  loops  are  formed.     The  arteries  are 
small  compared  with  the  size  of  the  veins. 

Lymph-vessels. — There  appear  to  be   also  superficial    and 
deep  lymph-plexuses  in  the  skin,  following  in  a  general  way  the 


22  DISEASES  OF  THE   SKIN 

blood-vessels.  Juice-spaces  filled  with  lymph  occur  at  all 
levels  in  the  corium.  Lymph  reaches  the  epidermis  through 
the  apices  of  the  papillae. 

Nerves. — The  skin  contains  both  medullated  and  non- 
medullated  nerve-fibers.  When  the  former  end  in  the  sub- 
cutaneous connective  tissue,  they  terminate  in  Pacinian 
corpuscles;  when  they  end  in  the  papillae  of  the  skin,  they  form 
tactile  corpuscles.  The  non-medullated  fibers  penetrate  the 
corium  and  are  lost  in  the  mucous  layer  of  the  epidermis.  The 
skin  also  contains  motor  and  vasomotor  nerves. 

Nerve-corpuscles. — (a)  The  corpuscles  of  Krause  (bulb- 
corpuscles)  are  found  chiefly  in  the  sensory  mucous  mem- 
branes— most  abundantly  in  the  conjunctiva.  They  are  round 
or  elongated  bodies,  and  resemble  the  Pacinian  corpuscles. 

(6)  The  tactile  corpuscles  (touch-corpuscle,  corpuscle  of 
Meissner)  are  found  in  the  skin  papillae — most  abundantly  in 
the  fingers.  They  are  round  or  oval  fibrous  masses  with  a 
striated  covering. 

(c)  The  Pacinian  corpuscles  are  most  numerous  in  the  skin 
of  the  fingers  and  toes.  They  lie,  for  the  greater  part,  in  the 
subcutaneous  tissue.  They  are  oval  bodies  made  up  of  a 
"central  nerve-fiber,"  a  "core"  or  surrounding  substance,  and 
a  "capsular  covering,"  which  has  many  concentric  layers. 

Muscles. — Both  voluntary  and  involuntary  muscle-fibers 
occur  in  the  skin.  Striated  muscle  is  found  in  the  skin  of  the 
face.  Smooth  muscle  exists  in  the  scrotum  and  in  connection 
with  hair-follicles.  The  contraction  of  the  hair-muscle  causes 
the  hair  to  rise,  and  also  expresses  sebum  from  the  sebaceous 
glands. 

Sebaceous  glands  are  racemose  or  acinous  glands  situated 
in  the  corium,  chiefly  in  relation  with  the  hair-follicles.  They 
may,  however,  occur  independently  of  them,  as  upon  the  border 
of  the  lip,  penis,  etc.  They  consist  of  one  or  more  pouches 
which  empty  into  a  common  duct.  Sebum  consists  of  fatty 
degenerated  cells  mixed  with  epithelial  debris. 

Sweat-glands  are  simple  tubular  glands  which  lie  in  coils 
in  the  deeper  layers  of  the  corium  and  in  the  subcutaneous 
tissue.  They  empty  into  excretory  ducts,  which  traverse  the 
corium,  penetrate  the  epidermis  between  the  papillae,  and  then 
pursue  a  spiral  course  to  the  surface  of  the  skin.  They  are  most 
abundant  in  the  palms  and  soles.  Sappey  estimates  that  there 
are  2,000,000  sweat-glands  in  the  skin. 


ANATOMV    OF    THK    SKIS" 


23 


Hair. — Hair  is  nothing  more  than  a  specialized  epidermal 
tissue.  The  corium  and  epidermis  are  somewhat  modified 
in  structural  arrangement  to  accommodate  the  hair.  This 
modification  gives  rise  to  the  hair-follicle.  Hair- follicles  are 
slender,  cylindric  pockets,  which  dip  down  into  the  corium  and 
the  subcutaneous  tissue. 


MS  .it 


x>)   (JlCh 


The  outer  or  dermic  coat  of  the  follicle  consists  of  three 
layers:  an  external  longitudinal  fibrous  layer,  a  middle  trans- 
verse layer,  and  an  internal  homogeneous  or  vitreous  layer. 

The  internal  or  epidermic  coat  (outer  root-sheath  of  some 
authors;  prickle-cell  layer)   is  a  tonUr  '«\)us 

layer  of  the  epidermis. 


The  root-sheath  proper  (inner  root-sheath  of  some  authors) 
is  composed  of  two  layers— an  external  layer  (layer  of  Henle) 
and  an  internal  layer  (layer  of  Huxley). 

The  cuticle  of  the  root-sheath  is  a  thin  layer  of  cells  lying 
internal  to  the  root -sheath. 

From  without  inward,  then,  the  coats  of  the  follicle  are: 
(a)  Dermic  coat,  three  layers.  (_b)  Epidermic  coat  (outer 
root-sheath;  prickle-cell  layer),  (e)  Root-sheath  proper  (inner 
root-sheath) — layer  of  Henle;  layer  of  Huxley,  ((f)  Cuticle 
of  the  root -sheath. 

The  skin  outlet  of  the  follicle  is  called  the  mouth.  The  neck 
corresponds  to  the  constriction  near  the  entrance  of  the  seba- 
ceous duct.     The  bulb  is  the  dilated  lower  end  of  the  follicle. 

The  hair  itself  consists  of  a  cortex  or  cortical  substance  which 
constitutes  the  bulk  of  the  hair,  the  medulla,  which  lies  in  the 


Fig.  6. — N.iil  (loBgftudlnaJ  section,  •:  100):  H,  Nail-plate  eonespunding  to 
hornv  Livers;  R.  K,  rut-  munsum;  I',  I',  janillarv  lavi-r:  B,  bed  of  nail;  E,  epidermis; 
D,  derma  with  iuje.teJ  Houd- vessels  (I.,  lleitzmann). 

medullary  canal,  and  the  cuticle,  a  thin  membrane  covering 
the  hair.  The  portion  of  the  hair  outside  the  skin  is  called  the 
shaft,  that  in  the  sldn,  the  root,  the  nether  termination  of 
which  constitutes  the  bulb;  the  concavity  of  the  bulb  fits  over 
the  papilla,  through  which  the  nourishment  of  the  hair  is  sup- 
plied. 

Hair  consists  of  a  nitrogenous  substance  containing  sulphur, 
fat,  pigment,  and  mineral  salts.  Von  Laer  gives  the  following 
analysis:  Carbon,  47  per  cent.;  oxygen,  23  per  cent.;  nitrogen, 
17  per  cent.;  hydrogen,  6  per  cent.,  and  sulphur,  5  per  cent. 


PHYSIOU)GY  OF  THE   SKIN  25 

Hair  is  one  of  the  last  tissues  of  the  body  to  undergo  decompo- 
sition. 

Nail. — The  nail,  like  the  hair,  is  a  specialized  epidermal 
structure.  It  is  composed  of  two  layers — the  mucous  or  soft 
layer,  and  the  horny,  which  constitutes  the  nail  proper. 

The  nail-bed  is  the  tissue  covered  by  the  nail.  The  posterior 
end  of  this  is  the  matrix  from  which  the  nail  grows.  The  ex- 
posed portion  of  the  nail  is  termed  the  body.  The  posterior 
portion  embedded  in  the  groove  is  the  root.  The  nail-groove  is 
the  groove  extending  around  the  proximal  portion  of  the  nail. 
From  this  springs  the  nail-fold.  The  thin  skin  that  often 
becomes  adherent  to  the  nail  is  called  the  nail-skin  or  epony- 
chium.  The  whitish  crescent  on  the  nail  is  the  lunula,  and  is 
due  to  a  lessened  translucency  of  that  portion.  Accidental 
white  spots  on  the  nails  are  alleged  to  be  due  to  the  presence  of 
air  between   the  lamellae. 


PHYSIOLOGY  OF  THE  SKIN 

It  has  been  seen  that  the  skin  is  made  up  of  a  complex 
structural  architecture.  It  must  be  regarded  not  merely  as 
the  protective  covering  of  the  body,  but  as  an  important  oi^an 
whose  proper  functionating  is  essential  to  health  and  life. 

The  skin  exercises  the  following  functions:  protection  to 
subjacent  tissues,  heat-regulation,  tactile  and  thermal  sensation, 
respiration,  secretion,  and  elimination. 

The  several  layers  of  the  skin,  but  particularly  the  corium, 
act  as  a  protective  barrier  against  injuries  to  the  underlying 
structures.  The  horny  cells  are  made  up  largely  of  keratin,  a 
resistant  substance  indestructible  by  strong  mineral  acids,  and 
indigestible  in  hydrochloric  acid  and  pepsin.  It  is  a  protein 
containing  considerable  sulphur,  and  one-third  of  its  ash  is 
said  to  be  composed  of  silicates.  The  heat-regulating  function 
of  the  skin  is  largely  exercised  through  the  condition  of  the 
cutaneous  blood-vessels  which  influence  perspiration  and  also 
radiation  and  conduction  of  heat  from  the  body  surface.  The 
skin  contains  the  nerve  elements  through  which  tactile  and 
thermal  sensations  are  appreciated.  The  respiratory  function 
of  the  skin  is  slight  and  unimportant  as  compared  with  the 
lungs.  Oxygen  is  absorbed  and  carbonic  acid  is  given  off.  It 
is  estimated  that  between  four  and  ten  grains  of  carbonic  acid 
are  given  off  from  the  skin  in  the  course  of  twenty-four  hours 


26  DISEASES  OP  THE   SKIN 

The  secretory  function  of  the  skin  is  carried  on  by  the  sweat- 
and  sebaceous  glands,  whose  products  tend  to  Jubricate  and  to 
soften  the  integument.  One  of  the  most  important  functions 
of  the  skin  is  that  of  elimination,  which  takes  place  through  the 
activity  of  the  sweat-glands.  Effete  and  noxious  products 
are  in  this  manner  removed  from  the  body.  Under  normal 
conditions  an  adult  will  lose  two  pounds  of  sweat  daily.  There 
is  a  complementary  relation  between  the  activity  of  the  sweat- 
glands  and  the  kidneys;  increased  elimination  of  fluids  through 
one  organ  is  accompanied  by  a  corresponding  decrease  through 
the  other. 

Charles,  from  a  compilation  of  several  analyses,  gives  the 
following  composition  of  sweat: 

Per  cent. 

Water 98.8 

Solids 1. 12 

Salts 0.57 

Sodium   chlorid 0.22    to  0.33 

Alkaline  sulphates,   phosphates,  lactates,  and  potas- 
sium chlorid o.  1 8 

Fats,  fatty  acids,  and  cholesterol 0.41 

Epithelium o.  1 7 

Urea 0.08 


a 


Sweat  is  colorless,  has  a  salty  taste,  acid  reaction,  and  a 
specific  gravity  of  1001  to  1010. 

It  is  believed  that  a  transudation,  of  water  through  the  skin 
may  take  place  independently  of  elimination .  through  the 
sweat-glands. 

SYMPTOMATOLOGY 

OBJECTIVE  SYMPTOMS 

It  is  essential  for  the  student  of  dermatology  to  recognize  the 
character  of  the  eruptive  elements  of  diseases  of  the  skin,  for 
these  are  of  great  importance  in  diagnosis. 

Lesions  upon  the  skin  may  be  primary  or  secondary.  The 
primary  lesions  constitute  the  initial  manifestations  upon  the 
skin.  The  secondary  lesions  result  from  either  natural  or 
accidental  modification  of  the  primary  lesions. 

The  primary  lesions  consist  of  macules,  papules,  vesicles, 
blebs,  pustules,  tubercles,  wheals,  and  tumors. 


SUBJECTIVE   SYMPTOMS  27 

Macula  (macules)  are  circumscribed,  discolored  patches  of 
skin  of  variable  shape  and  size,  without  elevation  or  depression. 

Papula  (papules)  are  circumscribed,  solid  elevations  of  the 
skin,  varying  in  size  from  a  pin-head  to  a  pea. 

Vesiculce  (vesicles)  are  pin-head-  to  pea-sized  circumscribed 
elevations  of  the  epidermis,  containing  clear  or  opaque  fluid. 

Bulla  (blebs)  are  round  or  irregularly  shaped  pea-  to  egg- 
sized  elevations  of  the  epidermis,  containing  clear  or  opaque 
fluid. 

Pustuke  (pustules)  are  circumscribed  flat  or  acuminate 
elevations  of  the  epidermis,  containing  pus. 

Pomphi  (wheals)  are  edematous,  circumscribed,  irregular 
pinkish  or  whitish  elevations  of  the  skin,  transitory  in  character. 

Tubercula  (tubercles)  are  circumscribed,  solid,  deep-seated 
elevations  of  the  skin  attaining  or  surpassing  the  size  of  a  pea. 

Tumor es  (tumors)  are  variously  sized  and  shaped  promi- 
nences, having  their  seat  in  the  corium  or  subcutaneous  tissue. 

The  secondary  lesions  comprise  scales,  crusts,  excoriations, 
fissures,  ulcers,  scars,  and  stains. 

Squama  (scales)  are  dry  epidermal  exfoliations  shed  from 
the  surface  of  the  skin. 

CrustcB  (crusts)  are  brownish  or  yellowish  masses  of  dried 
exudation. 

Excoriationes  (excoriations)  are  epidermal  denudations, 
usually  the  result  of  local  traumatism. 

Rhagades  (fissures)  are  linear  cracks  or  wounds  in  the  epider- 
mis or  corium  due  to  disease  or  injury. 

Ulcera  (ulcers)  are  round  or  irregular  losses  of  tissue  involv- 
ing the  skin  and  subcutaneous  tissue. 

Cicatrices  (scars)  are  connective-tissue  new-formations 
occupying  the  region  of  former  losses  of  tissue. 

Pigmentaiiones  (stains)  are  discolorations  of  the  skin  left 
after  the  disappearance  of  cutaneous  lesions. 

SUBJECTIVE  SYMPTOMS 

Among  the  subjective  phenomena  occurring  in  skin  diseases 
may  be  mentioned  sense  of  heat,  burning,  itching,  smarting, 
tingling,  tenderness,  and  pain.  These  are  present  in  the 
different  diseases  in  varying  degrees  of  intensity. 

Tenderness  and  pain  are  usually  encountered  in  phlegmonous 
conditions  and  in  malignant  neoplasms.  The  other  phenomena 
are  chiefly  present  in  the  inflammatory  dermatoses. 


28  DISEASES  OF  THE  SKIN 

CLASS  L    ANAEMIAE— ANEMIAS 

dome  writers  do  not  class  skin  pallor  in  the  category  of 
cutaneous  affections.  It  is  true  that  anemia  is  usually  the 
expression  of  a  systemic  disturbance;  nevertheless,  local  forms 
of  anemia  of  the  skin  are  a  part  of  the  symptomatology  of 
certain  cutaneous  diseases  below  referred  to. 

Anemia  of  the  skin  is  characterized  by  a  reduction  in  the 
quantity  or  a  change  in  the  quality  of  the  blood  in  the  integu- 
ment.    It  may  be  transient  or  persistent. 

Transient  anemia  occurs  after  hemorrhages,  during  certain 
nervous  states,  such  as  fear,  anger,  in  shock,  fainting,  etc., 
and  as  a  result  of  vasomotor  disturbances. 

Persistent  anemia  occurs  in  connection  with  the  various 
essential  anemias  and  cachexias.  It  occurs,  moreover,  in 
morphea,  scleroderma,  alopecia  areata,  and  Raynaud's  disease, 
as  a  result  of  trophic  and  vascular  disturbances. 

Local  anemias,  from  faulty  innervation,  and  the  chronic 
anemias  may  lead  to  the  development  of  seborrhea,  comedo, 
acne,  and  acne  rosacea. 

CLASS  IL    HYPERAEMIAE— HYPEREMIAS 

In  this  class  are  included  those  diseases  which  are  charac- 
terized by  an  overfilled  state  of  the  blood-vessels  of  the  integu- 
ment, unattended  by  inflammation.  As  Crocker  remarks,  the 
distinction  between  congestion  and  inflammation,  or  between  a 
congestive  erythema  and  an  inflammatory  erythema,  is  often 
one  of  clinical  convenience  rather  than  pathologic  accuracy. 

Hyperemias  may  be  active  or  passive.  Each  form  may  be 
further  subdivided  into  idiopathic  and  symptomatic  hyperemia. 

Idiopathic  active  hyperemia  includes  forms  of  erythema  due 
to  the  action  of  local  irritants.  These  substances  may  produce 
an  evanescent  redness  without  leading  to  inflammation. 

Symptomatic  active  hyperemia  is  due  to  visceral  or  nervous 
disturbances.  Flushing  and  blushing  are  examples  of  this 
form.  Flushing  is  a  congestion  resulting  usually  from  reflex 
stimulation.  Blushing  is  of  psychic  origin,  and  necessitates 
self -thought.  Darwin  says:  "  blushing  is  the  most  peculiar 
and  the  most  human  of  all  expressions,"  for  none  of  the  lower 
animals  blush. 

Idiopathic  passive  hyperemia  is  characterized  by  blueness  of 
the  skin  or  livedo.     It  may  be  caused  by  exposure  to  cold  or 


ERYTHEMA  HYPERiBMICUM  29 

heat,  chemic  substances,  continued  pressure,  contusions,  and 
circulatory  obstructions  resulting  from  bandages,  ligatures, 
articles  of  dress,  etc. 

Symptomatic  passive  hyperemia  results  from  some  general 
disturbance  of  the  cardiac,  circulatory,  or  respiratory  system. 
It  is  characterized  by  blueness  of  the  skin,  a  condition  which  is 
designated  cyanosis. 

ERYTHEMA  HYPERAEMICUM 

Derivation. — 'EpUhjfia,  a  blush.  Synonyms. — Erythema  simplex;  Ery- 
thema congestivum. 

Definition. — Erythema  hyperaemicum  is  a  congestive  dis- 
order of  the  skin  characterized  by  non-elevated  patches  of 
redness  of  variable  size  and  shape. 

Symptoms. — Redness  is  the  essential  characteristic  of  the 
disease.  It  may  be  a  bright  or  a  dull  red,  but  always  disappears 
under  pressure.  Infiltration  and  elevation  are  absent.  Mild 
burning  and  itching  are  usually  present. 

Etiology. — Erythema  hyperaemicum  may  be  due  to  external 
or  local  causes  and  internal  causes.  When  not  arising  from 
local  causes,  it  is  due  to  a  toxemia  of  one  character  or  another. 
Among  the  local  causes  may  be  mentioned  heat,  cold,  trauma- 
tism, poisons,  etc. 

Erythema  caloricum  is  a  redness  produced  by  exposure  to 
either  extremely  high  or  low  temperatures.  When  the  redness 
results  from  the  influence  of  the  chemically  active  rays  of  the 
sun,  it  is  termed  erythema  solar e. 

Erythema  ab  igne  is  a  condition  due. to  the  exposure  of  the 
skin  to  artificial  heat,  it  occurs  chiefly  in  cooks,  stokers, 
kitchen  employees,  and  those  who  acquire  the  habit  of  toast- 
ing their  legs  at  the  fire.  In  this  affection  annular  and  gyrate 
patches  are  seen,  particularly  upon  the  anterior  surface  of  the 
legs.  The  patches  disappear  upon  the  cessation  of  the  caus- 
ative influence. 

Erythema  traumaticum  results  from  various  cutaneous  injuries, 
such  as  friction,  pressure,  rubbing,  etc.  This  is  seen  in  the 
pressure  of  nose-glasses,  trusses,  and  like  articles. 

Erythema  venenatum  is  a  name  given  to  transient  hyperemias 
due  to  the  action  of  drugs,  such  as  arnica,  mustard,  chloroform, 
etc. 

Many  descriptive  adjectives  have  been  employed  to  designate 


30  DISEASES  OF  THE   SKIN 

minor  forms  of  erythema  of  diverse  origin.  Erythema  lave  is 
a  term  formerly  employed  to  designate  the  shining,  tense 
redness  seen  on  edematous  members.  Erythema  fugax  is  a 
transitory  redness  of  a  patchy  nature  allied  to  urticaria.  Ery- 
thema paratrimma  is  an  obsolete  term  applied  to  redness  over 
bony  prominences. 

The  internal  or  toxemic  erythemata  are  exemplified  in  the 
stomach  rashes  of  children,  in  intestinal  autointoxication,  after 
the  use  of  various  antitoxins,  etc. 

Treatment. — If  the  erythema  is  due  to  a  toxemia,  it  is 
evident  that  treatment  must  be  directed  toward  this  condition. 

A  saline  purge  will  promptly  relieve  an  erythema  due  to  the 
absorption  of  ptomains  or  other  poisons  from  the  intestinal 
canal. 

Stomach  rashes  in  children  will  nearly  always  yield  to  frac- 
tional doses  of  calomel. 

The  local  treatment  consists  of  the  use  of  dusting-powders 
or  cooling  lotions.     The  following  may  be  employed : 

H .    Acidi  carbolici Tftxxx; 

Acidi  borici 3 j ; 

Glycerini f^ij ; 

Pulv.  zinci  oxidi 3j; 

Aquae q.  s.  ad  f g vj. — M. 

ERYTHEMA    INTERTRIGO 

Erythema  intertrigo  (chafing)  is  a  form  of  traumatic  ery- 
thema occurring  chiefly  in  those  regions  where  skin  surfaces  are 
in  apposition,  such  as  the  genitals,  flexures  of  joints,  neck,  etc. 
It  is  common  in  children  and  fat  individuals.  Moist  diapers 
and  the  contact  of  intestinal  discharges  are  often  causative. 
The  condition  may  remain  as  an  erythema  or  may  develop  into 
dermatitis  or  an  eczema.  It  is  then  characterized  by  redness, 
excoriation,  and  a  mucoid  discharge.  There  is  usually  a  feeling 
of  heat  and  soreness. 

Treatment. — When  the  condition  remains  as  a  true  ery- 
thema, dusting-powders  suffice  to  effect  a  cure.  Such  a 
combination  as  the  following  answers  well: 

R .    Acidi  borici 3j ; 

Zinci  stearat gij ; 

Talci  Venet 3  j. — M. 

Sig. — Dusting-powder. 


ERYTHEMA   MULTIFORME  31 

Or  a  lotion  may  be  employed,  such  as: 

B.    Resorcin.     1 

Acidi  borici  \  Hi  ;jj ; 

Glycerini      ) 

Aquic  ham  am  did  is f,5J; 


Zinci  oxidi . . 


siy, 

.  .q.  s.  ad  13  vj.- 


If  an  eczema  or  a  dermatitis  supervene,  the  condition  should 
be  treated  according  to  the  principles  laid  down  in  the  treat- 
ment of  those  affections. 

CLASS  ILL    EXSUDATIONES— INFLAMMATIONS 
ERYTHEMA  EXSUDATIVUM 

As  has  been  remarked,  the  line  of  demarcation  between  a 
congestive  erythema  and  an  inflammatory  or  exudative  ery- 
thema cannot  always  be  discerned ;  nevertheless,  the  separation 
of  these  groups  is  convenient  for  didactic  purposes.  Erythema 
exsudativum  comprises  a  group  of  diseases  characterized  by  an 
acute,  short  course,  multiformity  of  lesions,  as  a  rule,  and 
tendency  to  recurrence.  In  this  group  are  to  be  included 
erythema  multiforme,  erythema  nodosum,  erythema  scarla- 
tinoides,  the  exanthems  of  the  acute  eruptive  fevers,  and  the 
various  accidental  rashes  accompanying  such  diseases  as  sep- 
ticemia, Bright's  disease,  etc. 

ERYTHEMA  MULTIFORME 

Synonym.--  Erythema  exsudativum  multiforme. 

Definition. — Erythema  multiforme  is  an  inflammatory 
disease  characterized  by  variously  sized  and  shaped  patches  of 
erythema,  papules,  vesicles,  or  blebs,  one  type  of  lesion,  as  a 
rule,  predominating.  The  disease  runs  an  acute  course  and 
is  occasionally  accompanied  by  constitutional  disturbance  of 
mild  degree. 

Symptoms. — The  disease  is  preceded  or  accompanied,  in  a 
certain  proportion  of  cases,  by  mild  febrile  disturbances, 
malaise,  and  rheumatoid  pains.  The  eruption,  which  comes 
out  more  or  less  suddenly,  may  consist  c  " 
papules,  papules,  tubercles,  vesicles,  blebs,  c 


32 


DISEASES    OF   THE    SKIN 


rhages,  one  type  of  lesion,  as  a  rule,  predominating.  Any 
part  of  the  body  may  be  involved,  although  the  disease  exhibits 
a  pronounced  predilection  for  the  extensor  surfaces  of  the  hands, 
feet,  legs,  and  arms.  The  face  and  neck  not  infrequently  are 
attacked.  At  times  the  mucous  surfaces  of  the  eyelids,  nose, 
mouth,  and  throat  become  involved.  I  recall  a  young  colored 
man  in  whom,  in  five  periodic  attacks,  the  mucous  surfaces 
mentioned  and  the  hands  were  the  seat  of  an  extensive  bullous 
outbreak.  The  lesions  are  at  first  pinkish  or  bright  red,  but 
later  acquire  a  characteristic  bluish-red  or  violaceous  tint. 

According  as  one  or  another  type  of  lesion  predominates, 
different  designations  are  employed.  The  commonest  form 
{erythema  papulatum)  is  characterized  by  pin-head-  to  split- 
pea-sized,  obtuse  papules.     At  times  the  lesions  are  maculo- 


— Erylhi 


papular,  with  clear  centers  producing  ring-shaped  patches 
(erythema  annulare  or  erythema  circinatum).  It  is  not  rare 
to  see  small,  ring-shaped  patches  of  a  bluish-red  color  with  a 
slight  central  crusting  representing  an  abortive  vesicle.  When 
nodules  or  tubercles  are  present,  the  type  is  called  erythema 
tuberculatum. 

Erythema  marginatum  is  that  variety  characterized  by  patches 
of  erythema  with  sharply  defined  borders  and  central  fading  of 
the  redness.  Concentric  rings  of  varying  coloration,  from 
purple  to  pink,  constitute  the  type  called  erythema  iris. 


ERYTHEMA   MULTIFORME 


33 


Erythema  or  herpes  iris  was  formerly  regarded  as  a  separate 
affection;  it  is  now  generally  recognized  as  one  of  the  varieties 
of  erythema  multiforme.  In  this  form,  instead  of  the  con- 
centric erythematous  rings  seen  in  erythema  iris,  concentric 
rings  made  up  of  vesicles  or  blebs  occur.  Upon  the  reddened 
areola  surrounding  a  papule  or  vesicle  a  circle  of  vesicles 
develops;  beyond  this  a  second  ring  of  vesicles  may  appear,  and 
later  a  third,  or  even  a  fourth.  Wilson  saw  a  case  in  which 
seven    distinct    circles    were    present.     The    central    portions 


undergo  involution  as  the  patch  spreads  upon  the  periphery. 
As  a  result,  gradations  of  color  are  noted — from  a  central  purple 
to  a  vivid  redness  upon  the  periphery — thus  giving  rise  to  the 
name  iris. 

Mention  might  here  be  made  of  a  rare  affection  called  ery- 
thema Persians,  although  it  is  not  proved  that  it  is  a  variety  of 
erythema  multiforme.  In  this  condition  patches  of  erythema, 
usually  assuming  a  circinate  or  gyrate  configuration,  are  pres- 
ent, and  persist  without  much  change  for  a  period  of  months. 

Various  types  of  lesions  are  seen  in 


34 


DISEASES  OF  THE  SKIN 


multiforme ;  it  is  not  rare  to  note  a  papular  eruption  upon  the 
hands,  with  a  tendency  to  vesiculation  upon  the  ears  and  neck. 
The  subjective  symptoms  are  rarely  troublesome,  except  in  those 
cases  in  which  an  urticarial  element  is  present,  when  burning 
and  itching  may  be  quite  severe. 

Osier  has  recently  published  several  interesting  communica- 
tions upon  the  visceral  manifestations  associated  with  erythema 
multiforme.     In  many  of  these  cases  he  regards  the  cutaneous 


buttocks.     Cured  by 


eniptions  as  merely  conspicuous  manifestations  of  an  internal 
disorder.  He  has  observed  alarming  symptoms  referable  in 
different  cases  to  the  gastro-intestinal  tract,  kidneys,  brain, 
lungs,  or  joints.  The  same  cause  may  produce  in  a  patient  an 
erythema  multiforme  at  one  time,  and  during  a  subsequent 
attack  urticaria,  angioneurotic  edema,  or  purpura.  There  is 
unquestionably  a  close  family  relation  between  these  various 
cutaneous  manifestations. 

We  occasionally  observe  patients  who  suffer  from  recurrent 
attacks  of  erythema  multiforme.  In  some  instances  there  may 
be  periodic  outbreaks  at  regular  intervals. 

The  duration  of  erythema  multiforme  is  ordinarily  between 
ten  days  and  four  weeks. 


ERYTHEMA  MULTIFORME  35 

Etiology. — The  disorder  occurs  most  frequently  in  youth 
and  early  adult  life.  Most  cases  are  observed  in  spring  and 
autumn. 

Many  authors  allege  a  relationship  between  erythema  mul- 
tiforme and  rheumatism.  It  appears  that  the  evidence  is  very 
slight  upon  which  to  base  the  assumption  that  the  associated 
joint  pains  are  true  rheumatism.  Articular  pains  and  swellings 
are  not  uncommon  in  connection  with  the  eruptions  (of  the 
erythema  multiforme  group)  that  follow  the  use  of  antitoxic 
sera,  and  in  these,  true  rheumatic  complications  cannot  possibly 
be  suggested. 

In  a  general  way  it  may  be  said  that  all  or  nearly  all  cases  of 
erythema  multiforme  are  due  to  the  circulation  in  the  blood  of 
a  poison;  the  poison  may  be  introduced  from  without,  or  it  may 
be  generated  within  the  body  (autotoxic).  Among  the  poisons 
from  without  may  be  mentioned  drugs,  food-stuffs,  accidental 
microbic  infection,  etc.  Quinin,  arsenic,  belladonna,  salicylic 
acid,  etc.,  are  known  to  have  caused  erythemata  of  the  multi- 
form variety.  Ptomains,  introduced  in  certain  food-stuffs, 
are  often  responsible  for  outbreaks  of  this  affection.  Tissue 
poisons,  generated  in  the  various  viscera  and  due  to  functional 
or  organic  disease,  are  probably  much  more  commonly  causa- 
tive than  has  been  thought. 

Pathology. — The  toxins  or  poisons  above  referred  to,  no 
matter  what  their  nature  or  origin,  circulate  in  the  blood  and 
act  upon  nerve-centers  and  perhaps  also  upon  the  blood-vessels, 
and  cause  the  various  clinical  phenomena.  The  affection  is 
regarded  by  many  as  an  angioneurosis. 

Microscopic  examination  of  the  skin  reveals  nothing  dis- 
tinctive of  the  disease.  The  affection,  according  to  the  type  ex- 
amined, exhibits  hyperemia  of  the  cutaneous  blood-vessels,  cell- 
exudation  into  the  corium  and  subcutaneous  tissue,  and,  at  times, 
transudation  of  serum,  producing  vesicles,  blebs,  or  edema. 

Diagnosis. — Erythema  multiforme  may  be  distinguished 
from  urticaria  by  the  greater  persistence  of  the  lesions,  the 
occurrence  of  bluish-red  papules,  the  predilection  for  certain 
regions,  the  absence  of  distinct  wheals,  and  the  very  moderate 
grade  of  the  subjective  symptoms. 

Measles  and  rubella  may  be  simulated  at  times,  but  should 
be  readily  differentiated. 

Bullous  erythema  must  be  distinguished  from  dermatitis 
herpetiformis  and  pemphigus. 


36  DISEASES  OP  THE   SKIN 

Prognosis. — The  prognosis  is  nearly  always  favorable,  the 
eruption  disappearing  in  from  one  to  four  weeks.  Periodic 
recurrences  are  not  rare.  When  the  eruption  is  the  expression 
of  some  serious  underlying  systemic  disturbance,  the  latter 
condition  may  lend  gravity  to  the  disease. 

Treatment. — Erythema  multiforme  is  a  self-limited  affection, 
the  eruption  disappearing  in  one  to  several  weeks  in  the  vast 
majority  of  cases.  As  the  disease  is  nearly  always  due  to  a 
poison  introduced  from  without  or  elaborated  within  the  sys- 
tem, stimulation  of  the  various  emunctories  is  desirable.  When 
intestinal  autoinfection  is  suspected,  calomel  should  be  admin- 
istered and  followed  by  a  saline  purge.  Many  authors  advise 
the  use  of  such  intestinal  antiseptics  as  salol,  phenacetin,  etc. 
Calomel,  by  promoting  a  flow  of  bile  into  the  intestines,  appears 
to  be  a  superior  antiseptic. 

Every  effort  should  be  made  to  determine  the  cause  of 
recurrent  attacks,  with  a  view  to  preventing  them.  The  nature 
of  these  will  often  be  found  to  be  obscure  and  their  prevention 
difficult. 

Local  treatment  is  of  but  little  importance,  and  is  confined 
to  the  use  of  sedative  and  antipruritic  lotions.  The  following 
will  be  found  useful: 

H .    Resorcin 3j; 

Acidi  borici 31 ; 

Glycerini f^j; 

Zinci  oxidi zij ; 

Spirit,  vini  rect 13  j; 

Aquae q.  s.  ad  f  ^ij. — M 

Sic. — Apply  frequently. 

ERYTHEMA   NODOSUM 

Synonym. — Dermatitis  contusiformis. 

Definition. — Erythema  nodosum  is  an  acute  inflammatory 
disease  of  the  skin,  characterized  by  the  formation  of  roundish 
or  oval  node-like  swellings  occupying  chiefly  the  tibial  regions. 
This  affection  is  classified  by  some  authors  as  a  variety  of 
erythema  multiforme. 

Symptoms. — The  disease  is  usually  ushered  in  with  fever, 
articular  pains,  malaise,  and  coated  tongue.  Soon  roundish 
or  oval  node-like  swellings,  varying  in  size  from  a  hazel-nut  to 
an  egg,  develop  over  the  region  of  the  tibiae.  In  some  cases 
the  forearms,  trunk,  and,  more  rarely,  the  face  are  involved. 
The  nodes  are  rosy  red  in  color,  tense  and  shining,  like  erysipelas, 


ERYTHEMA  NODOSUM  37 

and  exquisitely  tender  to  the  touch.  At  first  hard,  they  later 
soften,  but  never  suppurate.  Their  duration  is  from  a  week  to 
ten  days,  during  which  time  they  undergo  all  the  color  grada- 
tions observed  in  common  contusions.  In  number  they  vary 
from  about  five  to  twenty.  Erythema  nodosum  is  frequently 
associated  with  other  forms  of    rythema  multiforme. 

Etiology. — The  affection  is  largely  observed  in  youth  and 
early  adult  life.  It  is  uncommon  after  the  age  of  thirty.  It  is 
met  with  two  to  five  times  as  frequently  in  females  as  in  males. 
Rheumatism,  gastro-intestinal  disorders,  and  general  nutritive 
disturbances  are  not  infrequently  associated.  S.  Mackenzie, 
from  a  study  of  108  collected  cases,  concluded  that  erythema 
nodosum  is  frequently,  if  not  generally,  an  expression  of  rheu- 
matism, even  when  no  definite  rheumatic  symptoms  are  present. 
Harrison,  who  personally  observed  80  cases  of  erythema 
nodosum  among  15,000  skin-diseases,  denies  its  relationship  to 
rheumatism. 

That  this  cutaneous  manifestation  is  a  genuine  rheumatic 
process  there  is,  in  my  opinion,  grave  reason  to  doubt.  I 
believe  that  erythema  nodosum  is  a  toxic  affection,  and,  like 
erythema  multiforme,  may  be  produced  by  a  variety  of  poisons. 
The  rheumatic  infection  constitutes  one  of  the  most  frequent 
poisons  capable  of  producing  the  disease. 

Erythema  nodosum  occurs  occasionally  in  the  course  of 
syphilis,  tuberculosis,  glandular  fever,  diphtheria,  malaria,  and 
is  believed  to  be  induced  at  times  by  digestive  disorders, 
autointoxication,  bad  sanitation,  and  such  drugs  as  iodids  and 
antipyrin.  I  have  observed  a  case  of  erythema  nodosum 
during  the  secondary  period  of  syphilis. 

Pathology. — The  nodes  show  serous  exudation  throughout 
the  entire  cutis,  and  even  the  subcutaneous  tissue.  There  is 
dilatation  of  the  blood-vessels  and  the  lymph-spaces,  and  some 
cell-infiltration.     Blood-pigment  from  hemorrhages  is  present. 

Diagnosis. — The  distribution,  tenderness,  symmetry,  course, 
and  color  changes  of  the  lesions  enable  one  to  differentiate  the 
affection  from  bruise,  abscess,  gumma,  and  erythema  induratum. 

Prognosis. — Favorable,  recovery  ensuing  in  from  two  to 
six  weeks.     Recurrences  are  comparatively  rare. 

Treatment. — The  bowels  should  be  kept  freely  open. 
Sodium  salicylate  commonly  gives  relief  from  the  associated 
joint  pains.  Locally,  lead-water  and  laudanum  applications, 
with  rest  and  elevation  of  the  limbs,  gfr 


DISEASES  OF  THE   SKIN 


ERYTHEMA  SCARLATINOIDES 

Definition.— Scarlatiniform    erythema    is    the    cutaneous 

expression  of  a  non-contagious  disorder  resembling  true  scarla- 


Hg.   io.-S. 


tina  in  its  surface  manifestations,  but  running  a  quite  differenl 
course. 

Symptoms.' — The  condition  comes  on  suddenly,  and  is  often 
attended  with  malaise,  chill,  and  a  temperature  varying  from 


ERYTHEMA  SCARLAT1NOIDES  39 

ioo°  to  1030  F.  The  eruption  is  either  punctiform  or  diffuse, 
and  may  begin  on  any  portion  of  the  body.  The  eruption  is 
often  partial,  not  involving  the  trunk  in  its  entirety;  patches 
of  redness  with  marginated  borders  are  sometimes  seen.  The 
face  is  often  free  of  eruption ;  at  other  times  intensely  involved. 
The  duration  of  the  eruption  varies  according  to  its  intensity. 
Desquamation  begins  early — about  the  third  or  fourth  day— 
and  may  be  either  furfuraceous  or  lamellar. 


Schamberg). 


In  the  type  designated  by  the  French  '  'erythema  scarla- 
tiniforme  desquamativum  "  the  symptoms  are,  as  a  rule,  more 
severe  and  the  eruption  more  intense.  The  rash  ordinarily 
lasts  from  one  to  six  days.  The  resulting  desquamation  is 
most  profuse,  leading  often  to  the  throwing  off  of  epidermal 
casts  of  the  hands  and  feet.  The  hair  and  nails  are  occasionally 
shed.  This  type  of  the  disease  is  extremely  apt  to  recur  from 
time  to  time — not  infrequently  at  periodic  intervals.  A  patient, 
twenty-nine  years  of  age,  who  consulted  me  during  an  attack, 
gave  the  history  that  he  had  had  two  outbreaks  each  year  since 
the  first  year  of  his  life.     Some  of  the  multiple  attacks  of 


4Q 


DISEASES  OP  THE  SKIN 


scarlet  fever  recorded  by  the  older  writers  should  doubtless  be 
included  under  this  head. 

Etiology. — The  etiology  is  obscure.  Idiosyncrasy  plays  a 
most  important  r61e.  Scarlatinoid  erythema  is  apt  to  super- 
vene during  the  course  of  other  diseases,  chief  among  which 
may  be  mentioned  rheumatism,  pyemia,  septicemia,  malaria, 
peritonitis,  ptomainpoisoning,  small-pox,  typhoid  fever,  diph- 
theria, etc.  Rashes  of  this  character  may  occur  in  the  preemp- 
tive period  of  varicella  and  measles.  The  affection  is  less 
common  since  the  introduction  of  antisepsis.  A  scarlatiniform 
erythema  may  follow  at  times  the  ingestion  of  drugs,  par- 
ticularly quinin,  but  also  salicylates,  veronal,  mercury,  opium, 
antipyrin,  copaiba,  belladonna,  etc.  It  may  also  appear  after 
the  use  upon  the  skin  of  such  external  applications  as  the 
unguentum  hydrargyri,  iodoform,  etc. 

Diagnosis. — It  is  extremely  important  to  differentiate  this 
disease  from  scarlatina. 


Scarlatiniform  Erythema. 

i.  Onset  with  constitutional  symp- 
toms, which  are  usually  very 
mild  compared  with  intensity 
of  eruption. 

2.  Eruption  frequently  not  gener- 

alized; erythema  at  times  mar- 
ginated. 

3.  Face  either  exempt  or  more  in- 

volved than  in  scarlet  fever. 

4.  Tongue  may  be  quite  normal. 

5.  Fauces  may  be  reddened. 

6.  Desquamation   may   be   intense 

but  terminates  comparatively 
early. 

7.  Frequent    history    of    previous 

attacks. 

8.  Not  contagious. 


Scarlet  Fever. 

1.  Onset    with    more    severe    con- 

stitutional   disturbances,    and 
commonly     with     vomiting. 

2.  Eruption    punctate,   generalized 

and  not  marginated,   save  at 
times  on  arms. 

3.  Face   frequently   exhibits   erup- 

tion.     Cheeks  deeply  flushed, 
with  circumoral  pallor. 

4.  Tongue  coated,  edges  red,  pap- 

illa? enlarged. 

5.  Fauces  swollen,  tonsils  enlarged 
and  often  coated  with  thin, 
yellowish  exudate. 

6.  Desquamation     may     continue 

from  four  to  ten  weeks. 

7.  Second    and    third    attacks    of 

genuine  scarlet  fever  are  rare. 

8.  Frequently  history  of  contagion. 


Prognosis. — Favorable.     Recurrences  are  frequent. 

Treatment. — For  the  eruption,  simple  dusting-powders  or 
starch  or  bran  baths  may  be  used,  followed  by  a  mild  emollient 
ointment.  The  underlying  condition  must  be  ascertained  and 
treated.     A  saline  purge  is  usually  indicated  at  the  outset. 


ERYTHEMA   ELEVATUM  DIUTINUM  4 1 

ERYTHEMA  INDURATUM 
Synonym. — Erytheme  indurl  des  scrofuleux  (Bazin). 

Definition. — Erythema  induratum  is  an  inflammatory 
affection  occurring  in  scrofulous  individuals,  characterized  by 
circumscribed,  purplish-red  nodular  infiltrations  of  the  skin, 
particularly  involving  the  legs  and  disappearing  either  by- 
absorption  or  necrosis. 

Symptoms. — Strumous  girls  and  young  women  are  most 
liable  to  the  disease.  It  may,  however,  occur  in  boys,  and 
occasionally  in  elderly  subjects.  The  affection  is  most  fre- 
quent in  winter,  and  attacks  individuals  who  suffer  from  cold 
hands  and  feet.  Overwork  and  prolonged  standing  seem  to  s 
be  etiologic  factors.  The  lesions  consist  of  ill-defined,  finger- 
nail-sized or  larger,  bluish-red,  infiltrated  patches  involving  by 
predilection  the  calves  of  the  legs.  The  infiltrations  can  often 
be  better  felt  than  seen.  In  rare  cases  the  thighs  or  upper 
extremities  may  be  attacked.  As  a  rule,  but  one  or  two  patches 
are  present.  Pain  and  tenderness  are  generally  absent,  but 
in  some  cases  may  be  marked.  The  infiltration  may  gradually 
be  absorbed  or  may  slough,  leaving  an  indolent  ulcer.  The 
affection  is  uncommon. 

Diagnosis. — The  absence  of  systemic  disturbance  and 
tenderness,  the  long  duration,  the  relapses,  and  the  paucity  of 
lesions  distinguish  this  affection  from  erythema  nodosum.  The 
subjects  may  present  other  signs  of  the  tuberculous  diathesis. 

Prognosis. — The  affection  may  persist  for  a  long  time. 
Even  after  apparent  cure,  relapses  are  prone  to  occur. 

Treatment. — The  treatment  leaves  much  to  be  desired. 
Cod-liver  oil,  tonics,  good  food,  and  prolonged  rest  with  eleva- 
tion of  the  legs  are  the  chief  therapeutic  measures.  When  the 
patient  is  upon  her  feet,  a  well-applied  bandage  should  be  worn. 

ERYTHEMA  ELEVATUM  DIUTINUM 

In  1894  Campbell,  Williams,  and  Crocker  proposed  the  above 
designation  for  a  rare  disease  characterized  by  small,  pea-  to 
bean-sized  painless  nodules,  at  first  pinkish  in  color,  but  later 
acquiring  a  purplish  tinge.  The  lesions  are  convex  in  the 
beginning,  with  a  tendency  to  form  raised  plaques  or  irregular- 
lobed   infiltrations   by   coalescence.     In   severe   cases   actual 


42  DISEASES  OP  THE  SKIN 

nodular  tumors  may  form.  The  parts  usually  affected  are  the 
extensor  surfaces  of  the  limbs,  particularly  over  the  joints, 
elbows,  knees,  fingers  and  toes.  They  may  also  be  present 
upon  the  palms,  soles,  buttocks,  and  ears.  The  lesions  are 
firm  to  the  touch,  and  usually  persist  for  a  long  time.  In  some 
cases,  however,  they  undergo  involution.  Nearly  all  the  cases 
reported  have  been  female  children  or  young  female  adults. 
Gout  and  rheumatism  are  regarded  as  factors  in  the  etiology 
of  the  disease. 

Pathologically,  the  lesions  appear  to  be  fibromata  of 
inflammatory  origin. 

The  treatment  is  unsatisfactory.  One  case  recovered  while 
taking  arsenic  internally  and  using  locally  the  liquor  carbonis 
detergens. 

PELLAGRA 

Derivation. — L.,  pcllis,  skin;  ceger,  diseased,  or  agra,  rough. 

Definition. — Pellagra  is  an  endemic,  constitutional  disease, 
characterized  by  symptoms  affecting  the  alimentary,  nervous, 
and  cutaneous  systems,  and  not  infrequently  terminating 
fatally. 

The  disease  was  first  described  by  the  Spanish  physician, 
Casal,  in  1735.  The  disease  is  common  in  Italy,  Spain,  Egypt, 
and  the  provinces  of  southern  Europe.  Within  recent  years  a 
considerable  number  of  cases  have  been  observed  in  the  United 
States,  particularly  in  the  Gulf  States. 

Symptoms. — Prior  to  the  onset  of  characteristic  symptoms, 
patients  may  complain  for  quite  a  time  of  lassitude,  vertigo, 
epigastric  pain,  loss  of  appetite,  diarrhea,  headache,  and,  at 
times,  vomiting.  These  usually  occur  in  the  early  spring,  and 
are  followed  rather  suddenly  by  the  appearance  of  the  skin  mani- 
festations. The  eruption  develops  upon  those  areas  exposed 
to  the  sun's  rays — namely,  the  face,  neck,  hands,  and,  at  times, 
the  feet.  The  "  pellagrous  collar,' '  one  of  the  characteristic 
cutaneous  features,  corresponds  to  the  area  exposed  to  light,  and 
is  limited  by  the  upper  border  of  the  shirt. 

The  backs  of  the  hands  exhibit  the  most  common  expression 
of  the  disease.  Here  there  is  seen  a  dull  red  erythema  or 
sunburn,  which  gradually  deepens  to  a  brownish  red  and 
finally  eventuates  in  a  brownish  pigmentation.  In  the  begin- 
ning the  skin  is  tense,  swollen,  and  the  seat  of  burning.  Vesicles 
and  blebs  may  at  times  be  present.     The  eruptive  phenomena 


PELLAGRA  43 

subside  in  a  fortnight,  leaving  the  skin  pigmented,  roughened, 
and  desquamating.  Ultimately  atrophic  thinning  of  the  skin 
takes  place.  A  conspicuous  and  highly  characteristic  feature 
of  the  erythema  and  subsequent  pigmentation  is  the  sharp 
margi nation  of  the  upper  border  upon  the  wrist  or  forearm, 
producing  the  so-called  "  pellagrous  glove."  The  feet  are  in 
some  cases  involved,  and  a  "  pellagrous  boot  "  has  been  des- 


<e  {patient  of  Dr.  Clan  Fitzgerald). 


cribed.  More  rarely  other  portions  of  the  cutaneous  surface 
may  be  the  seat  of  the  eruption. 

The  nervous  symptoms  consist  of  spinal  tenderness,  exagger- 
ated reflexes,  mental  depression,  often  ending  in  melancholia, 
psychic  irritability,  convulsions,  stupor,  hallucinations,  etc. 
Pellagrous  insanity  is  usually  of  the  depressive  type. 

The  gastrointestinal  symptoms,  which  may  develop  at  any 
stage,  consist  of  a  reddened  tongue,  with  prominence  of   the 


DISEASES  OP  THE  SKIN 


papilla,  salivation,  stomatitis,  intense  thirst,  and  severe  and 
intractable  diarrhea. 

The  disease  is  apt  to  undergo  exacerbations  in  the  spring 
and  fall,  increasing  in  severity  with  the  recurring  seasons.  In 
the  interim  there  is  often  an  abatement  of  the  symptoms. 

In  the  final  stage,  when  prostration,  emaciation,  stupor,  and 
low  delirium.set  in,  a  condition  resembling  typhus  is  developed, 


Fig-  T( 


(patient  of  Dr.  Clara  Fitmerald). 


and  the  terra  "  typhus  pellagrosus  "  has  been  applied  to  this 
state.  Pellagra  is  usually  afebrile,  but  in  the  acute  or  terminal 
stages  fever  may  be  present. 

Etiology  and  Pathology. — The  cause  of  pellagra  is  unknown. 
It  was  for  a  long  time  believed  to  be  due  to  the  ingestion  of 
diseased  maize  or  corn,  but  this  theory  is  by  no  means  proved. 


ACRODYNIA  45 

and  there  are  many  observers  who  do  not  subscribe  to  this 
doctrine.  The  subjects  are  largely  poverty  striken,  poorly 
nourished,  and  living  under  bad  hygienic  conditions,  although 
isolated  cases  among  the  affluent  are  not  unknown.  Some  writ- 
ers regard  pellagra  as  a  symptom-complex,  rather  than  a  disease 
entity.  Amebae  have  been  found  in  the  stools  of  many  of  the 
patients  in  this  country.  The  poison  of  the  disease  appears 
to  sensitize  the  skin  to  the  action  of  the  chemic  rays  of  light. 

At  autopsy  various  tracts  of  the  spinal  cord  have  at  times 
been  found  to  be  degenerated;  pachymeningitis  and  sclerosis 
of  the  brain  have  also  been  noted.  Most  patients  are  between 
twenty  and  fifty  years  of  age. 

Diagnosis. — The  most  characteristic  symptoms  of  pellagra 
are  indicated  by  the  alliterative  formula — the  three  d's — derm- 
atitis, diarrhea,  and  depression.  The  concurrence  of  a  sun 
erythema  of  the  face  and  hands,  of  the  character  previously 
described,  with  disturbances  of  the  digestive  tract  and  nervous 
system,  should  cause  one  to  suspect  this  disease.  Poorly 
marked  cases  may  present  difficulties  and  require  observation. 

Prognosis. — Mild  cases  often  recover  under  appropriate 
hygienic  treatment.  Severe  or  advanced  cases  are  incurable, 
and  usually  fatal  in  five  years  or  less.  Moderately  mild  cases 
may  live  for  a  much  longer  period. 

Treatment. — Good  food  and  proper  hygienic  surroundings 
appear  to  be  the  most  important  therapeutic  considerations. 
Arsenic,  iron,  and  tonics  have  been  advised. 

ACRODYNIA 

Synonym. — Epidemic  erythema. 

Definition. — Acrodynia  is  an  acute  epidemic  disease,  charac- 
terized by  an  erythematous  eruption,  thickening,  desquamation, 
and  pigmentation  of  the  skin,  and  disorders  of  the  nervous 
system.  The  disease  first  occurred  in  Paris  about  1830,  when 
almost  forty  thousand  persons  were  attacked. 

Symptoms. — The  salient  features  of  the  affection  are: 
gastro-intestinal  irritation,  conjunctival  injection,  edema  of  the 
face,  erythematous  eruption  upon  the  hands  and  feet,  thicken- 
ing, desquamation,  and  pigmentation  of  the  skin,  and  sensory 
disturbances  (pain,  hyperesthesia,  anesthesia,  etc.).  Cramps, 
spasms,  and  tetanic  contractures  are  also  common. 

Etiology. — The  disease  is  probably  caused  by  the  action  of 


46  DISEASES   OP  THE   SKIN 

some  toxic  substance  upon  the  central  nervous  system.  It  is 
somewhat  related  to  pellagra. 

Prognosis. — Favorable,  most  cases  recovering  in  a  few 
weeks  to  a  few  months. 

Treatment. — To  be  based  upon  general  principles.  Brocq 
advises  counterirritation  to  the  spine. 

URTICARIA 

Derivation. — L.,  urtica,  a  nettle.     Synonyms. — Hives;  Nettle-rash. 

Definition. — Urticaria  is  an  inflammatory  affection  of  the 
skin,  characterized  by  the  formation  of  evanescent  whitish  and 
pinkish  elevations  of  an  edematous  nature,  attended  by  intense 
itching. 

Symptoms. — The  eruption  appears  suddenly,  manifesting 
itself  as  firm,  circumscribed,  whitish  or  pinkish  elevations 
(wheals,  pomphi)  with  reddish  areolae.  The  wheals  last  from 
a  few  minutes  to  several  hours,  disappear,  and  are  succeeded 
by  others.  They  are  asymmetric,  though  usually  bilateral, 
of  pea  or  bean  size,  and  irregular  in  shape,  often,  however,  being 
linear.  They  may  involve  any  portion  of  the  cutaneous  sur- 
face, or  even  the  mucous  membranes.  When  the  pharynx  or 
larynx  is  involved,  alarming  suffocative  attacks  may  occur. 
The  lesions  mav  be  few  in  number  or  mav  cover  almost  the 
entire  surface  of  the  body. 

The  itching  in  urticaria  is  intense,  the  relief  produced  by 
scratching  being  purchased  at  the  cost  of  the  excitation  of  new 
lesions.  The  skin  is  markedly  sensitive  to  all  sorts  of  irritation, 
and  responds  by  the  production  of  wheals.  The  artificial 
production  of  wheals  gives  rise  to  the  form  termed  urticaria 
factitia.  In  some  urticarial  subjects  one  can  inscribe  a  name 
upon  the  skin  with  a  pointed  instrument,  and  in  a  few  minutes 
observe  the  letters  stand  out  in  wheals  as  if  embossed.  To 
this  phenomenon  the  term  dermographism  is  given.  Such  a 
reaction  may  also  be  provoked,  at  times,  in  those  who  may  not 
be  the  subjects  of  spontaneous  urticarial  outbreaks. 

In  children  urticaria  is  apt  to  take  the  papular  form — 
urticaria  papulosa  (tichen  urticatus).  In  such  cases  there  are 
hard,  skin-tinted  inflammatory  papules  present,  with  a  reddish, 
edematous  areola;  the  areolae  later  disappear,  but  the  papules 
persist.  The  summits  of  the  papules  are  apt  to  be  excoriated 
on  account  of  the  scratching  pr6mpted  by  the  intolerable  itching. 

When  papules  are  present  upon  the  hands,  the  disease  bears 


URTICARIA 


47 


a  considerable  resemblance  to  scabies.  Papular  urticaria  is 
often  rebellious  in  its  response  to  treatment,  particularly  in 
cases  in  which  it  is  impossible  to  control  the  diet  of  the  child. 

In  some  individuals  wheals  attain  the  size  of  an  egg  or  even 
larger.  This  form  is  called  urticaria  tuber osa  or  urticaria 
gigans  (giant  urticaria).  Hemorrhage  into  the  wheal  occurs 
occasionally,  giving  rise  to  the  form  known  as  urticaria  hemor- 
rhagica. At  times  the  upper  layers  of  the  wheal  are  raised 
into  a  bleb  by  the  subjacent  serum:  this  type  is  designated 
urticaria  bullosa. 

Wheals  or  *vheal-Iike  lesions  which  tend  to  persist,  as  they 


Fig.  14.— Dermalographism  (urticaria  faclilia). 


occasionally  do,  for  some  days  or  weeks,  have  given  rise  to  the 
type  designated  urticaria  perstans. 

Urticaria,  as  a  rule,  runs  an  acute  course,  subsiding  in  a  few 
days  to  a  week.  In  many  cases  the  attack  lasts  but  twenty- 
four  hours.  In  exceptional  instances,  however,  urticaria  may 
become  chronic,  wheals  appearing,  disappearing,  and  reappear- 
ing, the  process  extending  over  a  period  of  months  or  even  years. 

Etiology. — The  great  majority  of  cases  of  acute  urticaria 
are  produced  through  some  disorder  of  the  alimentary  tract. 
Substances  taken  into  the  stomach  may  cause  urticaria,  either 


48  DISEASES  OP  THE  SKIN 

by  a  mechanical  irritation  of  the  stomach  or  bowel  or  by 
producing  a  toxemia.  Intestinal  parasites  and  undigested 
aliment  act  by  mechanical  irritation.  The  substances  capable 
of  producing  toxemia  are  almost  numberless.  They  may  be 
primarily  toxic,  or  may  develop  their  toxicity  through  putre- 
factive changes  while  in  the  bowel.  Again,  a  large  number  of 
substances,  both  food  and  drugs,  perfectly  innocuous  to  the 
ordinary  individual,  act  as  poisons  to  others.  The  following 
articles  of  food  are  apt  to  produce  hives :  lobsters,  crabs,  mus- 
sels, cheese,  sausage,  pork,  nuts,  strawberries,  oatmeal,  mush- 
rooms, caviar,  shrimps,  salted  fish,  clams,  oysters,  scrapple, 
veal,  grape-skins,  etc. 

The  following  drugs  are  prone  to  produce  urticarial  eruptions : 
quinin,  copaiba,  cubebs,  salicylic  acid,  morphin,  turpentine, 
chloral,  valerian,  arsenic,  glycerin,  and  many  of  the  coal-tar 
products.  Antitoxic  sera,  such  as  those  used  in  diphtheria, 
tetanus,  streptococcus  infection,  etc.,  commonly  induce 
an  urticarial  eruption.  Urticaria  may  be  produced  reflexly 
also  by  irritation  of  viscera  other  than  the  alimentary  tract. 
Thus,  irritation  of  the  uterus  and  adnexa  may  act  as  an  etio- 
logic  factor.  Rupture  or  puncture  of  hydatid  cysts  or  puncture 
of  pleural  effusions  may  be  followed  by  hives.  Again,  the 
disease  may  be  produced  by  direct  local  irritation,  such  as  the 
sting  of  a  nettle,  the  bite  of  the  jelly-fish,  mosquito,  wasp,  etc. 
Among  the  causes  of  chronic  urticaria  may  be  prominently 
mentioned  gastro-intestinal  disorders,  neurasthenia  in  its  va- 
rious forms,  and  renal  disease. 

Pathology. — The  wheal  is  produced  as  the  result  of  direct 
or  reflex  disturbance  of  the  vasomotor  apparatus.  The  lesion 
consists  of  a  circumscribed  edema  of  the  cutis.  A  momentary 
spasm  of  the  cutaneous  vessels  is  followed  by  a  dilatation,  with 
exudation  of  serum  and  some  leukocytes.  At  the  summit  of 
the  lesion  the  effusion  is  so  great  as  to  produce  a  pressure  anemia, 
hence  the  whitish  coloration.  The  peripheral  vessels  are 
engorged,  hence  the  reddish  areola.  The  lesions  are  remark- 
able for  the  rapidity  of  the  evolution  and  involution  of  the 
inflammatory  processes  that  take  place  in  them.  According 
to  Gilchrist,  wheals  artificially  produced  show  within  a  few 
minutes  cellular  extravasation  into  the  tissues  and  other  evi- 
dences of  inflammation. 

Urticaria  is  regarded  by  many  as  an  angioneurosis,   but 


URTICARIA  49 

Phillipson,  Torok,  Hari,  and  others  dissent  from  this  view 
and  conclude,  from  numerous  experiments,  that  the  lesions  are 
due  to  the  action  of  irritants  upon  the  blood-vessel  walls. 

Wright  and  Paramore,  as  a  result  of  their  researches,  believe 
that  an  attack  of  urticaria  may  result  from  a  defective  coagu- 
lability of  the  blood,  due  to  the  lessening  of  lime  salts. 

Diagnosis. — Urticaria  is  usually  distinguished  without 
difficulty.  The  presence  of  wheals,  their  rapid  evolution  and 
brief  duration,  and  the  intense  itching  enable  one  to  rapidly 
establish  the  diagnosis.  Urticarial  lesions  are  often  produced 
by  various  parasites  and  insects,  such  as  bedbugs,  fleas,  etc. 
In  this  case  a  central  punctiform  hemorrhage  or  blood-crust  is 
often  seen.  Urticaria  papulosa  is  often  erroneously  diagnosed, 
particularly  when  nothing  remains  but  the  scratched  papules. 
Patients  sometimes  present  themselves  without  any  lesions  of 
urticaria,  but  with  the  history  of  an  evanescent  itching  eruption. 

Prognosis. — Ordinary  attacks  of  acute  urticaria  recover 
in  a  few  days ;  some  cases  may  persist  for  a  few  weeks.  Chronic 
urticaria  may  last  for  a  long  time  and  may  exhaust  the  entire 
therapeutic  armamentarium  of  the  physician. 

Treatment. — In  severe  acute  cases,  if  seen  early,  an  emetic 
may  be  given,  as  nearly  all  such  cases  are  urticaria  ab  ingestis; 
at  a  later  period  the  offending  material  may  be  removed  by 
calomel,  followed  by  the  use  of  saline  purgatives,  such  as 
Rochelle  salts  or  magnesium  sulphate.  In  subacute  cases 
salol,  phenacetin,  or  anti pyrin  in  five-grain  doses  will  often 
serve  a  useful  purpose. 

Wright  and  his  followers  advise  the  use  of  calcium  lactate 
in  a  single  dose  of  30  grains,  particularly  where  acid  fruits 
appear  to  have  brought  on  the  attack. 

In  chronic  urticaria  the  initial  object  is  to  determine  the 
cause  and  then  to  effect  the  removal  thereof.  The  patient's 
dietary  must  be  the  subject  of  careful  study.  Every  detail  of 
mode  of  life,  occupation,  environment,  habits,  as  to  exercise, 
eating,  drinking,  sleep,  etc.,  must  be  studiously  investigated. 
The  urine  should  be  carefully  examined,  and  the  functions  of 
the  various  organs  studied.  Usually  the  alimentary  canal  will 
be  found  to  be  the  fans  et  origo  malt.  Dyspepsia,  if  it  exists, 
must  be  corrected  and  the  diet  carefully  regulated ;  the  intelli- 
gence of  the  patient  will  often  aid  one  in  discovering  an  offending 
article  of  diet.  It  is  important  to  keep  the  bowels  freely  open. 
Intestinal  antiseptics  are  often  of  value;  it  is  doubtless  on  this 


> 

■  >  i  >  J         J      J       »  J  J  '      ■'     r 

•"  ,  J     J    J 

1  1  J 

J      t     > 


50  DISEASES  OP  THE  SKIN 

account  that  sulphurous  acid  has  been  found  useful.  It  is  to 
be  given  in  one-half  to  one-dram  doses  in  water  after  meals. 
Duhring  speaks  well  of  the  sodium  hyposulphite  in  ten-  to 
fifteen-grain  doses.  The  natural  Carlsbad  Sprudel  salts,  a 
teaspoonful  in  a  cup  of  hot  water  before  breakfast,  should  be 
tried  where  there  is  a  tendency  to  hepatic  sluggishness.  Crocker 
says  that  the  gouty  diathesis  is  frequently  causative,  and 
advises  the  alkalis  in  such  subjects.  I  have  known  long- 
standing cases  in  neurasthenic  subjects  to  recover  only  after 
a  protracted  rest-cure. 

In  obscure  cases  some  of  the  following  remedies  may  be 
tried:  atropin  by  mouth  or  hypodermatically,  antipyrin, 
phenacetin,  quinin,  long-continued  small  doses  of  arsenic,, 
sodium  salicylate,  bromids,  pilocarpin,  suprarenal  extract,  etc* 

Local  treatment  is  necessary  to  give  the  patient  relief  from 
the  harassing  itching.  Often  a  hot  bath  on  retiring,  containing 
a  handful  of  washing-soda,  will  give  great  comfort  to  the  patient. 
In  some  patients  a  warm  bath  will  act  better  than  one  of  higher 
temperature. 

The  patient  should  wear  undergarments  of  soft  linen,  cotton, 
or  silk.  The  best  antipruritics  are  carbolic  acid,  tar,  menthol, 
chloral,  camphor,  etc. 

The  following  lotion  will  be  found  of  great  value;  where 
excoriations  from  scratching  are  present,  it  may  prove  a  little 
too  strong,  and  may  require  dilution: 

B .    Menthol gr.  xxx ; 

Acidi  phenici f,^j ; 

Tinct.  picis  mineralis f&j~*j» 

Ext.  hamamelidis  dest f 3 j ; 

Zinci  oxidi gij ; 

Glycerini   fjjij ; 

Spirit,  vini  rect fgij ; 

Aquae  camphorae f.^ij; 

Aquae q.  s.  ad  f^viij. — M. 

In  some  patients  soft  ointments  appear  to  do  well  and  to  give 
a  longer  period  of  relief  from  itching.  The  following  combina- 
tion is  one  of  the  most  useful: 

B .    Menthol  gr.  x; 

Acidi  phenici gr.  xx; 

Adipis  benzoat 3J. — M. 


V     ~  ■-   >.    V 


-  »    •    ••       ••  • 

•'«•■.<-«.  «i  %  •    •       •   •         •••« 


URTICARIA    PIGMENTOSA  51 

URTICARIA  PIGMENTOSA 
Synonym.  — X  an  t  h  el  asm  0  i  dea . 

Definition. — Urticaria  pigmentosa  is  an  inflammatory  affec- 
tion of  the  skin  beginning  usually  in  the  first  six  months  of 
infancy,  and  characterized  by  persistent,  buff-colored,  wheal- 
like  nodules,  with  or  without  itching. 

Symptoms. — The  eruption  is  most  abundant  upon  the  neck 
and  trunk.     It  consists  of  ye  Ho  wish -red,  split-pea- sized  nodules 


or  wheals  with  pinkish  areolae.  The  nodules  later  become 
yellow,  and  may  remain  stationary  for  months  or  years.  Some 
undergo  involution,  leaving  brownish  stains  after  them.  Itching 
is  often  severe,  but  may  be  moderate  or  entirely  absent.  The 
eruption  prefers  the  trunk,  but  not  infrequently  spreads  into 
.  the  scalp  and  upon  the  extremities. 

Etiology. — All  that  can  be  said  as  to  cause  is  that  there  is 
a  strong  congenital  predisposition. 

Diagnosis. — The   affection    at    times    presents   a    striking 


52  DISEASES  OF  THE  SKIN 

resemblance  to  xanthoma  tuberosum,  but  the  onset  in  early 
infancy  and  the  occurrence  of  ordinary  wheals  will  help  to 
differentiate  it. 

Pathology. — Inflammatory  changes  similar  to  those  seen 
in  ordinary  urticaria  are  present.  A  highly  characteristic 
feature  is  the  presence  of  mast-cells  in  great  abundance  and 
arranged  in  rows  in  the  papillary  layer. 

Prognosis. — The  disease  not  infrequently  disappears  as 
the  period  of  puberty  is  reached.  Sometimes  cure  takes  place 
at  an  earlier  period,  although  the  disease  is  notoriously  obsti- 
nate to  treatment. 

Treatment. — Itching  may  be  relieved  by  the  remedies  re- 
ferred to  under  the  head  of  Urticaria.  No  internal  medication 
appears  to  exert  much  influence  upon  the  disease,  although  in 
one  of  Crocker's  cases  small  doses  of  arsenic  were  found  to  be 
helpful.  The  diet  and  the  condition  of  the  gastro-intestinal 
tract  should  be  regulated. 

ANGIONEUROTIC   EDEMA 

Synonyms. — Acute  circumscribed  edema;  Quincke's  disease;  Giant 
swelling. 

Definition. — An  affection  characterized  by  the  rapid  appear- 
ance of  circumscribed  edematous  swellings,  chiefly  attacking 
the  face  and  tending  to  disappear  after  several  hours  or  days. 

Symptoms. — The  swellings  come  on  suddenly,  developing 
often  within  the  course  of  a  few  minutes  or  hours.  Patients 
often  awake  in  the  morning  with  the  eyelid  swollen  shut  or  a 
protuberant  lip  or  ear.  Large  areas  or  the  whole  of  an  extrem- 
ity may  also  be  involved.  The  mucous  membrane  of  the 
alimentary  or  respiratory  tract  may  be  the  seat  of  edema, 
producing  in  the  latter  case  marked  suffocative  attacks. 

Itching  is  not  so  pronounced  a  symptom  as  in  urticaria. 
The  affection  is,  however,  closely  related  to  this  disease,  and, 
according  to  Osier,  is  merely  '  'an  urticaria  writ  large."  There 
is  a  pronounced  tendency  to  recurrence  of  the  attacks. 

Etiology. — Hereditary  predisposition,  digestive  disturbances, 
with  formation  of  intestinal  toxins,  and  the  causes  of  urticaria 
in  general  are  doubtless  responsible  for  most  cases. 

Treatment. — The  treatment  consists  in  the  removal  of  the 
cause  and  is  virtually  that  of  urticaria. 


ECZEMA  53 


Derivation. — En&etv,  to  boil  over.     Synonyms. — Tetter;  Salt  rheum,  etc. 

Definition. — An  acute,  subacute,  or  chronic  non-contagious 
inflammatory  disease  of  the  skin,  characterized  primarily  by 
erythema,  vesicles,  papules,  or  pustules,  and  secondarily  by 
scaling  and  crusting,  and  accompanied  by  itching  and  burning. 

Eczema  constitutes  about  30  per  cent,  of  all  skin  diseases. 
It  is  met  with  at  all  ages  and  in  all  conditions  of  life.  It  may, 
therefore,  be  said  to  be  the  most  important  of  all  dermatoses. 

Symptoms. — There  are  four  elementary  types  of  eczema: 
eczema  erythematosum,  eczema  papulosum;  eczema  vesiculo- 
sum,  and  eczema  pustulosum. 

These  terms  indicate  that  the  disease  begins  with  the  forma- 
tion of  patches  of  redness,  of  papules,  vesicles,  or  pustules. 
Often  the  peculiar  type  of  the  eruption  remains  distinctive, 
even  though  secondary  modifications  occur.  For  instance,  an 
erythematous  eczema  can  usually  be  recognized  as  such  for  a 
considerable  period  of  time.  The  papular  and  vesicular  forms 
may  preserve  their  special  characteristics  or  may  be  trans- 
formed into  one  of  the  other  forms. 

While  it  is  clinically  convenient  thus  to  classify  the  primary 
forms  of  eczema,  it  must  be  remembered  that  the  varieties 
described  cannot  be  too  trenchantly  separated.  They  are  all 
manifestations  of  the  same  morbid  process,  and  intermingled 
forms  are  quite  common.  Several  varieties  of  lesions  may 
appear  simultaneously,  or  one  form  may  quickly  eventuate 
in  another.  In  mixed  eruptions,  however,  one  type  of  lesion 
usually  predominates. 

Eczema  Erythematosum. — This  variety  of  eczema  is  encoun- 
tered most  frequently  upon  the  face,  the  arms,  and  the  genitalia, 
but  may  occur  upon  any  portion  of  the  cutaneous  surface. 
It  begins  as  vaguely  defined  bright-  or  dull-red  spots,  which 
soon  coalesce  and  form  diffuse  areas.  The  skin  is  roughened 
and  slightly  infiltrated.  When  the  region  about  the  eyes  is 
involved,  there  is  marked  edema,  which  results  in  a  partial  or 
complete  closing  of  the  lids.  The  eruption  is  accompanied  by 
considerable  heat  and  itching.  Convalescence  is  indicated  by 
a  fading  of  the  color,  by  a  branny  desquamation,  and  the 
occurrence  of  islets  of  sound  skin.  This  form  of  eczema  exhibits 
a  marked  tendency  to  recurrence.  It  is  more  particularly 
seen  in  adults  of  middle  or  advanced  life. 


54 


DISEASES   OP  THE   SKIN 


The  erythematous  type  may  run  an  acute  course  and  end 
in  recovery,  or  it  may  become  chronic.  It  is  not  infrequently 
transformed  into  the  vesicular,  pustular,  or  squamous  variety. 

Eczema  Papillosum. — Papular  eczema  involves  by  predilec- 
tion the  arms,  back,  and  legs.  It  is  characterized  by  pin-head- 
sized,  round  or  acuminate,  reddish  elevations,  either  discrete 
or    closely    aggregated.     Not    infrequently    the    papules    are 


Fig.  i&. 


al  years'  dura 


closely  grouped,  forming  finger-nail-sized  or  larger  patches. 
Much  larger  areas  may  be  formed  by  the  coalescence  of  lesions, 
producing  large  infiltrated  plaques  in  which  the  papules  as  such 
cannot  be  distinguished.  These  areas  show  an  exaggeration 
of  the  furrows  of  the  skin  and  undergo  what  the  French  call 
"  lichenification."  The  itching  is  apt  to  be  severe,  leading 
to  scratching  and  consequent  excoriations  and  superficial 
losses  of  tissue.     Not  infrequently  discretely  arranged  papules 


ECZEMA  55 

aie,  upon  close  examination,  seen  to  be  surmounted  by  minute 
vesicles. 

Papular  eczema  is  often  refractory  to  treatment ;  even  after 
the  disappearance  of  the  eruption  there  is  a  strong  tendency 
to  relapse.  The  itching  in  this  variety  of  eczema  is  more 
pronounced  than  in  most  of  the  other  forms. 

Eczema  Veticulosum. — The  onset  of  a  vesicular  eczema  is 
heralded  by  tingling  and  a  feeling  of  heat.  Soon  there  develop, 
upon  an  erythematous  and  swollen 
base,  numerous  pin-point-  to  pin- 
head-sized  vesicles,  which  rapidly 
become  confluent  and  rupture,  per- 
mitting the  escape  of  a  viscid  and 
sticky  serum.  The  drying  of  this 
exudation  produces  yellow,  gummy 
crusts.  The  rupture  of  the  vesicles 
is  followed  by  an  abatement  of  the 
subjective  phenomena.  Beneath 
the  crusts  the  serous  exudation  con- 
tinues. The  body  linen  is  stained 
and  stiffened  by  this  constant  ooz- 
ing or  weeping. 

The  eruption  may  develop  upon 
any  portion  of  the  body;  it  is 
common  upon  the  faces  of  infants, 
in  which  locality  it  has  been  des- 
ignated milk-crust  by  the  older 
writers.  It  is  also  extremely  fre- 
quent upon  the  hands  and  feet  of 
adults.  In  this  region  the  lesions 
develop  in  small  groups  and  ap- 
pear in  crops  at  variable  intervals. 
Patches   of    vesicular    eczema  are 

usually  not  sharply  marginated,  but  fade  gradually  into  the 
surrounding  healthy  integument. 

Acute  attacks  may  recover  in  one  or  two  weeks.  Commonly 
there  is  a  tendency  to  recurrence.  Convalescence  is  indicated 
by  a  cessation  of  oozing,  lessening  of  the  redness,  throwing  off 
of  the  crust,  and  the  formation  of  a  new  epithelial  covering. 
A  certain  amount  of  redness  will  persist  for  some  time  after 
healing. 

Burning,  itching,  and  soreness  are  often  pronounced.     The 


56  DISEASES  OF  THE  SKIN 

itching  increases  with  each  renewed  development  of  vesicles. 
Mechanical  rupture  of  the  vesicles  purchases  a  certain  degree 
of  relief  from  itching.  Infants  commonly  scratch  their  faces 
in  a  most  cruel  fashion,  producing  not  only  an  outpouring  of 
serum,  but  often  streams  of  blood. 

Vesicular  eczema  frequently  terminates  in  eczema  rubrum. 
Through  infection  with  pyogenic  organisms  a  pustular  eczema 
may  supervene. 


Fig.  18. — Crusted  vesicular  eczema,  of  face;  duration,  iwo  weeks. 


Eczema  Pustulosum  (Eczema  Impetiginosum). — Pustular 
eczema  may  begin  as  such,  or  may  develop  from  the  vesicular 
variety.  It  occurs  most  commonly  upon  the  face  and  scalp 
of  strumous  and  poorly  nourished  children.  Rupture  of  the 
pustules  is  followed  by  the  formation  of  profuse  yellowish, 
brownish,  or  greenish  crusts.  This  variety  of  eczema  is  most 
common  in  hairy  regions.  In  adults  it  is  often  seen  in  the  mus- 
tache, beard,  or  on  the  hairy  parts  of  the  body.  The  itching 
is  less  pronounced  than  in  the  other  forms  of  eczema. 


Eczema  Rubrum. — Eczema  rubrum  is  due  to  an  aggravation 
and  modification  of  one  of  the  primary  forms  of  the  disease. 


particularly  the  vesicular  or  pustular  varieties.     It  is  char- 
acterized by  redness,  swelling,  infiltration,  surface  exudation, 


and  frequently  crusting.  It  is  commonly  seen  upon  the  legs 
of  elderly  persons  and  upon  the  faces  of  infants.  When  upon 
the  legs,  the  skin,  in  pronounced  cases,  exhibits  a  vivid  red 


58  DISEASES  OP  THE   SKIN 

color  with  denudation  of  the  homy  layer  of  the  epidermis, 
permitting  the  exudation  upon  the  surface  of  a  yellowish,  clear 
or  turbid  serum ;  this  oozing  may  occur  as  a  diffuse  and  scarcely 
visible  transudation,  or  it  may  be  present  in  numerous  discrete 
droplets.  The  fluid  is  viscid  and  dries  in  the  form  of  crusts  of 
a  yellowish  color,  or  if  there  be  an  admixture  of  blood,  of  a 
brownish  tint.  The  skin  is  infiltrated,  and  not  infrequently 
the  entire  leg  is  hot  and  swollen. 


— Eczema    rubnim, 


A  similar  appearance  is  presented  upon  the  faces  of  infants; 
the  skin  is  either  red,  raw,  and  weeping,  or  covered  with 
yellowish  or  brownish  crusts.  To  that  form  in  which  moisture 
constantly  oozes  from  the  skin  the  name  eczema  madidans  has 
been  given. 

Pronounced  burning  and  itching  are  present,  leading,  espe- 
cially in  children,  to  scratching  and  to  consequent  bleeding. 


ECZEMA  59 

Eczema  Squamosum. — The  term  squamous  eczema  is  applied 
to  a  modified,  chronic  erythematous  or  papular  eczema  in 
which  infiltration  and  scaling  are  pronounced  features.  To 
be  sure,  the  convalescent  and  regenerative  stage  of  all  eczemas 


y^ggi 

- 

m :  i  .i**v ■'■'.'.'" 

Bflt- 

Fig.  ij. — ThicVentd  squamous  eczema  in  a  patient  whose  hands  were  much  eiposed 

is  characterized  by  a  certain  degree  of  scaling,  and  to  this 
terminal  transitional  condition  the  designation  squamous 
eczema  is  likewise  given-  Erythematous  eczema  is  particularly 
prone  to  terminate  in  the  squamous  form. 


Fig.  13. — Squamous  eciei 

It  often  follows,  or,  more  properly  speaking, 
with,  the  erythematous  form.  Squamous  eczema  may  involve 
large  areas  of  the  cutaneous  surface  or  may  be  present  in  small 
patches.  The  scales  are  thin,  flaky,  and  usually  of  a  grayish- 
white  color;  they  are  much  more  scanty  and  easily  detached 
than  those  of  psoriasis. 


60  DISEASES  OF  THE   SKIN 

It  would  appear  appropriate  to  include  under  squamous 
Eczema  the  horny  variety  so  frequently  seen  upon  the  palms 
of  the  hands  and  soles  of  the  feet.  In  this  condition,  which 
is  sometimes  called  eczema  tyloticum,  owing  to  the  resemblance 
to  callosities,  the  horny  layer  of  the  epidermis  is  enormously 
thickened;  indeed,  it  is  often  impossible  to  close  the  hand. 
Painful  fissures  develop,  not  infrequently  leading  to  bleeding. 
Similar  fissures  are  also  commonly  present  upon  the  fingers 
and  toes,  where  the  epidermis  is  more  moderately  hypertro- 
phied,  or,  indeed,  where  there  is  no  thickening  at  all,  the  skin 
being  merely  reddened,  glazed,  and  tense.  To  these  various 
fissured  conditions  the  term  eczema  fissum  has  been  applied. 

Chapping  is  a  familiar  but  mild  example  of  this  form  of 
eczema,  due  to  cold  winds,  immersion  of  the  skin  in  cold  water, 
the  use  of  irritating  soaps,  etc. 

At  times  leathery  infiltrations  of  the  skin  unaccompanied 
by  much  redness  gradually  develop;  this  condition,  which  is 
chronic  and  indolent  and  accompanied  by  much  thickening 
and  at  times  hardening  of  the  skin,  is  called  eczema  sclerosum. 
It  is  most  often  encountered  upon  the  extremities. 

Eczema  verrucosum  is  characterized  by  warty  excrescences 
covering  long-standing  patches  of  the  disease;  sometimes  a 
foul-smelling  discharge  exudes  from  the  vegetations.  A  more 
exaggerated  papillary  hypertrophy  leads  to  eczema  papillo- 
matosum. 

Etiology. — It  is  difficult  to  comprehend  how  a  morbid 
entity,  such  as  eczema,  can  be  the  direct  result  of  so  numerous 
and  diverse  causes  as  are  generally  held  to  be  responsible  for 
this  condition.  The  causes  are  both  constitutional  and  local, 
the  former  acting  from  within  and  the  latter  from  without. 
While  local  and  constitutional  factors  may  in  some  cases  lead 
to  the  development  of  an  eczema  independently  of  each  other, 
they  more  often  are  associated  in  the  causation.  In  many 
instances,  therefore,  the  constitutional  factors  may  be  regarded 
as  predisposing  causes,  in  that  they  create  a  cutaneous  weak- 
ness or  vulnerabilitv.  Under  such  circumstances  local  irritants 
of  various  kinds,  ordinarily  inadequate  to  cause  an  eczema, 
may  bring  about  such  a  result. 

Local  causes  may  come  under  three  classes  of  irritants — 
chemical,  thermal,  and  mechanical — or  a  combination  of  these 
may  be  operative  in  the  production  of  an  eczema. 

Chemical  irritants  comprise  various  medicinal  agents,  such 


ECZEMA  6 1 

as  iodin,  arnica,  mustard,  soap  containing  an  excess  of  alkali, 
dye-stuffs,  surgical  antiseptics,  etc.  In  certain  occupations 
eczema  is  produced  by  repeated  chemical  irritation;  the 
most  common  trade  eczemas  are  seen  in  washerwomen,  bakers, 
grocers,  surgeons,  chemical  workers,  etc. 

Thermal  irritants  comprise  the  solar  rays  and  artificial  heat 
from  stoves,  furnaces,  etc.  Stokers  and  blacksmiths  often 
develop  eczema  from  this  source. 

Cold  is  probably  a  more  potent  factor  in  the  production  of 
eczema  than  heat:  the  cold  winds  of  winter  and  early  spring 
are  responsible  for  many  eczemas  of  the  face  and  hands. 

Among  mechanical  irritants  are  included  scratching,  a  fre- 
quent factor  in  the  production  and  aggravation  of  eczemas, 
parasites,  friction,  pressure  from  clothing,  trusses,  garters,  etc. 

Among  the  constitutional  causes,  alimentary  disorders  play 
a  most  important  role.  Errors  of  diet,  digestion,  assimilation, 
and  elimination,  leading  to  absorption  of  toxins  and  leuko- 
mains,  must  be  regarded  as  common  causes  of  eczema  in  both 
infants  and  adults.  These  manifest  themselves  as  dyspepsia  in 
one  form  or  another,  constipation,  and,  in  many  instances,  gout. 

The  gouty  and  rheumatic  diatheses,  so  called,  are  invoked 
as  frequent  causes  of  eczema  by  nearly  all  writers.  Functional 
or  organic  defect  of  any  abdominal  viscus  may  be  a  causative 
factor  in  eczema. 

Some  cases  of  eczema  are  distinctly  due  to  disturbance  of 
the  nervous  system;  these  may  develop  as  a  result  of  psychic 
shock,  emotional  excitement,  or,  as  is  more  commonly  the  case, 
from  a  lowered  and  depraved  state  of  the  nervous  system — in 
other  words,  from  neurasthenia. 

Other  well-recognized  predisposing  causes  of  eczema  are 
nephritis,  diabetes,  utero-ovarian  disease,  anemia,  tuberculosis, 
malaria,  and  such  physiologic  conditions  as  dentition,  preg- 
nancy, and  lactation. 

It  is  not  likely  that  microorganisms  play  any  part  in  the 
primary  development  of  a  true  eczema ;  they  are  often  respon- 
sible, however,  for  secondary  changes. 

Pathology. — The  blood-vessels  are  markedly  dilated  and 
there  is  a  fluid  and  cellular  exudation  into  the  tissues.  The 
papillary  layer  of  the  corium  is  swollen  and  the  seat  of  a  round - 
cell-infiltration.  When  vesicles  are  formed,  the  rete  cells 
exhibit  a  parenchymatous  edema;  an  intercellular  edema  also 
develops  which  pushes  aside  the  cells  and  forms  a  lake  of  serum. 


62  DISEASES  OF  THE  SKIN 

The  roof  of  the  vesicle  is  usually  formed  by  the  corneous  layer 
of  the  epidermis.  In  eczema  rubrum  the  horny  layer  is  cast 
off  without  vesiculation,  leaving  the  rete  mucosum  exposed. 
In  chronic  eczema  the  cell-infiltration  extends  deep  into  the 
corium,  almost  to  the  subcutaneous  tissue,  and  the  papillae 
become  hypertrophied. 

Diagnosis. — The  clinical  expressions  of  eczema  are  most 
diverse  and  varied,  but  may  be  recognized  by  attention  to 
certain  cardinal  symptoms:  these  are — (a)  redness;  (6)  the 
development  of  papules,  vesicles,  or  pustules;  (c)  the  tendency 
to  surface  discharge  of  a  mucilaginous  character;  (d)  crusting 
and  scaling;  (e)  thickening  and  infiltration;  (/)  itching  and 
burning. 

These  phenomena  are  not  all  noted  in  each  case,  but  a  suffi- 
cient number  is  present  in  the  various  forms  of  eczema  to 
permit  identification. 

Scabies  is  commonly  confounded  with  eczema.  In  this 
disease  there  is  a  characteristic  distribution  of  the  lesions, 
viz.,  webs  of  fingers,  flexor  surface  of  wrists  and  arms,  axillary 
folds,  nipples,  umbilicus,  penis,  buttocks,  and  inside  of  thighs 
and  legs.  The  itching  is  severe  and  is  distinctly  worse  at 
night  on  retiring.  The  lesions  are  multiform,  and  burrows 
are  present  between  the  fingers  and  on  the  wrists.  There  are 
commonly  several  persons  affected  in  the  same  household. 
These  features  will  serve  to  distinguish  this  disease  from  eczema. 

Herpes  zoster  may  be  differentiated  from  vesicular  eczema 
by  the  unilateral  character  of  the  eruption,  its  localization 
in  the  area  of  distribution  of  a  nerve-trunk,  the  arrangement 
of  the  vesicles  in  clusters,  the  large  size  of  the  vesicles  and 
their  lack  of  tendency  to  spontaneous  rupture,  the  neuralgic 
pains,  and  the  absence  of  itching. 

Dermatitis  from  the  operation  of  mechanical,  chemical,  or 
thermal  irritants  may  so  closely  resemble  eczema  as  to  defy 
differentiation.  Indeed,  some  schools  regard  them  as  identical. 
Inflammations  of  the  skin  from  irritants,  particularly  from 
contact  with  poisonous  plants,  are  characterized  by  a  greater 
degree  of  swelling,  as  a  rule,  than  in  true  eczema;  moreover, 
myriads  of  minute,  closely  aggregated  vesicles  are  seen  and  there 
is  a  tendency,  in  many  cases,  to  the  formation  of  bullae.  Often 
burning  is  more  pronounced  than  itching.  The  condition  is, 
as  a  rule,  more  quickly  amenable  to  treatment.  Dermatitis 
may  eventuate  in  eczema. 


ECZEMA  63 

Impetigo  contagiosa  must  be  differentiated  from  pustular 
eczema;  the  former  affection  is  contagious  and  autoinoculable. 
The  lesions  begin  as  discrete  vesicles  and  blebs,  instead  of 
aggregated  pustules,  as  in  eczema;  they  are  more  superficially 
located,  tend  to  rupture  rapidly,  and  form  yellowish,  "stuck-on" 
crusts. 

Sycosis  differs  from  pustular  eczema  in  its  limitation  to  hairy 
regions,  particularly  the  beard,  mustache,  and  often  the  eyelids. 
The  lesions  occur  only  about  the  hair-follicles,  and  the  inter- 
follicular  skin  is  free.  Itching  or  burning  is  mild;  there  is  a 
tendency  to  chronicity  and  recurrences. 

Erysipelas  bears  only  a  superficial  resemblance  to  erythe- 
matous eczema  of  the  face.  The  former  mav  be  differentiated 
by  the  fever  and  other  constitutional  symptoms. 

Psoriasis  may  be  readily  distinguished  from  eczema,  as  a 
rule.  Circumscribed  eczema,  on  the  one  hand,  and  diffuse 
psoriatic  areas,  on  the  other,  may  present  some  difficulties  in 
diagnosis.  The  predilection  of  psoriasis  for  the  elbows,  knees, 
and  scalp,  the  sharp  definition  of  the  patches,  the  heaped-up, 
silvery  or  mica-like  scales,  the  moderate  degree  of  itching,  and 
the  history  of  recurrent  attacks  will  clarify  the  diagnosis. 

Tinea  circinata  bears  a  strong  resemblance  to  a  certain  form 
of  squamous  eczema  of  the  face  in  children  occurring  partic- 
ularly in  the  early  spring  months.  In  tinea  circinata  the 
patches  are  circular,  marginated,  and  distinctly  clear  in  the 
center;  but  few  lesions  are  present,  as  a  rule.  Ring- worm 
fungus  is  present  in  the  scales.  The  eczema  patches  are 
round,  but  seldom  annular — that  is,  clear  in  the  center. 

Lichen  planus  may  be  distinguished  from  papular  eczema 
by  the  angularity,  flatness,  umbilication,  and  violaceous  color 
of  the  papules,  and  by  their  persistence  aud  tendency  to  affect 
the  flexor  surface  of  the  wrists,  the  trunk,  and  the  mucous 
membrane  of  the  mouth. 

Lupus  erythematosus,  seborrhea,  pediculosis  corporis,  etc., 
may  sometimes  be  simulated  by  eczema,  but  may  usually  be 
differentiated  by  attention  to  the  special  features  of  those 
diseases. 

Prognosis. — Nearly  all  eczemas  will  yield  to  skilful  and 
persevering  treatment.  Acute  eczema  responds  much  more 
rapidly  than  those  of  long  standing;  it  should  be  the  studious 
aim  of  physicians  to  cure  eczematous  processes  in  their  early 
stages,  for  as  the  disease  becomes  subacute  and  chronic,  struc- 


64  DISEASES  OF  THE   SKIN 

tural  changes  occur  in  the  skin  which  greatly  increase  the 
difficulties  of  successful  treatment.  The  prognosis  is  greatly 
influenced  by  the  type  of  the  disease,  the  duration  and  extent 
of  the  eruption,  the  tendency  to  recurrences,  the  removability 
of  the  cause  or  causes,  and,  finally,  the  ability  of  the  patient 
properly  to  care  for  himself. 

Treatment. — General  Considerations. — There  are  no  specifics 
in  the  treatment  of  eczema:  the  methods  of  treatment  are  as 
varied  as  the  diverse  causes  which  give  rise  to  the  disease. 
As  far  as  internal  measures  are  concerned,  the  patient  should 
be  treated  rather  than  the  disease.  Many  eczemas  are  purely 
of  local  origin  and  require  merely  topical  treatment  to  effect 
a  cure.  In  those  cases  in  which  the  eruption  is  the  cutaneous 
expression  of  some  underlying  disease,  as,  for  instance,  diabetes 
or  gout,  the  treatment  must  obviously  be  directed  toward  the 
origo  malu  In  many  cases  both  local  and  general  measures 
are  necessary,  including  attention  to  the  important  matters 
of  diet,  exercise,  sleep,  and  habits  of  living. 

The  first  therapeutic  endeavor  should  be  directed  toward 
the  discovery  and  removal  of  the  cause,  but  this  is  often  difficult 
to  ascertain. 

Diet. — Much  difference  of  opinion  exists  as  to  the  degree 
and  character  of  dietary  restriction  advisable.  Certainly  no 
general  laws  can  be  formulated  as  to  the  proper  diet  in  eczema. 
The  quantity  and  quality  of  food  to  be  permitted  is  purely  an 
individual  question.  Many  patients  require  no  dieting  what- 
ever, while  others  need  to  be  placed  under  a  most  strict  r6gime. 
Often  a  reduction  in  the  quantity  rather  than  a  change  in  the 
quality  is  desirable.  Regularity  in  eating  and  proper  masti- 
cation are  not  unimportant  considerations. 

In  a  general  way  it  may  be  said  that  salt  meats,  pork,  shell- 
fish, pastries,  confections,  stimulating  sauces,  condiments, 
cheese,  and  excess  of  starchy  and  sugary  foods  should  be 
avoided.  Tea  and  coffee  should  be  reduced  to  a  minimum, 
and  alcoholic  beverages,  as  a  rule,  prohibited.  Lean  meats 
in  moderate  amount  and  fresh  fish  will  usuallv  do  no  harm. 

Relief  of  Constipation. — Regulation  of  the  bowels  is  an  impor- 
tant consideration  in  the  treatment  of  many  eczemas,  and 
accomplishes  more  actual  good  than  the  administration  of 
remedies  supposed  to  exert  a  direct  influence  upon  the  skin. 
It  is  preferable,  if  possible,  to  correct  the  constipation  without 
resort  to  drugs.     The  free  use  of  water  between  meals,  the 


ECZEMA  65 

eating  of  fresh  and  stewed  fruits,  particularly  prunes  and 
figs,  and  abdominal  massage  or  gymnastics  are  measures  to 
be  advised.  In  many  cases  these  will  not  succeed,  and  it 
then  becomes  necessary  to  employ  laxatives. 

In  acute  eczemas  it  is  desirable  to  inaugurate  the  treatment 
with  free  catharsis.  This  is  best  accomplished  by  the  use 
of  salines  alone  or  preceded  by  calomel. 

A  very  useful  preparation  in  the  treatment  of  eczema  com- 
plicated by  constipation  and  anemia  is  the  '  'acid  mixture  of 
iron."     It  combines  the  advantages  of  a  tonic  and  laxative: 

&.    Ferri  sulphatis gr.  xxxvj; 

Magnesii  sulphatis £iss; 

Acidi  sulphurici  dil fgij; 

Tinct.  cardamomi  comp ^SnJ» 

Aquae q.  s.  ad  13 vj. — M. 

Sig. — Tablespoonful  in  a  tumbler  of  water  before  breakfast. 

I  have  often  prescribed  a  more  palatable  mixture,  having 
much  the  same  effect,  save  that  its  laxative  properties  are 
less  marked : 

B .    Strychnia?  phosphatis gr.  j; 

Ferri  phosphatis gr.  xlviij-lxxij; 

Sodii  phosphatis £J ; 

Syrupi  aurantii  J aa  c,.  s.  ad  fgvj.-M. 

SiG. — Two  "fluidrams  in  water  before  meals. 

The  saline  waters,  of  which  Hunyadi  Janos,  Apenta,  Pluto, 
and  Carabana  water  are  types,  are  both  efficient  and  conveni- 
ent of  administration. 

When  constipation  is  associated  with  congestion  of  the 
liver,  the  natural  Carlsbad  salts  may  be  used  with  great  advan- 
tage. The  usual  dose  is  one  teaspoonful  dissolved  in  a  cup  of 
hot  water  fifteen  minutes  before  breakfast. 

In  infantile  eczema  I  have  often  employed  with  good  results 
the  following  prescription : 

B.    Hydrargyri  chloridi  mitis gr.  j; 

Syrupi  rhei f.jiij ; 

Olei  ricini 1,5  j ; 

Pulv.  acaciae gr.  xx; 

Aq.  menthae  piperita q.  s.  ad  f^ij. — M. 

Sig. — Teaspoonful  at  bedtime. 

Digestive    Remedies. — Dyspepsia    is    often    responsible    for 
eczema,   and    must   be   combated   by   appropriate    measures. 
Diet  is,  of  course,  of  supreme  importance.     In  certain  cases 
5 


66  DISEASES  OF  THE  SKIN 

the  mineral  acids,  particularly  hydrochloric  acid,  act  well;  in 
other  cases  alkalis  are  indicated.  Rhubarb  and  bicarbonate 
of  soda  may  be  used  in  the  latter  class.  In  patients  with 
atonic  dyspepsia  and  constipation  the  following  formula  is 
useful : 

B.    Tinct.  nucis  vomicae ^3*v» 

Fluidext.  cascarae  sagradae 13  vj ; 

Tinct.  cardamomi  comp q.  s.  ad  f^iij. — M. 

Sig. — One  fluidram  in  water  after  meals. 

Diuretics. — Diuretics  are  often  of  value  both  in  acute  and 
subacute  eczema.  The  free  use  of  water  before  meals  and  at 
bedtime  is  a  simple  but  highly  useful  method  of  flushing  the 
kidneys.  Potassium  acetate,  citrate,  or  bicarbonate,  in  ten- 
to  twenty-grain  doses,  may  be  given  one-half  hour  before 
meals,  or  the  alkaline  mineral  waters  may  be  employed.  These 
remedies  are  particularly  indicated  in  renal  insufficiency. 

Tonics. — In  strumous  individuals,  particularly  in  children 
with  glandular  enlargement,  cod -liver  oil  is  a  remedy  of  the 
greatest  efficiency.  In  anemic  patients  iron  in  one  of  its  various 
forms  should  be  administered.  The  use  of  milk  and  eggs  should 
not  be  forgotten  in  the  treatment  of  these  conditions. 

Special  Remedies  in  Eczema. — The  value  of  arsenic  in  this 
disease  has  been  greatly  overestimated ;  in  reality  it  has  a  most 
restricted  field  of  usefulness.  It  is  capable  of  acting  injuri- 
ously upon  the  skin,  and  should  never  be  used  in  acute  eczema 
and  whenever  the  degree  of  inflammation  is  pronounced.  It 
is  occasionally  of  value  in  chronic  papular  and  scaly  eczemas; 
in  other  words,  in  those  varieties  which  most  nearly  approach 
psoriasis  in  appearance. 

The  wine  of  antimony  has  been  highly  vaunted  by  certain 
English  dermatologists.  It  is  most  useful  in  acute  eczema 
in  plethoric  individuals.  It  is  given  in  five-minim  doses  three 
times  a  day. 

Crocker  advises,  in  obstinate  cases,  oil  of  turpentine  in  an 
acacia  emulsion  flavored  with  essence  of  lemon.  It  should 
not  be  used  where  the  kidneys  and  alimentary  canal  are  not 
healthy.  The  initial  dose  is  ten  minims,  to  be  gradually 
increased  to  twenty  or  thirty;  a  quart  of  barley-water  is  to  be 
imbibed  each   day. 

Spinal  counterirritation,  by  means  of  a  mustard  leaf  applied 
over  the  centers  governing  the  affected  areas  of  skin,  is  also 
advised  by  Crocker  as  a  means  of  lessening  the  severe  itching. 


ECZEMA  67 

For  the  relief  of  itching  Hyde  and  Montgomery  advise  full 
doses  of  quinin,  particularly  in  children.  Calcium  chlorid  is 
also  recommended. 

Opium  is  nearly  always  to  be  avoided ;  in  urgent  cases,  where 
sleep  is  impaired,  chloral,  antipyrin,  or  sulfonal  may  be  used. 

Local  Treatment. — The  local  treatment  of  eczema  is  perhaps 
the  more  important  in  the  majority  of  cases.  The  selection 
of  remedies  and  their  strengths  must  be  governed  by  the  grade 
of  inflammatory  reaction  present.  In  an  acute  eczema  the 
remedies  cannot  be  too  soothing.  Too  strong  an  application 
works  immediate  injury;  too  weak  an  application  can  do  no 
worse  than  fail  to  do  good. 

Water  is  an  irritant  in  all  acute  and  in  many  subacute  eczemas, 
and  is  to  be  used  as  infrequently  as  is  compatible  with  cleanli- 
ness. It  may  be  made  less  irritant  and,  indeed,  soothing  by 
the  addition  of  bran,  starch,  or  gelatin.  A  pound  of  ordinary 
washing  starch  or  bran  is  to  be  used  to  a  tub  of  water;  the  latter 
is  placed  in  a  gauze  bag  in  the  water.  Starch  baths  are  exten- 
sively employed  in  France  for  eczema.  In  indolent  chronic 
eczemas  soap  and  water  are  of  therapeutic  value.  They  are 
useful  at  times  also  to  remove  crusts  in  the  acute  varieties.  It 
is,  however,  a  better  plan  to  remove  crusts  by  the  process  of 
softening.  Pieces  of  flannel  soaked  in  linseed  or  olive  oil  kept  in 
contact  with  crusts  for  some  hours  will  soften  and  loosen  them; 
if  they  are  very  adherent,  a  lukewarm  starch  or  flaxseed  poultice 
may  be  applied.  Pastes  and  salves  should  likewise  be  removed 
from  the  skin  by  oily  and  unguentous  substances.  Petro- 
latum (vaselin)  or  olive  oil,  and  not  soap  and  water,  should 
be  employed  for  this  purpose. 

Local  Treatment  of  Acute  Eczema. — At  the  onset  of  a  vesic- 
ular eczema  dusting- powders  may  be  used  with  advantage. 
Many  substances  have  been  employed  for  this  purpose :  wheat- 
starch,  corn-starch,  rice-flour,  bismuth  subnitrate,  talcum, 
magnesium  carbonate  (most  absorbent),  zinc  oxid,  boric  acid, 
kaolin,  etc.     The  following  is  a  useful  combination: 

R.    TalciVenet.  \  --   „iv. 

Zinci  oxidi    J    °     ' 

Amyli §j. — M. 

Or,  if  a  more  astringent  one  is  desired: 

R.    Bismuth,  subnitrat.  \  --  .... 

Acidi  borici  J ^  ^ ' 

Amyli ,^iv. — M. 


68  DISEASES  OF  THE  SKIN 

Lotions  are  of  paramount  value  in  moist  eczemas.  They 
are,  as  a  rule,  borne  much  better  than  ointments.  The  simplest 
is  a  saturated  solution  of  boric  acid.  This  has  been  found  to 
be  just  as  soothing  to  the  skin  as  it  is  to  mucous  membranes. 
Sopped  on  every  hour  in  acute  eczemas,  it  acts  admirably  in 
reducing  inflammation.  The  following  formula  combines  the 
advantage  of  a  lotion  and  dusting-powder: 

R .    Zinci  oxidi giij ; 

Glycerini f;jj ; 

Aquae  calcis q.  s.  ad  i^vj. — M. 

Sig. — Use  locally. 

The  addition  of  a  dram  of  calamin  to  this  lotion  gives  it  a 
pinkish  coloration,  which  renders  the  powder  less  conspicuous. 
When  there  is  much  itching,  carbolic  acid  may  be  added  to 
any  of  the  above  liquids,  in  the  strength  of  one-half  to  one  dram 
to  six  ounces  of  the  lotion. 

A  preparation  which  is  termed  in  our  hospital  pharmacopeia 
*  'compound  resorcin  lotion' '  has,  after  extensive  trial,  given 
most  satisfactory  results.     Its  composition  is  as  follows: 

R.    Resorcini     )  ..      . 

Acidi  borici  (    aa  5h 

Glycerini f£j ; 

Zinci  oxidi sij ; 

Aquae f  3  v  j . — M. 

The  addition  of  lime-water  to  this  sometimes  increases  its 
efficiency.  In  certain  acute  weeping  eczemas,  when  all  oint- 
ments seem  to  increase  discomfort  and  do  harm,  splendid 
results  will  be  obtained  by  applying  continuous  moist  com- 
presses of  cheese-cloth  wet  with  a  2  per  cent,  solution  of  boric 
acid  and  resorcin. 

Another  lotion  of  great  value  is  one  modelled  somewhat  after 
Burrow's  formula: 

R  .  Liq.  plumbi  subacetat.  dil f3J-iJ '» 

Potassii  et  alumini  sulphatis  (alum) gr.  xxx; 

Glycerini fgiv; 

Aquae  camphorae f g j ; 

Aquae q.  s.  ad  f£vj. — M. 

A  favorite  treatment  of  J.  C.  White,  of  Boston,  is  the  appli- 
cation of  black  wash  (lotio  nigra),  either  pure  or  diluted  one- 
half  with  lime-water,  followed  by  the  use  of  the  plain  zinc 
oxid  ointment. 


ECZEMA  69 

Soothing  ointments  are  often  indicated  in  acute  eczema.  In 
some  cases  ointments  of  no  character  can  be  borne,  because  of 
the  increased  heat  and  irritation  produced  by  them.  Good 
results,  however,  will  usually  follow  the  use  of  sedative  lotions 
during  the  day  and  mild  ointments  at  night.  It  is  a  mistake 
to  regard  ordinary  zinc  ointment  as  inert  and  devoid  of  medi- 
cinal properties:  it  is  extremely  useful  in  early  eczemas,  par- 
ticularly of  the  vesicular  variety.  Lassar's  paste,  consisting 
of  one  part  each  of  zinc  oxid  and  starch  and  two  parts  of  vaselin, 
has  greater  consistency  and  does  not  tend  to  run  so  readily. 
To  these  salves  as  bases  may  be  added  five  to  ten  grains  of 
salicylic  or  phenic  acid. 

A  very  old  remedy,  still  employed  with  good  results,  is  the 
diachylon  ointment  of  Hebra.  It  must  be  freshly  prepared 
and  should  be  applied  upon  strips  of  soft  linen  or  muslin.  It 
is  made  as  follows : 

]&.    Olei  olivae ^3XV» 

Uthargyri £iij-v; 

Aquae q.  s. — M. 

SlG. — Coq.  et  ft.  ung. 

Local  Treatment  of  Subacute  Eczema. — When  the  stage  of 
acute  inflammation  has  subsided,  more  stimulating  appli- 
cations are  desirable  and  necessary.  For  the  relief  of  itching, 
always  a  troublesome  symptom  in  eczema,  we  may  use  carbolic 
acid,  tar,  menthol,  camphor,  etc.  Mercurial  preparations  are 
also  useful  as  antipruritics;  they,  moreover,  act  admirably  in 
controlling  pyogenic  infection  of  the  skin. 

We  may  employ,  with  excellent  results,  in  a  large  variety 
of  subacute  eczemas,  the  following  paste  of  phenol  and  calomel: 

R .    Acidi  phenici gr.  x; 

Hydrargyri  chloridi  mitis gr.  xv; 

Pulv.  amyli  \  . .     .. 

Pulv.  zinci  oxidi  /   **  3UJ 

Vaselini 3iv.— M. 

This  is  one  of  the  most  generally  useful  formulae  in  eczema 
that  I  know.  Tar  may  be  employed  in  this  stage,  but  should 
be  used  rather  weak  in  the  beginning. 

A  lotion  which  enjoys  an  excellent  reputation  among  English 
dermatologists  is  the  ' '  liquor  carbonis  &**  "  or  tincture 

of  mineral  tar.    It  is  made  by 
tar  with  nine  ounces  of  tine 
and  then  filtering.    It  is  to 


70  DISEASES  OF  THE  SKIN 

in  water.  I  have  for  some  time  used  a  tincture  of  vegetable 
tar  made  with  pix  liquida  instead  of  coal-tar.  The  following 
lotion  will  be  found  most  valuable  in  subacute  itching  eczemas, 
particularly  of  the  papular  variety: 

R .    Tinct.  picis  liquids f £iv-f gj ; 

Acidi  phenici gr.  xxx-lx; 

Glycerini Wss; 

Zinci  oxidi Jrj ; 

Ext.  hamamelidis  dest f,|j; 

Aquae q.  s.  ad  fjvj. — M. 

Local  Treatment  of  Chronic  Eczema. — In  this  stage  the  skin 
is  thickened  and  infiltrated,  and  stimulating  remedies  are 
required  to  promote  absorption  of  the  cellular  exudate  and 
restore  the  integument  to  its  normal  condition.  In  some 
cases  keratolytic  substances  to  soften  and  remove  thickened, 
horny  epidermis  are  necessary. 

Tar  ointment  finds  its  most  important  therapeutic  scope 
in  obstinate  papular  and  thickened  eczema.  It  should  never 
be  used  in  acute  eczema,  and  only  with  caution  in  the  subacute 
forms.  Liquid  tar  and  the  oil  of  cade  are  the  two  best  prepa- 
rations; they  may  be  incorporated  in  any  ointment  base: 

R.    Picis  liquids  or  Olei  cadini 3J— ij ; 

Zinci  oxidi 3J. — M. 

In  non-inflammatory  leathery  patches  oil  of  cade  with  an 
equal  part  of  olive  oil  may  be  rubbed  in  with  advantage. 

The  "liquor  picis  alkalinus,"  suggested  by  Bulkley,  is  an 
excellent  remedy  in  sluggish  and  thickened  eczemas;  it  is  freely 
miscible  with  water : 

R  .    Picis  liquids f$ij; 

Potasss  caustics x] ; 

Aquae f*v. 

Sig. — Dissolve  the  potash  in  water  and  add  slowly  to  the  tar  in  a 
mortar  with  friction.     To  be  diluted  twenty  times  or  more. 

An  application  much  employed  in  Europe  in  the  treatment  of 
eczema  is  the  glycerogelatin  jelly  of  Unna;  it  is  made  up  of — 

Gelatin 15  parts. 

Glycerin 15 

Zinc  oxid 30 

Water 40 


<< 

<< 


To  the  above  may  be  added  5  per  cent,  of  ichthyol  or  2  per 
cent,  of  salicylic  or  carbolic  acid.     At  the  temperature  of  the 


ECZEMA  71 

air  this  combination  has  the  consistence  of  a  firm  jelly,  which 
is  heated  upon  a  water-bath  until  it  can  be  easily  poured.  A 
double  boiler  can  be  used,  or  an  ordinary  porcelain  kitchen  cup 
containing  the  medicament  can  be  placed  in  a  pipkin  containing 
water.  The  melted  material  is  then  painted  upon  the  skin, 
and  the  part  covered  with  a  thin  layer  of  absorbent  cotton. 
This  becomes  quite  dry  in  about  ten  minutes,  when  the  excess 
of  cotton  may  be  stripped  off.  A  firm,  impermeable  covering 
is  thus  formed.  It  relieves  itching  admirably,  probably  by 
excluding  the  air.  It  is  of  particular  value  in  subacute  eczemas. 
The  application  will  remain  on  the  skin  for  one  or  two  days 
before  it  begins  to  peel  off. 

The  soft  soap  and  diachylon  treatment  may  be  tried  in  cir- 
cumscribed, sluggish  eczemas  of  the  leg  when  other  remedies 
fail.  The  leg  is  briskly  rubbed  with  the  soap,  which  is  then 
removed  and  followed  by  the  application  of  the  ointment  on 
strips  of  muslin. 

Baths  are  sometimes  of  value  in  eczema,  although  they 
should  be  employed  with  care.  The  most  frequently  used 
medicated  baths  are  those  containing  bran,  starch  (one  pound  to 
the  bath),  borax,  or  soda  (one-half  pound  to  the  bath).  Sulphur 
baths  are  sometimes  useful  in  chronic  papular  eczema.  They 
can  be  prepared  by  adding  two  to  three  ounces  of  the  liquor 
calcis  sulphurata  or  Vleminckx's  solution  to  30  gallons  of  water. 

Rest  is  a  factor  of  considerable  importance  in  treating  eczemas 
upon  dependent  portions  of  the  body,  as,  for  instance,  the 
legs.  Many  patients  with  eczema  rubrum  of  the  legs  accom- 
panied by  venous  stateis  and  swelling  will  make  more  improve- 
ment in  three  weeks  in  bed  than  in  a  similar  number  of  months 
upon  their  feet. 

Special  Treatment  of  Regional  Eczema. — Eczema  of  the 
Scalp  (Eczema  Capitis). — Eczema  upon  the  scalp  in  infants 
and  young  children  is  apt  to  be  of  the  pustular  type ;  in  school- 
children it  is  commonly  due  to  animal  parasites;  in  adults  it 
is  usually  scaly,  and  of  the  seborrheic  variety.  Weak  sulphur 
and  mercurial  ointments  act  well;  thirty  to  forty  grains  of 
precipitated  sulphur  or  twenty  grains  of  ammoniated  mercury 
in  one  ounce  of  benzoated  lard  or  vaselin  may  be  advised. 

Eczema  of  the  Face  (Eczema  Faciei). — The  erythematous, 
vesicular,  and  weeping  forms  of  eczema  are  tr^e  most  common 
varieties  seen  upon  the  face.  The  lotions  referred  to  in  the 
treatment  of  acute  eczema  are  appropriate  for  eczema  in  this 


72  DISEASES   OP  THE   SKIN 

region.  When  there  is  much  crusting,  an  oil  lotion  combining 
the  advantages  of  a  salve  and  wash  may  be  employed  with 
advantage : 

R.    Resorcini      \  S5  -• 

Acidi  borici/   **  5J' 

Olei  amygdal.  dulc f 3ij ; 

Aquae  calcis fdivj 

Pulv.  zinci  oxidi 3ij. — M. 

Sig. — Shake  well  and  dispense  in  a  wide-mouthed  bottle. 

The  plain  ointment  of  zinc  oxid  will  often  do  more  good 
than  complicated  combination  of  drugs. 

Marginal  eczema  of  the  eyelids,  or  blepharitis,  will  usually 
respond  to  boric-acid  instillations  and  an  ointment  of  the 
yellow  oxid  of  mercury,  five  grains  to  the  ounce  of  vaselin. 
The  same  salve  is  useful  in  eczema  of  the  nostrils.  The  patient 
should  be  cautioned  against  inserting  the  fingers  into  the  nos- 
trils. Eczema  of  the  vermilion  border  of  the  lips  often  runs 
an  obstinate  course.  Lotions  of  resorcin  and  boric  acid  and 
weak  ointments  of  salicylic  and  boric  acids  in  cold  cream 
are  useful.  The  same  ingredients  incorporated  in  a  quince 
jelly  frequently  act  well.  Hyde  and  Montgomery  advise 
equal  parts  of  benzoin,  alcohol,  and  glycerin.  In  chronic 
cases  weak  solutions  of  silver  nitrate  and  caustic  potash  are 
sometimes  serviceable.  In  eczema  of  the  lips  the  subject  of 
the  dentifrices  employed  should  be  investigated. 

Eczema  of  the  Hands  and  Feet  {Eczema  Manuum;  Eczema 
Pedum). — The  vesicular,  the  squamous,  and  the  fissured  varie- 
ties are  the  most  common  types  upon  the  hands  and  feet. 
Eczema  of  the  hands  is  frequently  an  occupation  disease,  as 
in  washerwomen.  The  hands  should  be  protected  from  heat 
and  cold.  In  the  vesicular  forms  good  results  are  obtained 
with  the  phenol-calomel  pastfe,  black  wash,  salicylic-acid 
salve  (10  to  15  grains  to  the  ounce),  diachylon  ointment,  and 
similar  remedies.  I  have  found  at  times  a  1  per  cent,  solution 
of  picric  acid  promptly  to  relieve  itching  when  other  remedies 
had  failed;  this  solution  hardens  the  horny  layer  and  reinforces 
the  protective  covering. 

For  the  horny,  thickened  eczemas  of  the  palms  and  soles 
the  best  remedy  is  a  25  per  cent,  salicylic  acid  plaster.  A 
5  to  10  per  cent,  salicylic  acid-resorcin  paste  is  also  useful. 
Tar  may  also  be  employed  with  advantage.  The  wearing  of 
rubber  gloves  will  macerate  and  soften  a  thickened  and  horny 
eczema. 


ECZEMA  73 

The  x-rays  are  of  great  value  in  recurrent  vesicular  eczema 
of  the  hands  and  feet.  Indeed,  in  no  other  variety  of  the  dis- 
ease is  radiotherapy  so  uniformly  successful.  This  treatment 
assures  a  grater  permanence  of  cure  than  any  other  method. 
The  rays  should  be  used  in  conjunction  with  other  approved 
measures.  In  scaly  eczemas  of  the  palm  and  soles  the  results 
are  less  certain. 

Eczema  of  the  Bearded  Region  {Eczema  Barbce). — The  eruption 
is  not,  as  a  rule,  circumscribed  to  the  region  of  the  beard  and 
mustache,  but  extends  upon  the  non-hairy  areas.  When  the 
lesions  are  entirely  limited  to  the  hairy  portions,  differentiation 
from  sycosis  may  be  difficult.  The  two  most  common  varieties 
in  these  regions  are  the  pustular  and  the  seborrheic  forms. 
Mild  remedies,  such  as  are  advised  in  acute  eczema,  are  appli- 
cable in  the  early  stages.  Weak  sulphur  or  mercurial  ointments 
often  act  well.  It  is  best  in  acute  cases  not  to  shave  the  beard, 
but  to  crop  it  closely  with  a  curved  scissors.  When  pustules 
are  penetrated  by  hairs,  the  plucking  of  the  latter  effects  an 
evacuation  of  the  pus.  In  subacute  and  chronic  cases  shaving 
should  be  frequently  performed. 

Eczema  of  the  Nipples  and  Breast  {Eczema  Mamma). — This 
usually  occurs  in  nursing  women.  The  nipple  is  commonly 
reddened,  thickened,  fissured,  and  oozing.  Each  nursing 
causes  the  most  exquisite  pain.  When  cracks  are  present,  the 
infant  should  suckle  through  an  artificial  rubber  and  glass 
nipple.  In  obstinate  cases  it  may  become  necessary  to  wean 
the  baby.  The  nipples  should  be  gently  cleansed  with  boric- 
acid  solution  after  each  nursing.  Mild  lotions  and  protective 
ointments,  such  as  a  bismuth  or  zinc  salve,  may  be  applied 
between  nursings.  The  ointments  should  be  carefully  removed 
with  sweet  oil.  I  have  found  painting  with  a  dram  to  the  ounce 
solution  of  ichthyol  in  water  successful;  before  nursing  this  is 
to  be  removed  with  a  lotion  containing  boric  acid  and  glycerin. 
Poisonous  ingredients  should  not  be  incorporated  in  the  appli- 
cations used. 

Eczema  of  the  genitals  {eczema  genitalium)  occurs  both  in  men 
and  women.  In  the  former  the  scrotum  is  most  commonly 
involved,  although  the  glans  or  the  shaft  of  the  penis  may  be 
the  seat  of  the  trouble.  The  erythematosquamous  variety  of 
eczema  is  most  frequently  encountered.  The  scrotum  is 
reddened,  thickened,  scaly,  and  often  tf-  "  The  itching 
is  violent,  and  leads  to  the  most  u 


74  DISEASES  Off  THE  SKIN 

coming  only  with  abrasion  and  weeping  of  the  surface.  In 
women  the  labia  majora  and  at  times  the  labia  minora  and 
vestibule  are  reddened,  thickened,  and  excoriated. 

Glycosuria  is  a  common  cause  of  genital  eczema  in  women; 
it  is  not  so  often  productive  of  this  condition  in  men.  Many 
genital  eczemas  have  their  origin  as  a  pruritus,  the  repeated 
scratching  causing  the  eczema.  The  heat,  moisture,  and 
friction  of  this  region  favor  the  development  of  eczema.  A 
constant  sitting  posture  also  conduces  to  eczema  of  the  genitals, 
as  is  seen  in  tailors.  Vaginal  discharge  often  excites  eczema 
labiorum. 

The  treatment  often  requires  patience  on  the  part  of  the 
physician  and  the  sufferer.  In  acute  eczema  mild  lotions  are 
indicated:  equal  parts  of  lotio  nigra  and  lime-water  with  a 
little  carbolic  acid  and  glycerin  added  often  does  well.  One 
may  also  use  the  calamin  lotion  or  a  2  per  cent,  solution  of 
resorcin  and  boric  acid.  Very  hot  boric-acid  fomentations  give 
relief  for  a  time  from  the  distressing  itching.  In  subacute  or 
chronic  cases  the  following  lotion  has  given  me  good  results: 

H.    Menthol gr.  xx; 

Acidi  phenici gr.  xxx ; 

Tinct.  picis  liquids  or  Tinct.  picis  mineralis.  .  f,jss-iss; 

Ext.  hamamelidis  dest f . $j; 

Glycerini f^iss; 

Aquae q.  s.  ad  f§vj. — M. 

Weak  bichlorid  lotions,  the  tincture  of  benzoin,  a  2  per  cent, 
solution  of  silver  nitrate  in  spirits  of  nitrous  ether,  may  all 
be  resorted  to  in  obstinate  cases.  Diachylon,  carbolic,  and 
mercurial  ointments  are  also  at  times  useful.  In  a  long-standing 
and  obstinate  genital  eczema  in  a  young  woman  under  my 
care  a  brilliant  and  rapid  cure  was  effected  with  the  use  of  the 
x-rays.     I  have  had  similar  successes  in  men. 

Eczema  of  the  Legs  (Eczema  Crurum). — The  legs  are  the  most 
frequent  site  of  eczema  in  persons  of  middle  or  advanced  years. 
Varicose  veins  and  resulting  venous  stasis  are  commonly 
responsible  for  the  lessened  resistance  in  these  parts.  All  forms 
of  eczema  may  be  encountered,  but  eczema  rubrum  usually 
with,  but  sometimes  without,  weeping  is  the  commonest.  The 
skin  often  has  a  purplish  or  bluish  coloration,  and  later  a 
brownish  pigmentation.  Ulceration,  often  the  result  of  super- 
ficial venous  thrombi,  is  a  common  complication. 

The  treatment  does  not  essentiallv  differ  from  that  of  eczema 
elsewhere.     In  severe  acute  cases  rest  in  bed  with  elevation  of 


ECZEMA  75 

the  leg  is  a  most  important  consideration.  Where  varicose 
veins  are  present,  bandaging  is  of  great  aid ;  in  moist  eczemas 
a  firm  and  well-applied  muslin  roller-bandage  should  be  used: 
where  no  moisture  is  present,  a  woven  elastic  strand  bandage 
may  be  employed  or  an  ordinary  rubber  bandage  over  muslin, 
or  a  white  stocking. 

Eczema  Liberorum. — Eczema  in  children  presents  certain 
features,  both  as  regards  symptomatology  and  treatment, 
which  merit  special  mention.  The  face  and  scalp  are  the 
favorite  seats  of  the  disease.  The  diaper  region  is  also  com- 
monly affected,  as  the  result  of  the  too  infrequent  changing 
of  the  napkins,  from  the  excessive  use  of  soap  and  water,  and, 
most  frequently  of  all,  from  acid  diarrheas. 

The  type  of  eczema  usually  seen  upon  the  face  is  the  vesico- 
pustular:  this  is  frequently  transformed  into  a  weeping  eczema 
by  scratching.  Although  eczema  may  last  a  long  time  in 
infants,  it  usually  presents  an  acute  appearance;  this  is  doubt- 
less due  to  the  tenderness  of  the  infantile  skin  and  to  noxious 
scratch  effects. 

A  prominent  cause  of  infantile  eczema  is  disturbance  of  the 
gastro-intestinal  tract.  Improper  diet  and  overfeeding  are 
fruitful  etiologic  factors.  Local  causes,  such  as  the  prolonged 
contact  of  excreta,  the  use  of  irritant  soaps,  exposure  to 
cold  winds,  are  responsible  for  many  cases.  Dentition  rarely 
causes  an  eczema,  although  it  appears  capable  of  aggravating 
an  existing  one.  In  my  experience  infantile  eczema  usually 
begins  within  the  first  six  weeks  or  two  months  of  life.  Unless 
skilfully  treated, — and  at  times  despite  such  treatment, — it  is 
apt  to  last  for  many  months. 

The  treatment  does  not  differ  essentiallv  from  that  of  acute 
and  subacute  eczema  in  adults,  save  that  the  remedies  employed 
should  be  very  mild.  There  are  no  internal  drugs  of  special 
value.  The  proper  adaptation  of  the  food  to  the  nutrition  of  the 
child  is  of  far  greater  importance.  Where  the  infant  is  not  at 
the  breast,  the  selection  of  a  proper  milk  combination  is  a  most 
vital  consideration.  Some  babies  develop  eczema  when  put 
upon  an  unsuitable  food.  When  the  mother  is  badly  nourished 
or  sick,  even  the  maternal  milk  may  prove  an  improper  diet 
for  the  child.  Excessive  adiposity  is  regarded  by  some  physi- 
cians as  a  cause  of  infantile  eczema;  in  such  cases  it  is  said  a 
reduction  in  the  carbohydrates  is  followed  by  prompt  improve- 
ment. 


76  DISEASES  OF  THE  SKIN 

A  matter  of  great  importance  is  the  prevention  of  scratching. 
When  this  cannot  be  accomplished  by  the  use  of  masks  and 
bandages,  it  must  be  effected  by  Some  form  of  physical  restraint. 
Often  it  will  suffice  to  place  padded  mittens  or  bags  on  the 
hands;  in  many  instances  it  will  be  necessary  to  place  splints 
upon  the  arms  to  prevent  the  child  from  scratching  its  face. 
The  immobilization  of  the  elbows  may  be  conveniently  accom- 
plished by  bandaging  a  paste-board  cylinder  around  the  arms  or 
by  simply  fastening  a  pair  of  starched  cuffs  over  the  elbows  with 
a  heavy  rubber  band. 

In  obstinate  infantile  eczemas  removal  to  the  seashore  or 
mountains  will  sometimes  accomplish  more  than  all  other 
therapeutic  measures. 

ECZEMA  SEBORRHOICUM  (DERMATITIS  SEBORRHEICA) 

Synonyms. — Seborrheic  eczema;  Seborrhoea  corporis. 

Definition. — Eczema  seborrhoicum  is  an  inflammatory  dis- 
ease of  the  skin,  beginning  usually  upon  the  scalp,  and  charac- 
terized by  scaliness,  redness,  and  fatty  hypersecretion,  with  a 
tendency  to  downward  extension. 

Symptoms. — The  disease  almost  invariably  begins  upon 
the  scalp,  to  which  it  may  be  limited  for  a  long  period  of  time 
without  exciting  any  special  attention.  The  eczema  has  its 
origin  in  an  antecedent  seborrhoea  capitis  characterized  by 
fine  scaling.  Either  gradually  or  rapidly  there  may  develop 
a  marked  increase  in  the  scaling,  loss  of  hair,  or  reddish  patches 
associated  with  some  itching.  The  scalp  presents  either  diffuse 
or  circumscribed  reddening,  covered  with  loosely  attached 
greasy  scales.  The  scales  are  softer  and  less  adherent  than 
in  ordinary  eczema,  owing  to  the  excessive  fatty  content.  The 
reddish  patches  not  infrequently  extend  beyond  the  hairy 
border  upon  the  forehead,  constituting  the  so-called  corona 
seborrhoica.  The  patches  are,  as  a  rule,  free  of  exudation  save 
when  artificially  irritated. 

The  eruption  is  often  seen  behind  the  ears,  and  at  times  in 
the  internal  auditory  canal.  Yellowish-red  and  scaly  patches 
are  also  seen  upon  the  face,  particularly  about  the  hairy  por- 
tions— the  eyebrows,  mustache,  and  beard.  The  nasolabial 
fold  is  a  very  common  seat  of  the  eruption. 

From  the  scalp  the  disease  may  spread  gradually,  or  more 
rarely  rapidly,  by  the  facial  or  postauricular  route,  to  the 
trunk.     Sometimes  distant  regions  are  affected,  without  the 


ECZEMA  SBBORRHOICUH  77 

presence  of  the  eruption  upon  intervening  areas.  The  sternal 
and  interscapular  regions  are  the  favorite  seats  of  the  type 
described  by  Duhring  as  seborrhea  corporis.  This  variety  is 
characterized  by  circinate  or  crescentic  yellowish-red  patches 
with  oily  scales. 

The  axillary,  anal,  and  inguinocrural  creases  may  exhibit 
dry  or  moist  patches,  often  indistinguishable  from  an  ordinary 
eczema. 

Tne  subjective  symptoms  in  seborrheic  eczema  are  not  pro- 


mt region;  favorite  s< 


nounced.  In  many  cases  itching  is  entirely  absent;  it  is 
usually  proportionate  to  the  grade  of  inflammatory  reaction 
present. 

In  the  localized  forms  of  the  disease — j.  e„  those  limited  to 
the  scalp,  the  nasolabial  folds,  the  sternum,  etc. — the  eruption, 
untreated,  persists  for  a  long  period.  After  disappearance  under 
treatment  the  eruption   commonly  returns  at  a  later  period. 


78  DISEASES  OP  THE  SKIN 

The  acute,  rapidly  spreading,  and  highly  inflammatory  varieties 
are  not  so  prone  to  recur. 

Etiology. — Unna  and  Elliott  both  insist  upon  the  parasitic 
nature  of  this  disease.  Unna  found  a  mulberry-shaped  coc- 
cus which  he  called  the  morococcus,  and  which  he  regarded 
as  the  cause  of  the  disease.  Merrill,  working  in  collaboration 
with  Elliott,  found  a  diplococcus  with  which  he  claims  to  have 
reproduced  the  disease  by  inoculation.     The  prevailing  view 


is  that  seborrheic  eczema  is  a  parasitic  affection  having,  how- 
ever, but  a  feeble  contagiousness  and  requiring  a  favorable 
soil.  Elliott  regards  an  indoor  life  as  a  favoring  condition. 
It  is  probable  that  all  factors  that  lower  the  general  resist- 
ing power  or  that  of  the  skin  aid  in  the  production  of  the 


Pathology. — Both  Unna  and  Elliott  regard  the  process  as 
a  dermatitis  of  catarrhal  character,  caused  by  the  invasion  of 
a  microorganism.  Even  ordinary  dandruff  or  pityriasis  capitis 
was  found  by  Elliott   to  be   characterized   histologically  by 


ECZEMA   SEBORRHOICUM  79 

inflammatory  changes  in  the  skin.  Unna  believes  the  fatty 
hypersecretion  in  seborrheic  eczema  to  issue  from  the  sweat- 
glands  and  not  from  the  sebaceous  glands.  Elliott  failed  to 
confirm  Unna's  finding  of  fat  in  the  sweat -coils,  but  noted  their 
participation  in  the  general  inflammatory  process. 

Diagnosis. — Eczema  seborrhea  cum  may  be  distinguished 
from  ordinary  eczema  by  its  origin  in  the  scalp,  the  tendency 
to  downward  extension,  the  absence  of  well-developed  vesicles 
and  pustules,   the  mild  character  of  the  inflammation,   the 


Fig.  *6.— Severe  and  acutely  inflammatory  type  of 


greasy  character  of  the  scales,  the  superficiality  of  the 
patches,  the  absence  of  marked  infiltration,  the  tendency 
to  crescentic  or  annular  configuration,  and  the  mild  grade 
of  the  itching. 

The  affection  may  bear  a  close  resemblance  to  pityriasis 
rosea,  but  the  latter  seldom,  if  ever,  attacks  the  scalp;  it,  more- 
over, is  often  preceded  by  a  primitive  patch  on  the  trunk 
or  extremities.  The  lesions  are  often  oval,  the  long  diameter 
running  parallel  to  the  long  axis  of  the  ribs;  the  centers  of  the 


80  DISEASES  OP  THE  SKIN 

lesions  are  fawn  colored  and  covered  with  fine  scales  which, 
however,  are  not  greasy.  The  itching  is  variable,  often  severe. 
Pityriasis  rosea  runs  a  rapid  course,  with  spontaneous  cure, 
in  from  six  to  eight  weeks;  this  is  not  true  of  seborrheic  eczema. 

Some  forms  of  the  disease  bear  a  remarkable  similarity  to 
psoriasis.  The  resemblance  is  closest  in  lesions  upon  the  scalp. 
The  distribution  of  the  eruption  in  the  two  disease  is,  however, 
dissimilar.  Patches  about  the  elbows  and  knees  bespeak  a 
psoriasis.  The  lesions  of  seborrheic  eczema  lack  the  silvery 
scales  of  psoriasis  and  are  distinctly  more  greasy. 

Treatment. — The  best  remedies,  in  the  order  of  their  efficacy, 
are:  sulphur,  resorcin,  salicylic  acid,  and  ammoniated  mer- 
cury. Upon  the  scalp  it  will  be  found  most  convenient  to 
employ  a  lotion.     The  following  is  highly  useful : 

H .    Resorcini £ij ; 

Olei  ricini f.^j ; 

Aquae f  £ij ; 

Spirit,  vini  rect f^;vj. — M. 

Sig. — Apply  each  night. 

Where  an  ointment  and  lotion  are  both  used  upon  the  scalp,  it 
will  be  well  to  omit  the  oil  from  the  lotion.  I  have  often  seen 
excellent  results  from  the  alternate  use  of  the  resorcin  alcohol 
and  an  ointment  containing: 

H .    Sulph.  praecip 3J ; 

Adipis J5J; 

Olei  bergamot y(\  xxx. — M. 

Sig. — Apply  every  night,  rubbing  well  into  the  scalp. 

I  have  met  with  some  cases  of  patches  on  the  face  in  which  all 
ointments,  no  matter  how  mild,  seemed  to  aggravate  the  con- 
dition. Lotions  containing  resorcin  and  boric  acid  were  well 
borne.  The  glycerogelatin  jelly  of  Unna,  containing  a  little 
ichthyol  or  salicylic  acid,  does  well  in  these  cases. 

In  seborrheic  eczema  of  the  chest  sulphur  in  vaselin,  forty  to 
sixty  grains  to  the  ounce,  acts  with  magical  rapidity.  If  the 
treatment  is  not  continued,  the  patches  are  likely  to  return, 
particularly  in  warm  weather. 

Medicated  soaps  containing  resorcin,  salicylic  acid,  and  sul- 
phur are  of  considerable  value  on  the  scalp  and  trunk.  They 
are  often  too  strong  for  the  face.  In  obstinate  cases  resort 
may  be  had  to  mercury,  chrysarobin,  or  tar.  Mild  x-ray  expo- 
sures have  been  very  useful  in  my  hands  as  auxiliary  treatment. 


IMPETIGO  CONTAGIOSA  8 1 


DERMATITIS  REPENS 


Definition. — Dermatitis  repens  is  a  spreading  inflammation 
of  the  skin  having  its  origin  usually  in  an  injury  upon  the  upper 
extremities  and  advancing  by  a  vesicular  undermining  of  the 
epidermis.     The  disease  was  first  described  by  Crocker  in  1888. 

Symptoms. — In  practically  all  cases  an  injury,  oftentimes 
trivial  in  character,  is  the  starting-point  of  the  eruption.  Vesi- 
cles or  bullae  appear  at  the  site  of  the  trauma,  followed  by  a 
throwing  off  of  the  epidermis  after  their  rupture.  A  red,  raw, 
oozing  surface  is  usually  left,  from  the  borders  of  which  extension 
takes  place  by  a  serous  undermining  of  the  epidermis.  Fresh 
vesicles  and  blebs  may  develop  in  the  area  beyond,  or  detach- 
ment of  the  epidermis  may  take  place  as  a  result  of  subjacent 
exudation.  Sometimes  the  denuded  surface  remains  dry. 
The  condition  is  usually  limited  to  the  hand ;  but  one  of  Crocker's 
cases  extended  up  the  arm,  across  the  back,  and  down  the 
other  arm.  The  affection  may  last  for  weeks,  months,  or  even 
years.  Crocker  believes  the  condition  to  be  due  primarily 
to  a  neuritis  as  the  result  of  the  injury  and  secondarily  to  bac- 
terial invasion. 

Treatment. — Crocker  advises  trimming  away  the  partly 
detached  epidermis  and  applying,  once  a  day,  a  10  per  cent, 
solution  of  permanganate  of  potash.  He  also  had  success 
with  a  lotion  of  lactate  of  lead.  Ointments  of  iodoform  and 
aristol    are    also    advised. 

Acrodermatitis  perstans  is  an  allied  disorder  in  which  the 
fingers  are  successively  affected  by  a  vesicular  or  pustular 
eruption.     The  nails  are  altered  and  may  be  lost. 

IMPETIGO  CONTAGIOSA 

Derivation. — h.,   impetcre,   to  attack. 

Definition. — Impetigo  contagiosa  is  an  acute,  contagious, 
inflammatorv  disease  of  the  skin,  characterized  bv  discrete  flat, 
superficial  vesicles  or  blebs,  which  rapidly  become  pustular  and 
dry  upon  the  skin  as  thin  crusts. 

Symptoms. — The  lesions  begin  as  flat  vesicles  or  blebs  which, 

in  the  course  of  twenty-four  hours  or  less,  become  vesicopustular 

or  pustular.     The  vesicles  vary  in  size  from  a  pin-head  to  a 

pea  or  larger;  they  are  not  distended,  but  exhibit  a  wrinkled, 

flaccid  appearance.     The  epidermal  covering  is  so  thin  as  to 
6 


82 


DISEASES   OP   THE   SKIN 


permit  rupture  upon  the  slightest  pressure.  Usually  there  is  no 
inflammatory  areola.  The  contents  dry  up  into  a  thin,  wafer- 
like crust  of  a  straw-yellow  color.  The  edges  of  the  crust 
become  detached  and  curl  up,  and  the  crust  has  an  appearance 
described  by  Tilbury  Fox  as  "stuck  on."  Not  infrequently 
the  center  of  the  crust  is  depressed,  producing  a  sort  of  umbili- 
cadon.  When  the  crust  is  completely  detached  and  thrown 
off,  there  is  seen  beneath  a  reddish  spot,  which  disappears  in 
the  course  of  a  few  days. 


Fig.  a?. — Impeli 


The  lesions  are  usually  discretely  scattered,  but  a  coalescence 
of  neighboring  vesicles  may  lead  to  the  formation  of  patches 
of  considerable  size.  Sometimes  the  lesions,  particularly 
under  the  influence  of  an  irritant  application,  spread  by  peri- 
pheral extension,  the  advancing  border  being  preceded  by  a 
vesicular  epidermic  undermining,  until  a  patch  the  size  of  a 
silver  quarter-dollar  is  produced. 

The  eruption  ordinarily  is  limited  to  the  exposed  surfaces — 


IMPETIGO  CONTAGIOSA  83 

the  face,  neck,  and  hands.  Other  parts  of  the  body  may  become 
affected,  particularly  in  infants.  The  contents  of  the  lesions 
are  autoinoculable  and  new  vesicles  develop  constantly  from 
digital  inoculation. 

Occasionally  the  eruption  takes  on  a  circinate,  annular, 
gyrate,  or  serpiginous  form.  Crocker  calls  this  variety  impetigo 
contagiosa  gyrata. 

In  some  cases  the  lesions  consist  of  blebs,  varying  in  size  from 
a  pea  to  a  cherry  (impetigo  contagiosa  bullosa).  Bullous  impetigo 
occurs  at  times  in  infants  and  may  become  epidemic  in  institu- 


tions. It  is  accompanied  by  fever  and  often  ends  fatally. 
Some  of  these  cases  have  been  called  acute  contagious  pem- 
phigus. 

Impetigo  simplex  is  a  name  given  by  Duhring  to  a  form  of 
impetigo  that  differs  from  the  usual  type  in  that  the  lesions  are 
primarily  pustules,  have  thick  walls,  are  globular,  and  do  n-t 
lead  to  rupture,  coalescence,  -or  umbilication.  This  form  is 
said  to  be  non-contagious.    The  t»  wenes 

and  staphylococcia  are  appropri' 
The  impetigo  of  Bockhart  is  pi 
an  alleged  peculiarity  of  the 


S4  DISEASES  OP  THE  SKIN 

are  penetrated  by  hairs  and  have,  therefore,  their  seat  at  the 
mouth  of  a  hair- follicle. 

Impetigo  complicates  nearly  all  cases  of  severe  small-pox 
during  the  stage  of  decrustation.  It  is  also  seen  at  times  in 
chicken-pox.  The  terms  impetigo  variolosa  and  impetigo  vari- 
cellosa  appear  appropriate  for  these  conditions. 

Etiology. — The  disease  appears  to  be  caused  by  inoculation 
with  the  germs  of  contagious  pus.  It  is  readily  transmissible 
from  one  individual  to  another  through  accidental  inoculation. 
Formerly  the  affection  was  seen  almost  exclusively  in  children 
of  the  poorer  classes;  it  is  not  so  rare  now  to  observe  cases  in 


barber-  shop. 


adults.  Barber-shop  transmission  is  a  fertile  source  of  the 
disease  in  men.  I  have  observed  the  disease  develop  in  twenty 
men  who  occupied  the  same  barber's  chair  on  two  successive 
afternoons.  The  infection  was  in  all  probability  transferred  to 
the  strap,  and  from  this,  each  time,  to  the  razor. 

Pediculosis  capitis,  with  its  consequent  scratching,  is  fre- 
quently causative.  In  my  experience  the  variety  associated 
with  pediculosis  is  not  apt  to  be  primarily  vesicular,  and  does 
not  appear  to  be  very  contagious.  Purulent  discharges  from 
the  eyes,  nose,  and  ears  produce  similar  lesions.  The  1 
are  disseminated  by  digital  inoculation. 


IMPETIGO   CONTAGIOSA  85 

Pathology.— Unanimity  of  opinion  does  not  exist  as  to  the 
character  of  the  exciting  organism.  Sabouraud  and  certain 
other  investigators  have  found  the  streptococcus  in  pure  culture 
or  associated  with  the  staphylococcus;  others  have  observed 
only  the  staphylococcus  aureus.  It  is  quite  possible  that  the 
primarily  vesicular  and  actively  transmissible  form  is  due  to 


Fig-  so- — Impetigo  contagit 


the  streptococcus  and  the  pustular  form,  resulting  from  pyo- 
genic infection,  to  the  staphylococcus. 

Diagnosis. — Impetigo  is  to  be  differentiated  from  pustular 
eczema,  varicella,  and  perhaps  pemphigus.  The  discreteness, 
superficiality,  flaccidity,  and  inocul ability  of  the  vesicles  are 
distinguishing  characteristics,  Pustular  eczema  occurs  in 
patches  with  a  reddened  base,  is  itchy,  and  does  not  yield  so 
promptly  to  treatment.  Varicella  is  characterized  by  smaller 
vesicles  with  reddish  areola  :  it  prefers  the  covered  surfaces, 


86  DISEASES  OF  THE  SKIN 

frequently  attacks  the  mouth,  and  is  ushered  in  with  fever. 
Pemphigus  is  a  serious  chronic  disease,  characterized  by  large, 
distended  blebs,  the  contents  of  which  are  not  inoculable. 

Prognosis.— The  disease  is  readily  curable  in  one  to  three 
weeks. 

Treatment. — The  crusts  when  bulky  should  be  anointed  with 
vaselin  and  then  gently  removed  with  soap  and  water.  Ammo- 
niated  mercury  or  calomel,  five  to  twenty  grains  to  the  ounce  of 
vaselin  or  zinc  ointment,  should  then  be  applied.  To  prevent 
autoinoculation  the  fingers  should  be  kept  away  from  the  face 


4 


Fig.   31.— Impetigo   varicellosa,   due    lo   secondary   pyogenic   infection   (Welch   and 
Schsmberg). 

and  the  following  lotion  applied  frequently,  preferably  from  an 
1  atomizer : 

I  B .  Hydrarg.  bichlorid gr.  j ; 

r  Glycerini 13J; 

■  Aquir f §ij. — M. 

I 

It  is  well  to  apply  the  lotion  during  the  day  and  the  ointment  at 
night.  Too  strong  or  irritating  applications  should  be  avoided, 
as  they  sometimes  cause  spreading  of  the  eruption. 


ECTHYMA  87 

IMPETIGO  HERPETIFORMIS 

Synonym. — Herpes  pyaemicus. 

Definition. — An  inflammatory  disease  of  the  skin,  character- 
ized by  the  appearance  of  miliary  pustules  arranged  annularly 
or  in  clusters,  attended  by  constitutional  disturbance,  occurring 
usually  in  puerperal  women,  and  generally  fatal. 

Symptoms. — The  lesions  begin  as  small,  superficial  pustules, 
which  come  out  in  successive  crops  and  are  arranged  in  groups 
which  heal  in  the  center  and  spread  by  peripheral  extension, 
often  producing  annular  patches.  In  the  course  of  several 
months  the  eruption  may  become  universal.  Elevation  of 
temperature  and  chills  accompany  each  outbreak.  Dry  tongue, 
vomiting,  diarrhea,  albuminuria,  and  delirium  are  apt  to  super- 
vene and  death  result.  The  anterior  surface  of  the  trunk,  the 
thighs,  and  inguinal  regions  are  the  seats  of  predilection.  The 
disease  is  very  rare. 

Etiology. — The  vast  majority  of  cases  have  been  observed 
in  pregnant  women.  The  process  is  looked  upon  as  pyemic 
or   septicemic   in   character. 

Prognosis. — The  disease  is  extremely  fatal.  A  few  cases 
have  recovered. 

Treatment. — General  supportive  treatment,  such  as  is 
employed  in  pyemic  and  septicemic  conditions,  is  indicated. 

ECTHYMA 

Derivation. — *Ek%/o,  a  pustule. 

Definition. — The  term  ecthyma  is  applied  to  an  eruption 
characterized  by  discrete,  flat,  deep-seated  pustules  with  broad 
inflammatory  bases.  Many  dermatologists  no  longer  look 
upon  ecthyma  as  a  distinct  disease,  but  rather  as  a  form  of 
dermic  pus-infection.  The  legs  and  thighs  are  the  seats  of 
predilection,  although  the  trunk  is  occasionally  attacked. 

Symptoms. — The  lesions  begin  as  small,  pea-sized  pustules, 
which  rapidly  increase  in  size  until  the  diameter  of  a  centi- 
meter is  attained.  They  are  discrete,  flat,  and  surrounded  by 
a  markedly  reddened  and  often  infiltrated  zone.  When 
rupture  takes  place,  an  irregular  yellowish  or  brownish  crust  is 
formed,  beneath  which  suppuration  goes  on.  Pigmentation  or 
superficial  scarring  may  persist  after  the  disappearance  of  the 
lesions.     A  rare  form  of  the  disease,  known  as  ecthyma  gangrcen- 


88  DISEASES  OP  THE   SKIN 

osutn,  is  sometimes  encountered  in  poorly  nourished  children, 
or  after  an  attack  of  one  of  the  exanthemata.  In  such  cases  the 
buttocks,  thighs,  or  inguinal  region  is  usually  attacked. 

Etiology  and  Pathology. — Debility,  bad  food,  and  improper 
hygiene  are  said  to  play  an  important  predisposing  rdle.  The 
eruption  attacks  adults  rather  than  children.  The  exciting 
cause  is,  in  all  probability,  the  introduction  of  a  microorganism 
into  the  cutaneous  follicular  openings.  It  is  evident  that 
scratching  would  greatly  facilitate  such  an  inoculation. 

Diagnosis. — Ecthyma  is  to  be  differentiated  from  con- 
tagious impetigo,  pustular  eczema,  and  the  large,  flat,  pustular 
syphiloderm. 

Ecthyma.  Impetigo  Contagiosa. 

i.  Seat   of   predilection,    the   legs.  i.  Face    and    hands. 

2.  Primarily  pustular.  ^.  Primarily  vesicular. 

3.  Pustules  deep.  3.   Pustules  superficial. 

4.  Marked  inflammatory  areola.  4.  No  inflammatory  areola. 

5.  More    common    in    adults.  5.  More  common  in  children. 

6.  Non-contagious.  6.  Contagious. 

Ecthyma.  Pustular  Eczema. 

1.  Seat    of   predilection,    the   legs.  1.  Indefinite  localization. 

2.  Pustules  discrete.  2.  Grouped,    often   coalescing. 

3.  Pustules   large    and    flat.  3.  Small  and  round  or  acuminate. 

4.  Red    and    infiltrated    areola.  4.  No  inflammatory  areola. 

5.  More  common  in  adults.  5.  More  common  in  children. 

Ecthyma  may  be  distinguished  from  the  pustular  syphilo- 
derm by  the  more  inflammatory  character  of  the  lesions,  the 
absence  of  true  ulceration,  the  distribution  of  the  lesions,  and 
the  absence  of  other  signs  of  syphilis. 

Prognosis. — The  affection  responds  satisfactorily  to  appro- 
priate treatment. 

Treatment. — Tonics,  good  food,  and  improved  hygiene  are 
to  be  advised.  The  local  treatment  consists  of  the  removal  of 
the  crusts  and  the  application  of  an  ointment,  such  as  the 
following: 

fc.    Ichthyol Tltxxx-3j; 

Hydrarg.  ammoniat gr.  xx ; 

Ung.  zinci  oxidi 3J. — M. 


• 


DERMATITIS  HERPETIFORMIS  89 

DERMATITIS  HERPETIFORMIS 
Synonyms. — Duhring's  disease;  Hydroa;  Herpes  gest at ionis. 

Definition. — Dermatitis  herpetiformis  is  an  inflammatory 
disease  of  the  skin,  characterized  by  grouped,  erythematous, 
papular,  vesicular,  pustular,  or  bullous  lesions,  occurring  in 
varied   combinations,   accompanied   by   burning  and   itching 


FJg.  ii. — Dermatitis  herpetiformis 


and  running  a  chronic  course  with  remissions.  According  to 
Duhring,  more  or  less  well-defined  prodromata,  consisting  of 
malaise,  chilliness,  febrile  disturbance,  and  constipation,  are 
apt  to  precede  the  cutaneous  outbreak  in  severe  cases. 

Symptoms. — Itching  may  be  complained  of  before  the  erup- 
tion appears.  The  eruption  may  appear  gradually  or  suddenly; 
often  within  a  few  days  it  has  covered  a  considerable  area. 

The  erythematous,  vesicular,  bullous,  pustular,  and  multi- 
form eruptions  are  the  common  varieties  of  the  disease.  There 
is  a  distinct  tendency  for  one  variety  to  pass  into  another 
variety — for  instance,  the  *•  r  form  may  become  pustular 

or  bullous,  or  the  Burning  and  itching 

>n  some  cases  are 


90  DISEASES  OP  THE  SKIN 

Erythematous  Variety. — This  form  occurs  in  marginate 
patches  or  diffuse  efflorescences  resembling  erythema  multi- 
forme. Urticaria-like,  edematous  infiltrations  may  also  occur. 
The  color  may  be  raspberry-red,  mottled,  and  tinged  with 
yellowish,  brownish,  or  variegated,  with  later  a  variable  degree 
of  pigmentation.  Erythematopapular  and  vesicular  lesions 
often  coexist.     Itching  and  burning  are  marked. 

Vesicular  Variety. — This  is  the  most  common  form.  It  is 
marked  by  pin-head-  to  pea-sized,  flat  or  raised,  irregularly 
shaped  or  stellate,  distended  vesicles,  frequently  without  an 
inflammatory  areola.  They  are  usually  aggregated  in  clusters 
of  three  or  four  lesions.  They  tend  often  to  coalescence,  but 
not  to  rupture.  Itching  is  severe,  often  intense,  but  abates 
considerably  upon  rupture  or  laceration  of  the  vesicles.  The 
eruption  comes  out  in  crops,  which  often  succeed  each  other 
with  great  rapidity. 

Bullous  Variety. — The  lesions  consist  of  distended,  irregular- 
shaped,  angular  bullae,  occurring  in  groups  of  three  or  more, 
often  without  areola.  Small  pustules  frequently  appear  in  the 
neighborhood,  and  erythematous  and  vesicular  lesions  may 
likewise  be  present.     Itching  and  burning  are  severe. 

Pustular  Variety. — Two  kinds  of  pustules  appear:  the  one 
small  (miliary),  pin-point-  to  pin-head-sized,  and  perfectly 
flat;  the  other  large,  elevated,  rounded  or  acuminated,  and 
situated  upon  an  inflammatory  base.  There  is  a  tendency  to 
arrangement  in  clusters  of  three  or  four.  Vesicles  and  blebs 
may  complicate  the  eruption,  although  the  pustular  type 
often  remains  as  such,  even  throughout  successive  outbreaks. 
Papular  lesions  remaining  as  such  occur  with  great  variety. 

Papular  Variety. — This  variety  is  the  mildest  expression  of 
the  disease.  More  commonly,  papulovesicles  resembling  abor- 
tive herpes  lesions  develop. 

Multiform  Variety. — This  is  a  polymorphous  form,  in  which 
erythematous  patches,  papules,  vesicles,  blebs,  pustules,  and 
pigmentation,  in  various  combinations,  are  commingled. 

The  course  of  dermatitis  herpetiformis  is  variable,  but  in 
nearly  all  cases  is  eminently  chronic,  lasting  for  years  in  the 
form  of  relapses,  or,  indeed,  at  times  continuously.  Commonly 
a  few  lesions  persist  during  the  periods  of  relative  freedom. 

Etiology. — The  disease  occurs  most  often  between  the  ages 
of  thirty  and  sixty.  It  is  due  to  various  causes,  among  which 
may  be  mentioned  physical  or  psychic  shock,  pregnancy,  dis- 


DERMATITIS  HERPETIFORMIS  9 1 

ordered  menstruation,  puerperal  septicemia,  gastro-intestinal 
disorders,  and  renal  insufficiency;  the  nervous  system,  how- 
ever, is  directly  responsible  for  the  cutaneous  manifestations. 
There  is  in  most  cases  a  lowering  of  the  general  nerve-tone. 

Pathology. — There  is  an  acute  inflammation  of  the  papillary 
layer  of  the  corium,  with  the  formation  of  vesicles  between  the 
corium  and  epidermis  and  the  exudation  of  large  numbers  of 
polymorphonuclear  leukocytes  and  eosinophiles.  The  epider- 
mis is  but  secondarily  involved.  Eosinophilia  is  present  in  the 
vast  majority  of  cases;  it  is  not,  however,  peculiar  to  this 
disease. 

Diagnosis. — The  polymorphism  and  herpetiformity  of  the 
eruption,  the  intense  itching,  and  the  history,  course,  and 
chronicity  of  the  disease  will  enable  one  to  distinguish  it  from 
pemphigus,  erythema  multiforme,  and  impetigo  herpetiformis — 
diseases  which  it  at  times  closely  resembles. 

The  vesicles  and  blebs  of  dermatitis  herpetiformis  are  peculiar 
in  that  they  are  often  of  markedly  irregular  outline — sometimes 
stellate,  quadrate,  or  oblong,  etc.  In  drying  they  are  apt  to 
present  a  puckered  appearance. 

They  are  herpetiform  in  that  they  occur  in  groups,  have 
inflammatory  bases,  and  do  not  tend  to  spontaneous  rupture, 
resembling  in  these  respects  the  lesions  of  herpes  zoster. 

Prognosis. — Guarded.  The  disease  is  often  persistent  and 
refractory  to  treatment.  In  addition,  there  is  a  strong  tendency 
to  recurrence.  In  rare  cases  the  pustular  or  bullous  type  may 
prove  fatal. 

Treatment. — The  first  effort  should  be  directed  toward  the 
removal  or  modification  of  the  underlying  cause,  if  ascertain- 
able. The  nervous  system  is  in  most  cases  at  fault,  and 
remedies  should  be  administered  with  a  view  to  restoring  the 
normal  nerve-tone.  There  are  no  specifics,  but  arsenic  often 
acts  in  a  gratifying  manner.  In  several  cases  of  the  vesicular 
and  bullous  variety  under  my  care  the  eruption  could  be 
completely  controlled  by  the  use  of  arsenic  in  fairly  large  doses. 
It  should  be  given  in  ascending  doses  by  mouth,  if  well  borne; 
if  not,  hypodermically  until  an  impression  is  made  upon  the 
disease  or  upon  the  patient.  In  other  cases,  however,  it  is  of 
no  value.  Phenacetin,  cannabis  Indica,  and  belladonna  may 
be  tried,  and  such  tonics  as  quinin,  strychnin,  and  iron  are 
sometimes  of  value. 

Local  Treatment. — Blebs  should  be  incised  or  punctured  and 


92  DISEASES  OP  THE  SKIN 

the  contents  evacuated.  Lotions  containing  tar,  carbolic 
acid,  ichthyol,  and  resorcin  are  useful.  They  may  be  fol- 
lowed by  an  ointment  of  salicylic  acid.  Duhring  advises  in 
the  vesicular  and  pustular  forms  (particularly  the  chronic) 
the  use  of  a  strong  sulphur  ointment,  well  rubbed  in. 

PEMPHIGUS 

Derivation. — Xlefitptg,  a  blister. 

Definition. — Pemphigus  is  an  acute  or  chronic  inflammatory 
disease  of  the  skin,  characterized  by  the  formation  of  successive 
crops  of  variously  sized,  rounded  or  oval  blebs,  affecting 
seriously  the  general  health  and  often  terminating  fatally. 

Symptoms. — There  are  two  principal  types  of  the  disease — 
pemphigus  vulgaris  and  pemphigus  foliaceus.  Some  authors 
add  pemphigus  vegetans  and  pemphigus  neonatorum. 

Pemphigus  Vulgaris. — The  cutaneous  outbreak  is  usually, 
though  not  always,  preceded  or  accompanied  by  some  systemic 
disturbance  consisting  of  chills,  fever,  malaise,  etc.  The  blebs 
may  appear  upon  previously  pale  skin  or  a  reddish  spot  may 
indicate  the  site  of  the  developing  blister.  The  lesions  vary  in 
size  from  a  pea  or  a  hazel-nut  to  a  walnut  or  larger.  They  rise 
abruptly  from  the  skin,  and  while  having  at  times  a  slightly 
reddened  base,  have  no  areola.  Thev  are  usuallv  round  or 
oval  in  shape.  The  blebs  are  distended  with  a  clear,  serous 
fluid,  which  later  becomes  turbid  or  even  puriform.  At  times 
a  reddish  tint  develops  as  a  result  of  some  hemorrhage  into  the 
bleb. 

The  eruption  occurs  in  crops  which  may  recur  from  time  to 
time  for  an  indefinite  period.  Each  outbreak  is  apt  to  be 
accompanied  by  renewed  febrile  symptoms.  The  number  of 
lesions  may  vary  from  a  half-dozen  to  several  score.  The 
bullae  persist  from  three  or  four  days  to  a  week  or  longer,  the 
fluid  disappearing  by  absorption  if  accidental  rupture  does  not 
take  place. 

The  parts  most  affected,  in  the  order  of  their  frequency, 
are  the  limbs,  the  face,  and  the  trunk.  The  mouth,  vagina, 
conjunctiva,  and  other  mucous  membranes  may  become 
involved. 

The  disease  in  some  cases  runs  a  more  or  less  acute  course, 
getting  well  in  a  few  months.  Far  more  frequently,  however, 
it  persists  for  years,  greatly  impairing  the  general  health. 


PEMPHIGUS  93 

Pemphigus  Acutus. — There  is  an  acute  form  of  pemphigus 
(so  called)  which  runs  a  rapid  and  usually  febrile  course,  ter- 
minating in  death  or  recovery  within  a  fortnight  to  a  month. 
The  more  favorable  cases  occur  in  children  and  are  rare. 

Within  recent  years  a  number  of  malignant  and  fatal  cases 
have  been  reported,  more  particularly  in  England,  in  butchers 
and  others  coming  in  contact  with  animals,  who  have  suffered 
some  trivial  wound.  The  blebs  develop  in  a  week  to  a  month, 
appearing  first,  as  a  rule,  in  the  neighborhood  of  the  wound, 
which  is  commonly  on  the  hand.  Subsequent  research  will 
doubtless  prove  these  cases  to  be  due  to  a  direct  parasitic 
infection,  entitling  the  affection  to  be  regarded  as  a  disease 
SM»  generis. 

A  number  of  writers  have  described  a  form  of  the  acute 
disease    appearing   in   infants  a   short    time    after   birth,    and 


tended  blebs. 


frequently  occurring  in  epidemics  in  institutions;  to  this  variety 
the  term  pemphigus  neonatorum  has  been  applied.  It  is 
probable  that  many  of  these  cases  are  really  instances  of 
bullous  impetigo,  for  contagion  appears  to  play  the  essential 
role. 

Pemphigus  Foliaceus. — This  variety  may  develop  from 
common  pemphigus  or  may  appear  primarily  as  a  distinct  type. 
In  this  form  the  blebs,  which  are  flaccid  and  purulent,  rupture 
before  distention  and  dry  to  crusts,  which  are  thrown  off  with 
the  surrounding  epidermis,  exposing  to  view  the  reddened 
mucous  layer.  A  new  crop  of  blebs  succeeds  the  old,  often 
developing  upon  the  same  site,  and  giving  to  the  skin  the  appear- 


94  DISEASES  OP  THE  SKIN 

ance  of  a  severe  scald.  The  entire  cutaneous  surface  may  thus 
become  involved  and  the  general  health  seriously  compromised. 
The  process  lasts  for  months  or  years,  and  almost  always  leads 
to  a  fatal  termination,  often  through  complications  of  the 
intestinal  or  respiratory  mucous  membranes. 

Neumann  has  described  a  rare  form  of  pemphigus  charac- 
terized by  the  development  of  wart-like  or  papillary  vegetations 


upon  the  sites  of  ruptured  bulla?.  This  form  he  has  called 
pemphigus  vegetans.  The  mouth,  vagina,  or  other  mucous 
membranes  are  often  first  affected.  The  favorite  situations 
upon  the  skin  are  the  genital  and  anal  regions,  the  neck,  axilla?, 
and  flexures  of  the  extremities.  The  affection  may  be  rapidly 
fatal  or  may  last  for  months,  ultimately  terminating  in  death. 
The   subjective   symptoms  in   pemphigus  are   usually   not 


PEMPHIGUS  95 

pronounced.     There  may  be  moderate  itching  and  burning, 
and  in  some  cases  tension  and  soreness. 

Pemphigus  is  a  rare  disease.  In  this  country  about  one 
case  is  seen  among  every  700  of  miscellaneous  skin  diseases. 
Many  bullous  affections  that  should  be  classed  elsewhere  are 
called  pemphigus  by  those  unskilled  in  diagnosis. 

Etiology. — The  causes  of  pemphigus  are  involved  in  obscur- 
ity. The  disease  has  been  observed  in  many  cases  in  which 
marked  changes  in  the  central  and  peripheral  nervous  systems 
were  noted.  In  addition,  chilling  of  the  body,  mental  strain, 
nervous  exhaustion,  and  a  lowered  or  vitiated  state  of  the 
general  health  are  considered  to  be  causative.  A  number  of 
acute  cases  have  occurred  after  wound  infections ;  it  is  probable 
that  the  organism  of  sepsis  may  be  causative.  The  action  of 
toxins  from  various  sources  on  nerve  structure  appears  to 
explain  best  the  phenomena  of  the  disease. 

Pathology. — The  blebs  are  usually  situated  between  the 
horny  layer  and  the  rete  mucosum,  but  may  occur  at  any  depth 
in  the  epidermis.  The  contents  of  the  bullse  consist  of  a  slightly 
alkaline  serum  containing  a  few  leukocytes.  There  are  dilata- 
tion of  the  papillary  vessels  and  a  leukocytic  infiltration  of  the 
papillae,  corium,  and  subcutaneous  tissue. 

Demm£,  Whiphouse,  and  others  have  found  diplococci  in 
the  contents  of  blebs ;  the  former  also  noted  their  presence  in  the 
blood.     A  high-grade  hemic  eosinophilia  is  commonly  observed. 

Diagnosis. — It  must  be  recognized  at  the  outset  that  every 
bullous  eruption  does  not  constitute  pemphigus.  A  clear 
conception  of  the  disease  would  lessen  the  liability  to  error. 
The  essential  features  of  the  disease  are  the  development  of 
crops  of  blebs  distended  with  serum,  springing  up  from 
the  healthy  integument  without  any  pronounced  areola,  and 
running  a  chronic  course  with  recurrences.  In  dermatitis 
herpetiformis  there  is  much  greater  itching,  the  lesions  are 
polymorphous,  there  is  pronounced  tendency  to  grouping,  and 
the  general  health  is  not  much  compromised.  Erythema 
multiforme  runs  an  acute  course,  prefers  the  extensor  surfaces 
of  the  extremities,  exhibits  multiform  lesions,  and  the  blebs, 
when  present,  rise  from  an  erythematous  base.  In  the  bullous 
form  of  contagious  impetigo  a  history  of  contagion,  the  inocula- 
bility  of  the  fluid,  and  the  presence,  somewhere  on  the  surface 
of  typical  lesions,  will  enable  one  to  recognize  the  picture. 
Blebs  may  occur  in  syphilis,  leprosy,  urticaria,  etc.,  but  these 
diseases  are  easilv  differentiated. 


96  DISEASES  OP  THE  SKIN 

Prognosis. — The  course  of  the  disease  is  uncertain.  Mild 
cases  may  recover  after  a  duration  of  months.  Severe  cases, 
particularly  pemphigus  foliaceus  and  pemphigus  vegetans,  are 
apt  to  end  fatally.  The  occurrence  of  flaccid  or  hemorrhagic 
blebs,  extensive  cutaneous  involvement,  frequent  outbreaks, 
or  constitutional  depression  are  all  unfavorable  signs. 

Treatment. — Both  internal  and  local  treatment  are  to  be 
employed,  the  former  alone,  however,  being  curative.  Arsenic 
is  by  far  the  most  valuable  remedy.  It  is  to  be  perseveringly 
tried,  beginning  with  small  doses  and  increasing  until  the 
physiologic  limit  is  reached.  Quinin  in  full  doses  is  also  of 
value,  as  are  at  times  iron,  strychnin,  and  cod-liver  oil.  Nutri- 
tious food,  good  hygiene  and  bodily  and  mental  rest  are 
important  therapeutic  factors. 

Local  treatment  is  designed  to  heal  the  abraded  surfaces 
and  to  relieve  the  subjective  symptoms.  The  blebs  should  be 
evacuated,  and  simple  dusting- powders,  ointments,  or  lotions 
applied.  The  calamin  lotion  is  a  most  grateful  application. 
Bran  and  starch  baths  are  useful  in  extensive  cases.  In  grave 
forms  of  pemphigus  the  continuous  warm  bath  is  perhaps 
the  best  treatment,  the  patient  living  day  and  night  for  weeks 
and  months  immersed  in  water. 

EPIDERMOLYSIS  BULLOSA  HEREDITARIA 

Synonyms. — Congenital  traumatic  pemphigus;  Aeantholysis  bullosa. 

Epidermolysis  bullosa  is  a  rare  disease,  characterized  by  the 
rapid  formation  of  blebs  of  various  size  following  the  slightest 
traumatism.  The  disease  usually  develops  in  infancy  or  early 
childhood  and  persists  until  late  in  life.  There  is  in  most  cases 
a  distinct  history  of  heredity ;  in  some  instances  the  tendency 
is  transmitted  through  several  generations.  In  Bonaiuto's  case 
the  disease  manifested  itself  in  five  generations.  Valentine  re- 
ported eleven  cases  occurring  in  four  generations.  Not  all  cases, 
however,  give  a  hereditary  history.  In  early  infancy  or  child- 
hood it  is  noted  that  the  slightest  physical  violence,  such  as 
the  pressure  of  a  shoe,  the  weight  of  the  elbow  on  the  table, 
the  friction  of  clothing,  the  grasping  of  a  firm  object,  is  capable 
of  determining  the  rapid  formation  of  a  bleb.  The  bullae  vary 
in  size  irom  a  pea  to  a  silver  dollar;  they  are  irregular  in  shape, 
and  often  of  a  claret  color,  due  to  hemorrhage  into  the  fluid 


EPIDERMOLYSIS   BULLOSA   HEREDITARIA 


97 


contents.     The  disappearance  of  the  bleb  is  often  followed  by 
a  certain  degree  of  atrophy  of  the  skin. 

The  areas  attacked  are  those  most  subject  to  injury,  such  as 
the  hands,  feet,  elbows,  knees,  anterior  surfaces  of  the  legs, 
etc.  The  finger-nails  are  often  permanently  lost  as  a  result  of 
involvement  of  the  matrices  of  the  nails.     The  skin  of  the 


fingers  is,  at  times,  furrowed  and  atrophic.  In  the  patient 
shown  in  the  accompanying  photograph  superficisJ  ulcerations 
occurred  upon  the  legs  at  the  sites  of  ruptured  blebs. 

The  etiology  and  pathology  are  both  obscure.  It  is  believed 
that  there  is  an  excessive  sensitiveness  of  the  vasomotor  nerves 
and  blood-vessels  of  the  skin.     Elliott  described  degenerative 


98  DISEASES  OP  THE   SKIN 

changes  in  the  rete  mucosum  just  above  the  basal  layer.     Eng- 
man  and  Mook  have  noted  the  absence  of  elastic  tissue. 

Treatment  thus  far  has  been  of  no  avail.  I  used  the  x-rays 
over  the  affected  areas  in  a  patient  without  any  permanent 
improvement. 

POMPHOLYX 

Derivation. — TlofijdXvg,  a  bubble.  Synonyms. — Cheiropompholyx ;  Dysi- 
drosis. 

Definition. — Pompholyx  is  an  acute  inflammatory  disease 
of  the  skin,  characterized  by  the  development  of  numerous 
hard,  deep-seated  vesicles  upon  the  hands  and  feet,  and  occa- 
sionally upon  contiguous  surfaces. 

Symptoms. — The  affection  attacks  symmetrically  the  hands 
and  feet,  although  the  latter  may  escape  involvement.  When 
the  hands  are  involved,  closely  aggregated,  deep-seated,  tense 
vesicles  are  seen  upon  the  lateral  aspects  of  the  fingers  and  upon 
the  palms.  They  have  been  aptly  likened  to  boiled  sago- 
grains  embedded  in  the  skin.  A  feeling  of  heat,  burning,  ting- 
ling, or  itching  is  nearly  always  present.  The  vesicles  may 
remain  discrete  or  mav  coalesce  and  form  bullae;  these  some- 
times  reach  the  size  of  a  cherry  or  larger.  The  fluid  often 
becomes  absorbed,  and  the  vesicles  and  blebs  dry  up  in  the 
course  of  a  few  days  or  a  week.  New  lesions  may,  however,, 
continue  to  appear,  the  surrounding  skin  becoming  sodden 
and  painful,  later  exfoliating.  There  is  not  infrequently  an  ac- 
companying hyperidrosis.  Recurrences  are  quite  common,  par- 
ticularly in  the  warm  months ;  the  different  attacks  vary  greatly 
in  intensity.     Constitutional  symptoms  are,  as  a  rule,  absent. 

Etiology. — The  affection  is  most  common  in  early  and  middle 
adult  life;  it  is  more  frequent  in  women  than  in  men.  The 
disease  is  especially  observed  in  persons  whose  nervous  system 
is  lowered  in  tone.  Overwork,  loss  of  sleep,  excessive  worri- 
ment,  etc.,  may  precipitate  attacks. 

Pathology. — The  disease  is  generally  regarded  as  a  vaso- 
motor neurosis.  Tilbury  Fox,  Crocker,  and  others  believe 
that  the  lesions  are  in  anatomic  relation  with  the  sweat-struc- 
tures; on  the  other  hand,  Hutchinson,  Robinson,  and  their 
followers  declare  that  the  disease  does  not  involve  the  sweat- 
apparatus,  but  is  an  inflammatory  dermatosis  related  to  herpes 
and  pemphigus.  The  clinical  phenomena  rather  support  the 
former  view.     The  vesicles  and  blebs  lie  in  the  lower  layers  of 


HYDROA   VACCINIFORME  99 

the  rete  mucosum*  their  contents  are  of  neutral  or  alkaline 
reaction. 

Diagnosis. — Kaposi  held  that  the  disease  was  in  reality  an 
acute  eczema.  There  are  many  cases  in  which  it  is  most  diffi- 
cult to  differentiate  this  disease  from  vesicular  eczema  of  the 
hands,  and  some  cases  in  which  a  typical  pompholyx  of  the  hands 
is  associated  with  eczema  in  other  regions.  The  following  are  the 
most  important  points:  the  circumscription  of  the  lesions  to 
the  lateral  digital  and  palmar  surfaces,  the  tendency  of  the 
vesicles  to  persist  unruptured,  the  absence  of  surface  discharge, 
the  mild  grade  of  the  inflammatory  reaction,  the  predominance 
of  burning  over  itching,  and  the  course  of  the  disease. 

Prognosis. — Ordinary  attacks  are  usually  well  at  the  end 
of  a  fortnight.     Recurrences  are  extremely  common. 

Treatment. — The  general  health  of  the  patient  requires 
careful  attention.  Good  hygiene  and  nutritious  diet  are 
important  considerations.  Tonics,  such  as  arsenic,  iron, 
strychnin,  quinin,  and  cod-liver  oil,  are  often  indicated. 
Locally,  the  following  formula  may  be  employed : 

R.    Acidi  salicylic!  1 

Acidi  phenici     (  6       ' 

Pulv.  amyli  \  --      ... 

Pul  v.  zinci  oxidi  J    °  J ' 

Vaselini £iv. — M. 

Saturated  solution  of  picric  acid  often  does  well,  followed 
after  a  few  days  by  a  mild  ointment.  Diachylon  ointment, 
oleate  of  zinc,  and  similar  remedies  are  at  times  useful.  I  have 
found  the  x-rays  of  value  in  persistent  or  recurrent  cases. 

HYDROA  VACCINIFORME  (HYDROA  AESTIVALE) 

Synonyms. — Recurrent  summer  eruption  (Hutchinson) ;  Hydroa  puero- 
rum  (Unna). 

Definition. — This  is  a  recurrent  vesicular  affection  of  child- 
hood, occurring  chiefly  in  the  summer  months  and  prone  to 
produce  scars. 

Symptoms. — The  disease  begins  usually  during  the  first  few 
years  of  life,  and  tends  to  disappear  at  or  about  puberty.  The 
lesions  develop  particularly  upon  the  exposed  surfaces,  such  as 
the  face*.    At  fin*  spots,  with  accompanying 

burnt  "tag  in  size  from  a  pin- 


IOO  DISEASES  OF  THE  SKIN 

head  to  a  pea,  spring  up;  the  vesicles  may  dry  up,  form  crusts, 
or  may  acquire  a  ringed  vesicular  or  pustular  border  and  de- 
pressed center,  resembling  a  vaccine  lesion.  In  the  last-named 
form  the  central  crust,  when  thrown  off,  discloses  to  view  a 
reddish  scar,  which  ultimately  becomes  white.  In  some  cases 
extensive  scarring  may  be  produced. 

The   eruption  develops  in  crops  in   the   summer   months; 
during  the  winter  the  eruption  is  in  abeyance,  save  in  excep- 


Fig.  36.— Hydr 


tional  cases,  in  which  it  may  be  worse  during  the  cold  period. 
It  is  thought  that  the  heat-rays  of  summer  and  occasionally 
the  cold  winds  of  winter  are  responsible. 

Treatment. — The  results  of  treatment  are  in  general  unsat- 
isfactory. The  face  should  be  protected  from  the  solar  rays 
and  from  the  impact  of  winds.  Mild  applications,  such  as  the 
calamin  lotion,  are  useful. 


HERPES   SIMPLEX  IOI 

HERPES   SIMPLEX 

Derivation. — 'E/nrav,  to  creep.     Synonyms. — Fever-blister;  "Cold  sore," 

Definition.— Herpes  simplex  is  an  acute,  inflammatory  dis- 
ease of  the  skin,  characterized  by  the  formation  of  small  groups 
of  closely  aggregated  vesicles  upon  reddened  bases. 

Symptoms. — There  are  two  chief  varieties,  according  to 
localization:  (i)  herpes  facialis  and  (2)  herpes  genitalis. 

Herpes  facialis  has  its  favorite  scat  near  the  oral  commissures 
and  upon  the  lips  (herpes  labialis),  although  it  may  occur  any- 
where upon  the  face,  neck,  or  ears.  Herpetic  lesions  may  also 
appear  upon  the  tongue  and  the  buccal  mucous  membrane, 
where  they  are  called  by  the  laity   "canker  sores."     When 


Herpes  lahialis. 


associated  with  fever,  the  condition  is  commonly  called  herpes 
jebrilis.  The  lesions  consist  of  closely  aggregated  pin-head- 
sized  and  larger  vesicles,  which,  through  coalescence,  often 
form  flat  blebs.  The  lesions  are  grouped  in  distinct  clusters, 
which  are  seated  upon  an  inflammatory  base.  The  vesicles 
become  pustular,  rupture  or  desiccate,  and  are  converted  into 
yellowish  or  brownish  crusts.  Red  stains  are  often  left  after 
detachment  of  the  crusts  and  occasionally  slightly  depressed 
scars. 

The  clusters  sometimes  appear  in  crops  at  an  interval  of 
twelve  or  twenty-four  hours.     Burning  and  itching  are  often 
present.     Not  infrequently  there  is  a  marked  * 
rence.     Some  patients  suffer  attacks  of  fat 
or  more  times  a  year. 


IOZ  DISEASES  OP  THE    SKIN 

Herpes  genitalis  (herpes  progenitalis  or  praputialis)  occurs 
both  in  males  and  in  females.  The  groups  of  vesicles  in  the 
former  are  located  upon  the  inner  surface  of  the  prepuce,  upon 
the  glans  penis,  or  upon  the  shaft  of  the  penis.  In  women  the 
favorite  seats  are  the  labia  majora  and  minora  and  the  vesti- 
bule. In  these  locations  they  may,  through  subsequent  in- 
fection, become  the  sites  of  chancres  or  chancroids. 

Etiology. — Herpes  facialis  may  result  from  gastro- intestinal 
derangement,  coryza,  and  many  infectious  processes.  It  occurs 
in  about  one-third  of  all  cases  of  pneumonia  and  malaria,  and  in 
almost  one-half  of  the  cases  of  cerebrospinal  meningitis.     In 


Fig,  j8. 


influenza  it  has  been  found  in  about  6  per  cent,  of  the  cases. 
In  typhoid  fever  and  in  the  exanthemata  it  is  relatively  rare. 

Rolleston  found  simple  herpes  in  3  per  cent,  of  cases  of 
diphtheria  and  in  12  per  cent,  of  cases  of  pseudodiphtheria. 

The  impact  of  cold  winds  and,  on  the  other  hand,  strong 
solar  rays  appear  capable  in  some  individuals  of  exciting  re- 
peated attacks. 

In  herpes  genitalis  a  long  and  adherent  prepuce  is  alleged  to 
act  as  a  predisposing  cause.     Excessive  genital   irritation   is 


HERPES   ZOSTER  103 

regarded  as  causative  in  many  instances;  it  is  more  common  in 
prostitutes  than  in  chaste  women. 

Pathology. — The  structural  nerve  changes  in  herpes  simplex 
are  not  definitely  determined,  but  recent  studies  would  indicate 
that  they  closely  resemble  those  found  in  herpes  zoster. 
Howard,  of  Cleveland,  found  in  a  case  of  facial  herpes  profound 
changes  in  the  Gasserian  ganglion.  It  is  probable  that  the 
attacks  accompanying  infectious  processes  are  due  to  the 
influence  of  a  toxin  upon  nerve-structures.  Certain  diseases 
seem  to  produce  such  an  "herpetogenic  "  toxin  more  readily 
than  others. 

Prognosis. — The  eruption  spontaneously  disappears,  but 
some  patients  are  subject  to  recurrences. 

Treatment. — In  recurrent  cases  the  long-continued  use  of 
small  doses  of  arsenic  has  been  advised.  Where  the  face  is 
repeatedly  attacked,  protection  of  this  part  from  cold  winds  by 
the  use  of  a  veil  should  be  counseled. 

In  herpes  genitalis  thorough  cleanliness  and  the  avoidance 
of  sexual  excitement  are  indicated.  In  both  forms  the  follow- 
ing lotion  will  be  found  useful  in  expediting  the  disappearance 
of  the  lesions : 

H .    Resorcin 3 j ; 

Acidi  borici i\; 

Glycerini TTl,xl ; 

Zinci  oxidi £ij ; 

Alcoholis f^j; 

Aquae q.  s.  ad  f3vj. — M. 

HERPES  ZOSTER 

Derivation. — 'Epmiv,  to  creep;  ZwH/p,  a  girdle.  Synonyms. — Shingles; 
Zoster;  Zona;  Cingulum. 

Definition. — Herpes  zoster  is  an  acute  inflammatory  disease 
of  the  skin,  characterized  by  the  formation  of  grouped  vesicles 
over  the  area  of  distribution  of  cutaneous  nerves,  and  accom- 
panied by  neuralgic  pains. 

Symptoms. — After  prodromal  neuralgic  pains,  more  or  less 
severe  in  character,  there  appear  in  crops  irregular  groups  of 
pin-head-to  pea-sized  vesicles,  which  follow  in  an  interrupted 
manner  the  distribution  of  the  nerve  or  nerves  affected.  When 
seen  early,  macules,  papules,  or  papulovesicles  may  sometimes 
be  distinguished.  The  vesicles  rest  upon  a  highly  inflammatory 
base.  The  eruption  is  distinctly  unilateral,  bilateral  cases 
being  of  great  rarity. 


io4 


DISEASES  OP  THE  SKIN 


In  the  course  of  some  days  the  vesicles,  which  do  not  tend  to 
spontaneous  rupture,  dry  upon  the  skin  as  yellowish-brown 
crusts  and  fall  off.  As  a  rule,  no  permanent  trace  is  left, 
although  in  some  cases  there  may  be  considerable  scarring. 
The  vesicles  may  become  pustular,  hemorrhagic,  or  even  gan- 
grenous. There  is  nearly  always  enlargement  of  the  neighbor- 
ing lymphatic  glands. 

The  most  frequent  regions  affected  are  those  supplied  by  the 
intercostal,  lumbar,  and  trifacial  nerves,  although  any  portion 
of  the  cutaneous  surface  may  be  involved.     In  herpes  zoster 


Fig-  39-— Severe  herpes 


and  upper  poni 


ophthalmicus  severe  destructive  inflammation  of  the  cornea, 
iris,  and,  indeed,  of  the  entire  eye,  may  occur  in  rare  cases. 

Pain  is  nearly  always  present.  It  may  be  slight  or  so  severe 
as  to  prevent  sleep.  It  is  variously  described  as  of  a  darting, 
burning,  drawing,  or  tugging  character.  It  may,  especially 
in  elderly  people,  persist  indefinitely  after  the  disappearance 
of  the  eruption,  and  may  prove  most  refractory  to  treatment. 


HERPES   ZOSTER 


106  DISEASES  OF  THE  SKIN 

In  rarer  instances  persistent  itching  in  the  affected  areas  may 
continue  after  the  disappearance  of  tlie  eruption.  In  children, 
the  pain  is  usually  slight  or  absent.  * 

In  severe  cases  febrile  disturbances  maybe  present.  Herpes 
zoster  seldom  occurs  twice  in  the  same  individual.  There  are 
a  number  of  recurrent  cases  on  record,  many  of  which,  however, 
present  peculiar  features  and  are  not  typical  .cases. 

Etiology. — The  disease  is  said  to  occur  more  frequently  in 
winter  and  spring,  although  my  own  personal  experience  does 
not  indicate  any  special  seasonal  tendency.  Of  156  cases 
observed  at  the  Polyclinic  Hospital  during  the  course  of  about 
eight  years,  the  monthly  incidence  has  been  as  follows: 

January :  1 3       July 19 

February 15       August 10 

March 12       September ._.  13 

40  42 

April 11        October 12 

May .   8       November 16 

June 16       December ri 

35  39 

Total 156 

Atmospheric  changes,  exposures  to  wet  and  cold,  mechanical 
violence  to  nerve  structure  (such  as  may  result  from  injury, 
surgical  operations,  pressure  of  tumor,  etc.),  are  all  considered 
causative.  The  long-continued  use  of  arsenic  has  produced 
typical  zoster  in  a  considerable  number  of  cases.  Herpes 
zoster  may  be  associated  with  pleuritic  and  pulmonary 
affections.  Curtin  and  Watson  and  others  have  observed 
zoster  occurring  during  the  course  of  influenza;  malaria  may 
likewise  act  as  a  cause.  Neligan,  Kaposi,  Weis,  and  others 
have  noted  apparent  epidemicity  of  the  disease.  It  seems 
probable  that  herpes  zoster,  when  not  traumatic,  is  an  infec- 
tious process,  due  to  the  action  of  toxins  developed  from  varied 
sources. 

Pathology. — Zoster  is  due  essentially  to  an  irritative  or 
inflammatory  lesion  of  sensory  nerve  structure  in  any  part  of 
its  course  from  the  spinal  cord  to  the  integument.  Commonly, 
the  sensory  ganglia  on  the  posterior  roots  of  the  spinal  cord  are 
affected,  or  their  analogue,  the  Gasserian  ganglion.  Head  and 
Campbell  describe  the  process  as  an  acute  posterior  poliomye- 
litis.    In  such  cases  a  descending  interstitial  neuritis  develops. 


HERPBS  zoster 


107 


In  other  cases  there  may  be  a  simple  inflammation  of  the 
peripheral  nerves. 

In  the  cutaneous  lesions  during  vesiculation  a  peculiar  epithe- 
lial degeneration  occurs,  which  Uiina  has  described  as  "balloon- 
ing" and  "reticulating  colliquation."  This  process  is  similar 
to  that  seen  in  the  vesicles  of  small-pox  and  chicken-pox. 
Peculiar  epithelial  cell  inclusions,  formerly  suspected  of  being 
protozoa,  are  frequently  found. 

Diagnosis. — Herpes  zoster  has  such  characteristic  features 
that  it  is  one  of  the  easiest  of  all  cutaneous  diseases  to  recognize. 
A  unilateral  eruption,  consisting  of  groups  of  large  vesicles  upon 
an  erythematous  base,  following  the  course  of  cutaneous  nerves, 


. — Herpes  zoster — interroslaJ. 


and  accompanied  or  preceded  by  neuritic  pains,  is  character- 
istic of  herpes  zoster.  The  vesicles  of  zoster  differ  from  those 
of  eczema  in  being  larger  and  in  showing  little  tendency  to 
spontaneous  rupture. 

Prognosis. — Favorable.  Most  cases  get  well  spontaneously 
in  one  to  three  weeks.  It  should  not  be  forgotten  that  some 
cases  are  followed   by  persistent  neuralgia,  especially   in   the 


108  DISEASES  OF  THE   SKIN 

aged,  and  others  may  lead  to  scarring,  or,  in  the  case  of  the 
ophthalmic  form,  to  serious  impairment  or  loss  of  vision. 

Treatment. — Local  treatment  is  concerned  merely  in  pro- 
tecting the  parts  from  injury  and  infection  and,  to  a  certain 
extent,  in  the  relief  of  pain.  Ordinary  dusting  powders,  such 
as  zinc  oxid,  starch,  talcum,  etc.,  may  be  employed,  or,  if  there 
is  much  pain,  morphin  and  camphor  may  be  added.  The  part 
may  then  be  protected  with  absorbent  cotton  and  a  bandage. 

An  excellent  method  is  to  paint  the  affected  areas,  when  not 
too  extensive  and  when  not  occupying  flexures,  with  collodion 
containing  ichthyol : 

U .    Ichthyol 2j; 

Collodii £  j.— M. 

The  galvanic  current  mildly  applied  along  the  nerve  often 
gives  marked  relief  from  pain. 

Internal  Treatment — The  pain  is  often  so  severe  as  to  require 
the  use  of  an  anodyne.  The  following  prescription  will  be 
found  of  service : 

U .    Codeinse  sulphat gr.  \ ; 

Phenacetin gr.  ij ; 

Quiniae  sulphat gr.  j. — M. 

Sic — One  capsule  every  four  hours  or  oftener. 

The  treatment  of  herpes  zoster  with  zinc  phosphid  in  one- 
third  of  a  grain  doses  every  three  hours  is  warmly  advocated 
by  some.  In  the  neuralgia  persisting  after  the  disappearance 
of  the  eruption  antipyrin,  quinin,  iron,  strychnin,  arsenic,  and 
the  galvanic  current  are  of  value.  In  several  cases  recently 
treated  I  have  obtained  rapid  amelioration  of  the  pain  from 
the  use  of  the  x-rays. 

LICHEN  PLANUS 
Synonym. — Lichen  ruber  planus.     Derivation. — Ae/xl7A  a  lichen  or  moss. 

m 

Definition. — Lichen  planus  is  an  inflammatory  disease  of 
the  skin,  characterized  by  small,  flat,  angular,  red  or  bluish- 
red,  shining  papules,  tending  at  times  to  coalescence  forming 
patches,  and  accompanied  by  a  variable  amount  of  itching. 

Formerly  lichen  planus  and  lichen  acuminatus  were  con- 
sidered as  different  varieties  of  the  same  disease.  There  is 
general  agreement  now  that  the  latter  is  identical  with  the 
pityriasis  rubra  pilaris  of  Devergie. 

Symptoms. — The  disease  begins  as  pin-point-  to  pin-head-sized 


LICHEN    PI^NUS  log 

reddish  papules,  which  soon  acquire  an  angular,  polygonal, 
or  faceted  contour.  The  papules  are,  furthermore,  flat  and 
shining,  particularly  when  viewed  in  proper  light.  A  small 
depression  or  umbilication  is  seen  in  many  lesions,  as  a  rule, 
due  to  the  presence,  in  the  center  of  the  papule,  of  a  glandular 
orifice.  In  color,  the  eruption  varies  from  a  pinkish-red  during 
the  evolutionary  period,  to  a  dull  bluish-red,  violaceous,  or 
purple  tint.  The  surface  of  the  papule  has  a  grayish  trans- 
lucence,  and  often  exhibits,  upon  close  scrutiny,  grayish  trails 
or  striae.  As  a  rule,  no  distinct  scaling  is  present.  The  lesions 
may  be  discrete  and  disseminated,  but  are  more  commonly 
closely  aggregated  in  groups  or  patches.  In  rare  cases  there 
is  a  tendency  to  annular  arrangement  of  the  papules,  a  variety 
which  has  been  designated  lichen  planus  annularis.     At  times 


the  papules  are  arranged  in  linear  patches;  when  a  beaded 
linear  arrangement  predominates,  the  term  liclten  ruber  monili- 
formis is  employed.  New  papules  may  follow  scratch -marks 
and  other  trauma,  and  thus  some  linear  arrangement  may  be 
accounted  for. 

The  favorite  seat  of  the  eruption  is  the  flexor  surfaces  of  the 
wrists  and  arms;  the  abdomen,  legs,  and  back  of  the  hands  are 
also  often  attacked.  In  extensive  cases  large  areas  of  the  body 
surface  may  be  affected.  It  is  not  rare  to  note  whitish  patches 
and  streaks  upon  the  buccal  mucous  membrane  and  at  times 
upon  the  tongue. 

Upon  the  legs,  the  form  most  commonly  seen  is  that  termed 
lichen    planus    hypertrophicus.     The    papules  are  large — often 
pea-sized— and  are  more  elevated  and  less  angular.     They  t* 
to  coalesce  and  form  raised  patches  of  variable  size, 
patches  are  infiltrated,  scaly,  and  often  verrucous.  The 


HO  DISEASES    OF   THE    SKIN 

lose  their  individual  outlines,  and  only  far  out  upon  the  peri- 
phery can  lesions  characteristic  of  the  disease  be  seen.  The 
color  of  the  patches  is  violaceous,  bluish,  or  lilac  tinted,  often 
with  a  surrounding  pigmented  zone. 

Itching  is,  in  the  majority  of  cases,  a  prominent  and  annoying 
symptom.  In  some  cases,  however,  it  may  be  slight  or  absent. 
On  the  other  hand,  it  may  be  so  intense  as  to  be  scarcely  bear- 
able. 

Lichen  planus  is,  as  a  rule,  slow  in  both  evolution  and  involu- 
tion. The  eruption  comes  out  gradually.  Its  duration  is 
variable,  lasting  weeks,  months,  or,  more  rarely,  years.  Re- 
lapses occur  at  times,  but  distinct  second  attacks  are  un- 
common. 


Fig.   44. — Lichen   planus   in    hypertrophic   patches.     Primary    discrete    papules   not 


When  the  eruption  disappears,  a  brownish  pigmentation 
Is  usually   left,   which   slowly   fades. 

The  general  health,  as  a  rule,  is  not  seriously  disturbed.  I 
have  observed,  however,  coincident  with  attacks,  a  consider- 
able falling  off  in  the  body  weight. 

Etiology. — The  disease  is  nearly  always  of  neurotic  origin. 
The  most  common  cause  is  nervous  exhaustion  from  anxiety, 
grief,  overwork,  and  all  forms  of  mental  strain.  Digestive 
disturbances  seem  to  be  causative  in  some  cases.  Lichen  planus 
is  essentially  a  disease  of  adult  life,  and  is  rare  in  children. 

Pathology. — The  pathologic  process  consists  of  a  circum- 
scribed lymphoid  cell-infiltration  in  the  papillary  layer  of  the 
corium.    The  papule  is  usually  situated  about  a  sweat-duct. 


LICHEN  PLANUS  ,  III 

although  a  hair-follicle  may  occupy  the  center.  There  is  a 
hypertrophy  of  the  cells  of  the  rete  mucosum  (acanthosis), 
followed  by  epithelial  atrophy  and  colloid  degeneration.  Hyper- 
keratosis or  overgrowth  of  the  horny  layer  is  commonly  asso- 
ciated. 

Diagnosis. — The  characteristic  features  of  the  papules  of 
lichen  planus  are  their  angularity,  flatness,  shining  surface, 
violaceous  color,  and  umbilication. 

These  peculiarities,  with  the  distribution  of  the  eruption  on 
the  wrists,  abdomen,  and  legs,  and  the  absence  of  antecedent 
moisture,  will  distinguish  this  disease  from  eczema.  The  infil- 
trated plaques  on  the  legs  may  be  confounded  with  eczema 
or  psoriasis,  but  their  purple  or  lilac  tint  and  the  frequent 
presence  of  outlying  discrete  papules  will  help  clarify  the  diag- 
nosis. 

Prognosis. — The  prognosis  is  favorable,  but  the  eruption 
often  lasts  for  weeks,  months,  or  even  longer. 

Treatment. — The  treatment  is  both  general  and  local. 
Attention  to  hygiene  and  diet  is  often  of  importance.  Arsenic 
has  been  for  many  years  viewed  with  special  favor  in  the  treat- 
ment of  lichen  planus.  It  often  fails,  however;  it  is  chiefly 
indicated  in  the  subacute  and  chronic  cases./  Mercury  is  fre- 
quently of  value,  and  is  in  many  cases  an  excellent  substitute 
for  arsenic.  The  two  preparations  may  be  administered  in 
combination  in  the  form  of  Donovan's  solution.  Crocker  is 
fond  of  using  salicin  in  fifteen-  to  twenty-grain  doses  in  sub- 
acute and  chronic  cases. 

Chlorate  of  potash,  dilute  nitric  acid,  and  quinin  have  also 
been  advised  in  obstinate  cases.  Change  of  climate  sometimes 
effects  a  cure. 

Local  Treatment — Applications  containing  tar,  carbolic  acid, 
menthol,  salicylic  acid,  mercury,  etc.,  act  most  favorably.  A 
lotion  of  phenol  and  the  tincture  of  mineral  tar  is  useful  in 
relieving  itching.  The  following  formula,  suggested  by  Unna, 
may  be  heartily  indorsed : 

R .    Hydrargyri  bichloridi gr.  j-ij; 

Acidi  phenici gr.  xv; 

Lanolini  |  ._      .        xt 

Vaselini  \ **  3™— M. 

In  indolent  plaques  on  the  legs  strong  remedies  are  necessary. 
I  have  employed  a  chrysarobin  ointment,  twenty  to  forty 
grains  to  the  ounce,  with  good  results. 

The  s-rays  are  valuable  in  many  cases. 


112  DISEASES   OF    THE   SKIN 

LICHEN  RUBER  ACUMINATUS  (PITYRIASIS  RUBRA  PILARIS) 

Synonyms. — Lichen  ruber  (Hebra) ;  Pityriasis  rubra  pilaire  (Devergie). 

Definition. — Lichen  ruber  acuminatus,  or  pityriasis  rubra 
pilaris,  is  a  mildly  inflammatory  disease,  characterized  by 
small,  conical,  dry  papules  with  horny  centers,  occurring  at  the 
mouths  of  hair-follicles,  running  a  chronic  course  and  tending 
to  gradual  extension.  The  three  cardinal  features  of  the 
eruption  are:  (i)  Horny  follicular  papules;  (2)  pityriasic 
desquamation;  (3)  exaggeration  of  natural  folds  of  skin.  The 
disease  usually  develops  gradually,  although  less  commonly 
the  eruption  may  appear  with  considerable  rapidity. 

The  palms,  soles,  scalp,  or  face  may  be  the  first  areas  involved. 
Upon  the  palms  and  soles  there  may  be  roughness  and  scaling 
and  generalized  redness.  The  scalp,  when  first  attacked, 
presents  the  appearances  of  a  dry  seborrhea.  On  the  face, 
fine  adherent  scales  are  observed  in  the  frontal,  orbicular,  and 
nasolabial  regions.  The  characteristic  lesions  of  the  disease 
are  small,  conical  or  acuminated,  hard,  dry  papules  which  are 
located  at  the  sites  of  hair-follicles.  These  are  of  a  pale  yellow, 
pale  red,  or  duller  hue.  The  papules  are  pierced  by  hairs, 
many  of  which  are  of  the  fine  lanugo  variety.  A  horny  sheath 
surrounds  the  hair  and  penetrates  the  follicular  opening. 
Many  papules  have  a  distinct  horny  plug  in  the  center  which, 
when  removed,  leaves  a  crateriform  depression. 

In  well-pronounced  cases  the  eruption  involves  large  areas 
of  cutaneous  surface.  The  lesions  may  coalesce  and  form 
patches  which  exhibit  a  goose-flesh  or  nutmeg-grater  appear- 
ance, or  they  may  be  covered  with  fine  adherent  grayish  scales 
or  larger,  flaky  lamellae.  The  face  may  be  .whitish,  with  fatty 
scales,  or  red,  branny,  and  infiltrated,  the  latter  condition  often 
producing  an  ectropion.  Around  the  joints  the  folds  of  the 
skin  are  considerably  exaggerated,  and  a  resemblance  to  ichthy- 
osis is  sometimes  presented. 

A  highly  significant  feature  from  a  diagnostic  point  of  view 
is  the  presence,  upon  the  backs  of  the  first  digital  phalanges, 
of  a  number  of  horny  black  points  or  plugs  occupying  the 
hair-follicles.  A  similar  condition  may  sometimes  be  seen  at 
the  nape  of  the  neck.  The  nails  are  often  affected,  being  gray- 
ish or  yellowish  and  softened  or  striated. 

Itching  may  be  present,  but  it  is  usually  not  a  pronounced 
symptom.  The  course  of  the  disease  is  chronic,  with  a  tendency 
to  exacerbations.     Some  cases  terminate  in  pityriasis  rubra. 


LICHEN    RUBER   ACUMINATUS  1 13 

The  general  health  is  ordinarily  not  impaired.  Long- 
standing and  severe  or  acute  wide-spread  attacks  may  termi- 
nate in  death.  Hebra's  cases  were  of  unusual  severity  and 
fatality,  but  such  cases  are  rare  now. 


—Pityriasis  rubra  pil: 


Etiology. — The  cause  of  the  disease  is  involved  in  complete 
obscurity.  It  attacks  more  commonly  children  and  young 
adults. 

Pathology. — The  horny  papule  is  produced  by  comification 
of  the  epithelial  strata  about  the  orifices  of  the  hair -follicles ; 


114  DISEASES  OF  THE   SKIN 

the  essential  lesion  is,  therefore,  a  follicular  hyperkeratosis. 
In  long-standing  cases  chronic  inflammatory  changes  in  the 
corium  are  observed. 

Diagnosis. — The  disease  is  to  be  distinguished  from  psoriasis, 
lichen  planus,  pityriasis  rubra  (Hebra),  and  in  mild  cases  from 


Fig.  46.  —Pityriasis  rubra  pilaris 


ichthyosis.     The  presence  of  horny  black  follicular  plugs  upon 
the  backs  of  the  fingers  is  highly  characteristic. 

Prognosis. — The   disease   runs  an   extremely  slow   course, 
sometimes  ending  in  recovery,  although  commonly  persisting 


RESISTANT    SCALY    ERYTHRODERMIAS  115 

for  an  indefinite  period.     Cases  apparently  cured  may  suffer 
recurrence.     A  fatal  outcome  is  nowadays  rare. 

Treatment. — The  treatment  in  general  is  that  employed 
in  psoriasis.  Measures  directed  toward  the  general  health 
should  not  be  neglected.  Arsenic,  mercury,  pilocarpin,  thyroid 
extract,  and  tonics  are  advised.  Locally,  alkaline  baths, 
salicylic  acid,  tar,  pyrogallic  acid,  chrysarobin,  and  the  like 
are  to  be  used,  depending  upon  the  stage  of  the  disease. 


RESISTANT  SCALY  ERYTHRODERMIAS 

The  above  title,  similar  to  that  suggested  by  Fox  and  McLeod, 
applies  to  a  number  of  dermatoses  described  under  various 
designations,  but  closely  allied  in  their  clinical  and  histologic 
appearances.  In  this  group  may  be  included — (1)  Parakera- 
tosis variegata;  (2)  e>ythrodermie  pityriasique  en  plaques 
diss£minees  (Brocq) ;  (3)  pityriasis  lichenoides  chronica  (Julius- 
berg)  ;  (4)  dermatitis  psoriasiformis  nodularis  (Jadassohn) ; 
(5)  lichenoid  psoriasiform  exanthem  (Neisser).  Brocq  has 
given  the  designation  parapsoriasis  to  this  group,  and  Crocker 
includes  them  under  the  term  lichen  variegatus. 

Parakeratosis  variegata  begins  usually  as  pin-point-  to 
pin-head-sized  reddish  macules  or  papules,  somewhat  sug- 
gesting lichen  planus.  They  are  covered  with  a  fine  adherent 
scale.  The  lesions  tend  to  coalesce,  as  a  result  of  which  a  pecu- 
liar network  arrangement  is  produced.  The  color,  which 
varies  from  a  pinkish  to  a  bluish-red,  and  the  retiform  appear- 
ance together  give  the  integument  the  marbled  or  variegated 
effect  so  characteristic  of  the  disease.  Almost  any  part  of 
the  body  may  be  affected.  Subjective  sensations  are  absent. 
The  disease  is  refractory  to  treatment. 

£rythrodermia  pityriasique  en  plaques  disseminees 
occurs  on  the  trunk,  extremities,  and  less  commonly  the  face, 
as  non-elevated,  pale-red  patches  of  a  round  or  oval  shape. 
They  are  covered  by  a  fine,  furfuraceous  scaling.  Older 
patches  may  present  a  brownish  or  mahogany  tint.  The 
disease  runs  over  a  period  of  years  and  is  obstinate  to  all 
treatment.  There  are  no  subjective  disturbances.  Seborrheic 
eczema  and  pityriasis  rosea  are  Simula***1  :-  «■*«»  beginning. 
In  a  case  of  this  kind  under  my  o**  ^s 

underwent  involution  and  wer 
skin. 


DISEASES   OP   THE   SKIN 


PROGRESSIVE  PIGMENTARY  DERMATOSIS 

In  1901  the  author  published  a  description  of  an  affection 
beginning  as  pin-head,  reddish  puncta  or  dots  forming  irregular 
patches  which  slowly  extend  by  the  formation  of  new  lesions 
upon  the  periphery.  The  patches  are  irregular  in  shape, 
smooth,   non-elevated,   of  a   reddish-brown    or   burnt-sienna 


Fig.  48.  —  Progressive 
pigmentary  disease.  Same 
patient    as    Fig.    47    [old 


color.  The  border  of  the  patches  was  made  up  of  puncta  closely 
resembling  grains  of  Cayenne  pepper,  although,  perhaps,  of  a 
slightly  darker  tint;  they  had  somewhat  of  a  telangiectatic  ap- 
pearance.    The  patches   in  the   course  of  time  disappeared, 


PRURIGO  117 

leaving  behind  brownish-yellow  or  reddish-brown  pigmentations 
which  slowly  faded.  The  process  was  extremely  slow,  and  the 
patches  may  remain  practically  unchanged  for  several  years. 

The  disease  involved  both  wrists  and  both  legs  from  the  ankle 
to  the  knee.  The  affection  was  progressive,  a  constant  spread 
taking  place  for  a  period  of  five  years.  Spontaneous  involution 
occurred  in  the  oldest  areas,  some  of  which  were  ultimately  re- 
stored to  their  normal  condition.  There  was  entire  absence  of 
subjective  symptoms.     The  patient  was  a  boy  fifteen  years  old. 

The  pathologic  process  had  its  chief  seat  in  the  subpapillary 
layer  of  the  corium,  with  greatest  intensity  in  the  immediate 
neighborhood  of  the  sweat-ducts.  There  was  pronounced 
cell -infiltration  about  the  blood-vessels.  In  the  region  of  the 
sweat-ducts  the  cells  were  arranged  much  in  the  manner  of 
hanging  branches  of  a  palm-tree.  No  pigment-cells  or  free 
pigment-granules  were  found.  The  specimen  examined,  how- 
ever, was  a  recent  lesion  from  the  border  of  the  patch. 

PRURIGO 

Derivation. — L.,  prurire,  to  itch. 

Definition. — Prurigo  is  an  inflammatory  disease  of  the 
skin,  characterized  by  the  occurrence  of  pin-head-  to  lentil- 
seed-sized,  flesh-tinted  or  pale-red  papules,  occurring  chiefly 
upon  the  extensor  surfaces  of  the  extremities,  beginning  in 
infancy  or  early  childhood,  lasting  for  years  or  through  a 
lifetime,  and  accompanied  by  intense  itching.  The  term 
prurigo  is  here  confined  to  the  disease  described  under  that 
title  by  Hebra;  some  of  the  older  writers  have  loosely  applied 
the  designation  "prurigo"  to  a  variety  of  itching  dermatoses. 

Symptomatology. — According  to  the  severity  of  the  disease, 
two  tvpes  are  distinguished — prurigo  ferox  (severe  prurigo) 
and  prurigo  mitis  (mild  prurigo). 

The  disease  begins  usually  in  the  first  year  of  life,  not  infre- 
quently taking  the  form  of  an  ordinary  urticaria.  Later,  there 
appear  upon  the  extensor  surfaces  of  the  legs  and  arms,  the 
trunk,  and  sometimes  the  forehead,  pin-head-sized  or  larger 
discrete,  firm  papules.  These  may  be  pale  red  or  may  possess 
the  natural  color  of  the  skin.  The  itching  is  intense,  as  a 
result  of  which  the  affected  areas  are  covered  with  scratch 
excoriations  and  blood-crusts.  After  a  time  the  skin  becomes 
harsh,    dry.    greatly   thickened,    and    sometimes    pigmented. 


Il8  DISEASES  OF  THE   SKIN 

The  natural  furrows  of  the  skin  are,  after  a  time,  greatly  exag- 
gerated. 

The  neighboring  lymphatic  glands,  particularly  those  in 
the  inguinal  regions,  are  often  so  markedly  enlarged  as  to  be 
apparent  to  the  eye. 

The  disease  is  extremely  rebellious,  and  may  persist  for  years 
or  even  throughout  the  entire  lifetime  of  the  individual.  It  is 
apt    to   undergo   spontaneous   improvement   in    the    summer 

season. 

Prurigo  is  chiefly  encountered  in  Austria;  the  true  prurigo 

of  Hebra  is  rarelv  seen  in  this  country. 

Etiology  and  Pathology. — The  disease  is  engendered  by 
the  environment  of  "misery" — poor  food,  bad  hygiene,  etc. 
It  is  largely  limited  to  the  poorer  classes.  Tuberculosis  is 
regarded  by  some  as  a  causative  factor. 

The  microscopic  changes  are  those  of  a  chronic  inflammation, 
and  practically  identical  with  those  seen  in  long-standing 
papular  eczema. 

Diagnosis. — The  disease  is  chiefly  to  be  distinguished  from 
a  chronic  papular  eczema.  The  extreme  rarity  of  prurigo  in 
this  country  should  be  borne  in  mind.  Attention  to  the  locali- 
zation and  character  of  the  papules,  their  uniform  appearance, 
the  marked  adenopathy,  the  chronic  and  refractory  course, 
and  the  origin  of  the  disease  in  early  childhood  will  usually 
render  the  diagnosis  easy. 

Prognosis. — Severe  cases  often  persist  for  a  life-time.  Milder 
cases  may,  under  judicious  treatment,  be  cured.  Some  cases 
get  spontaneously  well  around  the  age  of  puberty. 

Treatment. — The  therapeutic  indications  are  to  relieve 
the  intense  itching,  to  effect  a  disappearance  of  the  eruption, 
and  to  improve  the  general  health.  Nutritious  food  and 
proper  hygiene  are  essentials.  Tonics,  such  as  iron,  cod-liver 
oil,  and  the  hypophosphites,  are  often  indicated.  Arsenic  is 
of  little  or  no  value.  Crocker  recommends  for  the  relief  of  the 
itching  the  tincture  of  cannabis  indica,  beginning  with  five- 
minim  doses— in  a  child  of  eight,  for  instance — and  increasing 
to  the  physiologic  limit. 

Locally,  ointments  of  betanaphthol,  sulphur  (one  dram  to 
the  ounce),  and  tar  are  of  value.  The  Wilkinson  salve,  con- 
taining tar,  sulphur,  and  green  soap,  is  distinctly  useful. 
Kaposi  strongly  advocates  the  following: 


ACNE  II9 

H  •    Betanaphthol gr.  x-xxx; 

Petrolati lj.— M. 

Sig. — Rub  in  each  night. 

Baths  are  extremely  useful,  particularly — (1)  The  alkaline 
bath  (sodium  bicarbonate,  4  ounces  to  30  gallons  of  water) 
and  (2)  the  sulphur  bath  (precipitated  sulphur  or  potassium 
sulphid,  4  ounces  to  30  gallons  of  water). 


LICHEN  SCROFULOSUS  SEU  SCROFULOSORUM 

Definition. — Lichen  scrofulosus  is  a  chronic  inflammatory 
disease,  characterized  by  millet-seed-sized,  flat,  reddish  or 
yellowish,  more  or  less  grouped,  scaly  papules,  occurring  in 
scrofulous  subjects. 

Symptoms. — The  disease  occurs  in  young  individuals  exhib- 
iting other  evidences  of  the  scrofulous  diathesis.  The  papules, 
which  are  scattered  over  the  chest  and  abdomen,  have  their 
origin  about  the  hair-follicles.  They  are  pin-head-sized,  pale- 
red  or  yellowish,  somewhat  scaly,  and  tend  to  become  aggregated 
in  groups.     Itching  is  absent. 

The  course  of  the  disease  is  chronic,  lasting  for  years.  The 
disease  is  rare. 

The  eruption  is  supposed  to  be  due  to  the  toxins  of  the 
tubercle  bacillus.  The  organisms  themselves  are  ordinarily 
not  found  in  the  lesions. 

The  disease  must  be  differentiated  from  the  miliary  papular 
syphilid,  papular  eczema,  and  lichen  planus.  The  distinction 
can,  as  a  rule,  be  made  without  difficulty. 

Treatment. — Good  food  and  proper  hygiene  are  indicated. 
Cod-liver  oil,  used  both  internally  and  externally,  will  usually 
effect  a  cure. 

ACNE 

Derivation. — 'Am/,  a  point.     Synonym. — Acne  vulgaris. 

Definition. — Acne  is  an  inflammatory  disease  occurring  in 
and  around  the  sebaceous  glands,  characterized  by  papules, 
tubercles,  or  pustules,  affecting  chiefly  the  face,  and  running  a 
more  or  less  chronic  course. 

Acne  is  an  extremely  common  disease,  comprising  over  7 
per  cent,  of  all  dermatoses.  It  is  much  more  common  in  private 
practice  than  among  hospital  cases.  It  is  essentially  a  disease 
of  youth,  and  is  usually  seen  in  the  second  decade  ^r 


120  DISEASES   OF   THE   SKIN 

although  it  is  not  uncommon  in  the  first  half  of  the  third 
decade. 

Symptoms. — The  forehead,  cheeks,  and  chin  are  the  regions 
usually  affected,  although  the  chest,  shoulders,  and  back  are 
not  infrequently  involved.  The  lesions  are  papular,  pustular, 
or  nodular,  or  a  combination  of  these  may  be  present.  They 
are  irregularly  scattered  over  the  surface,  without  any  definite 
tendency  to  grouping.  The  primary  lesions  are  pin-head-  to 
lentil-sized,  bright  or  dark-red  papules,  appearing  about  the 
orifices  of  the  sebaceous  ducts.     After  a  period  of  a  few  days 


or  a  week  the  lesions  either  become  pustular  and  discharge, 
or  undergo  absorption,  leaving  behind  reddish  stains  or,  in 
some  cases,  scars.  A  new  crop  succeeds  the  old,  the  affection 
thus  continuing  for  months  or  years.  The  eruption  is  seen  in 
various  stages  in  the  same  patient,  papules,  pustules,  stains, 
etc.,  being  present  at  the  same  time. 

Blackheads,  or  comedones,  are  an  essential  part  of  the 
disease.  The  bluish -black  color  is  due  somewhat  to  dust 
accretions  from  without,  but  more  to  chemical  changes  in  the 
sebum.  Not  infrequently  small  white  pin-head-sized  promi- 
nences are  present;    these  represent  collections  of  sebaceous 


ACNE  121 

material  which  may  be  expressed  in  thread-like  filaments. 
The  blackheads  usually  eventuate  in  acne  papules  or  pustules 
unless  they  are  mechanically  removed.  The  number  of  come- 
dones varies  in  different  cases,  being  sometimes  abundant  and 
at  other  times  present  only  in  small  numbers.  When  they  are 
numerous,  there  is  usually  a  concomitant  oily  seborrhea  which 
renders  the  skin  greasy  and  facilitates  the  deposition  of  aerial 
dust. 


For  purposes  of  teaching  various  designations  have  been 
given  to  acne  eruptions  presenting  certain  characteristics. 
When  the  predominant  eruption  is  represented  by  small  conical 
elevations  with  central  sebaceous  openings  containing  dark 
points,  the  term  acne  punctata  is  applied.  Acne  papulosa  is 
characterized  by  pin-head-sized  or  larger  reddish. 
papules.  When  the  latter  suppurate,  they 
pustulosa.    The  variety  with  numerous  small  1 


122  DISEASES  OF  THE   SKIN 

in  very  young  girls  and  boys,  and  is  particularly  refractory  to 
treatment. 

In  acne  indurata  the  lesions  are  nodular,  deep  seated,  and 
often  painful.  In  their  inception  they  can  be  better  felt  than 
seen.  Soon  the  overlying  skin  assumes  a  deep-red  or  purplish 
coloration ;  the  sebaceous  duct  being  obstructed  or  obliterated, 
there  is  no  follicular  opening.  This  condition  is  popularly 
called  a  "blind  boil.,,  Suppuration  and  rupture  gradually 
take  place,  although  the  lesions  may  remain  as  an  indurated 
nodule  for  some  time.  When  these  deep  lesions  are  punctured 
with  a  fine  bistoury,  frank  pus  or  inspissated  sebum  is  always 
evacuated;  this  effects  a  disappearance  of  the  lesions.  When 
the  inflammatory  process  affects  several  adjacent  glands, 
the  suppurating  lesions  may  coalesce,  forming  cherry-  to  hazel- 
nut-sized sebaceous  abscesses.  These  deep  acne  nodules  lead 
to  considerable  scarring,  particularly  if  left  to  spontaneous 
evacuation. 

Acne  artificialis  is  a  papular  or  pustular  eruption  produced 
by  the  internal  administration  of  the  iodids  and  bromids  or 
external  exposure  to  tar  (tar  acne)  or  paraffin. 

Acne  cachecticorum  is  an  acne  occurring  usually  upon  the 
trunk  and  extremities  of  tuberculous,  scorbutic,  or  anemic 
subjects.  The  eruption  consists  of  large  suppurating  lesions, 
often  with  a  purplish  color,  due  to  the  presence  of  blood. 
There  is  a  distinct  tendency  to  scarring.  This  form  of  acne  is 
due  to  the  depraved  condition  of  the  patient's  health  and  may 
continue  into  adult  life. 

The  subjective  symptoms  in  acne  are  extremely  mild. 
Itching  and  burning  are  usually  absent,  but  in  some  cases  exist 
in  a  mild  degree.  The  large  indurated  lesions  are  often  painful 
or  rather  tender  to  the  touch. 

The  course  of  acne  is  chronic,  the  disease,  untreated,  tending 
to  last  for  months  or  years.  In  girls,  periodic  aggravation 
occurs  with  great  constancy  before,  during,  or  after  each 
menstruation.  Spontaneous  improvement  commonly  takes 
place  between  the  ages  of  twenty-five  and  thirty. 

Etiology. — Puberty  is  the  most  potent  predisposing  cause, 
the  vast  majority  of  cases  of  acne  occurring  between  the  ages 
of  fifteen  and  twenty-five;  after  thirty  acne  is  extremely 
uncommon. 

There  are  several  theories  regarding  the  causation  of  acne. 
One  supposes  that  acne  is  largely  a  local  skin  disease  and  that 


ACNE  123 

it  is  but  little  influenced  by  internal  conditions  and  internal 
treatment.  It  is  held  that  there  is  a  follicular  hyperkeratosis 
which  obstructs  the  hair-follicles  and  sebaceous  glands  and 
leads  to  sebaceous  retention,  inflammation,  and  suppuration. 
The  influence  of  special  microorganisms  is  recognized  by  many 
of  the  advocates  of  this  view. 

According  to  another  theory,  internal  disorders,  particularly 
those  related  to  the  alimentary  tract,  play  an  important  rdle 
in  the  production  of  acne. 

Acne  is  a  local  disease,  but  there  can  be  no  question  that 
it  is  influenced  by  systemic  conditions.  I  have  seen  a  severe 
and  persistent  acne  develop  after  an  attack  of  typhoid  fever 
in  a  young  woman  of  twenty-four  who  had  previously  never 
had  acne.  The  question  for  solution  is  whether,  in  ordinary 
cases,  the  local  or  general  causes  are  dominant. 

The  great  pilosebaceous  development  occurring  at  puberty 
is  easily  subject  to  pathologic  perversion.  There  may  be  an 
enervation  of  glandular  activity  as  a  result  of  dyspepsia, 
constipation,  uterine  or  menstrual  disorders,  anemia,  tuber- 
culosis, general  debility,  etc.  As  a  result  of  glandular  indo- 
lence, sebaceous  retention  and  obstruction,  with  their  train  of 
consequences,  may  develop.  Or  it  is  possible  that  the  general 
causes  referred  to  merely  render  the  skin  and  its  contained 
glands  favorable  seats  for  the  maintenance  and  growth  of 
certain  microorganisms. 

Unna,  Sabouraud,  and  Gilchrist  have  each  described  a 
bacillus  which  is  regarded  by  the  discoverer  as  the  cause  of 
acne.  Sabouraud' s  organism,  the  microbacillus  of  seborrhea, 
is  found  in  myriads  in  comedones  and  in  sebaceous  filaments. 
Staphylococci  are  generally  believed  to  cause  the  suppuration 
of  lesions. 

Pathology. — An  acne  lesion  pathologically  is  represented  by 
a  folliculitis  or  perifolliculitis.  There  is  an  engorgement  of  the 
surrounding  blood-vessels  and  an  intense  cell-infiltration.  The 
process  ends  in  resorption  or  suppuration,  with  or  without  the 
destruction  of  the  follicle. 

Diagnosis. — The  diagnosis  of  acne  is,  as  a  rule,  unattended 
with    difficulty.     Even    the    layman    recognizes    a    case    of 
"  pimples.' '     The  presence  of  discrete  papules,  pustules,  black- 
heads, and  enlarged  pores  upon  the  face  1*  #H" 
history  of  origin  at  puberty  and  rela 
the  picture. 


124  DISEASES  OF  THE   SKIN 

The  papulopustular  syphilid  may  be  readily  distinguished  by 
its  generalization,  acuteness,  and  the  presence  of  associated 
symptoms.  Acne  commonly  develops  in  syphilitics  who  are 
taking  the  iodids. 

Prognosis. — Nearly  all  cases  of  acne  may  be  cured  by  one 
means  or  another. 

Treatment. — The  treatment  is  both  constitutional  and  local. 
There  are  no  internal  remedies  which  exert  a  direct  action  upon 
acne.  Some  patients  are  in  such  excellent  health  that  no  inter- 
nal treatment  is  at  all  indicated.  In  general,  the  constitutional 
treatment  should  be  directed  toward  the  correction  of  systemic 
derangements. 

Dyspepsia  and  constipation  frequently  call  for  treatment. 
For  the  former,  the  bitter  tonics,  mineral  acids,  and  alkalis 
may  be  used,  according  to  the  exigencies  of  the  case.  Con- 
stipation may  be  combated  by  diet,  abdominal  massage  and 
exercises,  and  the  various  laxatives.  A  pill  of  aloin,  strychnin, 
and  belladonna,  blue-mass  or  calomel,  cascara  sagrada,  the 
salines,  etc.,  are  all  useful. 

The  following  is  an  admirable  combination  for  coexisting 
anemia  and  constipation  (Startin) : 

ft .    Ferri  sulphat gr.  xvj ; 

Magnes.  sulphat 3J; 

Acidi  sulphur,  dil f^j ; 

Aquae  menth.  pip q.  s.  ad  f.^iv. — M. 

Sig. — Tablespoonful  in  a  goblet  of  water  a  half-hour  before  break- 
fast. 

A  more  palatable  combination,  useful  in  the  same  class  of 
patients,  is  the  following: 

H .    Strychnia?  phosphat g^r.  j ; 

Ferri  pyrophosphat gr.  xlvuj-lxxij; 

Sodii  phosphat 3J ; 

Syrupi  aurantii  \  --  adf-vi— M 

Aqua  )    aa    q'  s'  aa  '« VJ*     M* 

Sig. — Two  fluidrams  in  water  before  meals. 

The  laxative  mineral  waters,  such  as  Hunyadi  Janos,  Cara- 
bana,  Pluto,  and  Saratoga,  may  also  be  employed. 

In  cases  attended  with  much  pustulation  the  sulphid  of  cal- 
cium, in  one-tenth  to  one-half  grain  doses  four  times  daily,  is 
said  to  be  servicable,  but  in  my  experience  has  never  been  pro- 
ductive of  results.  Ferruginous  preparations  are  of  value  in 
cases   complicated   by   chloroanemia.     Cod-liver   oil   and  the 


ACNE  125 

hypophosphites  are  indicated  in  strumous  and  rachitic  patients. 
Small  doses  of  arsenic,  strychnin,  and  mercury  bichlorid  are 
advised  in  individuals  with  lowered  nerve  tone. 

Hygienic  measures,  such  as  cold  baths,  outdoor  exercise,  and 
regular  life,  are  more  important  than  the  use  of  drugs.  In 
many  cases  dietary  restriction  is  necessary.  Highly  seasoned 
foods,  tea,  coffee,  pastries,  salt  meats,  and  alcoholic  beverages 
are  to  be  avoided  and  starchy  and  sugary  food  limited. 

Local  Treatment — The  object  of  local  treatment  is  to  hasten 
the  disappearance  of  existing  lesions  and  to  stimulate  the 
sebaceous  glands  to  healthy  action. 

The  nature  of  the  remedies  to  be  employed  depends  upon  the 
amount  of  inflammatory  reaction  present.  In  the  vast  majority 
of  cases  stimulating  applications  are  indicated.  Occasionally, 
however,  the  face  is  hyperemic  and  tender  and  requires  the  use 
of  sedative  lotions  and  salves. 

Before  the  local  remedies  are  applied,  the  face  should  be 
thoroughly  washed  with  soap  and  hot  water,  with  a  view  to 
opening  up  the  follicles.  For  this  purpose  ordinary  soap  may 
be  employed,  or  in  sluggish  cases  soft  soap  or  the  tincture  of 
green  soap.  Sulphur,  salicylic  acid,  and  resorcin  soaps  are 
valuable.  This  is  advantageously  followed  by  mopping  the 
face  for  five  minutes  with  very  hot  water. 

Salves  and  pastes  are  most  conveniently  applied  at  night. 
Lotions,  used  alone  or  in  conjunction  with  ointments,  may 
be  sopped  on  frequently  during  the  day. 

Sulphur  is  the  most  generally  useful  and  efficient  remedy. 
It  may  be  used  in  the  form  of  a  powder,  ointment,  paste,  or 
lotion.  When  the  lesions  are  deep  seated  and  the  face  dry, 
ointments  are  to  be  preferred;  when  superficial  and  the  face 
is  oily,  lotions  are  indicated. 

Incorporated  in  a  paste,  sulphur  may  be  used  as  in  the  follow- 
ing formula : 

ft  .    Sulph.  praecip £j ; 

(AmyH           \  aa  Sir 

Lassar's  paste:  I  Zinci  oxidi  J aa  dlJ' 

I  Petrolati ^iv. — M. 

Sic. — Rub  in  at  night. 

One  of  the  most  eligible  and  efficient  lotions  is  known  as 
the  "compound  zinc  sulphid  lotion."  It  may  be  used  four  or 
five  times  a  day,  and  has  the  advantage  that  it  may  be  employed 
upon  the  face  without  disfigurement.     Its  formula  is  as  follows: 


126  DISEASES  OP  THE   SKIN 

B.  Zinci  sulphat.     } ^  ^ 

Potass,  sulphid.  /  ... 

Aq.  rosae f 3"J  • 

(The  ingredients  are  to  be  dissolved  separately,  heated,  and  then 
mixed.  A  double  decomposition  takes  place,  with  the  precipitation  of  a 
whitish  powder.     The  potassium  sulphid  should  always  be  fresh.) 

When  numerous  blackheads  and  superficial  papules  and 
pustules  are  present,  the  following  lotion  will  be  found  useful 
in  effecting  marked  improvement  through  desquamation  of  the 
skin  : 

B .  Acidi  salicylici jjj ; 

Resorcini ,^ij ; 

Glycerini f3iv; 

Spts.  vini  recti.  V  **  rz-      w 

Aqua  i aafgij.— M. 

Sig. — Apply  twice  a  day. 

As  soon  as  peeling  begins,  the  use  of  the  lotion  should  be  inter- 
rupted and  a  soothing  ointment  applied.  The  lotion  may  be 
later  resumed. 

Another  useful  formula  is  that  devised  by  Kummerfeld : 

R .  Sulph.  praecip 3j-ij ; 

Pulv.  camphorae gr.  xv ; 

Pulv.  tragacanth gr.  xxv; 

Aq.  calcis )  „  f2..      «. 

Aq.  rosae    I  °  J 

Resorcin  is  likewise  a  remedy  of  value  in  acne.  It  may 
be  employed  in  varying  strengths  from  twenty  grains  to  a 
dram  to  the  ounce.  Patients  vary  considerably  in  their  reaction 
to  this  drug,  and  the  weaker  strengths  should  be  first  employed. 
It  is  advantageous  in  many  cases  to  produce  some  scaling. 
The  ointment  should  then  be  intermitted,  a  mild  unguent 
employed,  and  the  resorcin  salve  subsequently  resumed.  The 
following  combination  of  resorcin  and  sulphur  has  given  me 
good  results: 

R .     Resorcin gr.  xx-xl ; 

Sulph.  praecip .  gr.  xxx-^j ; 

Lanolini 3iv; 

Ung.  aq.  rosae 3iv; 

Olei  lavandulae     q.  s. — M. 

The  mercurials  are  sometimes  serviceable  in  the  treatment  of 
acne.     Care  must  be  taken  in  changing  from  sulphur  to  the 


ACNE  /  127 

mercurial  treatment,  or  vice  versa,  that  there  be  an  intermission 
of  a  few  days  and  that  the  face  be  thoroughly  cleansed  to  avoid 
the  disagreeable  though  temporary  crop  of  blackheads  result- 
ing from  the  formation  of  the  sulphid  of  mercury.  The  following 
is  a  much-used  formula : 

K-     Hydrarg.  chloridi  corrosiv gr.  ss-ij; 

Emuls.  amygdal.  amar ftfiv; 

Tinct.  benzoin,  comp f.^j. — M. 

Or  the  ammoniated  mercury  in  ointment  form  may  be  used : 

R.     Hydrarg.  ammoniat gr.  xxx-^j; 

Ung.  zinci  oxidi 5j. — M. ' 

In  addition  to  the  above  remedies,  betanaphthol  (10  to  30 
grains  to  the  ounce)  and  ichthyol  (1  to  2  drams  .to  the  ounce) 
may  be  found  useful. 

Mechanical    Treatment. — The   evacuation   of   acne    pustules 

and  the  expression  of  blackheads  are  essential  and  important 


Fig.  51. — The  author's  comedo  extractor;   the  smaller  loop  is  used  for  blackheads 

and  the  larger  one  for  pustules. 

parts  of  the  treatment  of  the  disease,  no  matter  what  other 
therapeutic   measures  are   employed. 

Some  form  of  comedo  extractor  should  be  used  to  press  out 
the  blackheads;  in  the  absence  of  an  instrument  of  this  char- 
acter the  rounded  end  of  a  strong  hairpin  is  a  good  substitute. 
The  pustules  should  be  opened  with  a  pointed  instrument,  and 
then  pressure  made  on  the  base  to  evacuate  the  follicle.  Every 
indurated  lesion  of  any  duration  contains  a  collection  of  sebum 
or  pus.  1  have  found  a  von  Graefe  cataract  knife  to  be  the 
best  instrument  to  puncture  these  with.  It  makes  a  very 
small  incision,  and  its  use  is  almost  painless.  Deep  lesions 
which  are  left  to  spontaneous  evacuation  are  more  apt  to  leave 

scars. 

Some  physicians  scrape  the  face  with  a  ringed  curet  to  evac- 
uate pustules  and  blackheads,  and  prefer  this  means  to  any 
other.  It  is  rapid,  but  temporarily  disfiguring.  Massage  and 
pinching  of  the  face  are  useful  in  expressing  sebum  and  stimu- 
lating the  glands  to  healthier  activity. 

The  x-rays  have  proved  a  useful  addition  * 
resources  in  the  treatment  of  acne,  but  P 


128  DISEASES  OF  THE  SKIN 

valuable  as  they  were,  in  the  enthusiasm  of  early  successes, 
thought  to  be.  Many  cases  of  acne,  even  of  long  standing 
and  refractory  to  other  methods  of  treatment,  may  be  cured  by 
the  x-rays.  The  disadvantages  are  that  mild  x-ray  treatment 
does  not  insure  against  relapses,  and  vigorous  treatment, 
although  it  may  cure  the  disease,  may  leave  scarring,  and  in 
some  cases  telangiectases  and  wrinkling.  The  x-rays,  there- 
fore, should  be  reserved  for  severe  cases  that  are  refractory  to 
other  methods  of  treatment.  When  used  in  mild  cases,  the 
rays  should  be  employed  with  the  greatest  care,  only  by  those 
skilled  in  their  use,  and  merely  as  an  auxiliary  to  other  methods. 
(See  chapter  on  x-Rays.) 

Actinic  Light  Treattnent. — The  actinic  rays  of  light  exercise 
a  favorable  influence  on  acne  lesions.  The  blue,  violet,  and 
ultra-violet  rays  are  not  only  microbicidal,  but  they  cause  a 
mild  erythematous  dermatitis  which  effects  a  retrogression  of 
superficial  acne  lesions.  I  use  a  mercury  vapor  lamp  of  special 
construction  or  a  powerful  arc  lamp  with  iron  carbons  as  an 
alternating  treatment  with  mild  roentgenization  in  many  cases 
of  acne.  It  is  advisable  to  produce,  with  each  actinic  treatment, 
a  mild  erythema. 

Vaccine  Therapy. — A  discussion  of  vaccine  therapy  in  acne 
will  be  found  in  the  special  chapter  on  this  subject  on  p.  414. 

ACNE  ROSACEA 

Synonym. — Rosacea. 

Definition. — Acne  rosacea  consists  of  two  processes:  a 
rosacea  and  an  acne.  The  former  is  a  chronic,  congestive  dis- 
order of  the  face,  particularly  of  the  nose,  chin,  and  forehead, 
characterized  successively  by  flushing,  permanent  enlargement 
of  the  blood-vessels,  and,  in  some  advanced  cases,  tissue  hyper- 
trophy.    The  acne  lesions  are  secondary  in  development. 

Acne  rosacea  is  comparatively  common,  and  occurs  in  per- 
sons beyond  the  age  of  twenty-five  or  thirty  years. 

Symptoms. — There  are  essentially  three  stages  to  the  dis- 
ease, although  only  rarely  does  the  disorder  develop  to  the 
third  one.  The  first  manifestation  is  a  tendency  to  flushing  of 
the  face,  which  becomes  especially  evident  after  eating  or  drink- 
ing stimulating  articles  or  after  exposure  to  cold  winds  or  upon 
entering  a  warm  room.     The  redness  may  be  bright  or  dull, 


ACNE  ROSACEA 


130  DISEASES  OF  THE   SKIN 

and  has  at  times  a  bluish  cast.  The  hose,  forehead,  cheeks, 
and  chin  are  commonly  involved.  Indeed,  there  is  a  distinct 
predilection  for  the  middle  vertical  third  of  the  face.  The 
redness  is  only  transitory  at  first,  and  fades  after  an  hour 
or  fraction  thereof.  The  color  disappears  under  pressure,  and 
a  cool  feel  is  imparted  to  the  finger. 

The  tendency  may  last  for  weeks  or  months,  and  then  dis- 
appear spontaneously  or  under  treatment.  In  many  cases 
the  condition  passes  on  to  the  second  stage.  The  frequent 
repetition  of  flushing  gradually  tends  to  an  enlargement  of  the 
caliber  of  the  capillaries  and  venules,  which  now  become  visibly 
dilated.  They  are  seen  as  small  tortuous  or  arborescent  vessels 
on  the  nose  and  cheeks.  The  redness  becomes  more  persistent, 
although  its  intensity  varies  from  time  to  time. 

The  causes  above  referred  to,  as  well  as  coughing,  laughing, 
and  mental  excitation,  lead  to  paroxysmal  exacerbations. 
Acne  papules  and  pustules  now  make  their  appearance,  usually 
in  crops,  as  in  ordinary  acne.  They  are  particularly  prone  to 
be  located  upon  the  nose,  chin,  forehead,  and  in  the  malar 
regions.  The  extreme  sides  of  the  face  exhibit  few  if  any 
lesions.  The  papules  are  commonly  large  and  disfiguring, 
being  covered  or  surrounded  by  a  deep-red  or  bluish  telangiec- 
tatic integument.  When  the  nose  is  markedly  affected,  the 
appearance  commonly  described  as  "brandy  nose"  is  presented. 
Very  often  there  is  a  coexisting  oily  seborrhea  and  the  nose  is 
greasy   and   shows   gaping   sebaceous   orifices. 

In  exceptional  cases  the  disease  progresses  to  a  third  stage, 
which  is  characterized  by  further  capillary  engorgement  and 
tissue  hypertrophy.  The  nose  may  be  bulbous  or  lobulated  or 
may  actually  be  the  seat  of  pendulous,  sessile,  or  pedunculated 
tumors. 

In  color  it  is  deep  red  and  often  purplish.  As  may 
be  imagined,  a  most  conspicuous  deformity  results.  To  this 
condition  the  term  "acne  hypertrophica "  or  "rhinophyma" 
is  applied.  In  some  cases  hypertrophy  of  the  skin  of  the  fore- 
head or  chin  takes  place. 

Etiology. — The  usual  type  of  the  disease  is  rarely  seen  before 
the  age  of  thirty.  I  have  observed  a  rosacea  limited  to  the 
nose  in  young  women  about  the  age  of  twenty.  The  milder 
forms  of  acne  rosacea  are  somewhat  more  common  in  women, 
but  the  hypertrophic  variety  is  seldom  seen  in  this  sex.  Gastro- 
intestinal   disorders    and    improper    diet    are    responsible    for 


ACNE   ROSACEA  131 

most  cases.  The  inordinate  use  of  coffee  and  tea  in  women 
is  an  important  factor.  Alcoholic  beverages  have  long  been 
recognized  as  a  fertile  cause.  Congestion  of  the  face  from 
gastric  stimulation  is  a  common  observation.  Stimulants 
doubtless  act  by  producing  a  catarrh  of  the  stomach.  Excessive 
beer-drinking  is  often  more  potent  a  factor  than  wine  or  whisky. 
Exposure  to  heat,  the  heat  of  the  sun,  stoves,  furnaces,  etc., 
or  to  cold  driving  winds,  particularly  in  drinkers,  may  lead  to 
the  hypertrophic  form.  Vasomotor  weakness,  utero-ovarian 
disease,  and  the  menopause  are  additional  causative  factors 
in  women. 

Pathology. — There  is  at  first  a  dilatation  of  the  blood-vessels, 
followed  by  permanent  enlargement.  Ultimately,  possibly 
as  a  result  of  hypernutrition,  hypertrophy  of  the  connective- 
tissue  elements  and  enlargement  of  the  sebaceous  glands  take 
place. 

Diagnosis. — Acne  may  be  distinguished  from  acne  rosacea 
by  the  age  of  the  patient  and  by  the  absence  of  telangiectases 
and  tissue  hypertrophy.  The  tubercular  syphiloderm,  lupus 
vulgaris,  and  leprosy  may  in  some  cases  simulate  rosacea, 
but  the  presence  of  hyperemia  with  enlargement  of  vessels 
and  of  acne  papules  and  pustules  occurring  upon  the  nose  and 
cheeks  and  running  a  chronic  course  will  render  the  diagnosis 
easy.     Both  syphilis  and  lupus  tend  to  ulcerate. 

Prognosis. — Cases  of  moderate  severity  may  be  much  bene- 
fited or  cured  by  judicious  treatment.  When  connective- 
tissue  hypertrophy  has  taken  place,  the  prognosis  is  more 
guarded.  The  disease  exhibits  no  such  tendency  to  spon- 
taneous cure  as  is  seen  in  simple  acne. 

Treatment. — Internal  and  external  remedies  are  both  of 
importance.  The  cause  or  causes  of  the  disease  must  be  assid- 
uously investigated.  When  the  stomach  is  at  fault,  the  diet 
should  be  carefully  regulated.  Condiments,  hot  beverages, 
alcohol,  tea,  excess  of  starchy  and  sugary  foods,  and  all  sorts 
of  stimulating  articles  are  to  be  prohibited. 

Due  attention  must  be  paid  to  the  condition  of  the  bowels. 
In  the  various  forms  of  dyspepsia,  nux  vomica,  the  stomachic 
bitters,  mineral  acids,  alkalis,  etc.,  are  to  be  prescribed.  In 
dyspepsia  with  fermentation  ichthyol  has  proved  of  value  in 
one-  to  two-grain  doses  after  meals.  A  few  cases  will  require 
the  use  of  iron,  strychnin,  cod-liver  oil,  and  like  tonics. 

Local    Treatment. — The    sulphur   preparations   used  in  t* 


132  DISEASES  OF  THE   SKIN 

treatment  of  simple  acne  are  valuable  also  in  rosacea.  Excel- 
lent results  often  follow  the  use  of  the  '  'compound  zinc  sulphid 
lotion"  or  Kummerfeld's  solution  (see  Acne).  Vleminckx's 
solution,  prepared  as  follows,  is  often  of  value : 

B .    Calcis ^ss; 

Sulphur  sublimat %\ ; 

Aquae f5x. — M. 

To  be  boiled  down  to  six  ounces  and  filtered.     Dilute  one  part  to 
ten. 

In  some  cases  a  sulphur  ointment,  one  dram  to  the  ounce, 
acts  efficiently. 

When  the  capillaries  are  large,  they  may  be  treated  by  scari- 
fication, by  slitting  them  with  a  fine  bistoury,  or  by  inserting 
the  electrolytic  needle.  I  have  found  the  use  of  Unna's  micro- 
burner  (needle-pointed  Paquelin  cautery)  superior  to  any  other 
method  in  destroying  enlarged  blood-vessels. 

In  hypertrophic  cases  ablation  of  the  diseased  tissues  may  be 
performed  with  a  knife  or  scissors. 

I  have  found  the  x-rays  most  valuable  in  the  treatment  of 
acne  rosacea,  more  valuable,  indeed,  than  in  ordinary  acne. 
With  skilful  treatment  cures  can  be  effected  without  scarring 
or  atrophy.  (For  technic,  see  article  on  x-Rays.)  The  visibly 
enlarged  blood-vessels  do  not,  as  a  rule,  disappear  under  this 
treatment.  Hyde  and  Montgomery  report  good  results  in 
removing  the  telangiectasis  by  the  use  of  actinotherapy,  employ- 
ing one  of  the  types  of  lamps  used  by  Finsen  for  lupus. 

With  these  various ,  physical  treatments  should,  of  course, 
be  conjoined  appropriate  general  and  local  treatment. 

ACNE  VARIOLIFORMIS 
Synonyms. — Acne  frontalis;  Acne  necrotica. 

Definition. — A  chronic  inflammatory  disease,  characterized 
by  papulopustules  with  necrotic  depressed  centers,  occurring 
for  the  most  part  about  the  forehead  and  scalp,  and  leaving 
pit-like  scars.  The  affection  is  relatively  rare.  It  is  classed 
by  many  writers  among  the  dermatoses  related  to  tuberculosis. 

Symptoms. — The  disease  is  usually  located  upon  the  margin 
of  the  hair,  scalp,  eyebrows,  etc.,  although  other  regions  may 
become  involved.  The  lesions  consist  of  firm,  reddish-brown 
papules  which  undergo  vesiculation  and  pustulation  and  become 
covered  with  a  firm,  adherent,  yellowish  or  brownish  crust  which 


DERMATITIS  PAPILLARIS  CAPILLITII  1 33 

conceals  a  small  central  ulceration.  On  the  fall  of  the  crust 
a  brownish-red  depressed  scar  is  seen.  There  is  sometimes  a 
disposition  of  the  lesions  to  group.  The  disease  is  essentially 
chronic,  and  there  is  a  marked  tendency  to  recurrence.  Sub- 
jective sensations  are  usually  absent,  although  itching  may 
be  more  or  less  marked.  In  severe  cases  the  resulting  scarring 
may  suggest  that  of  variola — therefore,  the  name. 

Etiology  and  Pathology. — The  disease  rarely  occurs  before 
puberty.  The  nature  of  the  disease  is  obscure.  Some  regard 
it  as  related  to  tuberculosis.  Sabouraud  invokes  seborrhea 
as  a  predisposing  cause,  and  looks  upon  his  microbacillus  as  an 
important  factor.  The  Staphylococcus  aureus  is  commonly 
present  and  may  play  a  r61e  in  the  production  of  the  lesions. 
The  disease  is  alleged  to  begin  in  the  upper  part  of  the  hair- 
follicle,  whence  it  spreads  downward  and  also  to  the  sebaceous 
glands. 

Diagnosis. — A  strong  resemblance  to  syphilis  is  sometimes 
presented.  The  chronicity  of  the  disease,  the  limitation  of 
the  lesions  to  hairy  regions,  and  the  history  will  serve  to  dis- 
tinguish acne  varioliformis. 

Treatment. — Sometimes  there  is  a  history  of  an  antecedent 
syphilis.  Such  cases  should  be  subjected  to  a  thorough  course  of 
the  iodids  and  mercury.  Measures  directed  toward  improvement 
of  the  general  health  should  be  employed  whenever  indicated. 
Locally,  the  best  results  are  obtained  with  sulphur  and  mercurial 
ointments.  In  rebellious  cases  the  electrocautery  or  thermocau- 
tery may  be  employed.     The  Rontgen  rays  might  also  be  tried. 

DERMATITIS  PAPILLARIS  CAPILLITII 

Synonyms. — Acne  keloid;  Keloid  acne. 

Definition. — Dermatitis  papillaris  capillitii  is  an  inflam- 
matory disease,  commencing  upon  the  hairy  border  of  the  nape 
of  the  neck,  characterized  by  papules,  pustules,  papillomatous 
vegetations,  and  keloidal  elevations. 

Symptoms. — The  disease  begins  as  pin-head-sized  papules 
or  pustules  upon  the  hairy  border  of  the  neck,  often  extending 
into  the  occipital  region.  These  may  remain  discrete  or  become 
confluent,  forming  either  papillomatous  outgrowths  or  keloidal 
elevations.  Pus  may  undermine  the  surrounding  skin.  Some 
areas  exhibit  permanent  loss  of  hair,  while  on  others  tufts  of 
hair  spring  up  from  the  hypertrophied  cicatricial  tissue 


134  DISEASES  OF  THE  SKIN 

disease  is  chronic  and  progressive.  In  my  experience  it  is  con- 
siderably more  common  in  negroes  than  in  whites.  It  is  almost 
exclusively  observed  in  adult  males. 

Treatment. — The  affection  is  markedly  refractory  to  treat- 
ment. Epilation,  followed  by  the  application  of  a  dram  to 
the  ounce  of  sulphur  ointment,  is  sometimes  efficacious. 

In  many  cases  it  will  be  found  necessary  to  resort  to  the  use 
of  the  electrolytic  needle,  the  electrocautery,  Unna's  micro- 
burner,  or  the  %-rays  to  destroy  the  growths  present.  When 
the  keloidal  growths  are  large,  excision,  followed  by  the  imme- 
diate use  of  the  x-rays,  should  be  carried  out. 

SYCOSIS  VULGARIS 

Derivation. — 'Zvkuoic,  fig-like,  from  avivw,  a  fig.  Synonyms. — Sycosis 
nonparasitica  (so  called);  Sycosis;  Folliculitis  barbae;  Coccogenic  sycosis. 

Definition. — Sycosis  is  a  chronic  inflammatory  disease  of 
the  hair-follicles,  usually  of  the  bearded  region,  characterized 
by  papules,  pustules,  and  tubercles  perforated  by  hairs. 

Symptoms. — The  disease  commences  by  the  formation  of 
discrete  pin-head-  to  pea-sized  papules  or  pustules  occupying 
the  sites  of  the  hair-follicles.  The  pustules  are  ordinarily  conical, 
although  they  may  be  obtuse.  The  contents  consist  of  a  yellow- 
ish pus  of  varying  degrees  of  consistence.  The  pus  may  become 
inspissated  and  dry  as  crusts,  or  the  lesions  may  undergo  rup- 
ture. The  surrounding  integument  is  commonly  reddened, 
sometimes  swollen  and  infiltrated,  and  the  seat  of  a  variable 
amount  of  itching,  burning,  and  soreness.  The  pustules  are 
discrete,  but  may  be  closely  aggregated.  A  hair  perforates 
the  center  of  each  lesion.  In  the  beginning  the  hair  is  firmly 
attached,  but  as  suppuration  becomes  free  it  is  more  easily 
extracted.     At  times  tubercles  are  present. 

The  affection  prefers  the  bearded  region  of  the  face,  par- 
ticularly the  cheeks;  it  may  or  may  not  be  symmetrical.  When 
the  mustache  is  involved,  it  is  usually  in  the  region  directly 
below  the  nostrils.  This  form  nearly  always  occurs  in  persons 
suffering  from  nasal  catarrh,  the  lip  becoming  infected  from 
contact  with  the  nasal  secretion. 

The  eruption  appears  in  crops,  like  the  lesions  of  acne.  The 
patient  is  often  encouraged  to  think  that  he  is  getting  well, 
when  a  new  outbreak  dooms  him  to  disappointment.  The 
eruption  may  disappear  under  treatment  for  a  shorter  or  longer 
period  and  then  relapse.  In  untreated  cases  the  exacerbations 
are  frequent  and  the  eruption  is  apt  to  be  constantly  present. 


SYCOSIS  VULGARIS  135 

The  neck,  border  of  the  hair,  axillae,  and  pubis  are  more 
rarely  affected.  In  severe  cases  I  have  frequently  noted 
involvement  of  the  hairs  of  the  eyelids,  producing  an  appearance 
resembling  an  ordinary  blepharitis. 

Etiology. — The  disease  is  obviously  limited  to  males;  it  is 
usually  seen  between  the  ages  of  twenty-five  and  fifty.  Nearly 
all  writers  regard  the  disease  as  microbic  in  origin,  and  attribute 
the  lesions  to  infection  with  staphylococci.  There  must,  how- 
ever, be  certain  predisposing  causes  which  are  not  yet  under- 
stood, for  sycosis  is  comparatively  uncommon,  whereas  staphy- 


Fig.  54. — Sycosis  vulgaris. 

lococci  may  be  found  upon  the  skin  of  practically  all  persons. 
Sycosis  of  the  upper  lip  usually  results  from  infection  by  nasal 
discharge;  these  cases  are  more  common  among  the  poor. 

Pathology.— The  pathologic  process  consists  of  a  folliculitis 
and  perifolliculitis,  due  to  the  invasion  of  pyogenic  cocci.  The 
inflammation  is  at  first  perifollicular,  the  follicle  becoming  only 
secondarily  invaded  by  serum  and  pus. 

Diagnosis. — Sycosis  vulgaris  may  be  confounded  with  tinea 
sycosis  and  pustular  eczema.  Below  is  appended  the  differ- 
ential diagnosis: 


136 


DISEASES  OF  THE   SKIN 


Sycosis  Vulgaris. 

i.  A  typical  case  shows  discrete 
papules  or  pustules  pierced 
by     hairs. 

2.  Hairs  firmly  attached  until  free 

suppuration       occurs.     Roots 
often    swollen    with    pus. 

3.  Course      slow.     Little      change 

from  week  to  week. 

4.  Mustache    frequently    affected. 

5.  Absence    of    fungus    in    hairs. 


Tinea  Sycosis. 

1.  A     typical     case     shows    large 

lumpy    or    nodular    tumefac- 
tions. 

2.  Hairs    broken    and    easily    ex- 

tracted. 

3.  Course  rapid.     Marked  changes 

from  week  to  week. 

4.  Mustache    rarely    affected. 

5.  Ring- worm  fungus  in  hairs. 


Sycosis  Vulgaris. 


1.  Lesions        strictly 

pierced  by  hairs. 

2.  Eruption    limited 

region. 

3.  Absence  of  oozing. 

4.  Itching  slight 


follicular, 
to    bearded 


3- 
4- 


Eczema  Pustulosum. 

Lesions  are  apt  to  be  inter- 
follicular  as  well. 

Tends"  to  spread  upon  non- 
hairy  regions. 

Oozing  marked. 

Itching  more  severe. 


Prognosis. — Very  few  cases  are  incurable.  The  disease, 
however,  is  often  refractory  to  treatment,  and  lasts  months  or 
years.     Recurrences  are  common. 

Treatment. — Internal  remedies,  such  as  iron,  arsenic,  cod- 
liver  oil,  etc.,  are  at  times  indicated  by  the  general  condition 
of  the  patient. 

External  treatment  is,  however,  far  more  important.  An 
essential  step  in  the  local  treatment  is  the  systematic  shaving 
or  clipping  of  the  hairs.  The  beard  should  be  closely  clipped 
with  scissors,  or,  better  still,  shaved  every  two  or  three 
days.  When  suppuration  is  free,  daily  depilation  should  be 
practised. 

When  the  inflammatory  signs  are  marked,  soothing  lotions, 
such  as  lotio  nigra  or  saturated  solution  of  boric  acid,  or  oint- 
ments of  cold  cream  or  zinc  oxid,  etc.,  may  be  employed.  Most 
cases,  however,  require  more  stimulating  applications. 

Sulphur  is  here,  as  in  most  follicular  inflammations,  of  great 
value.  It  is  best  employed  in  salve  form,  although  lotions 
may  also  be  used : 


R  .    Sulph.  prsecip gr.  xl-^j ; 

Petrolati. £j. — M. 


SYCOSIS    VULGARIS 


Fig.  55.— Rebellious  sycosis  vulgaris  of  five  months'  duration,  resisting 


Fig.  56. — Some  patient  cured  after  two  injections  of  sterilized  staphylococcic 
emulsion  (vaccine).  Represents  condition  two  weeks  after  first  photograph.  No 
other  treatment  used.    Patient  has  remained  well  now  for  several  years. 


138  DISEASES  OF  THE  SKIN 

A   mercurial  ointment   often   acts  efficiently: 

B  .    Hydrarg.  ammoniat gr.  xxx; 

Petrolati 3]. — M. 

The  following  formula  is  likewise  useful: 

B .    Ichthyol Jj; 

Petrolati 3j  — M. 

A  lotion  of  bichlorid  of  mercury,  one-fourth  to  one  grain  to 
the  ounce,  sopped  on  frequently  is  often  followed  by  good 
results. 

x-Ray  Treatment — In  severe  and  obstinate  cases  we  possess 
a  potent  measure  in  the  #-rays.  Roentgenization  will  often 
effect  a  cure  when  all  other  remedies  have  failed.  The  irradia- 
tions should  be  employed  for  five  to  seven  minutes  at  eight 
inches,  two  or  three  times  a  week.  A  medium  soft  tube  should 
be  used,  with  a  secondary  current  of  one  to  two  milliamperes. 
It  wrill  often  be  necessary  to  produce  epilation  before  the  dis- 
appearance of  the  eruption  is  effected.  Sometimes  the  disease 
relapses  when  the  hair  returns,  necessitating  further  treatment. 
In  extremely  chronic  and  disfiguring  cases  the  patients  often 
prefer  permanent  loss  of  hair  to  persistence  of  the  sycosis. 
(For  further  x-ray  technic  see  special  chapter,  p.  404.) 


SYCOSIS  LUPOEDES 

Synonyms. — Ulerythema  sycosiforme  (Unna);  Lupoid  sycosis. 

Definition. — An  inflammatory  disease  of  the  skin,  beginning 
as  a  sycosis,  but  leading  to  atrophy  of  the  hair  and  sebaceous 
follicles  and  atrophic  scarring.     The  disease  is  rare. 

Symptoms. — In  the  beginning  the  disease  is  not  to  be  dis- 
tinguished from  an  ordinary  sycosis.  In  the  course  of  some 
months  or  years  the  affected  hair  and  sebaceous  follicles  undergo 
atrophy,  producing  permanent  baldness  of  the  part  and  a 
whitish,  atrophic  scarring.  The  disease  spreads  by  centrifugal 
extension,  the  advancing  border  being  infiltrated,  often  serpi- 
ginous in  outline,  and  studded  here  and  there  with  pustules. 
Flat  vesicles  and  blebs,  attended  by  itching  and  burning,  may 
in  rare  cases  develop  over  the  affected  area.  Such  a  case  has 
been  under  my  observation  for  some  years;  this  patient  has, 
in  addition,  "essential  shrinking  of  the  conjunctivae. 


>> 


PSORIASIS  139 

The  disease  involves  by  predilection  the  beard,  and  is  in- 
clined to  be  symmetric. 

Pathology. — Obscure.  Some  believe  that  there  is  engrafted 
upon  an  ordinary  sycosis  a  tuberculous  infection.  In  a  well- 
marked  case  I  found  nests  of  dense  round-cell  infiltration 
throughout  the  corium,  but  no  giant-cells  or  tubercle  bacilli. 
Later  there  were  complete  atrophy  of  the  hair-follicles  and 
sebaceous  glands  and  overgrowth  of  fibrous  tissue. 

Diagnosis. — It  is  most  apt  to  be  confounded  with  lupus 
vulgaris  and  lupus  erythematosus.  The  chief  characters  of  the 
disease  are  an  antecedent  sycosis,  atrophy  of  follicles,  atrophic 
scarring,  centrifugal  extension,  and  vesicle  and  bleb  formation, 
the  disease  being  limited  to  the  bearded  region. 

Prognosis. — The  disease  is  refractory  to  treatment  and 
runs  a  course  of  years. 

Treatment. — No  treatment  has  been  of  much  avail. 

PSORIASIS 

Derivation. — *wp«,  the  itch.     Synonym. — Lepra  (used  by  early  writers) . 

Definition. — Psoriasis  is  a  chronic  inflammatory  disease  of 
the  skin,  characterized  by  variously  sized  reddish,  dry,  rounded, 
sharply  defined  patches,  covered  with  abundant  imbricated, 
silvery  scales.  Psoriasis  is  a  comparatively  common  disease, 
constituting  from  3  to  4  per  cent,  of  cases  observed  in  dermato- 
logic  practice. 

Symptomatology. — Psoriasis  may  begin  at  any  age,  but 
usually  manifests  itself  first  in  youth  and  early  adult  life. 

It  invariably  appears  first  as  small,  reddish,  pin-point-  to 
pin-head-sized  flat  or  acuminated  papules.  These  constitute 
the  sole  primary  lesions  of  psoriasis.  The  papules  are  early 
seen  to  be  surmounted  by  small  scales;  when  these  are  not 
apparent,  they  may  be  made  visible  by  slightly  scratching  the 
lesions;'  The  papules  increase  in  size,  gradually  or  rapidly,  by 
peripheral  extension  forming  patches  or  plaques  of  varying 
dimensions.  The  small  patches  are  usually  round  or  oval; 
when  increase  in  size  occurs  through  coalescence  of  neighboring 
patches,  all  sorts  of  forms  and  configurations  may  be  produced. 
The  patches  of  psoriasis  are  sharply  defined,  of  a  dull  reddish 
hue,  and  slightly  elevated  above  the  level  of  the  surrounding 
integument.  A  moderate  degree  of  infiltration  is  present. 
One  of  the  striking  features  of  the  disease  is  the  characteristic 
scaling.  The  papules  are  covered  with  profuse,  shining,  whitish, 
grayish,   or   mother-of-pearl   scales,   which   are   superimposed 


1.\a  DISEASES  OP   THE    SKIN 

upon  one  another  in  a  manner  somewhat  like  the  shingles  of 
a  roof,  or  in  other  cases  like  layers  of  isinglass.  When  the 
scales  are  removed,  a  reddish  base  is  exposed  which  exhibits, 
upon  scratching  with  the  finger-nail,  punctate  hemorrhages 
which  issue  from  the  apices  of  the  abraded  capillary  loops  of 
the  papillae. 

Serous  oozing  is  never  present  under  ordinary  circumstances; 
the  lesions  are  always  dry  and  scaly  and  unaccompanied  by 
vcsiculation  or   surface  exudation. 


The  eruption  attacks  with  predilection  the  scalp  and  the 
extensor  surfaces  of  the  extremities,  particularly  the  elbows 
and  knees.  It  is  not  uncommonly  limited  to  these  areas;  in 
most  cases,  however,  patches  will  be  seen  elsewhere.  In  exten- 
sive cases  the  trunk  may  be  profusely  attacked.  The  face 
is  usually  entirely  free,  but  in  other  cases  exhibits  reddish,  scaly 
patches  along  the  border  of  the  hair,  in  the  eyebrows,  and  even 


PSORIASIS  141 

occasionally  upon  the  cheeks.  The  palms  and  soles  are  rarely 
affected.  It  is  doubtful  whether  psoriasis  ever  attacks  the 
mucous  membranes. 

The  nails  are  occasionally  involved,  as  a  result  of  which  they 
become  discolored,  thickened,  transversely  grooved,  or  pitted. 
An  appearance  sometimes  observed  is  a  sharply  denned  yellowish 
discoloration  on  the  lateral  edges  of  the  nail. 

Psoriasis  is  not  attended  by  any  constitutional  disturbance; 
the  patients  are  ordinarily  in  good  health.     The  subjective 


Fig.  58.— Psoriasis  of  the 


symptoms  are  usually   slight.     Itching  is  commonly   absent 
or  moderate,  but  in  rare  cases  it  may  be  severe. 

According  to  the  size  and  configuration  of  the  patches,  various 
forms  of  psoriasis  are  distinguished:  when  the  lesions  consist 
of  small  scale-tipped  papules,  the  term  psoriasis  punctata  is 
employed;  when  these  attain  the  size  and  shape  of  drops  of 
water,  the  designation  psoriasis  guttata  is  applied.  In  psoriasis 
nummularis  the  patches  reach  the  dimensions  of  coins.  These 
vary  in  size  from  that  of  a  silver  dime  to  a  dollar.  Not  infre- 
quently the  center  of  the  patch  clears  up,  leaving  annular  or 
ringed  plaques;  this  variety  is  called  psoriasis  circinata  or 
annulata.  In  psoriasis  gyrata  or  fignrata  wavy  and  festooned 
outlines  are  produced  through  coalescence  of  annular  or  semi- 


I42 


DISEASES  OP  THE   SKIN 


circular  patches.  Uniform  involvement  of  large  areas  of  the 
body  surface  constitutes  the  variety  termed  psoriasis  diffusa. 
In  long-standing  and  rebellious  patches  with  extensive  infiltra- 
tion and  Assuring  the  condition  is  appropriately  designated 
psoriasis  inveterate.  Psoriasis  universalis  is  applied  to  cases 
in  which  extensive  sheets  of  eruption  almost  completely  cover 
the  cutaneous  surface. 

Psoriasis  pursues,   as  a  rule,  an  eminently  chronic  course. 
The  eruption  usually  disappears  either  as  a  result  of  treatment 


;  typical  di 


or  spontaneously,  but  in  most  instances  there  is  a  recurrence 
sooner  or  later.  The  eruption  varies  greatly  in  extent  in  differ- 
ent attacks.  It  is  not  uncommon  for  the  eruption  to  remain 
limited  for  a  year  or  more  to  a  few  patches  on  the  elbows  or 
knees.  The  lesions  frequently  disappear  in  the  warm  months 
of  the  year  and  reappear  in  cold  weather;  there  are,  however, 
exceptions  to  this  rule.  Many  patients  suffer  new  attacks  in 
the  early  spring. 

Etiology. — Our  knowledge  of  the  causation  of  psoriasis  is 


PSORIASIS  143 

still  involved  in  obscurity.  Sex  and  social  condition  do  not 
seem  to  exercise  any  particular  influence.  Psoriasis  usually 
begins  in  youth  or  early  adult  life;  it  seldom  makes  its  initial 
appearance  after  the  age  of  forty-five.  In  rare  cases  it  may 
develop  in  infancy  and  has  been  observed  as  early  as  the  sixth 
day  of  life.  Apparent  hereditary  influence  is  commonly  ob- 
served ;  in  a  considerable  proportion  of  cases  a  history  of  psoriasis 
in  one   of  the   parents  may   be  obtained.     Erasmus   Wilson 


Fig.  60, — Psoriasis 


estimated  the  proportion  as  30  per  cent.,  and  Greenough  found 
it  as  high  as  one-third  of  the  cases. 

There  is  no  definite  constitutional  error  which  can  be  invoked 
as  a  cause.  Many  patients  with  psoriasis  are  robust  and  ple- 
thoric, whereas  others  are  frail  and  anemic.  In  quite  a  number 
of  cases  a  history  of  gout,  rheumatism,  imperfect  digestion,  or 
defective  renal  activity  is  obtainable,  and  these  conditions  are 
regarded  by  some  as  causal.     The  disease  has  also  been  attri- 


144 


DISEASES  OF  THE   SKIN 


buted  to  nervous  disturbances  occasioned  by  fright,  shock, 
and  like  influences. 

More  recently  the  view  that  psoriasis  is  a  parasitic  disease 
has  been  championed  by  various  writers,  and  one  instance 
of  an  apparently  successful  inoculation  has  been  cited  in  favor 
of  this  proposition.  Although  the  parasitic  view  of  the  origin 
of  psoriasis  has  been  gaining  adherents,  no  specific  micro-organ- 
ism has  yet  been  found,  and  the  evidence  is  not  convincing.     It 


Fig.  6. 


lisoriasis  in  irregular  patches. 


is  possible  that  the  cutaneous  lesions  are  produced  by  a  parasite, 
but  it  would  appear  that  some  general  metabolic  disturbance  is 
necessary  to  render  the  skin  a  favorable  soil. 

Psoriasis  lesions  not  infrequently  develop  at  the  site  of  cuta- 
neous irritation,  such  as  that  produced  by  scratch-marks  or  pres- 
sure of  wearing  apparel.  This  occurs  only  during  periods  of 
developmental  activity  of  the  eruption,  and  not  during  quiescent 
periods.  Scratch-marks  in  lichen  planus  will  also  frequently 
become  the  seat  of  new  lesions. 


PSORIASIS  145 

Pathology. — The  essential  changes  are  a  hyperplasia  of  the 
rete  mucosum,  with  lateral  and  vertical  increase  in  the  inter- 
papillary  projections.  Intercellular  edema  is  present.  There 
is  imperfect  keratinization,  perhaps  due  to  the  rapidity  of  the 
cell-growth.  The  presence  of  air  between  the  horny  lamellae  is 
said  to  be  responsible  for  the  silvery  appearance  of  the  scales. 
Munro  claims  that  one  of  the  earliest  changes  is  the  accumula- 
tion of  leukocytes  constituting  microscopic  dry  abscesses 
between  the  lamella?  of  the  psoriatic  scales.  The  papillary 
blood-vessels  are  enlarged  and  there  is  a  cell  extravasation  into 
the  surrounding  tissues.  Histologists  differ  in  their  views  as 
to  whether  the  primary  disturbance  is  in  the  epidermis  or  in 
the  corium. 

Diagnosis.— Psoriasis,  owing  to  its  striking  features,  is 
readily  recognized,  save  in  poorly  marked  and  aberrant  cases. 


Fig.  6a.- 


iricatcd  character  of  scales. 


It  may  be  confounded  with  squamous  eczema,  the  squamous 
and  papulosquamous  syphilid,  seborrhcea  capitis,  seborrheic 
dermatitis,  pityriasis  rosea,  lichen  planus,  etc.  The  differ- 
ential diagnosis  between  psoriasis  and  the  first  three  dermatoses 
is  appended  in  tabular  form: 


Psoriasis. 

I.  Course  chronic. 

a.  Involves   with   predilection   ex- 
tensor    surfaces. 

3.  Itching    moderate    or    absent. 

4.  Patches  sharply  defined. 

5.  Patches    small    and    round. 

6.  Eruption  always  dry. 

7.  Patches   covered   with   profuse, 

shining,    »flv*"-   — *— 


Squamous  Eczema 

1.  Course      acute,      subacute,      or 

chronic. 
1.  Involves       with        predilection 

flexor  surfaces. 

3.  Itching  present,  often  well  pro- 

nounced. 

4.  Patches  fade  into  healthy  skin, 

5.  Patches  large  and  irregular. 

6.  Commonly   history   of  previous 

moisture. 

7.  Patches    covered    with    sparse, 

small,     yellowish     scales. 
*  or  less  rapid  changes   in 


146 


DISEASES  OF  THE   SKIN 


Psoriasis. 

1.  Negative  history. 

2.  No  concomitant  signs. 

3.  Knees    and    elbows    frequently 

involved,     palms     and     soles 
rarely. 

4.  Itching  variable. 

5.  Uniformity    of    lesions,     varia- 

tions in  size. 

6.  Scales  abundant,  lamellar,  and 

silvery. 

7.  Beneath  scales  is  an  unelevated 

reddish  patch. 


Papulosquamous  Syphiloderm. 

1.  History  of  syphilis. 

2.  Concomitant  signs  present. 

3.  Palms  and  soles  commonly  in- 

volved;    elbows     and     knees 
rarely. 

4.  Itching,  as  a  rule,  absent. 

5.  Multiformity    of    lesions,     uni- 

formity in  size. 

6.  Scales    scanty    and    yellowish. 

7.  Beneath  scales  is  an  infiltrated, 

elevated,  dull-red  papule. 


Psoriasis. 

1.  Occurs  upon  scalp  and  body. 

2.  Eruption    in    form   of   patches. 

3.  Scales  dry  and  silvery. 

4.  Base  inflammatory. 

5.  Apt    to    spread    beyond    hair- 

border. 


Seborrhea  Capitis. 

1.  More     commonly     confined     to 
scalp. 

2.  Eruption    diffuse;    involves   en- 

tire scalp. 

3.  Scales  greasy  and  dirty  yellow. 

4.  Base  pale. 

5.  Limited   often    to    hairy    scalp. 


Prognosis. — It  is  nearly  always  possible  to  effect,  by  one 
means  or  another,  the  disappearance  of  the  eruption.  In  the 
vast  majority  of  cases  the  eruption  will  return  after  varying 
intervals  of  freedom;  this  may  be  weeks,  months,  or  years. 
Occasionally  psoriasis  appears  to  be  permanently  cured,  but 
neither  the  character  of  the  case  nor  the  use  of  any  particular 
remedy  enables  any  one  to  predict  such  a  result  in  advance. 
It  is  advisable  to  attack  the  first  lesions  of  a  relapse  in  order  to 
lessen,  as  far  as  possible,  extension  of  the  eruption. 

Treatment. — At  the  outset  it  may  be  said  that  there  is  no 
specific  remedy  for  psoriasis — no  set  formula  which  will  do  well 
in  all  cases.  There  are,  however,  certain  empiric  medicaments, 
both  internal  and  external,  which  experience  has  proved  to  be  of 
distinct  value.  But  these  will  be  found  to  be  useful  in  some 
patients  and  not  in  others;  moreover,  a  remedy  may  be  effi- 
cacious at  one  time  and  fail  in  another  attack  in  the  same  indi- 
vidual. While  there  are  certain  general  indications  for  different 
therapeutic  procedures,  yet  in  the  majority  of  cases  the  treat- 
ment of  psoriasis  resolves  itself  into  a  trial  of  the  recognized 
remedies,  both  general  and  topical.  When  a  treatment  is 
once  instituted,  it  should  be  given  an  adequate  trial,  unless  it 
is   found    to   be    doing   harm. 


PSORIASIS  147 

If  the  patient  is  found  to  be  suffering  from  any  systemic  dis- 
turbances, it  is  obviously  important  to  correct  such  deviations 
from  health.  Gout,  rheumatism,  neurasthenia,  anemia,  diges- 
tive troubles,  etc.,  require  treatment  directed  toward  these 
special  conditions.  At  times  such  treatment  will  benefit 
psoriasis,  but  in  other  cases  it  will  fail.  Outdoor  life,  exposure 
to  sunshine,  muscular  exercise,  frequent  bathing,  are  all  valu- 
able adjuncts  to  any  therapeutic  regime  that  may  be  instituted. 

As  regards  diet,  no  dogmatic  rule  can  be  established.  A 
frail  and  anemic  girl  will  obviously  require  a  different  diet  from 
a  robust,  full-blooded  man.  It  is  not  the  disease  which  should 
indicate  the  diet,  but  the  condition  of  the  patient.  In  general 
the  dietary  should  be  simple,  with  limitation  of  nitrogenous 
articles,  more  particularly  red  meats.  Bulkley  advises  a 
vegetarian   diet   for   psoriatic   patients. 

Of  the  internal  remedies,  arsenic  has  enjoyed  the  widest 
reputation.  It  is  doubtful,  however,  whether  its  virtues  in 
this  disease,  as  in  many  other  dermatoses,  have  not  been  too 
highly  extolled.  Arsenic  does  remarkably  well  in  some  cases 
of  psoriasis  in  which  the  inflammatory  element  is  not  well 
marked.  It  should  not  be  used  during  an  acute  outbreak  or 
while  lesions  are  small  or  spreading,  for  it  may  stimulate  further 
extension  of  the  eruption. 

Arsenic  is  used  chiefly  in  the  form  of  Fowler's  solution  and 
arsenic  trioxid.  The  usual  initial  dose  of  the  former  is  one  to 
three  minims,  and  this  may  cautiously  be  increased  in  adults 
to  ten  minims  three  times  a  day,  if  such  doses  be  found  necessary 
to  influence  the  disease.  The  drug  should  be  thoroughly 
diluted  in  a  half  to  a  tumblerful  of  water  and  should  be  taken 
during  and  after  the  meal,  so  as  to  be  well  mixed  with  the  food. 

Arsenic  should  not  be  taken  over  too  prolonged  periods  of 
time,  owing  to  possible  injurious  after-effects.  Physicians 
should  counsel  patients  not  to  take  arsenic  upon  their  own 
responsibility,  for  it  is  a  remedy  potent  for  evil  as  well  as  good. 
The  long-continued  use  of  arsenic  may  lead  to  generalized  pig- 
mentation, keratoses  of  the  palms  and  soles,  and  in  rare  cases 
to  dangerous  cancer  of  the  skin. 

Potassium  iodid,  in  large  doses,  has  been  found  useful  in  this 
disease.  It  is,  like  arsenic,  inconstant  in  its  effects  and  will 
frequently  fail.  In  some  cases,  however,  it  produces  excellent 
results.  In  a  patient  under  my  care  with  a  universal  psoriasis 
of   a   most   inveterate   character   potassium  iodid,  increased 


148  DISEASES  OF  THE   SKIN 

gradually  to  sixty  grains  three  times  a  day,  later  supplemented 
by  active  local  treatment,  led  to  complete  disappearance  of  the 
eruption.  When  giving  large  doses  of  the  iodid  it  is  well  to 
have  the  patient  drink  considerable  quantities  of  water;  the 
drug  seems  thus  to  be  better  borne. 

The  salicylates,  and  particularly  salicin,  are  warmly  recom- 
mended by  Crocker,  especially  in  the  early  stages  of  psoriasis, 
when  arsenic  is  contraindicated.  Salicin  is  more  often  used,  as 
it  is  better  tolerated  by  the  stomach.  Crocker  usually  com- 
mences with  fifteen-grain  doses  three  times  a  day  and  increases 
to  twenty  grains.  I  have  used  salicin  in  ten-grain  doses  in  a 
number  of  cases  without  observing  much  result. 

The  alkalis  are  efficient  in  certain  cases  of  psoriasis,  partic- 
ularly in  robust  individuals  with  a  gouty  or  rheumatic  diathesis. 
The  most  eligible  preparation  is  the  liquor  potassae  in  ten-  to 
twenty-drop  doses,  well  diluted.  The  acetate  or  citrate  of 
potash,  in  twenty-grain  doses,  may  also  be  used  with  good 
results.  It  should  be  taken  in  a  half  tumblerful  of  water  one- 
quarter  of  an  hour  before  meals. 

Mercury  by  mouth  or  hypodermatic  injection  has  been  used 
in  psoriasis  with  satisfactory  results  in  some  cases.  About 
one-fifth  grain  of  the  iodid  of  mercury  three  times  a  day  is 
advised. 

Other  remedies  that  have  been  used  at  different  times  with 
varying  degrees  of  success  are  thyroid  extract  (Bramwell),  car- 
bolic acid,  in  doses  of  from  one  to  four  minims  three  times  a 
day  (Kaposi),  wine  of  antimony,  in  acute  cases,  five  to  ten 
minims  (Morris),  tar,  cantharides,  colchicum,  pilocarpin,  copa- 
iba, etc.  Turpentine,  ten  to  thirty  minims  in  emulsion,  is 
advised  by  Crocker  in  hyperemic  cases.  Barley-water  in  con- 
siderable quantity  should  be  taken  during  the  treatment.  It 
is  contraindicated  by  the  existence  of  any  kidney  trouble. 

Local  Treatment. — An  essential  preliminary  to  the  inaugu- 
ration of  topical  treatment  is  the  removal  of  the  scales.  It  is 
useless  to  make  liquid  or  unguentous  applications  to  an  impen- 
etrable mass  of  scales ;  they  must  be  removed  so  that  the  medic- 
aments may  be  applied  directly  to  the  skin  surface.  Scales 
may  be  removed  with  ordinary  soap  and  water,  by  friction 
with  soft  soap,  or,  best  of  all,  by  prolonged  baths  (simple  or 
alkaline)  with  the  use  of  soap. 

The  local  remedies  that  enjoy  the  greatest  reputation  in 


PSORIASIS  149 

psoriasis  are   chrysarobin,   tar,   pyrogallic  acid,   ammoniated 
mercury,   salicylic  acid,   resorcinol,   betanaphthol,   etc. 

Chrysarobin,  a  yellowish  powder  derived  from  the  Goa  powder 
of  the  East  Indies  or  from  a  similar  preparation  from  Brazil, 
is  the  most  rapidly  efficient  remedy  at  our  disposal.  It  has, 
however,  certain  grave  disadvantages  which  restrict  its  use  to 
selected  cases.  It  stains  the  skin  temporarily  and  the  under- 
clothing permanently.  Furthermore,  it  may  set  up  a  severe 
dermatitis  or  a  conjunctivitis,  particularly  when  used  upon 
the  face.  It  may  be  safely  employed  in  cases  with  a  limited 
number  of  large  chronic  patches  upon  the  body  or  extremities. 
It  may  be  incorporated  in  an  ointment  or  a  paint : 

H  .    Chrysarobini gr.  x-xl; 

Pulv.  amyli  1  ---?*•• 

Pulv.  zinci  oxidi  J    aa  3U » 

Petrolati ^iv. — M. 

Or— 

R  .    Chrysarobini gr.  x-xxx; 

Liquor  gutta  percha?  (traumatical)  or 

Collodii  flex f 3  j . — M. 

The  application  should  be  at  first  weak,  and  used  only  over 
a  limited  surface.  The  ointment  is  to  be  applied  once  or  twice 
daily,  the  paint  every  two  or  three  days.  The  use  of  the  chry- 
sarobin should  be  interrupted  when  the  skin  becomes  very  red 
and  tender.  If  too  much  dermatitis  has  been  set  up,  a  dusting- 
powder  or  soothing  lotion  should  be  applied.  When  the  patches 
are  sufficiently  treated,  the  psoriatic  patch  will  appear  white 
and  smooth,  while  the  surrounding  integument  is  stained 
purplish-red. 

Tar  is  a  valuable  application,  and  is  usually  well  borne.  Its 
odor  and  color  are  its  chief  disadvantages.  It  may  be  used  in 
the  form  of  an  ointment,  paint,  or  bath.  The  preparations 
usually  employed  are  the  unguentum  picis  (official  tar  oint- 
ment), oleum  cadini  (oil  of  cade),  and  oleum  rusci  (oil  of  birch), 
in  the  strength  of  one  to  four  drams  to  the  ounce : 

H  .    Ung.  picis,  Ol.  cadini,  or  Ol.  rusci 5J"9» 

Adipis  or  Collodii  flex q.  s.  ad  f,$j. — M. 

Sig. — To  be  used  night  and  morning. 

The  tar  bath  is  a  convenient  and  efficient  method  of  using 
this  medicament  in  extensive  cases.     The  patient  anoints  him- 


I50  DISEASES   OF   THE    SKIN 

self  with  tar  ointment  and  then  steps  into  a  warm  bath,  in 
which  he  remains  for  about  a  half-hour. 

A  purified  tar  oil,  anthrasol,  has  recently  been  placed  upon 
the  market.  It  is  colorless  and  almost  devoid  of  odor;  it  may 
be  used  in  ointment  form,  one  to  two  drams  to  the  ounce,  or 
in  alcoholic  solution.  In  very  young  subjects  and  in  those 
with  tender  skin  it  is  frequently  not  well  borne. 

Pyrogallic  acid,  in  5  to  10  per  cent,  ointments,  acts  much  in 
the  same  manner  as  chrysarobin,  though  less  efficiently.  It 
stains  the  body  linen,  and  if  used  over  too  great  an  area  of  the 
body,  may  produce  fatal  poisoning  through  absorption.  This 
disadvantage  has  very  greatly  lessened  its  use. 

Ammoniqted  mercury  is=  a  most  eligible  preparation  for  the 
treatment  of  patches  of  psoriasis  around  the  face  and  scalp;  it 
is  odorless  and  does  not  stain  the  skin.  It  may  be  combined 
with  salicylic  acid,  as  in  the  following  prescription : 

R  .    Acidi  salicylici gr.  xv-xxx ; 

Hydrarg.  ammoniat gr.  xx-xxx; 

Ung.  aq.  rosae §j. — M. 

Other  preparations  of  mercury,  as  the  yellow  oxid,  nitrate, 
and  bichlorid,  may  be  used.  •'■*  - 

Resorcin  may  also  be  used  on  the  face  in  the  strength  of  ten 
to  forty  grains  to  the  ounce  of  lanolin,  adeps,  or  cold -cream 
ointment. 

Actinotherapy  and  Radiotherapy* — Exposure  to  the  rays  of 
the  sun  or  one  of  the  various  forms  of  arc-lamps  is  of  value 
in  psoriasis.  More  rapid  effects,  however,  are  produced 
by  Rontgen  irradiation.  Psoriasis  patches  usually  respond 
well  to  *-ray  treatment.  The  cases  in  which  this  is  especially 
indicated  are  those  with  circumscribed  areas  of  disease  that 
have  resisted  other  therapeutic  methods.  The  technic  which 
I  employ  is  as  follows:  treatment,  twice  a  week,  five  to  six 
minutes'  duration,  medium  low  tube,  ten  inches'  distance  from 
skin  to  anticathode,  about  4  amp&res  of  primary  current  (no 
volts),  and  ^  to  f  milliamp£re  going  to  tube.  Other  parts  than 
the  skin  involved  should  be  carefully  protected.  Caution 
should  always  be  exercised  to  avoid  injurious  overtreatment. 
Occasionally  patients  have  long  periods  of  freedom  from  the 
disease  after  %-ray  treatment,  but  exemption  from  subsequent 
attacks  cannot  be  more  definitely  promised  than  after  other 
approved  methods  of  treatment. 


DERMATITIS    EXFOLIATIVA  151 

DERMATITIS  EXFOLIATIVA 

Synonyms. — Pityriasis  rubra;  General  exfoliative  dermatitis. 

Definition. — Dermatitis  exfoliativa  is  an  inflammatory  dis- 
ease of  the  skin,  characterized  by  intense  generalized  redness, 
followed  by  profuse  desquamation,  and  accompanied  by  fever 
and  other  constitutional  symptoms. 

Much  diversity  of  opinion  exists  as  to  the  classification  of 
these  exfoliative  dermatoses.      There  are  several  varieties  of 


Fig.   63. — Exfoliative  dermatitis  ol  several  months'  duration. 


dermatitis  with  universal  scaling  which  merit  separate  descrip- 
tion and  which,  indeed,  may  prove  to  be  distinct  clinical  entities. 
Pityriasis  Rubra  (Hebra)  Type. — In  this  affection,  which  is 
extremely  rare,  the  condition  is  chronic  and  there  is  a  slow 
progression,  ultimately  ending  in  death,  in  the  vast  majority 
of  cases.  Of  twenty-one  patients  observed  by  Hebra  and 
Kaposi,  twenty  died.  The  salient  features  are  a  generalized 
redness  of  a  dull  color,  profuse  and  continuous  exfoliation  of 
the  skin  in  small  papery  scales,  atrophic  thinning  and  con- 
traction of  the  skin,  often  leading  to  ectropion  or  permanent 


152  DISEASES   OF    THE    SKIN 

flexion  of  the  fingers,  and  a  serious  compromising  of  the  general 
health.  The  patient  is  sensitive  to  cold  and  often  complains 
of  chills.  Progressive  weakness  and  visceral  disease  usually 
close  the  scene. 


Fig.  64.— Epid. 
dernialilis;  rccurren 
scarlet  fever,  page  . 

Dermatitis  Exfoliativa  Acuta. — The  onset  of  the  disease  is 
sudden  and  attended  by  fever  and  malaise.  The  eruption, 
which  consists  of  an  intense  erythematous  efflorescence,  may 
be  either  diffuse  or  in  patches.  Rapid  spreading  over  the  entire 
bodv  soon  occurs,  followed  in  a  few  davs  bv  profuse  scaling  of 


PITYRIASIS    ROSEA  1 53 

a  flaky  character,  or  the  superficial  epidermis  may  peel  off  in 
strips.  Upon  the  palms  and  soles  the  horny  skin  may  be 
exfoliated  en  masse,  as  well-marked  epidermal  casts ;  when  com- 
plete, these  resemble  a  pair  of  gloves  or  moccasins.  In  severe 
cases  the  hair  is  sometimes  lost  and  the  nails  gradually  shed. 
Itching  and  burning  are  present  in  varying  degrees.  The  dis- 
ease runs  its  course  in  a  few  weeks  or  months.  It  is  extremely 
prone  to  recur,  at  times  exhibiting  well-pronounced  periodicity. 
A  twenty-nine-year-old  man  under  my  observation  had,  accord- 
ing to  his  statement,  one  or  two  attacks  every  year  since  the 
first  year  of  life.  Sometimes  this  variety  of  exfoliative  der- 
matitis becomes  chronic  and  lasts  for  one  or  more  years. 

A  somewhat  different  type  of  the  disease,  pursuing  a  more 
chronic  course,  is  the  so-called  secondary  exfoliative  dermatitis; 
this  develops  at  times  during  the  progress  of  a  long-standing 
eczema,  psoriasis,  or  lichen  planus. 

Etiology. — The  cause  of  pityriasis  rubra  is  Unknown.  It 
is  more  common  in  adult  life  and  in  males.  Acute  exfoliative 
dermatitis  is  in  all  probability  the  result  of  an  acute  toxemia 
or  poisoning.  It  is  simply  an  intensified  form  of  scarlatinoid 
erythema,  differing  therefrom  only  in  degree.  Both  conditions 
may  occur  in  the  course  of  septicemia,  small-pox,  malaria,  and 
other  infectious  diseases.  Drugs,  particularly  quinin,  may  be 
responsible.  I  recall  a  severe  case  in  which  the  hair  and  nails 
were  lost  following  the  ingestion  of  large  doses  of  antipyrin. 
Some  of  the  secondary  forms  may  be  due  to  too  severe  local 
treatment.  The  use  of  chrysarobin,  arnica,  and  mercurial 
ointment  has  been  known  to  call  forth  a  general  exfoliative 
dermatitis. 

Treatment. — Internal  treatment,  if  necessary,  must  be 
based  upon  individual  indications.  The  patient  should  be  con- 
fined to  bed  and  placed  upon  a  bland  diet.  Locally,  such  appli- 
cations as  are  applied  in  an  acute  eczema  should  be  used,  as, 
for  instance,  the  f%sorcin-lime- water-olive-oil  lotion. 

PITYRIASIS  ROSEA 

Synonyms. — Pityriasis  maeulata  et  circinata;  Herpes  tonsurans  macu- 
losus. 

Definition. — A  self-limited  inflammatory  disease  of  the  skin, 
characterized    by    rose-colored,    erythema  tosquamous,    ring- 
shaped  patches  occupying  chiefly  the  trunk,  and  e 
accompanied  by  mild  constitutional  disturban** 


154 


DISEASES  OF  THE  SKIN 


Symptoms. — The  disease  is  often  ushered  in  by  elevation  of 
temperature  (ioo°-io2°  F.),  with  malaise  and  the  associated 
expressions  of  fever.  A  primitive  patch  may  precede  the  general 
eruption  by  a  few  days  to  a  week.  The  eruption  comes  out 
more  or  less  rapidly,  so  that  in  the  course  of  a  week  or  ten  days 
the  trunk  and  thighs,  which  are  the  seats  of  predilection,  may 


Fig.  65—  Pityn'i 


be  profusely  covered.  The  lesions  consist  of  pinkish  or  rose- 
colored  macules  and  maculopa pules,  which  increase  in  size 
by  peripheral  extension,  many  reaching  the  dimensions  of  a 
silver  half-dollar.  The  patches  are  often  oval,  their  long  axes 
corresponding  to  the  lines  of  cleavage.  Central  involution 
occurs  in  many  patches,  giving  them  an  annular  or  circinate 
configuration.     At   this   stage   the   typical   lesion   presents   a 


PITYRIASIS    ROSEA  1 55 

yellowish  or  fawn-colored  center,  with  a  pinkish,  slightly  ele- 
vated border  covered  with  furfuraceous  scales. 

The  eruption  is  ordinarily  limited  to  the  trunk,  thighs,  and 
arms,  being  either  absent  or  sparse  on  the  legs  and  forearms. 
It  may  extend  upon  the  neck,  but  is  rarely,  if  ever,  seen  upon 
the  face.  A  variable  amount  of  glandular  enlargement  may 
be  present. 

The  disease  runs  its  course  in  from  two  to  eight  weeks,  the 
average  case  lasting  about  six  weeks.  There  are  recorded 
instances  of  durations  of  three,  four,  and  even  six  months. 

Itching  is  moderate,  but  in  some  cases  may  be  severe,  par- 
ticularly at  night. 

Etiology. — The  cause  is  obscure.  Neither  sex  nor  age 
appears  particularly  to  influence  it.  Crocker,  Zeisler,  For- 
dyce,  and  Fox  have  each  observed  two  cases  in  the  same 
family.  If  transmissible,  the  contagion  must  be  feeble.  The 
self-limitation  of  the  disease  and  the  rarity  of  recurrences 
suggest  that  some  antitoxic  principle  is  produced  in  the  body. 

Diagnosis. — The  acute  onset,  the  rapid  extension  over 
the  body,  the  extreme  superficiality  of  the  lesions,  their  peculiar 
shape  and  coloration,  the  definite  course  and  spontaneous 
involution,  will  usually  enable  one  to  make  the  diagnosis. 
Pityriasis  rosea  must  be  distinguished  from  seborrheic  eczema, 
the  maculopapular  syphilid,  psoriasis,  and  tinea  circinata. 

Seborrheic  eczema  presents  at  times  a  strong  resemblance. 
It  may  be  differentiated  usually  by  the  involvement  of  the  scalp, 
the  preference  for  the  sternal  and  interscapular  region,  the 
slower  extension,  larger  and  more  greasy  scales,  absence  of 
typical  oval  lesions  and  of  self-limitation. 

Confusion  with  syphilis  would  be  apt  to  occur  before  the 
development  of  the  characteristic  yellowish  circinate  patches 
of  pityriasis  rosea;  when  these  features  appear,  the  diagnosis 
is  cleared  up. 

Patches  of  psoriasis  are  slower  in  development  and  extension, 
the  scales  are  more  profuse  and  more  silvery,  and  the  scalp 
and  extensor  surfaces  are  preferred.  Ring-worm  would  rarely 
be  seen  in  extensive  patches  on  the  trunk.  The  patches  are 
round  or  oval,  and  the  border  sharply  defined.  Under  the 
microscope  the  ring-worm  fungus  can  be  found. 

Prognosis. — Always  favorable.     The  eruption  usually  d*" 
appears  spontaneously  in  from  four  to  six  weeks. 

Treatment. — The  course  of  the  disease  and  the  <* 


156  DISEASES  OF  THE   SKIN 

the  eruption  are,  as  a  rule,  not  greatly  influenced  by  treatment. 
There  are,  however,  exceptions  to  this  general  statement. 
There  are  no  internal  remedies  of  any  special  value,  although 
Crocker  advises  salicin.  Locally  mildly  stimulating  and  anti- 
septic ointments  may  be  employed,  such  as — 

R  .    Betanaphthol gr.  xl ; 

Adipis  benzoat 5J. — M. 

Or  sulphur  may  be  used  in  the  same  strength.  When  there 
is  much  itching,  the  following  lotion  will  be  found  useful : 

R .    Acidi  phenici 3J ; 

Glycerini f 3  j ; 

Ext.  hamamelidis  dest 1,5  j; 

Aquae q.  s.  ad  f Jviij. — M. 

ERYSIPELAS 

Derivation. — 'EpvSpoc,  red;  7r£%?Ait  the  skin.  Synonyms. — St.  Anthony's 
fire;  Ignis  sacer. 

Definition. — Erysipelas  is  an  acute  specific  inflammation 
of  the  skin  and  subcutaneous  tissue,  characterized  by  shining 
redness,  swelling,  heat,  pain,  and  vesication,  and  accompanied 
bv  fever  and  constitutional  disturbance. 

Symptoms. — The  disease  is  usually  ushered  in  with  a  chill, 
malaise,  headache,  and  elevation  of  temperature  (102  °- 
105  °  F.).  The  tongue  is  dry  and  coated,  later  becoming  brown 
and  fissured.  The  fever  exhibits  morning  remissions  and 
evening  exacerbations.  Sudden  rises  of  temperature  usually 
betoken  an  extension  of  the  erysipelatous  process.  Headache, 
vomiting,  somnolence,  and  delirium  are  present  in  severe  cases. 
Albumin  and  casts  are  usually  found  in  the  urine. 

The  erysipelatous  eruption,  which  begins  at  or  near  the  site 
of  the  infection,  is  highly  characteristic.  The  affected  area  is 
at  first  small,  with  defined  border,  swollen  and  elevated,  and 
of  a  shining  crimson-red  or  violaceous  color.  Palpation  dis- 
closes tenderness,  heat,  tenseness,  and  induration  to  the  edge 
of  the  redness.  The  amount  of  swelling  depends  somewhat 
upon  the  region  involved.  When  the  eyelids  are  affected, 
there  is  tremendous  swelling,  making  it  utterly  impossible  for 
the  patient  to  open  his  eyes.  Where  the  skin  is  firmly  bound 
down,  as  upon  the  scalp,  there  is  but  moderate  swelling. 

The  disease  spreads  insidiously  by  peripheral  extension  in 
several  directions,  the  red,  raised  border  marking  the  advance 


ERYSIPELAS  157 

of  the  process.  The  invasion  of  new  localities  is  accompanied 
by  involutional  changes  in  older  areas.  The  eruption  in  any 
one  region  runs  its  course  in  four  or  five  days,  ending  in  des- 
quamation. 

In  the  center  of  the  patches  it  is  quite  common  to  observe 
flat  vesicles  or  blebs;  these  may  be  small  and  barely  visible, 
or  the  bullae  may  be  large,  irregular,  and  confluent.  They 
contain  at  first  a  clear  serum,  but  this  is  prone  to  become  puru- 
lent and  dry  in  the  form  of  crusts. 

No  part  of  the  cutaneous  surface  enjoys  freedom  from  attack, 
although  the  face  is  by  far  the  most  frequently  affected  region. 
In  facial  attacks  the  eruption  may  spread  over  the  scalp  to 
the  nape  of  the  neck,  although  Boston  and  Blackburn  found 
records  of  this  extension  in  only  7  out  of  485  cases.  The  scalp, 
when  affected,  is  observed  to  be  red,  boggy,  and  extremely 
tender  to  the  touch. 

In  a  severe  erysipelas  involving  the  entire  face  the  patient 
presents  an  awful  picture:  the  eyelids  are  bulged  and  swollen, 
the  lips  protruded,  the  ears  enormously  tumefied,  and  the 
entire  head  enlarged  beyond  human  proportions.  Heat, 
burning,  and  itching  are  often  complained  of. 

Convalescence  is  indicated  by  a  decline  of  temperature  and 
subsidence  of  swelling,  induration,  heat,  and  redness.  In 
rare  instances  one,  two,  or  more  relapses  occur. 

An  average  attack  of  erysipelas  runs  its  course  in  a  week  or 
ten  days,*  but  extension  may  protract  the  disease  to  two,  three, 
or  more  weeks.  The  patient  is  usually  weak  and  prostrated 
after  the  attack.  The  hair  falls  out  after  involvement  of  the 
scalp,  but  is  ultimately  restored.  Frequent  attacks  in  the  same 
region  may  lead  to  elephantiasic  thickening  of  the  skin  and 
subcutaneous  tissues.  This  occurs  chiefly  upon  the  face  and 
legs. 

Erysipelas  ambulans  or  migrans  is  a  variety  which  tends  to 
subside  rapidly  in  one  region,  reappearing  in  another,  the 
whole  process  continuing  for  several  weeks. 

There  is  a  mild  recurrent  form  of  erysipelas  which  is  prone  to 
attack  the  cheeks  and  the  alae  of  the  nose.  The  constitutional 
disturbance  is  slight  (temperature,  99 °  to  100 °  F.)  or  entirely 
absent.  The  eruption  does  not  tend  to  spread  beyond  the 
cheeks,  and  usually  disappears  in  three  or  four  days.  It  is 
due  to  microdrganismal  infection  through  the  mucous  mem- 
branes of  the  adjacent  cavities,  particularly  the  nose. 


158  DISEASES   OF  THE   SKIN 

Etiology. — The  affection  is  due  to  the  introduction  into  the 
body  of  a  specific  organism,  the  Streptococcus  erysipelatis  of 
Fehleisen.  It  is  possible  that  other  pyogenic  organisms  may 
produce  inflammations  resembling  erysipelas.  The  germs 
gain  entrance  through  obvious  or  imperceptible  solutions  of 
continuity  of  the  skin  or  mucous  membranes.  The  existence 
of  a  wound,  therefore,  is  a  strong  contributory  factor.  Any 
age  may  be  attacked,  but  the  disease  is  most  common  between 
the  ages  of  twenty  and  fifty.  The  resisting  power  of  the  indi- 
vidual to  microbic  infection  must  play  an  important  r61e,  for 
many  persons  carry  streptococci  on  their  skin.  Alcoholic 
intemperance,  debility,  Bright's  disease,  etc.,  are  predisposing 
causes.  Erysipelas  is  not  an  uncommon  complication  of 
small-pox.  In  surgical  wards  of  hospitals  erysipelas,  at  times, 
occurs  in  epidemics. 

Diagnosis. — Facial  erysipelas  is  chiefly  to  be  distinguished 
from  an  erythematous  eczema  of  this  region.  In  the  latter 
disease  there  is  marked  redness,  with  often  great  swelling  and 
closure  of  the  eyelids.  The  itching,  however,  is  pronounced, 
and  there  is  absence  of  the  fever  and  accompanying  constitu- 
tional symptoms  so  constant  in  erysipelas.  In  erysipelas,  too, 
the  skin  is  firmly  indurated,  elevated,  and  glazed,  and  has  a 
sharply  defined  border. 

Prognosis. — The  vast  majority  of  cases  of  erysipelas  ter- 
minate in  recovery.  In  rare  instances  abscesses  or  gangrene 
may  develop.  In  cases  of  great  severity  death  may  occur, 
particularly  in  the  aged,  in  infants,  in  drunkards,  and  in  those 
debilitated  from  other  diseases. 

Treatment. — The  large  number  and  variety  of  remedies 
advocated  in  this  disease  is  evidence  that  no  one  treatment 
has  satisfied  the  intelligent  demand  of  physicians  in  general. 
The  capricious  course  of  the  affection  and  the  unexpected 
changes  frequently  observed  have  doubtless  caused  credit  to 
be  given  to  remedies  which  are  practically  inert. 

It  is  important  to  maintain  the  patient's  strength  by  a  nutri- 
tious and  easily  assimilable  diet.  Such  supportive  remedies 
as  whisky,  wine,  strychnin,  digitalis,  etc.,  are  often  necessary. 
The  drug  which  has  the  greatest  number  of  advocates  is  the 
tincture  of  the  chlorid  of  iron;  this  is  given  in  ten-  to  twenty- 
minim  doses  every  few  hours.  Camphor  has  also  been  warmly 
extolled.  Some  writers  have  reported  results  from  the  use  of 
antistreptococcus  serum. 


ERYSIPELOID  1 59 

Locally,  almost  every  remedy  in  the  pharmacopeia  has  been 
advised.     Ichthyol  in  ointment  or  lotion  is  the  most  popular 

annlirn  tion : 


application : 

li  .    Ichthyol 3j-ij ; 

Lanolini 
Adipis  benzoat 


Lanolini  )  ---•** 

> aa  31V. — M. 


Hot  or  cold  applications  of  lead-water  and  laudanum  are 
grateful  to  the  patient.  In  a  serious  relapsing  case  seen  by 
the  author  the  mild  use  of  the  *-rays  was  followed  by  a  rapid 
subsidence  of  the  process. 

In  the  recurrent  form  the  nose  and  mouth  should  receive 
careful  treatment,  detergent  washes,  such  as  Dobell's  solution, 
being  employed. 

ERYSIPELOID  (Roscnbach) 
Synonyms. — Erysipelas  chronicum;  Erythema  migrans. 

Definition. — Erysipeloid  is  an  inflammatory  affection  of 
the  skin,  resembling,  to  some  extent,  erysipelas,  produced  by 
infection  with  decomposing  animal  matter. 

Symptoms. — There  are,  as  a  rule,  no  constitutional  symp- 
toms. The  disease  begins  as  a  dark-red  or  violaceous,  sharply 
marginated  patch  at  the  site  of  infection.  The  skin  is  tense 
and  slightly  tumefied.  The  fingers  and  hands  are  the  common 
seats  of  the  eruption.  A  gradual  peripheral  extension  takes 
place,  always  with  a  deep- red,  defined  border.  The  spreading 
is  much  slower  and  less  extensive  than  in  erysipelas.  Only  in 
rare  cases  does  the  eruption  extend  beyond  the  wrist. 

A  variable  degree  of  heat,  pain,  burning,  and  itching  is 
present.  The  eruption  appears  usually  about  forty-eight 
hours  after  infection,  but  the  incubation  may  be  much  shorter. 
The  condition  lasts  from  one  to  six  weeks,  and  disappears 
without  desquamation. 

Etiology. — The  affection  is  due  to  poisoning  with  decom- 
posing animal  matter:  it  is  usually  observed  upon  the  hands 
of  fish-dealers,  butchers,  scullions,  etc.  The  infection  gains 
entrance  through  a  wound.  Gilchrist,  who  recorded  329  cases 
occurring  in  Baltimore,  states  that  all  but  6  were  due  to  crab- 
bites.  Rosenbach  regarded  a  microorganism  belonging  to 
the  family  of  cladothrix  as  the  cause,  but  Gilchrist's  studies 
failed  to  confirm  this  finding. 


160  DISEASES  OF  THE   SKIN 

Treatment. — The  disease  is  readily  amenable  to  antiseptic 
treatment.  Gilchrist  advises  a  25  per  cent,  salicylic  acid 
ointment  applied  over  and  beyond  the  affected  area.  I  have 
used  with  good  results  a  25  per  cent,  ichthyol  ointment. 

DERMATITIS 

Definition. — Dermatitis,  or  inflammation  of  the  skin,  is  a 
cutaneous  disorder  characterized  by  heat,  redness,  pain,  and 
swelling — in  other  words,  by  the  ordinary  phenomena  of  inflam- 
mation. The  term  is  here  restricted  to  acute  inflammations  the 
result  of  known  irritants.  For  purposes  of  classification  and 
study  several  varieties  of  dermatitis  are  distinguished:  (a) 
Dermatitis  traumatica,  (b)  Dermatitis  calorica.  (c)  Derma- 
titis venenata,  (d)  Dermatitis  medicamentosa,  (e)  Derma- 
titis gangrenosa. 

Dermatitis  Traumatica 

Under  this  head  are  included  all  forms  of  inflammation  the 
result  of  mechanical  violence  to  the  skin,  such  as  contusions, 
lacerations,  and  excoriations  (due  to  friction,  scratching,  etc.). 
The  traumatism  produced  by  scratching  is  of  especial  impor- 
tance to  the  dermatologist. 

Dermatitis  Calorica 

This  form  of  dermatitis  is  due  to  exposure  to  excessive  heat 
(dermatitis  ambustionis,  burn)  or  to  excessive  cold  (dermatitis 
congelationis,  frost-bite,  chilblain).  In  both  forms  we  have, 
according  to  the  severity  of  the  inflammation,  erythema,  vesi- 
cation, or  gangrene,  accompanied  by  severe  pain.  Burns  and 
frost-bites,  being  in  the  nature  of  emergency  accidents,  are 
more  commonly  regarded  as  surgical  conditions. 

Treatment  of  Burns. — Ichthyol,  3j;  petrolatum,  3j.  Carron 
oil  (equal  parts  of  linseed  oil  and  lime-water).  Acidum  car- 
bolicum,  gr.  x;  acidum  boricum,  gr.  xxx;  petrolatum,  Sj. 
Powder  or  solution  of  bicarbonate  of  soda.  One  per  cent, 
solution  of  picric  acid  has,  in  my  experience,  acted  admirably 
for  superficial  burns,  particularly  when  applied  soon  after  the 
accident. 

Treatment  of  Frost-bite. — Rubbing  with  snow.  Stimu- 
lating applications,  such  as  turpentine,  camphor,  iodin,  ichthyol, 
and  carbolized  oi* 


DERMATITIS 


161 


DERMATITIS  VENENATA 
Dermatitis  venenata  is  due  to  contact  with  deleterious  mineral 
and  vegetable  substances.  Among  these  may  be  mentioned 
acids  or  alkalis,  Croton  oil,  mustard,  arnica,  mercury,  chrysa- 
robin,  formalin,  cantharides,  anilin  dyes,  etc.  The  derma- 
tologist is  more  interested  in  the  dermatitis  produced  by  poison- 
ous plants,  chiefly  the  Rhus  toxicodendron  (poison  ivy),  the 
Rhus  venenata  (poison  sumac  or  dogwood),  and  Rhus  dtver- 
siloba  (poison  oak).  Within  recent  years  attention  has  been 
called  to  the  frequency  of  dermatitis  resulting  from  contact  with 


Fig.  66. — Dermal 


the  Primula  obconica,  or  primrose,  a  flowering  hot-house  plant 
much  in  vogue,  particularly  during  the  Easter  and  Christmas 
seasons.  The  recurrent  attacks  of  dermatitis  upon  the  face  and 
hands  are  apt  to  be  interpreted  as  eczema. 

A  great  variety  of  plants  have  been  found  capable  of  pro- 
ducing a  dermatitis  in  susceptible  individuals.  These  have 
been  described  in  a  valuable  book  on  "Dermatitis  Venenata," 
by  Dr.  J.  C.  White,  of  Boston. 

The  poisonous  principle  *  '-  believed  to  be 

a  volatile  substance  ]n 


1 62 


DISEASES   OF   THE    SKIN 


Symptoms. — From  a  lew  hours  to  several  days  after  exposure 
the  hands,  face,  and  genitalia,  in  a  typical  case,  become  the 
seat  of  innumerable  closely  studded  vesicles  and  blebs,  accom- 
panied  by  redness,   swelling,  and  great  burning   or  itching. 


Fig.  67.— Dermatitis  venenata  (ivy -poisoning). 

The  vesicles  and  blebs  are  at  times  angular  or  stellate,  and 
not  infrequently  appear  in  linear  streaks.  The  eruption  may 
be  carried   to  various  parts  of  the  body  by  autoinoculation. 

The  dermatitis  lasts  from  one  to  four  weeks.     Some  individuals 


Fig.  68.— Der 


are  extremely  susceptible  to  plant-poisoning — so  much  so 
that  proximity  without  contact  suffices  to  bring  on  an  attack. 
Other  individuals  enjoy  comparative  immunity.  Some  per- 
sons are  susceptible  at  one  period  of  life  and  become  immune 
later,  or  the  converse  of  this  may  be  true. 


DERMATITIS  163 

When  the  face  is  involved,  the  eyelids  are  greatly  swollen 
and  the  affection  may  simulate  an  erysipelas  in  appearance; 
the  absence  of  high  fever  and  other  systemic  symptoms  will 
readilv  exclude  the  latter  disease.  In  some  cases  considerable 
difficulty  will  be  experienced  in  distinguishing  rhus-poisoning 
from  an  acute  eczema.  History  of  previous  similar  attacks, 
exposure  to  plants,  the  presence  of  numerous  closely  aggregated 
pin-point-sized  vesicles,  and  the  more  rapid  involution  will 
distinguish  the  dermatitis  from  a  common  eczema. 

The  treatment  of  plant-poisoning  does  not  differ  essentially 
from  that  of  an  acute  vesicular  eczema.  The  following  com- 
bination has  yielded  most  satisfactory  results: 

R  .    Acidi  borici 31 ; 

Resorcin 3j ; 

Sodii  hyposulphit 3iij; 

Glycerini f^ij; 

Zinci  oxidi %\ ; 

Aquse q.  s.  ad  f^vj. — M. 

Wet  compresses  of  a  solution  of  sodium  hyposulphite,  one 
dram  to  the  ounce,  are  also  useful.  Likewise,  saturated  solu- 
tion of  boric  acid,  equal  parts  of  black-wash  ancL  lime-water, 
bromin  in  olive  oil,  ten  minims  to  the  ounce,  carbolated  zinc 
ointment,  and  a  host  of  other  remedies. 

Dermatitis  Medicamentosa 

(Drug  Eruptions) 

This  class  includes  eruptions  due  to  the  ingestion  or  absorp- 
tion of  medicaments.  Drug  eruptions  are  favored  by — (a)  idio- 
syncrasy; (/>)  excessive  cutaneous  elimination;  (c)  imperfect 
renal  and  intestinal  elimination  (often  due  to  renal  or  cardiac 
disease);  (d)  large  doses;  (e)  long-continued  administration. 
Individual  susceptibility  is  the  most  important  factor.  The 
eruption  may  be  macular,  papular,  vesicular,  urticarial,  bul- 
lous, or  hemorrhagic. 

Acetanilid  in  large  or  long-continued  doses  may  produce 
cyanosis.  It  occasionally  causes  an  erythematous  or  erythe- 
matopapular  rash. 

Antipyrin. — Out   of   52    cases   collected   by  Spitz,   41   were 
morbilliform,  4  urticarial,  and  7  erythematopapular.     Erup- 
tions prone  to  itch  and  desquamate.     I  have  seen  a  severe 
exfoliative  dermatitis  with  loss  of  nails  and  hair  fott 
doses  of  antipyrin. 


DISEASES  OF   THE    SKIN 


Arsenic. — Urticarial  eruption  most  frequent;  may,  however, 
be  erythematous,  papular,  or   vesicular.     Extensive   pigmen- 


Fig.  69.— Enfoliative  dennali 


pyrin.     Hair  and  nails  shed. 


tation  may  follow  long -continued  use  of  arsenic;  herpes  zoster 
thought  to  be  produced  by  it  at    times.     Hyperkeratosis   of 


Fig.  jo. — Bullous  eruption,  resembling  pemphigus,  from  the  inj 


the  palms  and  soles  may  result  from  long-continued  use  and 
may  eventuate  in  serious  cutaneous  cancer.  Arsenical  erup- 
tions are  relatively  uncommon. 


DERMATITIS  1 65 

Belladonna. — Erythematous  eruption  resembling  scarlatina. 
Not  uncommon. 

Boric  Acid  and  Sodium  Borate. — Rare.  Erythematous, 
with  small  vesicles.  Continued  use  may  cause  dry,  scaly  erup- 
tion with  loss  of  hair. 


fig.  71.— Puslulobulli 


the  ingestion  of 


Bromin    and    Bromids. — Pustular    (acneiform)    eruption    is 
the    most    frequent  •  type.     In    children,    large,    brownish-red, 


button-like  nodules  are  not  uncommonly  seen  and  are  quite 
characteristic.      Bromid   eruption   may  appear  after  the  ces- 


l66  DISEASES  OP  THE   SKIN 

sation  of  the  administration  of  the  drug.  An  infant  may 
absorb  the  drug  through  the  maternal  milk.  Less  common  are 
macular,  papular,  urticarial,  and  bullous  eruptions. 

Cantharides. — Erythematous  and  papular  eruptions,  chiefly 
about  genitals.     Rare. 

Capsicum. — Erythematous  eruption.     Rare. 


Fig.  IS.— Copai 


Chloral. — A  scarlatinoid  erythema,  with  subsequent  des- 
quamation, may  occur.  More  rarely  urticarial,  papular,  or 
vesicular  lesions. 

Copaiba  and  Cubebs. — Not  uncommon;  most  rashes  following 
the  combined  use  of  these  two  drugs  are  due  to  the  copaiba. 
Most  common  is  a  morbilliform  rash  strongly  resembling 
measles.  May  also  be  scarlatinoid  or  urticarial,  or,  in  rare 
cases,  vesicular,  bullous,  or  petechial. 


DERMATITIS  1 67 

Digitalis. — Rare.     Scarlatiniform    or    maculopapular. 

Ergot — Rare.  Vesicular,  pustular,  bullous,  petechial,  or 
gangrenous  lesions. 

Iodin  and  lodids. — The  pustular  acneiform  eruption,  like 
that  caused  by  bromids,  is  common.  Bullous,  erythematous, 
urticarial,  hemorrhagic,  papillomatous,  and  gangrenous  lesions 
may  rarely  develop.  As  with  the  bromids,  the  eruption  may 
appear  after  the  drug  has  been  discontinued. 

Iodoform. — Absorption  from  wounds  may  cause  grave  symp- 
toms and  erythematous,  papular,  vesicular,  bullous,  or  petechial 
eruptions. 

Mercury. — Uncommon.     Erythematous. 

Opium  and  its  Alkaloids. — Uncommon.  Itching  erythema- 
tous rash,  resembling  measles  or  scarlet  fever.  At  times  urti- 
carial. 

Potassium  Chlorate. — Rare.     Macular  and  papular  eruption. 

Quinin,  Cinchona,  etc. — Most  frequently  erythematous, 
resembling  scarlet  fever.  May  be  accompanied  by  some  fever, 
and  when  eruption  is  well  marked  it  is  followed  by  pronounced 
desquamation.  Throat  is  reddened,  but  not  edematous.  Of 
60  quinin  eruptions  analyzed  by  Morrow,  38  were  erythematous, 
12  urticarial,  5  purpuric,  and  2  vesicular  and  bullous. 

Salicylic  Acid  Group. — Occasional.  Erythematous  and  scar- 
latiniform, sometimes  followed  by  desquamation.  May  be 
urticarial,  purpuric,  vesicular,  or  bullous. 

Strychnin. — Scarlatiniform  rash  once  observed. 

Sulphonal. — Uncommon.  Macular  and  erythematous. 
Rarely  purpuric.  The  author  observed  a  giant  urticaria 
with  great  swelling  of  face  follow  a  twenty-grain  dose  in 
an  alcoholic. 

Thallium  Acetate. — Experimental  administration  in  animals 
has  caused  patchy  baldness. 

Turpentine  (Terebene). — Uncommon.  Erythematous,  vesic- 
ular, and  papular  eruptions. 

Veronal. — I  have  observed  eruptions  closely  resembling  the 
rashes  of  scarlet  fever  and  measles.  The  scarlatinoid  rash  was 
accompanied  by  fever. 

Dermatitis  Gangraenosa 

Synonym. — Sphaceloderma. 

Gangrene  of  the  skin  may  result  from  a  variety  of  causes. 
Heat,  cold,  and  diverse  local  irritants,  when  applied  in  their 


l6S  DISEASES  OP  THE   SKIN 

most  intense  form  and  continued  sufficiently  long,  produce 
cellular  death  and  gangrene.  Most  other  forms  of  gangrene 
are  of  blood-vessel  origin,  either  the  result  of  endarteritis, 
embolus,  or  thrombus,  or  are  due  to  vasomotor  disturbances 
associated  with  morbid  nervous  or  trophic  troubles.  Several 
distinct  varieties  of  gangrene  of  the  skin  are  recognized:  (i) 
Multiple  gangrene  of  the  skin;  (2)  neurotic  or  hysteric  gangrene; 
(3)  disseminated  gangrene  in  infants;  (4)  symmetric  gangrene 
(Raynaud's  disease) ;  (5)  diabetic  gangrene. 

Multiple  gangrene  of  the  skin  may  occur  in  the  course  of  many 
infectious  diseases,  particularly  typhoid  fever.  I  have  seen  it 
in  small-pox  and  scarlet  fever.  Osier  records-its  occurrence  in 
malaria.     It  may  also  develop  independently  of  such  diseases. 


Neurotic  or  hysteric  gangrene  is  a  variety  in  which  recurrent 
outbreaks  occur,  often  leading  to  progressive  loss  of  skin  and 
mutilation  of  members.  Some  of  the  lesions  are  doubtless 
due  to  central  nerve  lesions,  while  others  are  probably  self- 
produced. 

Dermatitis  Gancraenosa  Infantum 

ited    gangrene 

Definition. — A  gangrenous  affection  following  varicella 
and  other  pustular  affections  in  children. 

Symptoms. — Following  in  the  wake  of  varicella,  small-pox, 
or  simple  pustular  dermatoses  there  occur  crusted  pea-  to  coin- 
sized  pustules  with  inflammatory  areola?,  somewhat  resembling 
vaccine  lesions.     In  a  short  time  the  crusts  are  thrown  off  with 


SYMMETRIC  GANGRENE  1 69 

a  slough,  leaving  a  distinct  ulceration.  There  may  be  fever, 
vomiting,  diarrhea,  lung  complications,  and  symptoms  of 
pyemia.     Indelible  scars  are  left. 

Prognosis. — Guarded.  Depends  upon  age,  number  of 
lesions,  and  character  of  complications. 

Treatment. — Supportive.  Crocker  advises  quinin  in  one- 
or  two-grain  doses  in  milk  every  four  hours.  Complications 
should  be  treated  as  they  arise.  Locally,  antiseptic  applica- 
tions. 

SYMMETRIC  GANGRENE 

Synonyms. — Raynaud's  disease;  Local  asphyxia;  Spontaneous  gangrene. 

Definition. — A  local  arterial  ischemia,  generally  followed 
by  asphyxia,  occurring  at  the  periphery  of  the  circulation,  and 
producing  symmetrically  distributed  gangrene  of  the  skin  and 
other  tissues  in  the  affected  region  (Crocker). 

Symptoms. — The  disease  usually  attacks  the  fingers  and 
toes,  although  the  nose  and  ears  are  also  occasionally  affected. 
With  or  without  preceding  pain  and  numbness,  the  parts  become 
cold  and  whitish.  After  a  variable  persistence  of  this  stage, 
local  asphyxia  develops,  characterized  by  lividity,  bluish  dis- 
coloration, and  at  times  swelling  and  pain.  The  symptoms 
in  this  stage  often  exhibit  marked  change  from  time  to  time. 
In  most  cases  the  disease  goes  on  to  the  terminal  stage  of  gan- 
grene, the  sphacelated  tissues  being  cast  off,  leaving  granu- 
lating wounds.  Some  cases  continue  for  a  long  time  with  per- 
sistently livid  fingers  and  toes  without  the  development  of 
gangrene,  though  even  in  these  cases  relapses  are  the  rule. 

When  the  patient  is  debilitated  or  the  affected  areas  large, 
death  may  result. 

Etiology. — Exposure  to  cold  is  the  most  frequent  cause. 
The  affection  has  been  observed  to  follow  diphtheria,  typhoid 
fever,  scarlatina,  measles,  malaria,  syphilis,  tuberculosis,  and 
diabetes. 

Prognosis. — In  extensive  cases  in  the  very  old  or  young 
the  prognosis  is  serious.  When  the  affected  areas  are  small, 
the  prognosis  is  good,  but  there  is  tendency  to  recurrence. 

Treatment. — When  seen  early,  galvanism  with  one  electrode 
applied  to  the  spine  and  the  other  immersed  with  the  affected 
part  in  water,  is  the  best  treatment.  Friction  with  stimulating 
liniments,  as  for  frost-bites,  is  also  of  value. 


170  diseases  op  the  skin 

Diabetic  Gangrene 
In  advanced  cases  of  diabetes  mellitus  localized  cutaneous 
gangrene  may  occur.  The  process  is  apt  to  begin  as  a  bleb, 
which  dries,  forms  a  crust,  and  is  thrown  off  with  the  under- 
lying sphacelated  skin,  leaving  a  granulating  ulcer.  The  proc- 
ess is  apt  to  attack  the  middle  of  the  extremities  (calves,  etc.) 
rather  than  the  fingers  or  toes. 

FEIGNED  ERUPTIONS  (DERMATITIS  FACnTIA) 

Feigned  or  artificial  eruptions  are  self- produced,  with  the  idea 

of  gaining  exemption  from  work  or  of  exciting  sympathy  and 

charity.     They  are  seen  most  frequently  in  subjects  of  hysteria, 

in  paupers  seeking  admission  to  institutions,  and  in  soldiers 


Fit  75. — Self -produced 


and  sailors  who  desire  their  discharge  from  service.  A  hys- 
teric woman  will  frequently  submit  to  all  sorts  of  treatment, 
even  amputation  of  a  limb,  without  revealing  her  agency  in 
the  production  of  the  lesions. 

The  dermatitis  may  be  erythematous,  bullous,  or  gangrenous, 
and  is  produced  by  acids,  caustics,  friction,  etc.  The  peculiar- 
ities of  feigned  eruptions  are:  (a)  Their  oddity  or  deviation 
from  ordinary  types  of  skin  diseases;  (b)  their  sharp  definition; 
(c)  their  limitation  to  regions  accessible   to  the  hands.     By 


FURUNCULUS  1 7 1 

applying  a  fixed  dressing,  such  as  a  plaster-of- Paris  bandage 
that  cannot  be  disturbed,  the  nature  of  the  condition  may  often 
be  determined. 

FURUNCULUS 

Derivation. — L,,  furuactttus,  a  knave.     Synonyms. — Boil;  Furuncle, 

Definition. — A  furuncle  is  an  acute  circumscribed  inflam- 
mation of  a  cutaneous  gland  or  hair- follicle,  ending  in  sup- 
puration and  the  extrusion  of  a  central  necrotic  mass. 

Symptoms.— A  furuncle  begins  as  a  painful  induration  in 
the  skin  which  gradually  approaches  the  surface,  .showing  itself 
as  a  rounded  or  acuminate  reddish  prominence. 

The  boil  may  have  its  origin  deep  in  the  skin  and  the  sub- 
jacent tissues,  or  it  may  begin  comparatively  superficially. 
In  the  former  instance  it  may  sometimes  be  felt  before  it  is  seen 
as  a  circumscribed  nodular  tumefaction.  Soon  the  overlying 
skin  becomes  reddened  and  edematous;  when  suppuration  is 
imminent,  the  central  summit  begins  "to  point"  and  becomes 
yellowish.  When  accidentally  or  intentionally  opened,  the 
furuncle  gives  exit  to  a  thick  yellowish  pus,  often  commingled 
with  blood,  from  the  rupture  of  capillaries.  The  discharge 
continues  for  a  few  days,  after  which  the  abscess  cavity  is 
filled  by  granulation.  In  some  cases  a  greenish -ye  How  "core," 
consisting  of  partially  disorganized  and  necrotic  tissue,  is  ex- 
truded, after  which  prompt  healing  takes  place. 

The  more  superficial  furuncles  consist  of  small  conical  lesions 
with  a  pustular  apex  and  reddish  infiltrated  base,  the  former 
being  penetrated  by  a  hair.  When  the  pus  is  evacuated,  the 
furuncle  rapidly  disappears.  Around  one  boil  as  a  focus 
numerous  satellites  are  prone  to  appear.  This  may  result 
from  external  autoinoculation  or  intradermic  transmission 
through  lymphatic  channels. 

The  most  frequent  seats  of  furuncles  are  the  back  of  the 
neck,  buttocks,  face,  and  axilla?,  but  lesions  may  occur  upon 
any  portion  of  the  body. 

Furuncles  have  their  seat  about  hair-follicles,  sebaceous 
glands,  or  sweat-coils :  the  last-named  variety  is  chiefly  observed 
in  the  axilke  and  anogenital  regions. 

Furancuiosis  is  a  condition  in  which  there  are  intermittent 
outbreaks  of  boils  extending  over  a  period  of  weeks,  months, 
or  years. 

Etiology. — Boils  are  due  to  infection  of  the  skin  with  pyo- 


172  DISEASES  OF  THE   SKIN 

genie  microorganisms,  particularly  the  Staphylococcus  aureus. 
Inasmuch  as  this  and  other  organisms  are  usually  present  upon 
the  normal  skin,  other  etiologic  factors  must  be  coexistent. 
The  cutaneous  soil  must  be  favorable  to  the  noxious  activity 
of  staphylococci.  The  resisting  power  of  the  skin  is  especially 
lowered  by  such  diseases  as  diabetes,  enterocolitis  in  children, 
Bright's  disease,  gout  and  its  associated  states,  anemia,  etc., 
and  after  the  exanthematous  and  other  fevers.  Furunculosis 
and  abscess  formation  are  almost  constant  complications  of 
severe  small-pox. 

Localized  eruptions  of  boils  are  usually  the  result  of  traumatic 
injury  of  the  skin.  The  friction  of  frayed  collar-bands  makes 
the  nape  of  the  neck  a  favorite  seat ;  boils  on  the  buttocks  are 
common  in  equestrians.  The  scratching  in  eczema,  scabies, 
and  other  itching  dermatoses  frequently  causes  the  production 
of  boils.  Boils  are  commonly  observed  in  association  with 
prickly-heat  in  infants  suffering  from  intestinal  troubles.  It 
is  probable  that  some  cases  of  recurrent  boils  are  due  to  infec- 
tion from  pyogenic  foci  in  the  body;  thus  chronic  dental 
abscesses  have  been  alleged  to^cause  the  persistent  continuance 
of  boils.  Furuncles  mav  result  from  the  administration  of 
iodids;  they  may  also  occur  in  those  working  in  paraffin, 
petroleum,  and  tar. 

Pathology. — Boils  develop  about  hair-follicles,  sebaceous 
and  sweat-glands.  The  Staphylococcus  aureus  is  the  chief 
offending  organism.  Through  bacterial  toxins,  intense  inflam- 
mation, or  thrombotic  obstruction,  vascular  nutrition  is  com- 
promised and  a  necrosis  en  masse  takes  place.  Unna  believes 
that  most  furuncles  begin  as  a  follicular  impetigo,  the  cocci 
gradually  extending  along  the  hair  to  the  base  of  the  follicle 
and   to  the   sebaceous  glands. 

Diagnosis. — The  ordinary  characteristics  of  boils  are  too 
well  known  to  require  elucidation;  the  differentiation  of  car- 
buncles will  be  considered  under  that  head. 

Prognosis. — One  or  several  localized  furuncles  respond 
rapidly  to  treatment.  In  recurrent  furunculosis  much  depends 
upon  ability  to  remove  the  cause.  Though  refractory,  most 
cases  are  ultimately  cured. 

Treatment. — Apart  from  local  remedies,  the  patient  is  to 
be  treated  rather  than  the  disease.  The  urine  should  be  care- 
fully examined  to  determine  the  presence  or  absence  of  sugar 
and  albumin.     Gouty  patients  should   be   dieted   and   given 


FURUNCULUS  1 73 

alkalis.  Anemic  and  debilitated  persons  require  good  food, 
proper  hygiene,  and  tonics.  Cod-liver  oil  is  useful  in  such  cases. 
In  refractory  cases  change  of  climate  and  sojourn  at  health 
resorts  should  be  tried. 

Many  of  the  remedies  credited  with  antifuruncular  virtues 
are  disappointing.  Calcium  sulphid,  which,  in  yj-  to  £  grain 
doses,  has  been  highly  extolled,  is  usually  of  no  value.  Arsenic 
will  fail  to  accomplish  good  in  most  cases.  Fresh  brewers' 
yeast,  a  teaspoonful  to  a  tablespoonful  several  times  a  day, 
has  been  reintroduced  in  the  treatment  of  boils,  and  Lowenberg, 
Crocker,  and  Brocq  speak  highly  of  it  in  some  cases.  I  have 
seen  good  results  in  ordinary  furunculosis,  but  have  failed 
with  the  yeast  in  the  furunculosis  accompanying  small-pox. 
Sulphur  preparations  internally  likewise  failed  completely. 

Careful  examination  should  be  made  for  chronic  dental 
abscesses  and  other  purulent  foci  in  the  body. 

Local  Treatment — Single  lesions  should  be  incised  and 
evacuated  as  soon  as  the  first  evidence  of  suppuration  occurs, 
but  not  before.  Squeezing  and  excessive  digital  manipulation 
should  be  avoided,  as  they  may  increase  the  size  of  the  lesion. 
Abortive  applications,  such  as  carbolic  acid,  nitrate  of  silver, 
tincture  of  iodin,  sometimes  succeed,  but  often  fail;  they  may, 
however,  do  good  as  counter-irritants.  Crocker  advises,  to 
abort  the  lesion,  the  injection  beneath  the  boil  of  five  drops 
of  a  3  per  cent,  solution  of  carbolic  acid. 

In  lesions  at  the  nape  of  the  neck  which  are  rubbed  by  the 
collar  great  comfort  and  protection  are  secured  by  wearing  a 
25  per  cent,  ichthyol  plaster. 

When  suppuration  threatens,  an  excellent  method  is  to  apply 
hot  boric  acid  or  i  :  4000  bichlorid  of  mercury  compresses 
covered  with  oiled  silk.  The  use  of  this  lotion  upon  the  sur- 
rounding skin  lesions  lessens  the  liability  to  further  follicular 
infection. 

If  one  prefers,  the  surrounding  skin  may  be  sopped  with  a 
weak  bichlorid  solution.  In  refractory  localized  furunculosis 
the  x-rays  are  of  distinct  value.  (For  technic  see  special 
chapter.) 

Opsonic    Treatment. — The    treatment   of   furunculosis   with 
injections  of  sterilized  emulsions  of  the  organisms  cultivated 
from  the  lesions  (usually  staphylococci),  has,  in  general,  riven 
better   results  than   any  other  method  o? 
treatment,  which  has  been  recently  elate 


174  DISEASES   OP   THE    SKIN 

for  its  object  the  raising  of  the  specific  defensive  power  of  the 
individual  against  the  offending  microorganisms. 

CARBUNCULUS 
e  of  L.,  carbo,  a  live  coal.     Synonyms. — Anthrax 

Definition. — Carbuncle  is  an  acute  phlegmonous  inflam- 
mation of  the  skin  and  subcutaneous  tissue,  characterized  by 
multiple  foci  of"  necrosis  and  slpughing  of  the  superimposed 
integument.  ,     . 

Symptoms. — There  is,  .as  a  rule,  but  one  lesion  present, 
having  for  its  seat  of  predilection  the  neck  or  back.  It-begins 
as  a  flat,  painful  infiltration,  varying  in  size  from. a  chestnut 


Fig.  76.-Carl.mulc. 

to  an  orange.  The  skin  is  of  a  violaceous  hue  and  board-like. 
At  the  end  of  a  week  or  ten  days  the  overlying  integument 
sloughs  in  numerous  points,  exposing  to  view  grayish -yellow 
necrotic  masses  from  which  a  sanious  pus  exudes.  This  cribri- 
form appearance  is  characteristic  of  carbuncles.  Later,  the 
entire  superjacent  skin  becomes  gangrenous,  and,  being  thrown 


CARBUNCULUS  1 75 

off  with  the  necrotic  masses,  leaves  a  gaping  ulceration  which 
heals  up  by  granulation,  with  the  production  of  a  permanent 
scar. 

The  process  is  usually  accompanied  by  chill,  fever,  and  pros- 
tration. In  the  old  and  debilitated  a  fatal  septicemia  may 
develop. 

Etiology. —Occurs  usually  after  the  fortieth  year.  The 
same  predisposing  causes  are  operative,  as  in  furuncle — namely, 


Fig.  77. — Carbuncle  with  surrounding  et 


diabetes,  general  debility,  etc.  The  exciting  cause  is  the 
introduction  into  the  skin  of  a  pyogenic  microorganism. 

Pathology. — The  process  begins  in  the  subcutaneous  tissue. 
Suppuration  occurs  simultaneously  in  numerous  adjacent 
foci.  The  skin  and  subjacent  tissues  are  enormously  swollen 
and  have  imbedded  in  them  the  yellowish-white  necrotic  plugs. 
The  process  extends  laterally  and  vertically,  and  ends  in  a 
gangrene  of  the  entire  area. 

Diagnosis. — In  the  beginning  only  may  furuncle  and  car- 
buncle be  confounded : 


176 


DISEASES  OF  THE   SKIN 


Carbuncle. 

1.  Occurs    usually    in    late    adult 

life. 

2.  Slow  in  development  and  invo- 

lution. 

3.  Chestnut  to  orange  size. 

4.  Surface  flat. 

5.  Skin  board-like  or  brawny. 

6.  Multiple  suppurating  openings. 

7.  Terminates  in   gangrene. 

8.  Constitutional    disturbance. 


Furuncle. 

1.  Occurs  at  any  age. 

2.  Comparatively  rapid  in  develop- 

ment and  involution. 

3.  Pea   to   cherry   size. 

4.  Surface  round   or   conical. 

5.  Ordinary   inflammatory  indura- 

tion. 

6.  Single  opening. 

7.  Heals  after  extrusion  of  "core." 

8.  As  a  rule,  absent. 


Prognosis. — Favorable,  except  in  the  aged  and  debilitated 
and  in  diabetics  and  alcoholics.  Carbuncle  upon  the  head 
or  face  is  more  serious  than  in  other  localities. 

Treatment. — Various  methods  have  been  employed.  Most 
authors  favor  parenchymatous  injections  of  strong  caustics 
rather  than  making  crucial  incisions.  Crocker  recommends 
the  injection  of  glycerin  and  carbolic  acid,  one  to  two  or  four, 
as  soon  as  suppuration  begins.  Woods,  Taylor,  and  Manley 
advise  the  injection  of  pure  carbolic  acid  into  various  portions 
of  the  sloughing  area.  The  resulting  pain  is  of  but  short  dura- 
tion. The  stick  of  caustic  potash  may  be  bored  into  the  open- 
ings of  the  carbuncle.  After  gangrene  has  occurred,  antiseptic 
fomentations,  such  as  hot  boric-acid  compresses,  are  useful. 
When  septicemic  symptoms  become  marked,  it  is  justifiable 
to  excise  the  entire  affected  area.  This  is  usually  followed  by 
prompt  improvement  in  the  symptoms. 

Nutritious  food  and  stimulants  are  necessary  to  sustain  the 
strength.-  Morphin  and  chloral  are  often  demanded  co  relieve 
pain  and  produce  sleep. 

The  opsonic  treatment  has  been  highly  lauded  in  the  treat- 
ment of  carbunculosis. 

EQUINIA 

Derivation. — L.,  equus,  a  horse.     Synonyms. — Glanders;  Farcy. 

Definition. — Equinia  is  a  contagious  specific  disease  derived 
from  the  horse,  characterized  by  constitutional  disturbance 
and  lesions  of  the  respiratory  and  cutaneous  surfaces.  The 
disease  is  very  rare  in  the  human  subject. 

Symptoms. — The  site  of  inoculation  when  cutaneous  is 
marked  by  an  inflammatory  papule  or  pustule,  which  soon 
degenerates  into  a  ragged,  undermined,  spreading  ulcer,  with 
accompanying  lymphangitis  and   glandular   swelling.     Later, 


ANTHRAX  177 

numerous  cutaneous  and  subcutaneous  nodules  develop,  which 
break  down  and  discharge  (farcy-buds).  There  is  usually 
nasal  ulceration,  with  a  foul-smelling  discharge.  Most  cases 
run  an  acute  course,  ending  in  death.  Those  that  last  several 
months  may  recover.  The  constitutional  symptoms  are  fever, 
prostration,  joint  pains,  and  a  typhoidal  state. 

Etiology  and  Pathology. — The  disease  is  due  to  the  glanders 
bacillus  (Bacillus  mallei).  Stablemen  and  others  coming  in 
contact  with  horses  are  the  usual  victims. 

Prognosis. — In  the  acute  form  nearly  all  die;  in  the  chronic 
form  50  per  cent,  recover. 

Treatment. — Destruction  of  lesion  by  curet,  knife,  or  caus- 
tics. In  chronic  cases  quinin  in  large  doses  and  stimulants. 
Injections  of  mallein  have  been  successfully  employed  in  several 
cases. 

ANTHRAX 

Synonyms. — Pustula  maligna;  Charbon. 

Definition. — Anthrax  is  a  specific  disease  produced  by  the 
Bacillus  anthracis,  characterized  by  a  gangrenous,  carbuncle- 
like cutaneous  lesion. 

Symptoms. — The  lesion,  which  is  nearly  always  single  and 
which  is  usually  situated  upon  the  face,  neck,  or  hand,  begins 
as  an  extremely  painful  papule.  This  is  rapidly  converted 
into  a  hemorrhagic  vesicle  or  bleb,  which  soon  becomes  pustular. 
There  is  intense  inflammation,  quickly  terminating  in  the  for- 
mation of  a  depressed  gangrenous  eschar.  On  the  border  of 
this,  a  ring  of  large  firm  vesicles  commonly  develops.  The 
surrounding  skin  is  hard,  infiltrated,  and  edematous,  and  this 
may  spread  considerably  beyond  the  infected  area. 

The  constitutional  symptoms  consist  of  chill,  vomiting, 
prostration,  fever — 104  °  F.  or  more — and  pains  in  the  head 
and  bones.  Later  there  may  occur  typhoidal  symptoms,  and 
death  in  two  or  three  days.  Mild  cases  of  anthrax  may  exhibit 
comparatively  little  fever  and  systemic  depression. 

Etiology. — The  disease  is  more  often  derived  from  the  hides 
or  bodies  of  animals  affected  with  splenic  fever  than  from  the 
living  animals  themselves;  most  of  the  patients  observed  in 
cities  are  employees  in  leather  factories:  morocco  workers, 
butchers,  tanners,  and  wool-sorters  are  the  usual  victims. 

Pathology. — The  exciting  cause  is  the  Bacillus  anthracis, 
which,  after  a  few  days,  may  be  found  in  the  organs,  secretions, 
and,  at  times,  in  the  blood. 

12 


I78  DISEASES   OF   THE    SKIN 

Diagnosis. — The  distinctive  features  are  a  gangrenous  patch 
with  vesicular  border,  surrounded  by  great  edema  and  infiltra- 
tion, and  severe  constitutional  symptoms.  The  occupation  of 
the  patient  is  an  important  factor. 


Fig.  78. — Anthrax  maligna  in  a  morocto  worker;  patch  showed  central  necrosis, 
vesicles  upon  the  jwriphrry,  and  brawny  infiltration  "t  surrounding  tissues.     Re- 

Prognosis. — The  disease  is  fatal  in  about  33  per  cent,  of 
cases. 

Treatment.— Early  free  excision.  Supportive  treatment, 
An  anthrax  serum  has  been  manufactured  and  is  worthy  of 
trial. 

POSTMORTEM  PUSTULE 

Synonym. — Dissection  wound. 

Definition. — Postmortem  pustule  is  a  condition  resulting 
from  infection  from  the  cadaver,  and  is  characterized  by  an 
inflammatory  lesion  at  the  point  of  inoculation,  and  occasionally 
lymphangitis,  lymphadenitis,  and  slight  constitutional  disturb- 


tinea  Trichophytina  179 

Symptoms. — Inoculation  takes  place  at  the  site  of  a  cut  or 
abrasion.  An  itchy  red  spot  is  followed  by  the  development 
of  a  vesicopustule  with  a  broad,  painful,  inflammatory  areola. 
Suppuration  goes  on  beneath  the  crust,  which  reforms  as  soon  as 
removed.  The  lymphatic  vessels  and  glands  may  be  affected, 
and  there  is  often  slight  fever  and  malaise. 

Treatment. — Curetting  or  cauterization  of  the  pustule, 
followed  by  wet  antiseptic  dressings  of  boric  acid  or  bichlorid 
of  mercury. 

Postmortem  tubercle  will  be  considered  under  the  head  of 
Tuberculosa  Verrucosa  Cutis. 

TINEA  TRICHOPHYTINA 

Derivation. — L.,  tinea,  a  moth-worm;  Opi£t  hair;  *vr<5v,  a  vegetation. 
Synonym. — Ring- worm. 

Ring-worm  is  a  disease  capable  of  attacking  the  general  body 
surface,  the  scalp,  the  beard,  and  the  nails.  Investigations 
carried  out  by  Sabouraud  and  others  have  discovered  two  para- 
sitic fungi  as  the  causative  agents — the  Micros poron  Audouini, 
or  small-spored  fungus  and  the  trichophyton,  or  large-spored 
fungus,  of  which  there  are  several  varieties.  The  geographic 
distribution  of  the  microsporon  variety  shows  wide  differences. 
Ring- worm  of  the  scalp  due  to  the  small-spored  fungus  is  common 
in  England,  France,  and  the  United  States,  and  rare  in  Germany 
and  Italy. 

The  varieties  of  ring- worm  are:  (i)  Tinea  circinata,  or  ring- 
worm of  the  smooth  surface;  (2)  tinea  tonsurans,  or  ring-worm 
of  the  scalp;  (3)  tinea  sycosis,  or  ring- worm  of  the  beard; 
(4)  tinea  cruris,  or  ring-worm  of  the  genitocrural  region  (some- 
times called  eczema  marginatum);  (5)  tinea  unguium,  onycho- 
mycosis, or  ring-worm  of  the  nails. 

Tinea  Circinata 

Synonyms. — Ring-worm  of  the  body;  Herpes  circinatus;  Tinea  tricho- 
phytina  corporis. 

Definition. — Tinea  circinata  is  a  contagious  parasitic  disease, 
due  to  a  vegetable  fungus,  and  characterized  by  annular  vesic- 
ulosquamous  patches  upon  the  body  surface. 

Symptoms. — The  disease  begins  as  one  or  several  rounded 
or  irregular,  pea-sized,  hyperemir         *  -  few 

days  these  assume  a  circular 
scarcely  distinguishable 
ference. 


ISO  DISEASES   OP  THE    SKIN 

Peripheral  spreading  and  central  healing  progress  hand  in 
hand,  so  that  the  patches,  when  fully  developed,  are  distinctly 
annular  or  ring-shaped.  They  are  usually  coin-sized,  of  a  dull 
pinkish  or  reddish  color,  with  slightly  elevated  borders  which 
exhibit  a  branny  desquamation.  The  confluence  of  neighboring 
patches  may  occur,  leading  to  the  production  of  gyrate  lesions. 
Occasionally  patches  are  seen  with  several  concentric  rings. 
In  other  cases  patches  may  be  observed  without  central  clearing, 


Fig.  [ 

in  which  event  they  are  circular,  but  not  annular.  Rarely 
there  are  observed  elevated  plaques  with  deep  involvement  of 
the  skin;  in  these  cases  small  pustules  may  be  seen  at  the  sites 
of  the  hair- follicles.  Patches  of  ring-worm  are  usually  few  in 
number,  often  single.  In  rare  instances  a  large  number  may  be 
seen  on  the  face,  neck,  arms,  and  body. 

Itching  is  usually  slight.  The  face,  neck,  and  backs  of  hands 
are  the  most  frequent  seats. 

In  tinea  cruris  (eczema  marginatum),  the  clinical  appearances 
are  so  much  modified  as  frequently  to  simulate  an  eczema  inter- 


TINEA   TRICHOPHYTINA 


trigo.  The  patches  are  large,  diffuse,  of  a  dull  brownish-red 
color,  with  a  well-defined  marginated  and  at  times  slightly  ele- 
vated border.  Outlying  circinate  patches  are  often  present. 
The  eruption  may  spread  with  remarkable  rapidity,  successively 
involving  the  thighs,  groins,  genitals,  mons  veneris,  and  nates. 
Eczema  is  apt  to  complicate  this  affection.  The  itching  is 
often  severe,  particularly  at  night. 

Sabouraud  states  that  eczema  marginatum  or  tinea  cruris  is 
not  due  to  the  trichophyton  fungus,  but  to  another  variety  of 


Fig.  80.— Multiple 

mold  which  he  calls  "  epidermophyton  inguinale."  This 
investigator  also  claims  that  the  same  fungus  is  responsible 
for  certain  eczematoid  eruptions  involving  the  webs  of  the 
fingers  and  toes. 

Tinea  imbricata  is  a  form  of  tropical  body  ring-worm  in  which 
large  areas  or  the  entire  body  are  covered  with  brownish,  con- 
centric rings  and  large  bulky  scales.  The  body  often  looks 
clay  covered.     The  scalp  and  face  are  usually  exei 


[-82  DISEASES    OF   THE-  SKIN 

Tinea  Trickophytina  Unguium  (Onyclwmycosis ;  Ring-worm 
of  the  Nails). — Occasionally  the  nails  are  invaded  by  the  ring- 
worm fungus.  They  become  opaque,  white,  thickened,  soft, 
and  brittle.  Two  or  three  nails  are  usually  affected.  The 
disease  runs  a  chronic  course  and  is  refractory  to  treatment. 

Etiology. — Tinea  circinata  is  more  common  in  children 
than  in  adults.  It  is  transmitted  by  contact  and  through 
articles  of  toilet.  A  much  more  common  source  than  is  generally 
suspected  is  the  domestic  pet.  Cats  and  dogs  not  infrequently 
suffer  from  ring-worm,  exhibiting  partially  bald  and  "moth- 
eaten"  patches.  Ring-worm  contracted  from  animals  is  apt 
to  be  more  active  and  extensive. 


ring-w-orm;  eczema  marginatum). 


Pathology. — The  fungus  is  found  in  the  epidermis,  par- 
ticularly in  the  corneous  layer.  Mycelium  is  abundant,  spores 
scanty.  The  former  consists  of  long,  slender,  sharply  contoured, 
bifurcated,  jointed  threads.  The  spores  are  rounded,  highly 
refractile  bodies,  varying  from  ynW  to  S^iF  oi  an  inch  '" 
diameter. 

Method  of  Examining  the  Fungus. — Epidermic  scales  are 
scraped  off  with  a  knife  and  placed  on  a  microscopic  slide  with 
a  drop  of  caustic  potash  (10  to  40  per  cent.).  A  cover-glass 
is  then  applied,  with  sufficient  pressure  to  flatten  out  the  scales. 
The  fungus  is  best  studied  with  an  oil-immersion  lens,  although 
it  can  be  seen  with  a  ^-inch  dry  lens. 

Prognosis.— As   a    rule,    the   affection    yields    promptly    to 


TINEA   TRICHOPHYTINA  183 

treatment.  Tinea  cruris  is  more  rebellious  than  the  ordinary 
form. 

Treatment. — The  treatment  consists  in  the  use  of  parasiti- 
cide ointments  and  lotions.  Mercury,  sulphur,  betanaphthol, 
resorcin,  tar,  and  chrysarobin  are  all  valuable.  An  efficient 
formula  is : 

H .    Hydrarg.  ammoniat gr.  x-xxx; 

Ung.  zinci  oxidi 3J. — M. 

Hyposulphite  of  sodium  (one  dram  to  one  ounce  of  water)  and 
bichlorid  of  mercury  (■£  grain  to  one  ounce  of  water)  are  useful 
applications. 

In  the  treatment  of  tinea  cruris  the  remedies  must  not  be 
too  strong  or  an  acute  dermatitis  will  be  set  up.  A  soothing 
parasiticide  preparation  is  to  be  preferred.  The  following  has 
given  me  good  results: 

U  .    Hydrargyri  bichloridi gr.  j-ij; 

Resorcin 3J ; 

Glycerini f^ij ; 

Zinci  oxidi 3iss; 

Alcoholis f.^iv ; 

Aquae q.  s.  ad  f,5vj. — M. 

TINEA   TONSURANS 

Synonyms. — Ring- worm  of  scalp;  Herpes  tonsurans;  Tinea  tricho- 
phytina  capitis. 

Definition. — Tinea  tonsurans  is  a  contagious,  vegetable  para- 
sitic disease,  characterized  by  circumscribed  areas  of  partial 
baldness,  with  evidence  of  disease  of  the  hair. 

Symptoms. — The  disease  begins  as  small,  rounded,  reddened, 
scaly  patches,  occurring  upon  any  portion  of  the  hairy  scalp. 
At  the  very  onset  there  may  be  present  minute  vesicles,  but 
these  are  apt  to  be  overlooked.  The  condition  is,  in  the  begin- 
ning, a  surface  infection,  and  occasionally  patches  may  be 
observed  showing  a  slightly  elevated  annular  border.  Soon, 
however,  pilary  infection  takes  place;  the  follicles  and  hair- 
shafts  are  invaded,  the  latter  becoming  brittle  and  breaking 
off  about  a  quarter  of  an  inch  above  the  level  of  the  skin.  The 
hair-stumps  thus  produced  have  a  '  'gnawed-ofT '  appearance 
and  are  quite  characteristic  of  the  disease.  Some  of  the  affected 
hairs  fall  out.  Typical  lesions  consist  of  partially  bald,  dis- 
crete,   rounded,    coin-sized,    slightly    reddened    patches    with 


184  DISEASES  OP   THE   SKIN 

grayish  scales.  The  patches  vary  in  size  from  the  dimensions 
of  a  five-cent  piece  to  those  of  the  palm  of  the  hand.  Extension 
takes  place  by  involvement  of  fresh  hairs  upon  the  periphery 
of  the  patch.  In  some  cases  the  scalp  becomes  diffusely  affected 
and  no  distinct  circumscribed  patches  are  present.  A  thinning 
of  the  hair  over  a  considerable  area  is  observed.  This  is  called 
disseminated  ring-worm*  Such  cases  at  times  present  difficulties 
in  diagnosis. 

Tinea  kerion  is  a  highly  inflammatory  ring-worm,  terminating 
in  suppuration.  The  patches  are  reddish  or  yellowish,  raised, 
edematous,  and  boggy;  they  are  honey-combed  with  distended 


openings  of  hair- follicles,  through  which  exudes  a  yellowish 
pus.  Burning,  itching,  tenderness,  and  pain  are  present  in  a 
variable  degree.  The  suppuration  of  a  ring-worm  hastens  its 
cure,  but  may  destroy  the  follicles  and  produce  permanent 
baldness. 

The  appearances  of  microsporon  ring-worm  and  trichophyton 
ring-worm  vary  somewhat.  In  the  former,  the  patches  are 
prone  to  be  few  in  number,  but  mav  reach  a  considerable  size. 
The  follicles  are  prominent  and  the  skin  scaly.  The  hair- 
stumps  are  whitish  and  surrounded  by  a  sheath  filled  with 
fungus. 

Trichophyton  patches  are  prone  to  be  smaller,  but  more 


TINEA    TRICHOPHYTINA 


Fig.  84. — Ring-worm  on  border  of  hair,  showing  prominence  of  follicular  mouths. 
numerous;  the  tnW-  ™ominent.     Scales  are  sparse 

or  at  considerable  areas  may 


l86  DISEASES   OP    THE    SKIN 

be  attacked.  The  hair  commonly  breaks  off  at  the  level  of  the 
skin,  exhibiting  merely  blackish  points.  Diffuse  ring-worm 
and  the  so-called  bald  ring-worm  are  commonly  caused  by  the 
trichophyton. 

Itching  of  a  mild  character  is  usually  present  in  ring-worm. 
The  disease  occurs  almost  exclusively  in  children.  It  is  rare 
to  observe  cases  over  the  age  of  fifteen,  and  in  adults  ring-worm 
of  the   scalp  is  a  dermatologic  curiosity. 

The  course  of  the  affection  is  extremely  slow.  Untreated, 
it  will  last  from  one  to  several  years.     During  convalescence, 


pointed  hairs  grow  in  and  the  patch  is  gradually  covered.  Where 
follicles  have  been  destroyed  by  suppuration,  permanent  thin- 
ning will  take  place. 

Etiology. — The  disease  is  produced  by  a  vegetable  parasite — 
either  the  trichophyton  fungus  or  the  Microsporon  Audouini. 
Ring-worm  is  essentially  a  disease  of  childhood.  The  affection 
is  communicated  from  one  child  to  another  by  direct  contact, 
or  through  the  medium  of  caps,  brushes,  combs,  towels,  etc. 
It  may  be  contracted  from  the  lower  animals,  such  as  the  cat, 


TINEA    TRICHOPHYTINA  1 87 

dog,  rabbit,  horse,  or  ox.  Animal  infections  are  apt  to  pursue 
a  more  severe  course. 

Tinea  circinata  in  the  adult  may  produce  tinea  tonsurans  in 
the    child,    and    vice    versS. 

Pathology. — The  fungus  is  found  in  the  hair,  the  hair- 
follicle,  and  the  epidermis.  In  this  form  of  the  disease  the  spores 
are  extremely  abundant  in  the  lower  portion  of  the  hair,  pro- 
ducing, under  the  microscope,  a  fish-roe  appearance.  The 
mycelium  is  usually  scanty  or  absent.  The  hair  is  prepared 
by  immersion  in  liquor  potassae,  and  is  examined  without 
staining.  Only  broken-off  hairs  are  to  be  selected  for  exami- 
nation. 

Diagnosis. — The  characteristic  features  of  tinea  tonsurans 
are  circumscribed  patches  of  partial  baldness,  grayish  scales, 
goose-flesh  appearance,  broken-off  stumps  of  hair,  and  the 
presence  of  the  fungus. 

These  points  will  enable  one  to  distinguish  the  disease  from 
eczema,  psoriasis,  and  seborrhea.  The  most  important  is  the 
differential  diagnosis  from  alopecia  areata,  which  is  here 
appended : 

Tinea  Tonsurans.  Alopecia  Areata. 

1.  Slow  and  insidious  onset.  1.  Rapid  onset. 

2.  Patches  are:  2.  Patches  are: 

(a)  Covered  with  "broken-off  (a)  Totally  devoid  of  hair,  as  a 

stumps."  rule. 

(6)  More     or     less     reddened.  (6)   Pale  and  whitish. 

(c)  Rough  and  scaly.  (c)  Smooth  and  soft. 

(d)  Follicles  prominent;  goose-  (d)  Follicles  contracted, 
flesh  appearance. 

3.  Fungus  present.  3.  Absence  of  fungus. 

4.  Occurs    almost    exclusively    in  4.  May  occur  at  any  age. 

children. 

Prognosis. — As  to  ultimate  cure,  favorable.  As  to  duration, 
guarded.  Most  cases  persist  from  three  months  to  one  and 
one -half  years. 

Treatment. — As  a  matter  of  prophylaxis,  domestic  pet 
animals,  such  as  dogs,  cats,  rabbits,  birds,  etc.,  should  always 
be  carefully  examined  before  being  brought  into  a  home. 

The  cure  of  ring-worm  of  the  scalp  is  slow,  because  the  fungus 
invades  the  depths  of  the  hair-follicles  and  is,  therefore,  most 
inaccessible  to  parasiticide  remedies.  The  hairs  become  brittle  as 
a  result  of  infiltration  with  the  parasite,  and  break  off  just  above 
the  surface  of  the  skin.     It  is  evident  that  treatment  wfr" 


1 88  DISEASES  OF  THE   SKIN 

removes  the  hairs  causes  considerable  extrusion  of  the  fungus 
and  renders  the  follicles  more  patulous,  thus  permitting  greater 
penetration  of  the  remedies  employed. 

The  treatment  consists  of — (i)  Daily  soap  and  hot- water 
cleansings  of  the  scalp  (medicated  soaps  containing  tar,  carbolic 
acid,  or  mercury  are  useful) ;  (2)  depilation  of  diseased  hairs 
and  of  those  surrounding  the  affected  areas;  and  (3)  the  appli- 
cation of  parasiticide  ointments  and  lotions.  No  one  medica- 
ment is  immeasurably  superior  to  others;  it  is  the  persevering 
and  thorough  use  of  the  preparation  that  produces  a  successful 
result.  The  ointments  which  are  most  favorably  regarded  are: 
Betanaphthol,  one  dram  to  one  ounce;  iodin,  one  dram  to  one 
ounce ;  tar,  one  to  two  drams  to  one  ounce ;  chrysarobin,  20-40 
grains  to  one  ounce;  sulphur,  one  to  two  drams  to  one  ounce; 
carbolic  acid,  25  grains  to  one  ounce,  etc. 

The  best  results  in  my  hands  have  been  secured  by  brushing 
into  the  patches,  several  times  a  day,  the  following: 

B .    Olei  cadini  \  . .  f- .  _M 

Olei  olivse  j    aa  ^     M' 

In  the  morning  a  carbolic  soap  is  used  with  hot  water.  Good 
results  are  also  obtained  from  an  ointment  containing: 

R.    Sulph.  prtecip.  \  ..      . 

Betanaphthol   j ^J ' 

Vaselini 5J. — M. 

Follicular  suppuration,  as  in  tinea  kerion,  often  hastens  the 
cure  of  ring-worm.  Some  clinicians  endeavor  to  produce  such 
a  condition  by  having  various  irritants  rubbed  in,  such  as 
Croton  oil,  chrysarobin,  pyrogallic  acid,  etc. 

x-Rays. — The  x-ray  treatment  of  tinea  tonsurans  has  been 
brought  to  such  a  state  of  perfection  by  Sabouraud,  of  Paris, 
that  he  is  enabled  to  cure  a  patch,  in  the  vast  majority  of  cases, 
in  one  treatment. 

The  dosage  is  measured  by  the  effect  of  the  rays  upon  discs 
impregnated  with  platinocyanid  of  barium,  which  changes  in 
color;  this  measuring  of  the  dosage  is  insisted  upon.  The 
treatments  are  given  at  a  distance  of  15  centimeters,  and  the 
discs  are  placed  at  one-half  this  distance.  The  time  of  expo- 
sures varies  according  to  conditions,  but  averages  ten  to  fifteen 
minutes.     A  large  static  machine  and  small  diameter  tubes  of 


TINEA    TRICHOPHYTINA  189 

high  vacuum  are  preferred.  The  hair  falls  completely  in  from 
eighteen  to  thirty-five  days.  After  the  x-ray  exposure  the 
head  is  painted  daily  with  a  10  per  cent,  tincture  of  iodin,  and 
after  the  eighteenth  day  daily  soap-and- water  washings  are 
employed.  The  treated  areas  remain  bald  for  two  months, 
after  which  restoration  of  hair  occurs.  With  proper  technic 
Sabouraud  claims  constant  successes,  complete  depilation 
without  dermatitis,  and  with  subsequent  complete  hair  regrowth. 

Tinea  Sycosis 


Definition. — Tinea  sycosis  is  a  contagious  vegetable  para- 
sitic affection,  due  to  the  trichophyton  fungus,  and  attacking 
the  hairs  and  hair- follicles  of  the  bearded  region. 


Fig.  86.— Trichophyton  of  the  variety  ectothrix;  hairs  from  a  case  of  ring-worm 
of  the  bearded  region,  involving  also  the  upper  lip — hairs  from  the  latter  region. 
Fungus  on  surface  of  a  hair  (x  about  400}  (courtesy  of  Dr.  M.  B.  Haruell). 

Symptoms. — The  disease  begins  as  small,  rounded,  scaly, 
reddish  patches  (tinea  circinata)  occupying  the  bearded  region. 
The  hairs  and  their  follicles  soon  become  invaded,  with  the 
production  of  swelling  and  induration  and  the  appearance  of 
nodular  or  lumpy  tumefactions.  Numerous  pustules  mark 
the  sites  of  the  hair-follicles.  These  soon  rupture  and  give 
exit  to  a  yellowish  pus,  which  dries  in  the  form  of  crusts.     The 


19°  DISEASES  OF  THE   SKIN 

hairs  are  dry  and  brittle,  and  either  break  off  or  fall  out.  The 
chin,  neck,  and  submaxillary  region  are  the  regions  most  fre- 
quently affected.  The  upper  lip  is  more  rarely  attacked. 
Itching  and  burning  are  present  in  varying  degrees.  The  dis- 
ease, when  untreated,  persists  for  a  long  time.  Unless  treat- 
ment is  extremely  thorough,  relapses  are  liable  to  occur. 

Etiology. — The  disease  is  due  to  the  invasion  of  the  hair- 
follicles  by  the  trichophyton  fungus.  The  affection  is  usually 
acquired  in  the  barber-shop.  The  disease,  however,  is  not 
infrequently  contracted  from  horses  and  cattle.  When  acquired 
from  the  latter  source,  it  is  apt  to  be  more  severe. 

Pathology.— Both  the  hair  and  the  hair-follicles  contain 
the  fungus,  which  consists  of  threads  of  mycelium  and  spores. 


Fig.  B7.-T1*      .    . 
of  (he  bearded  region  involving  also  Ihe  upper  lip — haire  trot 
FungusinIhehair(Xaboul4oo)<cou"*syolD'--  M.  B.  Hamcll 

Secondary  inflammation  of  the  follicles  and  surrounding  tissues, 
with  swelling,  infiltration,  and  suppuration,  is  present  in  well- 
marked  cases. 

Diagnosis. — The  chief  affection  to  be  differentiated  is  ordi- 
nary sycosis.  Contagious  impetigo  of  the  bearded  region  is 
sometimes  erroneously  termed  barber's  itch.  It  is  frequently 
contracted  in  the  barber-shop,  but  is  easily  distinguished. 
The  primary  lesions  are  superficial  vesicles  which  rapidly  form 
crusts.     Impetigo  is  much   more   readily   cured. 


TINEA   TRICHOPHYTINA  191 

Tinea  Sycosis.  Sycosis  Vulgaris. 

1.  A     typical     case    shows    large       1.  A  typical  case  shows  small,  dis- 

lumpy    or    nodular    tumefac-  crete  pustules  pierced  by  hairs, 

tions. 

2.  Hairs    broken    and    easily    ex-       2.  Hairs  firmly  attached  until  free 

tracted.     Root     usually    dry.  suppuration       occurs.     Roots 

often  swollen  with  pus. 

3.  Course  rapid.     Marked  changes       3.  Course  slow.     Little  change  from 

from  week  to  week.  week  to  week. 

4.  Upper  lip  rarely  involved.  4.  Upper  lip  frequently  involved. 

5.  Trichophyton   fungus   in   hairs.       5.  Absence  of  fungus  in  hairs. 

Prognosis. — The  disease  is  at  times  rebellious  to  treatment, 
although  most  cases  get  well  in  one  to  two  months.  Relapses 
are  common. 

Treatment. — The  treatment  consists  of  epilation  and  the 
use  of  parasiticide  applications.  Crusts  should  be  softened 
with  bland  oils  and  then  removed  with  soap  and  warm  water. 
Epilation  of  the  diseased  hairs  should  be  practised  assiduously 
until  all  are  removed.  T|ie  healthy  areas  of  the  beard  should 
be  shaved. 

The  following  are  among  the  most  approved  local  applications : 

B .    Sulph.  praecip jj; 

Petrolat t$j. — M. 

R.    Hydrarg.  sulph  at.  flav gr.  x-xx; 

Petrolat.. 3J. — M. 

B  .    Sodii  hyposulph 3j ; 

Aqua f£y — M. 

B .    Hydrarg.  ammoniat gr.  xl; 

Ung.  zinci  oxidi §j. — M. 

B .    Hydrarg.  chlor.  corrosiv ct.  j ; 

Aqua fg  j. — M. 

These  should  be  applied  two  or  three  times  a  day. 

In  obstinate  and  refractory  cases  the  x-rays  may  be  employed 
to  cause  falling  of  the  hairs.  Care  should  be  used  in  such  expo- 
sures, as  too  vigorous  treatment  may  cause  permanent  loss  of 
hair. 

Tinea  Favosa 

Derivation. — L.,  favus,  a  honey-comb.     Synonym. — Favus. 

Definition. — Tinea  favosa  is  a  contagious,  vegetable  para- 
sitic disease,  due  to  the  Achorion  Schonleinii,  characterized  by 
cup-shaped,  sulphur-yellow  crusts  perfoi 


192  DISEASES  OF  THE  SKIN 

Symptoms. — The  usual  seat  of  the  disease  is  the  scalp.  The 
disease  begins  as  a  diffuse  or  circumscribed  superficial  inflam- 
mation, with  scaling,  soon  followed  by  the  appearance  of  pin- 
head-sized  yellowish  crusts  seated  about  the  hair-follicles.  The 
crusts  increase  to  the  size  of  peas,  when  they  acquire  the  char- 
acteristics of  the  "favus-cup,"  or  scutulum.  The  typical  favus- 
cup  is  split- pea-sized,  rounded,  umbilicated,  penetrated  by  a 
hair,  and  of  a  sulphur-yellow  color.  It  is  usually  friable, 
crumbling  between  the  fingers  like  dry  mortar.  When  dis- 
lodged from  its  bed  there  is  exposed  to  view  a  reddened,  shining, 
atrophic,   cup-shaped,   often   suppurating  excavation,    which 


nip  (Fox': 


heals  up  with  the  production  of  a  scar.  As  a  consequence, 
more  or  less  permanent  baldness  results.  Old  cured  cases 
present  irregular  bald  scars,  with  here  and  there  crinkled  hairs 
or  tufts  of  hair  growing. 

The  crusts  may  be  discrete  or  confluent,  forming  thick, 
irregularly  shaped  masses  of  a  honev-combed  appearance.  In 
well-marked  cases  a  peculiar  mouse-like  or  damp-straw  odor 
is  present,  which  is  quite  characteristic  of  the  disease. 

The  hairs  are  dry,  lusterless,  and  brittle,  and  are  apt  to 
split  longitudinally,  break  off,  or  fall  out.  Itching,  variable 
in  degree,  occurs  in  most  cases. 

Favus  occasionallv  attacks  the  non-hairy  portion  of  the  body 


TINEA    TRICHOPHYTINA 


(tinea  favosa  epidermidis).  It  may  also  affect  the  nails  (tinea 
favosa  unguium,  onychomycosis  favosa),  causing  them  to 
become  thickened,  yellowish,  opaque,  and  brittle. 


tremely  chronic,  lasting  years, 
The  affection  is  feebly  conta- 


The  course  of  the  disease  is 
and  in  some  cases  a  lifetime, 
gious  as  compared  with  ring- 
worm. 

Etiology.— The  cause  of  the 
disease  is  a  vegetable  organism 
known  as  the  Aclwrion  Sclion- 
leinii.  The  disease  usually  be- 
gins in  childhood.  It  exists 
chiefly  among  the  foreign  poor. 
In  this  country  it  is  more  com- 
monly seen  among  Russians, 
Poles,  and  Italians.  It  is  not 
infrequently  contracted  from 
cats  and  other  lower  animals. 

Pathology. — The  fungus  oc- 
curs in  the  hair,  hair-follicles, 
and  epidermis.  The  favus  crust 
is  made  up  almost  entirely  of 
fungus.  The  favus  mycelium 
consists  of  slender  threads, 
which  appear  as  flattened 
tubes,  either  clear  or  contain- 
ing spores.  The  threads  are 
broader  and  the  joints  more 
numerous  than  in  ring-worm. 
The  spores  are  rounded,  highly 
refractile  bodies,  varying  in 
size  from  7Jj  to  -jfa  of  an  inch 
in  diameter.  They  differ  from 
the  spores  of  ring -worm  in 
their  greater  variability  both 
as  to  size  and  shape.  Both 
spores  and  mvcelium  are  abun- 
dant. Secondary  inflammatory 
changes  occur  in  the  eorium. 

Diagnosis.— Favus  is  principally  to  be  distinguished  from 
tinea  tonsurans,  seborrheic  eczema,  and  pustular  eczema.  In 
long-standing  cases  in  which  we  observe  sulphur- yellow,  cup- 


Scalp  fr 


?a  favosa  of  body 


194  DISEASES  OP  THE  SKIN 

shaped,  friable  crusts  and  scarring  the  diagnosis  is  easy.  Where 
these  features  are  poorly  marked,  the  diagnosis  may  present 
difficulties.  Ring-worm  is  usually  of  shorter  duration,  exhibits 
rounded  patches,  "gna wed-off"  hair-stumps,  and  less  intense 
redness.  Seborrheic  eczema  may  cause  thinning  of  the  hair 
but  not  circumscribed  hair  loss ;  no  fungus  is  present.  Pustular 
eczema  and  purulent  crusts  due  to  pediculi  may  be  confounded 
with  favus,  but  the  crusts  are  ocher-colored  or  brownish,  and 
when  removed  show  no  deep  involvement  of  the  scalp.  The 
microscope  is  here  of  value. 

To  examine  for  fungus  a  fragment  of  crust  or  a  hair  is 
moistened  in  10  to  40  per  cent,  liquor  potassae  and  examined 
under  a  microscope  without  preliminary  staining.  Consider- 
able skill  is  necessary  to  distinguish  the  ring- worm  from  the 
favus  fungus  by  exclusively  morphologic  characteristics. 

Prognosis. — Favus  of  the  scalp  is  extremely  rebellious, 
lasting  for  years.  In  long-standing  cases  extensive  scarring 
and  permanent  hair  loss  are  apt  to  occur.  Favus  of  the  body 
responds  readily  to  treatment. 

Treatment. — The  treatment  of  favus  of  the  scalp  consists 
of  depilation  of  the  diseased  hairs  and  of  the  use  of  parasiticide 
ointments  and  lotions.  The  hairs  mav  be  removed  with  a 
depilation  forceps  or  may  be  pulled  out  with  adhesive  sticks, 
as  suggested  by  Bulkley.  The  formula  for  the  adhesive  mass 
is: 

U  .    Cera?  flavae ,~iij ; 

Laccse  in  tuhulis ^iv; 

Resina? ^vj ; 

Picis  Burgundies £xj  5 

Gummi  damar oiss. — M. 

The  mass  is  heated  and  then  placed  upon  the  affected  region. 
When  cool,  it  is  twisted  off  with  the  adherent  hairs. 

The  hair  should  be  closely  cropped  and  the  crusts  removed 
by  softening  with  oils  and  subsequent  soap-and-water  cleansing. 
The  parasiticide  applications  should  be  made  twice  daily. 

Among  the  more  commonly  employed  remedies  may  be 
mentioned  the  following: 

&  .    Hydrarg.  chlor.  corrosiv gr.  j-ij; 

Aqua fgj. — M. 

&  .    Sulph.  praecip 3j-ij ; 

Betanaphthol gj; 

Petrolat ^j. — M. 


TINEA    TRICHOPHYTINA  1 95 

R .    Hydrarg.  oleat 10-20  per  cent. 


B  •    Sodii  hyposulph. 
Aqua 


fii'.-M. 


K  .    Chrysarobin gr.  xx-xl; 

Petrolat 1  j— M. 

(To  be  used  with  caution.) 

R.    Olei  cadini )  ..  rr.      ,, 

Oleioliv*  }   aafsj.-M. 

The  treatment  is  long  and  tedious  and  is  apt  to  tax  the  per- 
severance of  the  patient.  The  microscope  should  be  repeatedly 
used  before  a  case  is  pronounced  cured.  Treatment  should  be 
continued  after  apparent  cure  to  guard  against  relapse. 

Favus  of  the  body  is  seldom  rebellious,  and  may  be  treated 
with  milder  remedies  than  scalp  favus.  The  crusts  should  be 
softened  and  removed  and  a  mercurial  or  sulphur  ointment 
rubbed  in. 

Favus  of  the  nails  is,  as  a  rule,  obstinate  to  treatment.  The 
nail  should  be  frequently  pared  and  scraped,  and  strong  tar  or 
mercurial  ointments  rubbed  in  twice  daily. 

x-Rays. — Sabouraud  has  used  the  Rontgen  rays  as  suc- 
cessfully in  favus  as  in  tinea  tonsurans.  The  greater  obsti- 
nacy of  favus  will  doubtless  establish  the  x-rays  as  the  treat- 
ment of  choice  when  the  technic  is  sufficiently  simplified  to 
warrant  the  general  use  of  this  measure.  (For  technic  see 
Tinea  Tonsurans.) 

Tinea  Versicolor 

Synonyms. — Pityriasis  versicolor;  Chromophytosis. 

Definition. — Tinea  versicolor  is  a  vegetable  parasitic  disease, 
due  to  the  Microsporon  furfur,  characterized  by  furfuraceous, 
yellowish,  macular  patches,  occurring  chiefly  upon  the  trunk. 

Symptoms. — The  disease  begins  as  pin-head-  to  pea-sized 
yellowish  macules,  scattered  over  the  affected  region.     These, 
in  the  course  of  a  few  weeks  or  months,  increase  in  size  and 
coalesce,  with  the  production  of  large  patches.     The  patches 
are  irregular  in  shape,  with  sharply  defined  edges.    They  lire,  as 
a  rule,  barely  elevated  above  the  surface  of  the  skin.    Occasion- 
ally the  border  is  raised,  in  which  event  sma" 
assume  an  annular  form.    The  color  is  usttf 
fawn-hued,  although  it  may  vary  from  a  pal 
Occasionally  it  has  a  distinct  pinkish  ' 


I9<»  DISEASES   OF   THE   SKIN 

patches  have  a  grayish  appearance.  The  affected  area  is 
covered  with  a  fine,  furfuraceous,  mealy  scaling.  When  this 
is  not  apparent,  it  may  be  rendered  evident  by  scratching  the 
surface  with  the  finger-nail. 

The  eruption  is  usually  confined  to  the  trunk,  particularly 
the  chest  and  interscapular  region.  The  neck,  axilla,  arm,  and, 
in  rare  cases,  the  face,  may  also  become  involved.  Itching 
of  a  mild  character  may  be  present,  especially  in  summer.  * 


Tinea  versicolor  pursues  a  chronic  course,  lasting,  untreated, 
for  months  and  years.  It  commonly  disappears  or  grows  less 
visible  in  the  cold  months,  reappearing  when  the  warm  season 
arrives.  I  have  also  observed  the  reverse  of  this.  The  disease, 
with  rare  exceptions,  is  confined  to  adults.  It  is  but  slightly 
contagious.  I  have  known  married  men  and  women  to  have 
tinea  versicolor  for  years  and  not  communicate  it  to  their 
spouses;  this  is  all  the  more  remarkable  when  one  considers  the 
abundance  of  fungus  on  the  skin. 

Etiology. — The  disease  is  due  to  the  presence  and  growth  nf 
a  vegetable  fungus  which  was  first  described  by  Eichsledt  in 


TINEA    TRICHOPHYTINA  1 97 

1846.  Robin  applied  to  this  the  name  of  Microsporon  furfur. 
The  disease  is  rare  in  childhood.  A  special  and  as  yet  unknown 
condition  of  the  skin  is  necessary  to  make  it  a  favorable  soil. 
Some  writers  believe  free  perspiration  to  be  a  predisposing  factor. 
Pathology. — The  corneous  layer  is  permeated  with  a  luxur- 
iant growth  of  mycelium  and  spores.  The  mycelia  consist  of 
short,  jointed,  and  angular  threads,  which  may  be  clear  or  con- 
tain spores.  The  spores  are  rounded,  highly  refractile  bodies, 
varying  in  size  from  one -nine -hundredth  to  one -three-hundredth 
of  an  inch  in  diameter.  In  tinea  versicolor  there  is  a  charac- 
teristic tendency  of  the  spores  to  become  aggregated  in  masses. 


Fig.  gi. — Photomicrotiraph  of  mycelia  and  spores  of  tinea  versicolor  in  Ihe  horny 


To  examine  for  the  fungus,  wash  the  scrapings  in  ether  to 
remove  the  fat,  and  soften  in  a  10  to  20  per  cent,  caustic  potash 
solution.  The  spores  may  be  made  more  refractile  by  exam- 
ining them  in  a  solution  of  equal  parts  of  glycerin  and  alcohol. 
The  fungus  may  be  grown  in  culture,  but  with  some  difficulty 
and  with  frequent  failures. 

Diagnosis. — Pawn-colored  patches  upon  the  chest  and  back, 
that  can  be  partly  scraped  away  and  in  which  abundant  fungi 
can  be  found  under  the  microscope,  should  give  rise  to  no  diffi- 
culty in  diagnosis.  Chloasma  is  more  common  on  the  face  and 
is  not  scaly.  The  same  is  true  of  vitiligo;  moreover,  there  is 
actually  loss  of  pigment,  surrounded  by  excessive  coloratif 
The  macular  syphiloderm  is  characterized   by  more  re 


I 


198  DISEASES  OP  THE   SKIN 

greater  symmetry,  and  more  uniformity  in  the  size  of  the 
patches.  • 

Prognosis. — The  eruption  responds  promptly  to  treatment, 
but  relapses  are  common,  owing  to  failure  to  destroy  all  the 
fungi  in  the  skin. 

Treatment. — The  treatment  is  rapidly  efficient,  a  few  weeks 
sufficing  in  most  cases  to  establish  a  disappearance  of  the 
eruption.  The  treatment  consists  of  hot  baths,  friction  with 
soap  (or,  better  still,  sapo  mollis),  followed  by  the  application 
of  a  parasiticide. 

Lotions  or  ointments  may  be  employed.  Sulphur,  mercury, 
tar,  resorcin,  etc.,  are  among  the  most  efficacious  remedies. 
The  following  is  useful : 

R .    Sulph.  praecip £j ; 

Acidi  salicylici gr.  xx ; 

Adipis  benzoat 5J. — M. 

Sig. — Rub  in  after  bath. 

Solutions  of  sodium  hyposulphite  (one  dram  to  one  fluid- 
ounce)  and  bichlorid  of  mercury  (one  grain  to  one  fluidounce) 
are  easy  of  application  and  eminently  useful.  When  the  erup- 
tion is  extensive,  baths  containing  2  to  4  ounces  of  liquor  calcis 
sulphurata  (Vleminckx's  solution)  to  30  gallons  of  water  have 
the  advantage  of  acting  on  the  entire  diseased  area. 

It  is  important  to  continue  the  treatment  for  some  time  after 
apparent  cure,  in  order  to  preclude  the  possibility  of  relapse. 

ERYTHRASMA 

Definition. — Erythrasma  is  a  rare  vegetable  parasitic  dis- 
ease, due  to  the  Microsporon  minutissimum,  characterized  by 
reddish  or  brownish  patches  occurring  in  the  axillary,  inguinal, 
and  genitocrural  regions. 

Symptoms. — The  disease  occurs  as  small,  rounded  or  irreg- 
ular, well-defined,  slightly  furfuraceous  patches  of  a  reddish 
or  brownish  color.  The  axillary,  inguinal,  genitocrural,  and 
nasal  folds  are  the  usual  regions  involved.  The  disease  is 
slowly  progressive  and  may  last  for  years.  It  is  accompanied 
by  slight  itching.  The  affection  is  often  undiscovered,  as  it 
gives  no  inconvenience  to  the  patient. 

Etiology  and  Pathology. — The  disease  is  due  to  the  Micro- 
sporon minutissimum,  which  consists  of  interlacing,  jointed, 
bifurcating,  mycelial  threads  and,  according  to  some,  minute 
spores.  The  mycelium  and  spores  are  about  one-third  the  size 
of  the  ring-worm  fungus. 


CRAW-CRAW  199 

Diagnosis. — The  disease  may  be  distinguished  from  tinea 
versicolor  by  the  absence  of  the  eruption  on  the  trunk,  the 
redder  color  of  the  lesions,  and  the  differences  in  the  macro- 
scopic appearances. 

Treatment. — The  disease  is  amenable  to  the  same  character 
of  local  treatment  as  is  employed  in  tinea  versicolor.  The 
affection  tends  to  relapse  unless  the  fungus  is  entirely  destroyed. 

PINTA 

Synonyms. — Caraat£;  Spotted  sickness,  etc. 

The  disease  is  indigenous  to  Mexico  and  Central  and  South 
America;  it  occurs  particularly  among  the  blacks,  but  also  in 
the  whites. 

It  is  characterized  by  the  appearance  of  scaly  spots,  which 
vary  greatly  in  coloration  according  to  the  particular  variety 
of  fungus  producing  the  disease  and  the  race  of  the  subject. 
The  exposed  parts,  such  as  the  neck,  face,  and  hands,  are  first 
attacked,  although  no  part  of  the  cutaneous  surface  is  exempt. 
The  size,  shape,  and  number  of  the  patches  are  most  variable. 
The  color  may  be  grayish,  black,  blue,  red,  or  dull  white.  The 
red  variety  attacks  whites  and  is  deeper  and  more  destructive ; 
in  negroes  the  patches  are  bluish-black ;  whitish  discolorations 
occur  during  the  stage  of  involution.  A  fine  furfuraceous 
scaling  covers  the  affected  areas. 

The  disease  runs  a  chronic  course,  extending  over  a  period 
of  months  or  years.  The  general  health  is  not  affected.  The 
disease  is  alleged  to  be  due  to  several  varieties  of  aspergillus 
fungus. 

Treatment. — Parasiticide  applications,  such  as  are  used 
in  the  vegetable  parasitic  diseases.  Montoya  especially  extols 
the  mercurials. 

CRAW-CRAW 

Craw-craw  is  a  disease  found  chiefly  upon  the  west  coast 
of  Africa.  The  eruption  attacks  by  predilection  the  fingers 
and  forearms,  and  resembles,  to  a  certain  extent,  scabies. 
Although  no  burrows  are  seen,  papules,  vesicles,  and  pustules, 
accompanied  by  itching,  are  present.  The  scratching  causes 
excoriations  and  crusting.  Both  nematodes  and  filaria  have 
been  discovered  in  the  lesions.  The  parasites  are  found  in  the 
exuding  fluid  and  scrapings.  The  disease  is  rebellious  to  treat- 
ment. 


Derivation. — L., 


DISEASES   OP   THE    SKIN 

SCABIES 

ibere,  to  itch.     Synonym. — Itch. 


Definition. — Scabies  is  a  contagious,  animal  parasitic  dis- 
ease, due  to  the  Sarcoptes  scabiei,  characterized  by  burrows 
and  a  multiform  eruption,  and  attended  by  severe  itching. 

Symptoms.- — The  itch-mite,  in  burrowing  into  the  skin,  pro- 
duees^at  the  point  of  entrance  a  small  papule,  vesicle,  or  pustule. 
Later,  a  burrow  or  cuniculus  is  formed  at  this  site.     The  burrow 


is  a  straight,  tortuous  or  zigzag,  grayish  or  blackish,  linear 
epidermal  elevation,  varying  in  length  from  !  to  i  of  an  inch. 

The  blackish  color  of  the  trail  is  due  largely  to  dust  and  dirt 
rubbed  into  the  epidermal  roughening.  The  burrow  is  peculiar 
to  scabies,  and  when  found,  constitutes  positive  evidence  of 
the  disease.  It  is  most  characteristically  seen  upon  the  lateral 
surface  of  the  fingers  and  upon  the  wrist. 

In  well-marked  cases  of  the  "itch"  there  are  seen,  in  addition 
to  the  burrows,  a  multiform  eruption  consisting  of  papules, 
vesicles,  pustules,  crusts,  and  excoriations  due  to  scratching. 


The  excoriations  exhibit  themselves  as  abraded  summits  of 
pin- head -sized  papules.  A  striking  feature  of  the  eruption  of 
scabies  is  the  distribution;  this  is  highly  diagnostic,  and 
commonly  enables  one  to  determine  the  nature  of  the  disease 
with  a  glance  of  the  eye.  The  affected  areas  comprise  the 
interdigital  spaces,  the  flexor  surface  of  the  wrist  and  arm.  the 
anterior  and  posterior  axillary  folds,  the  mammae  and  nipples 
(in  women),  the  umbilicus,  the  buttocks,  the  penis,  the  inner 
side  of  the  thighs  and  legs,  and  the  toes  (particularly  in  infants). 
The  face  is  exempt,  except  occasionally  in  infants. 

Itching  is  a  constant  and  prominent  symptom  of  the  disease, 
and  justifies  the  common  name  applied  to  the  affection.     A 


FifT.  93. — Acanw  scahiei  (ventral  surface):   i.  Female;  J,  male  (: 
Dr.  L.  A.  Duhring). 


peculiarity  of  the  itching  is  the  discrepancy  between  its  intensity 
during  the  day  and  at  night.  It  is  in  more  or  less  abeyance 
during  the  former,  but  after  retiring,  the  patient  suffers  such 
distress  as  frequently  to  render  sleep  impossible.  The  intensity 
of  the  pruritus  is  commonly  out  of  all  proportion  to  the  scanty 
eruption  present.  The  itching  incites  the  patient  to  violent 
scratching,  and  thus  abrasions,  eczematoid  dermatitis,  and 
secondary  pus-infection  are  produced.  In  children  and  persons 
with  sensitive  skin  th  eruption  may  reach  a  high  grade  of 
al  eczema  superadded. 

■*oid;  in  the  course  of  one  or 
itoms  a   well- pronounced 


202  DISEASES  OF   THE   SKIN 

eruption  may  be  present.  In  untreated  patients  the  disease 
lasts  for  many  months,  exhibiting  but  little  tendency  to  spon- 
taneous cure.  In  patients  who  bathe  frequently  and  use  soap 
the  parasitic  extension  is  apt  to  be  slower  and  the  distinctive 
features  of  the  disease  less  pronounced. 

Etiology. — Scabies  is  due  to  invasion  of  the  skin  by  the 
Acarus  or  Sarcoptes  scabiei.  The  affection  is  very  common  in 
the  lower  social  strata  and  is,  therefore,  largely  met  with  in 
dispensary  practice.  Now  and  then,  however,  we  observe  the 
disease  in  those  whose  bodily  hygiene  is  beyond  reproach. 
Scabies  is  essentially  a  household  disease,  particularly  where 
there  is  overcrowding.  Close  bodily  contact  and  the  occupancy 
of  a  bed  with  or  after  a  scabetic  subject  are  the  usual  methods 
of  transmission.  The  wearing  of  infected  apparel  may  likewise 
cause  the  disease.  Brief  contact,  as  exemplified  in  hand- 
shaking, is  not  likely  to  lead  to  infection. 

Pathology. — The  burrow  consists  of  a  narrow  tract  through 
the  epidermis  made  by  the  penetration  of  the  impregnated 
female  acarus,  which  alone  is  capable  of  producing  the  disease. 
The  mite  deposits  a  half-dozen  or  more  eggs  and  specks  of 
excrement  along  the  course  of  the  cuniculus,  and,  after  reaching 
the  mucous  layer,  perishes.  The  ova  hatch  out  in  eight  or  ten 
days,  and,  effecting  their  egress  from  the  burrows,  start  cuniculi 
of  their  own. 

The  itch-mite  is  a  yellowish- white,  ovoid  body,  just  about 
visible  to  the  eye.     The  female  is  twice  the  size  of  the  male. 

Eosinophilia  in  various  grades  may  be  found  in  a  large  per- 
centage of  cases  of  scabies. 

Diagnosis. — Scabies  consists  of  the  burrows  plus  an  arti- 
ficial inflammation  of  the  skin  produced  by  the  parasite  and 
the  scratching. 

The  characteristic  features  of  the  disease  are  the  presence  of 
burrows,  a  multiform  eruption  distributed  in  a  peculiar  manner 
over  the  surface  of  the  body,  the  intense  itching,  worse  at  night, 
and  the  history. 

Scabies  may  be  distinguished  from  vesicular  or  pustular 
eczema  by  the  presence  of  the  mite  and  the  burrows,  the  peculiar 
scattered  distribution  of  the  lesions,  the  progression  of  the  erup- 
tion from  day  to  day,  and  the  history  of  contagion. 

Pediculosis  corporis  is  characterized  by  scratch  excoriations 
across  the  shoulders,  chest,  and  around  the  waist;  the  hands 
are  free.     The  itching  is  often  greater  during  the  day. 


SCABIES  203 

Prognosis. — Favorable.  The  disease,  no  matter  of  what 
duration,   is  speedily   curable. 

Treatment. — The  objects  of  treatment  are  twofold — to  kill 
the  parasite  and  to  subdue  the  accompanying  dermatitis.  The 
itch-mite  is  easily  destroyed  by  such  remedies  as  sulphur,  beta- 
naphthol,  balsam  of  Peru,  styrax,  tar,  staphisagria,  etc.,  but 
it  must  be  remembered  that  such  remedies  irritate  the  skin  if 
used  too  strong  or  for  too  long  a  period. 

Sulphur  is  one  of  the  most  reliable  remedies,  and  is  best 
applied  in  ointment  form.  It  may  be  used  in  conjunction  with 
balsam  of  Peru,  as  in  the  following  formula: 

B .    Sulph.  praecip 3j ; 

Balsam  Peruv 3j ; 

Adipis ,5J. — M. 

Betanaphthol  possesses  the  advantage  of  being  free  from 
odor  and  more  cleanly,  and  is,  therefore,  a  more  eligible  prepa- 
ration in  private  practice.  It  may  be  used  alone  (one  dram  to 
one  ounce)  or  combined  with  sulphur. 

Styrax  is  less  irritating  than  sulphur,  and  is  especially  useful 
in  the  itch  of  children : 

R .    Styracis  liq fg  j ; 

Adipis 3ij. — M. 

Sherwell  prefers  to  use  sulphur  in  the  form  of  powder,  and 
states  that  it  is  less  irritating  than  an  ointment,  as  well  as  more 
cleanly.  The  powder  is  rubbed  over  the  body  at  night,  and 
a  small  quantity  is  strewn  between  the  bed-sheets. 

The  treatment  of  scabies  is  to  be  inaugurated  by  a  protracted 
hot  bath  with  the  vigorous  use  of  soap.  The  body  from  neck 
to  foot  is  then  to  be  thoroughly  anointed  with  the  ointment. 
This  may  be  rubbed  in  twice  a  day  for  three  days  or  nightly 
for  one  week.  At  the  end  of  this  time  another  bath  should  be 
taken  and  the  underclothing  and  bed-linen  changed  and  steril- 
ized. Ordinarily,  such  treatment  will  suffice  to  produce  a  cure ; 
occasionally,  it  must  be  repeated,  particularly  if  fresh  lesions 
appear. 

Care  should  be  exercised  not  to  overtreat  cases.     The  per- 
sistence of  itching  is  not  always  an  index  of  the  continuance  of 
the  scabies,  but  is  more  likely  to  result  from  the  dermatitis. 
which  is,  perhaps,  being  aggravated  by  the  parasit? 
cation.     In  such  cases  sedative  ointments  or  lo* 
are  used  in  eczema,  should  be  substituted. 


204  DISEASES  OF  THE   SKIN 


GRAIN  ITCH 

Synonyms. — Straw  itch;  Straw-mattress  disease;  Acarodermatitis  urti- 
carioides. 

Definition. — Grain  itch  is  an  eruptive  disorder  characterized 
by  a  wide-spread  urticarioid  eruption,  accompanied  by  intense 
itching,  and  due  to  the  noxious  activity  of  a  small  mite,  the 
pediculoides  ventricosus.  The  disease  has  been  observed  in 
the  eastern  section  of  the  United  States,  only  between  the 
months  of  May  and  October.  The  disease  was  clinically 
described  in  this  country  by  the  author  in  1901  and  in  1909. 
Dr.  Joseph  Goldberger,*of  the  U.  S.  Public  Health  Service,  and 
the  author  found  the  pediculoides  ventricosus  in  the  incriminated 
straw. 

Symptoms. — At  the  beginning  of  the  affection  the  patient 
may,  particularly  in  severe  attacks,  experience  chilliness,  a  slight 
rise  in  temperature,  malaise,  anorexia,  and  even  vomiting. 
The  systemic  symptoms  are,  however,  inconstant. 

The  eruptive  outbreak  consists  of  wheals,  many  of  which 
exhibit  at  their  summits  a  central  pin-point-sized  vesicle.  This 
is  the  peculiar  and  characteristic  lesion  of  the  disease.  The 
contents  of  the  vesicle  are  primarily  clear,  but  rapidly  become 
lactescent  or  distinctly  puriform.  Instead  of  frank  wheals,  the 
efflorescence  may  consist  of  barely  elevated,  erythemato-urti- 
carial  spots  or  papulo-urticarial  lesions.  The  latter  are  ede- 
matous in  character,  but  have  the  size  and  shape  of  papules. 
They  vary  in  size  from  a  lentil  to  a  finger-nail,  and  are  rounded, 
oval,  or  irregular  in  contour.  They  are  elevated  about  1  to  2 
mm.  above  the  level  of  the  skin. 

The  color  is  usually  of  a  warm  rose  tint.  The  central  vesicle 
or  pustule  is  usually  minute,  not  exceeding  in  diameter  0.5  mm. 
In  many  cases  it  is  pin-head-sized  (about  2  mm.);  exceptionally 
the  vesicle  or  pustule  may  reach  a  diameter  of  3  mm.  In  such 
cases  the  large  vesicle  situated  upon  an  erythematous  urticarial 
base  presents  a  strong  resemblance  to  the  lesions  of  chicken- 
pox. 

In  many  patients  the  summits  of  the  lesions  are  so  excoriated 
by  scratching  that  no  vesicles  are  seen — instead,  the  wheals  are 
surmounted  by  punctiform,  dark-red  blood-crusts. 

The  eruption  varies  in  extent  in  different  subjects:  usually 
it  is  profuse,  involving  the  neck,  chest,  abdomen,  and  back, 


GRAIN    ITCH 


205 


and  in  a  lesser  degree  the  arms  and  the  legs.  The  face  occasion- 
ally shows  a  few  lesions,  but  the  hands  and  feet  are  free. 

In  rare  instances  the  eruption  may  undergo  secondary 
modification  and  take  on  the  character  of  a  macular  erythema 
multiforme  or  a  scarlatinoid  erythema. 

The  eruption  is  usually  accompanied  by  the  most  violent 


in  itch:  luge  varicelloid  vesicles  interspersed  with  wheals. 


and  intolerable  itching.     This  is  worse  at  night,  and  seriously 
interferes  with  sleep.     When  the  disease  is  untreated  and  the 
cause  unsuspected,  the  eruption  may  continue  for  a  number  of 
weeks  (three  tu  seven  1,  giving  rise  to  the  keenest  distress. 
A   mild   albuminuria    is  pn.du<_vd   in   some  cases,  and  there 


206  DISEASES  OF  THE  SKIN 

is  rather  uniformly  a  slight  leukocytosis  with  a  moderate  eosino- 
philic. 

Etiology.— The  disease  is  due  to  contact  with  wheat,  barley, 
and  other  cereals  and  the  straw  therefrom,  infested  with  a 
minute  mite,  the  pediculoides  ventricosus.     Farmers  may  be 


Fig.  OS-—  (irain  itch:  wheals  surmounted  by 


attacked  from  contact  with  grain  in  the  field,  storehouse,  or 
granary,  porters  from  carrying  sacks  of  grain,  and  those  who 
use  straw  for  packing  purposes.  The  most  severe  attacks, 
however,  have  occurred  in  those  who  have  slept  upon  infected 
straw  mattresses. 


GRAIN   ITCH  207 

The  mite  is  predatory  and  parasitic  upon  grain-destroying 
insects,  particularly  the  wheat-straw  worm,  the  joint  worm, 
and  the  grain  moth. 

Pathology. — The  lesions  are  doubtless  produced  by  the  bite 


Fig.  go. — Grain  itch.     Profuse  eruption:  due  to  sleeping  on  infected  straw  mattress. 

of  the  pediculoides  and  the  injection  of  an  irritating  material. 
In  a  typical  lesion  studied  under  the  microscope  I  found 
epidermal   vesiculation,   dense    leukocyi  *™    the 

corium,  large  numbers  of  mast  cells,  ■<?• 


208  DISEASES   OF   THE    SKIN 

mentation.  The  histopathologic  changes  are  essentially  those 
of  urticaria. 

The  pediculoides  ventricosus  is  a  straw-colored  mite  scarcely 
visible  to  the  naked  eye.  It  has  four  pairs  of  legs  and  mouth 
parts  formed  for  biting  and  sucking.  It  belongs  to  the  class  of 
Arachnid  a  and  order  of  Acarina,  or  mites. 

Diagnosis. — The  affection  is  apt  to  be  confounded  with 
scabies,  urticaria,  chicken-pox,  or  pediculosis  corporis.  It 
may  be  distinguished  from  ordinary  "  hives  "  by  the  longer 
duration  of  the  individual  lesions,  by  the  central  vesiculation, 


IVrliruloiilo  found  iii  the  stiaw 


the  constitutional  disturbance,  the  greater  persistence  of  the 
attack,  and  the  incidence  among  several  members  of  a  household. 

Chicken-pox,  which  is  at  times  closely  simulated  by  the 
eruption,  may  be  excluded  by  the  duration  of  the  lesions,  the 
small ness  of  the  vesicles,  the  violence  and  persistence  of  the 
itching,  and  the  great  incidence  of  the  disease  among  adults. 

Scabies  may  be  strongly  suggested  when  the  lesions  are 
excoriated  by  scratching:  it  may  be  eliminated  from  considera- 
tion by  the  freedom  of  involvement  of  the  hands,  by  the  absence 
of  burrows,  and  by  the  uniform  eruption  of  erythema  to -urti- 
carial lesions  surmounted  by  vesicles. 


PEDICULOSIS  209 

Pediculosis  corporis  may  be  excluded  by  attention  to  the 
character  of  the  lesions  and  by  failure  to  find  pediculi. 

The  history  of  contact  with  grain  or  straw  is,  of  course,  of 
great  diagnostic  value. 

Prognosis  and  Treatment. — When  the  nature  of  the  disease 
is  recognized,  cure  is  easily  effected.  The  pediculoides  does 
not  burrow  into  the  skin,  but  merely  perambulates  upon  the 
surface,  and  punctures  the  skin  to  obtain  nutrition.  Frequent 
warm  baths,  with  the  use  of  soap,  would  doubtless  effect  a  cure 
if  contact  with  the  infected  straw  or  grain  were  not  repeated. 
When  the  use  of  an  infected  mattress  is  continued,  the  affection 
may  last  for  a  number  of  weeks. 

I  have  found  the  following  ointment  useful: 

R .  Betanaphtol gr.  xxx; 

Sulph.  praecip gr.  xl; 

Adipis  benzoat 3J. 

In  order  to  prevent  reinfection  of  the  patient,  his  clothing 
should  be  disinfected  by  boiling  or  careful  sulphur  or  formal- 
dehyd  fumigation. 

Where  the  source  of  the  parasite  is  a  straw  mattress,  the 
latter  and  the  bed-clothing  should  be  exposed  in  a  closed 
chamber  to  steam,  sulphur  dioxid,  or  formaldehyd. 

PEDICULOSIS 

Derivation. — L.,  pediculus,  a  little  foot.  Synonyms. — Lousiness;  Phthi- 
riasis. 

Definition. — Pediculosis  is  a  contagious  animal  parasitic 
disease,  characterized  by  the  presence  of  pediculi,  hemorrhagic 
points,  and  scratch-marks. 

Symptoms. — There  are  three  varieties:  (1)  Pediculosis 
capitis.  (2)  Pediculosis  corporis.  (3)  Pediculosis  pubis. 
Although  these  parasites  belong  to  the  same  family,  they  are 
anatomically  different,  and  each  variety  has  its  special  habitat 
in  relation  to  the  host. 

Pediculosis  Capitis 

Pediculosis  capitis  or  capillitii  is  due  to  the  invasion  of  the 
scalp  by  the  pediculus  capitis,  or  head-louse. 

It  is  characterized  by  severe  itching,  which  excites  scratching 
and  leads  to  the  formation  of  excoriations  with  serous,  purulent, 

14 


,\\\  iUhKAhKh  ,i|'  TIIK  SKIN 

iM  MWMWiilt  Ml  vMhtrilliW.  Till*  ilrlmi  lu  llw  fomi  of  crusts 
»\\\  ttwv«  \\<t>  \\M\  iwuvllwi.  A  tail  «tl»w  is  usually  present. 
\V\«W  \\\  Oh  miUUwn,  (he  |Hwhviviml  glands  may  become 
\\«Mik\^  Wtal  w*  WW  Nm  Mimmmlv,  IV  occipital  region 
v-  ,X>  w\\»*  t\>  >^v>  m  »\M  «M  i hi*  |xisiuLtt  vkrmatUU. 

Vw\>l  W«ufc*  ^Wwfcf*.  aifcl  vvwmiwo*  are  frequently 
wvtt  al\»u(  the  Sace  and  neck. 

l\\t».-«h  *w  pmvet  ic  varying 
wuttiVt^  ats.1  ovi  oc  =ics"  in 
.«Nsa&ukv-  Ovji  ire  jriyso,  Erans- 
:u<vt*t,    £"v.yj.i3t  SxSs*  ar=K3bsi£  bo 


'A»    tfci>    "X 


ncti*     j>ciKsisaci  Trim 
>:mi  it  „"•*■  ::tia  a  i«y% 


-.-v.    a,V.^n  3UT1T- 


PEDICULOSIS 


devitalize  the  ova,  and  subdue  the  accompanying  inflammation. 
Among  the  most  popular  and  efficacious  remedies  is  raw  petro- 


Pediculus  capitis.  Pediculus  corporis.  Pediculus  pubis. 

Female:  dorsal  surface  (X  15)  {courtesy  of  Dr.  L.  A.  Duhring). 

leum,  either  pure  or  with  equal  parts  of  olive  oil.  The  following 
formula  makes  an  efficacious  and  not  unpleasant  application : 

B.    Olei  petrolei fjvj; 

Olei  oliv:e f^iij ; 

Balsam.  Peruv '3J. — M. 

It  should  be  thoroughly  applied  to  the  scalp  for  one  or  two 
nights,  followed  in  the  morning  by  a  shampoo  of  the  scalp  with 
soap  and  water  or  tincture  of  green  soap.  Other  remedies, 
such  as  tincture  of  cocculus  indicus,  fluidextract  of  staphi- 
sagria  (two  fluidrams  to  six  fluidounces  of  dilute  acetic  acid), 
or  solutions  of  corrosive  sublimate  (one  or  two  grains  to  one 
fluidounce),  may  be  employed. 

Where  there  is  much  pustulation  and  crusting,  the  following 
ointment  may  be  applied: 


U  .    Hydraig.  ammonia! p.  xx; 

Petrolatt 3J— M. 

For  the  retnoyaj,,efcJ  line  solutions,  such  as  car- 
bonate -Iroxid  solution,  borax, 
etr  iould  be  frequently 
■1 


212  DISEASES   OF   THE    SKIN 

There  is  rarely  need  of  sacrificing  the  hair  in  women,  although 
this  may  be  done  in  children.  Much  time  and  labor  are  often 
necessary  to  cure  pediculosis  of  the  scalp.  A  fine-tooth  comb 
should  be  assiduously  used  to  detach  the  ova. 

PEDICULOSIS  CORPORIS 
This  is  produced  by  the  pediculus  corporis  or  vestimenti,  a 
parasite  larger  than  the  scalp  louse.  It  resides  in  the  seams  of 
the  underclothing,  where  the  ova  are  deposited.  They  hatch 
out  in  about  six  days.  The  louse  is  merely  present  upon  the 
skin  when  foraging. 


Fig.  ioj. — Pediculosis  corporis;  characteristic  location  of  the  scratch -marks. 

The  perambulation  of  the  parasites  and  its  blood  sucking 
give  rise  to  intense  itching,  which  causes  the  patient  to  scratch 
violently.  The  excoriations  are  usually  linear.  It  is  the  dis- 
tribution of  these  scratch-marks  which  constitutes,  apart  from 
the  finding  of  the  parasite,  the  strongest  evidence  of  the  disease. 

The  areas  of  predilection  are  the  back  in  the  scapular  region, 
the  chest,  the  waist-line,  and,  occasionally,  the  shoulders  and 
hips.     The  diagnosis  may  commonly  be  made  at  a  distance  by 


PEDICULOSIS  213 

observing  linear  scratch-marks  in  these  regions.  Small  hemor- 
rhagic points  are  occasionally  seen  on  the  skin ;  these  mark  the 
sites  where  pediculi  have  extracted  blood. 

The  parasites  are,  in  mild  cases,  not  found  upon  the  skin, 
but  upon  the  shirt  worn  next  to  the  body.  If  this  has  been 
recently  changed,  there  may  be  difficulty  in  discovering  the 
parasitic  offender.  To  avoid  exciting  the  suspicion  or  antag- 
onism of  the  patient  it  is  well  to  view  the  patient  from  the 
rear  and  to  examine  the  raised  undershirt  while  appearing  to 
scrutinize  the  skin.  In  long-standing  and  severe  cases  consider- 
able brownish  pigmentation  of  the  skin  may  be  induced. 

The  disease  is  common  among  the  poorer  classes  in  adults  of 
middle  and  advanced  years.  It  is  occasionally  encountered 
among  persons  in  the  higher  walks  of  life,  but  usually  in  the  old. 
It  is  distinctly  uncommon  in  children  and  young  adults.  I  do 
not  recall  ever  having  seen  body  lousiness  in  negroes. 

Diagnosis. — The  characteristic  features  are  the  presence  of 
excoriations,  nail-marks,  blood-crusts,  and  hemorrhagic  puncta 
upon  the  scapular  region  and  around  the  waist.  Careful  search 
of  the  undergarments  will  usually  reveal  the  existence  of  the 
pediculi. 

Eczema,  urticaria,  scabies,  and  especially  pruritus  are  the 
chief  diseases  to  be  differentiated. 

Treatment. — The  most  important  part  of  the  treatment  is 
the  disinfection  of  the  clothes  and  the  bed-linen.  These  should 
be  thoroughly  boiled,  baked,  or  fumigated  with  sulphur  dioxid. 

A  lotion  of  carbolic  acid  or  thymol  will  relieve  the  itching 
quite  effectually.  Where  disinfection  of  clothing  cannot  be 
carried  out,  it  is  best  to  prescribe  an  ointment  of  sulphur  (one 
dram  to  one  ounce)  or  staphisagria  (two  drams  to  one  ounce). 

Pediculosis  Pubis 

The  pediculus  pubis,  or  crab-louse,  is  responsible  for  this 
form.  It  is  the  smallest  of  the  pediculi,  and  is  found  clinging 
tenaciously  to  the  hair,  with  the  head  buried  in  the  follicular 
orifice.     The  "nits"  are  seen  attached  to  the  hair-shaft. 

Itching  about  the  genitalia,  variable  in  degree,  is  the  most 
prominent  feature.  Hemorrhagic  puncta,  papules,  and  excori- 
ations may  also  be  present.  The  pubis  and  perineum  are  the 
usual  regions  involved.  Occasionally  the  axillae  and  sternal 
region  are  attacked,  and  in  rare  cases  the  beard,  eyebrows,  and 
eyelashes. 


214  DISEASES   OF  THE    5KIN 

The  disease  is  almost  exclusively  observed  in  adults,  and  is 
usually  contracted  during  sexual  intercourse. 

Diagnosis. — The  diagnostic  features  are  itching  about  the 
genitalia  and  the  presence  of  pediculi  and  ova. 

Treatment. — The  parts  should  be  washed  with  soap  and 
water  twice  daily-     Lotions,  being  more  cleanly  than  ointments, 


are  to  be  preferred.  The  tincture  of  cocculus  indicus,  the  fluid- 
extract  of  staphisagria,  and  especial!  v  the  petroleum-olive -oil- 
balsam -of -Peru  lotion  are  excellent  applications. 

H  .    Fluidext.  staphisagriie f3'v- 


White  precipitate  (20-40  grains  to  one  ounce)  and  mercurial 
ointment  are  both  effective,  although  the  latter  may  irritate 
the  skin.  Vinegar  and  soda  and  borax  solutions  are  of  value 
in  effecting  the  removal  of  the  "nits." 

CYSTICERCUS  CELLULOSAE  CUTIS 

Symptoms. — Cysticerci  containing  the  larvae  of  tape-worms 

are  occasionally  observed  in  the  skin  as  rounded,  firm,  elastic, 

pea-  to  walnut-sized  tumors.     They  occur  upon  the  trunk  and 

extremities,  where  they  may  remain  unchanged  for  years. 


LEPTUS  215 

They  are  to  be  distinguished  from  gumma ta,  sarcomata,  etc. 
The  contents  under  the  microscope  are  seen  to  contain  the  para- 
sites. 

DRACUNCULOSIS 

Synonyms. — Filar ia  medinensis;  Guinea- worm. 

Symptoms. — The  lesions,  which  consist  of  pea-sized  or 
larger  vesicopapules,  are  due  to  the  presence  of  the  Dracunculus 
medinensis.  The  worms  may  at  times  be  felt  beneath  the  skin 
as  a  coil  of  soft  string.  They  are  swallowed  in  their  larval  form 
in  drinking-water  and,  migrating  through  the  tissues,  endeavor 
to  effect  an  exit  through  the  skin.  The  foot  is  the  region  usually 
affected. 

The  mature  female  is  a  cylindric  nematode,  twenty-five  to 
thirty  inches  in  length  and  one-tenth  of  an  inch  wide.  The 
disease  is  encountered  only  in  tropical  countries. 

Treatment. — The  best  treatment  is  the  injection  of  a  solu- 
tion of  1  :  1000  bichlorid  of  mercury,  followed  in  a  few  days 
by  incision  and  extraction  of  the  dead  worms. 

IXODES 

Synonym. — Wood  tick . 

Symptoms. — These  parasites  reside  but  temporarily  upon 
the  skin.  The  proboscis  of  the  tick  is  inserted  into  the  skin  for 
the  purpose  of  sucking  the  blood.  The  animal  may  thus  remain 
for  several  days,  until  the  body  swells  to  the  size  of  a  pea  or 
bean. 

Treatment. — Forcible  attempts  at  removal  of  the  invader 
should  be  avoided,  as  the  mandibles  might  thus  be  detached  in 
the  skin,  giving  rise  to  pain  and  subsequent  inflammation.  A 
drop  of  turpentine  or  benzin  placed  upon  the  head  kills  the 
parasite,  thus  causing  it  to  relinquish  its  hold. 

LEPTUS 

Synonyms. — Harvest-bug;  Leptus  autumnalis;  Mower's  mite. 

Symptoms. — The  leptus  is  a  minute,  brick-red  or  yellowish- 
red  insect,  found  in  summer  and  autumn  upon  bushes  and  grass. 
It  attacks  man  by  burying  its  head  in  the  follicular  orifices, 
particularly  of  the  lower  limbs. 

Treatment. — This  consists  in  the  application  of  carbolized 
oil,  balsam  of  Peru,  sulphur  ointment,  etc. 


2l6  DISEASES  OF  THE    SKIN 

OESTRUS 

Synonyms. — Gad-fly;  Bot-fly. 

Symptoms. — The  larvae  or  ova  of  the  gad-fly  are  deposited 
in  the  skin  by  the  adult  insect.  A  painful  furuncular  swelling 
occurs,  which  goes  on  to  suppuration.  The  larvae  may  be 
expressed  with  the  pus.     The  affection  is  common  in  the  tropics. 

Treatment. — The  furuncular  openings  should  be  syringed 
with  a  solution  of  carbolic  acid. 

PULEX  PENETRANS 

Synonyms. — Sand -flea;  Jigger. 

Symptoms. — The  minute  sand-fly  penetrates  the  skin, 
usually  at  the  toes,  giving  rise,  in  about  a  week,  to  painful  edema, 
pustulation,  and  at  times  ulceration  and  gangrene.  The  affec- 
tion is  confined  to  tropical  countries. 

Treatment. — The  insect  should  be  extracted  with  a  blunt 
needle.     The  application  of  chloroform  will  kill  the  parasite. 

PULEX  IRRITANS 
Synonym. — Common  flea. 

Symptoms. — The  flea-bite  consists  of  a  hemorrhagic  punctum 
with  an  erythematous  halo.  In  individuals  with  sensitive 
skin  a  wheal  develops. 

Treatment. — Lotions  containing  ammonia,  thymol,  or  car- 
bolic acid. 

OMEX  LECTULARIUS 

Synonym. — Bedbug. 

Symptoms. — This  parasite  preys  upon  the  skin,  sucking  the 
blood  of  the  individual  attacked.  An  inflammatory  papule  or 
wheal  with  a  central  hemorrhagic  punctum  marks  the  site  of 
the  bite. 

Treatment. — Consists  of  applications  of  ammonia  water, 
carbolic-acid  solution,  etc. 

CULEX 

Synonyms. — Gnat;  Mosquito. 

Symptoms. — The  lesions  produced  by  the  mosquito  consist 
of  an  erythematous  spot  or  wheal. 

Treatment. — A  solution  of  carbolic  acid  or  ammonia  will 
relieve  the  itching. 


PURPURA  217 

CLASS  IV.    HEMORRHAGIAE— HEMORRHAGES 

PURPURA 

Derivation. — Tlopfvpa,  purple. 

Definition. — Purpura  is  a  hemorrhagic  manifestation,  char- 
acterized by  the  appearance,  on  the  skin,  of  variously  sized  and 
shaped  reddish-purple  macules,  not  disappearing  under  pres- 
sure. 

Purpura  should  be  regarded  not  as  a  disease,  but  rather  as  a 
symptom;  it  is  associated  with  many  different  morbid  condi- 
tions and  merits,  therefore,  separate  consideration.  Nearly  all 
infectious  eruptive  diseases  may  at  times  be  characterized  by 
hemic  extravasation  into  the  skin.  In  most  cases  such  pur- 
puric conditions  indicate  malignancy,  as,  for  instance,  hemor- 
hagic  small-pox,  scarlet  fever,  or  measles.  In  typhus  and 
cerebrospinal  meningitis  hemorrhagic  exudation  is  a  regular 
feature  of  the  eruption.  Purpura  may  occur  in  malaria,  diph- 
theria, and  septic  conditions. 

There  are  other  purpuras,  however,  unassociated  with  serious 
infectious  diseases,  which  more  particularly  merit  description 
in  a  book  on  skin  diseases. 

Symptoms. — There  are  three  chief  varieties  of  purpura, 
distinguished  by  the  premonitory  and  concomitant  constitu- 
tional symptoms,  by  the  extent  of  hemorrhagic  extravasation, 
and  by  the  cause:  (1)  Purpura  simplex.  (2)  Purpura  rheu- 
matica.     (3)  Purpura  hemorrhagica. 

Purpura  Simplex. — The  eruption  usually  comes  out  suddenly, 
and  consists  of  pin-head-  to  pea-sized  round,  oval,  or  irregular 
claret-red  or  purplish  spots.  They  are  circumscribed,  smooth, 
and  non-elevated,  and  are  symmetrically  distributed,  tending 
particularly  to  occur  upon  the  lower  extremities.  Subjective 
symptoms  are,  as  a  rule,  absent.  There  is  commonly  no  sys- 
temic disturbance,  although  slight  lassitude  and  malaise  may 
be  present.  The  disease  tends  to  a  favorable  termination  in 
the  course  of  a  few  weeks. 

Purpura  Rheumatica  (Peliosis  Rheutnatica;  Schoerdein's  Dis- 
ease).— This  variety  of  purpura  is  ushered  in  with  fever,  lassi- 
tude, anorexia,  and  rheumatoid  pains,  particularly  in  the  lower 
extremities,  the  joints  of  which  may  be  swollen.  The  eruption 
consists  of  well-defined,  split-pea-  to  finger-nail-sized  hemor- 


2l8  DISEASES   OF   THE    SKIN 

rhagic  patches,  which  may  be  slightly  elevated  or  level  with  the 
skin.  At  first  of  a  pinkish,  reddish,  or  purplish  color,  they 
later  pass  through  the  color  transitions  of  all  ecchymoses.  The 
eruption  is  more  or  less  generalized,  but  is  most  marked,  as  a 
rule,  upon  the  extremities. 

The  disease  may  last  a  few  weeks  or  may  persist,  in  the  form 
of  relapses,  for  several  months.  The  arthritic  pains  vary  in 
intensity,  being  in  some  cases  mild  and  in  others  severe.  It 
is  by  no  means  proved  that  the  process  is  rheumatic  in  the 


strict  sense  of  that  term.  The  condition  is  closely  allied  to  and 
may  be  associated  with  erythema  multiforme.  Cases  are 
recorded  in  which  severe  visceral  disorders  existed,  affecting 
particularly  the  kidneys  and  heart. 

Purpura  Hemorrhagica  (Morbus  Maculosus  Werlhofii;  Land 
Scurvy). — The  onset  of  the  hemorrhagic  form  is  signalized  by 
the  occurrence  of  fever  and  symptoms  of  systemic  depression. 
The  eruption  consists  of  hemorrhagic  patches,  varving  in  size 
'  from  a  small  coin  to  the  palm  of  the  hand,  which  come  out 
suddenly  and  in  considerable  numbers.     The  trunk  and  extretni- 


PURPURA  219 

ties  are  the  regions  usually  involved.  At  the  same  time  bleeding 
from  the  mouth,  gums,  nostrils,  bowels,  bladder,  etc.,  may  take 
place.  The  disease  may  terminate  in  a  fortnight  or  may  con- 
tinue for  weeks.     In  a  certain  number  of  cases  it  proves  fatal. 

A  fulminating  form  of  purpura  (purpura  fulminans),  with 
profound  septic  or  toxic  symptoms  and  rapid  death,  has  been 
described. 

Etiology. — Purpura  is,  in  the  vast  majority,  if  not  all,  cases, 
the  result  of  the  action  of  a  poison  on  the  blood  and  blood- 
vessel walls.  As  has  been  stated,  purpura  is  common  in  various 
infectious  diseases.     It  may  also  be  caused  by  drugs  and  auto- 


Itrmimiiion  (Welch  and  SchamlxTg). 

toxins.  The  iodids,  bromids,  arsenic,  chloral,  quinin,  sali- 
cylates, copaiba,  etc.,  may  all  give  rise,  in  susceptible  subjects, 
to  purpuric  eruptions.  Most  of  the  ordinary  purpuras  are 
doubtless  due  to  autotoxins  resulting  from  faulty  metabolism. 
Not  infrequently  renal  insufficiency  or  disease  is  present. 
Osier  regards  purpura,  erythema  multiforme,  urticaria,  and 
angioneurotic  edema  in  many  cases  as  interchangeable  expres- 
sions of  metabolic  errors. 

Diagnosis.— The  evident  hemorrhagic  nature  of  the  lesions, 
as  evidenced  by  their  failure  to  disappear  upon  pressure,  dis- 
tinguishes them  as  purpuric.  Purpura  hemorrhagica  may  be 
confounded  with  scorbutus: 


220 


DISEASES  OF  THE  SKIN 


Scorbutus. 

i.  Occurs  in  those  subject  to  lack 
of  vegetable  food  and  to  bad 
hygiene. 

2.  Definite  antecedent  symptoms: 

weakness,  impaired  circulation, 
etc. 

3.  Onset  slow. 

4.  Gums     spongy,     swollen,     and 

bleeding;  teeth  loose. 

5.  Severe    muscular    pains. 

6.  Brawny    infiltration    of    lower 

extremities. 

7.  Hemorrhages  from  mucous  mem- 

branes, not,  as  a  rule,  profuse. 


Purpura  Hemorrhagica. 
1.  No   such   etiologic  relationship. 


2.  Antecedent  signs  slight  or  absent. 


3.  Onset  sudden. 

4.  Gums  often   bleeding,   but   not 

swollen. 

5.  Less  marked. 

6.  Not  present. 

7.  Hemorrhages  from  mucous  mem- 

branes often   so   severe  as  to 
prove  fatal. 


Prognosis. — In  purpura  simplex  and  rheumatica  the  prog- 
nosis is  favorable,  recovery  taking  place  in  several  weeks  or 
months.  In  purpura  hemorrhagica  the  prognosis  is  more 
guarded,  a  certain  number  of  cases  succumbing  to  internal 
hemorrhages.     Much  depends  upon  the  cause. 

Treatment. — The  treatment  of  purpura  must  be  adapted  to 
the  exigencies  of  the  individual  case.  The  treatment  of  the 
patient  is  more  important  than  that  of  the  disease.  Ergot, 
tincture  of  the  chlorid  of  iron,  quinin,  turpentine,  and  the 
mineral  acids  are  useful  in  all  forms  of  the  disease.  I  have,  in 
several  cases,  found  turpentine,  in  five-minim  doses,  given  in 
tragacanth  emulsion,  particularly  efficacious.  The  combina- 
tion may  be  flavored  with  syrup  of  lemon.  In  purpura  rheu- 
matica and  hemorrhagica  the  patient  should  be  confined  to 
bed  and  placed  upon  a  nutritious  and  easily  assimilable  diet. 
Locally,  astringent  lotions  and  ice,  if  necessary,  may  be 
employed. 

CLASS  V.    HYPERTROPHIAE— HYPERTROPHIES 


LENTIGO 

Derivation. — L.,  lens,  a  lentil.     Synonyms. — Freckles;  Ephelides. 

Definition. — Lentigo  consists  of  pin-head-  to  pea-sized, 
yellowish,  brownish,  or  blackish  spots  of  pigment,  occurring 
chiefly  on  the  face  and  hands. 

Symptoms. — The  lesions,  commonly  known  as  freckles,  are 


LENTIGO  221 

pin-head-  to  pea-sized,  round,  oval,  or  irregular,  and  of  a  yellow 
ish,  brownish,  or  blackish  color.  They  occur  chiefly  upon  the 
face  and  the  backs  of  the  hands,  although  they  are  occasionally 
observed  on  the  trunk.  They  are  more  common  during  adol- 
escence than  at  any  other  period,  although  they  often  develop  in 
children  of  seven  or  eight  years.  Freckles  are  more  marked  in 
individuals  of  blonde  complexion,  particularly  red-haired  sub- 
jects. They  ordinarily  make  their  appearance  during  the 
summer,  and  fade,  partially  or  completely,  during  the  cold 
seasons.  A  form  of  freckle-like  pigmentation  is  sometimes 
observed  with  other  senile  changes  in  the  skin. 

Etiology. — The  condition  is  due  to  exposure  to  the  chemical 
or  actinic  rays  of  the  sun.  They  may  also  be  produced  by 
exposure  to  arc-light  or  to  the  jc-rays.  Some  writers  believe 
that  a  congenital  predisposition  is  necessary. 

Pathology. — Freckles  are  due  to  an  increased  deposition  of 
pigment  in  circumscribed  areas  of  cells  in  the  basal  layer  of  the 
epidermis. 

Prognosis. — A  disappearance  of  the  freckles  may  be  brought 
about  by  treatment,  but  they  are  extremely  apt  to  return. 

Treatment. — The  object  of  treatment  is  to  produce  an 
exfoliation  of  the  epidermal  cells  containing  the  pigment.  For 
this  purpose  solutions  of  corrosive  sublimate,  acetic  acid,  and 
like  preparations  are  used.  I  have  found  the  following  prepara- 
tion efficacious : 

R.    Hydrarg.  bichloridi gr.  iv-vj ; 

Glycerini f^ij ; 

Spirit,  vini  rect.      |  ; 

Aquae  cologniensis  >   aaf^iss. — M. 

Aquae  j 

The  lotion  is  applied  to  the  freckles  two  or  three  times  a  day 
on  absorbent  cotton.  As  soon  as  redness  appears,  the  appli- 
cations are  interrupted  and  a  little  emollient  ointment,  such  as 
cold-cream,  applied.  The  freckles  disappear  with  the  mild 
desquamation  that  follows.  Different  persons  vary  in  their 
reaction  to  a  lotion  of  this  character,  and  its  strength  must  be 
diminished  or  increased  according  to  indications.  It  is  well 
to  use  the  weaker  lotion  first.  Instead  of  a  lotion,  a  desquamat- 
ing ointment  may  be  used.  I  have  used  the  following  combina- 
tion with  satisfactory  results: 


222  DISEASES   OF  THE   SKIN 

H  .  Acidi  salicylici gr.  xx-xxx; 

Hydrargyri  arrfmoniat gr.  xl-^j ; 

Ung.  aquae  rosae  I **  31V*     M" 

It  is  well  to  begin  with  the  weak  strength  and  then  increase. 
The  use  of  large  protective  hats  and  closely  meshed  red  or 
black  veils  in  the  warm  months  tends  to  prevent  the  develop- 
ment of  freckles. 

CHLOASMA 

Derivation. — jAod^ttv,  to  be  pale  green. 

Definition. — Chloasma  is  characterized  by  yellowish,  brown- 
ish, or  blackish  pigmentation  of  the  skin,  occurring  in  variously 
sized  and  shaped  patches  or  as  a  diffuse  discoloration. 

Symptoms. — The  patches  may  be  any  size  from  a  coin  to 
the  palm  of  the  hand  or  larger.  They  are  irregular  or  rounded, 
with  fairly  well-defined  borders.  They  are  usually  fawn-colored, 
yellowish,  brownish,  or  blackish  (melanoderma).  In  the  diffuse 
form  the  color  merges  imperceptibly  into  the  surrounding  skin. 
The  patches  are  often  referred  to  in  common  parlance  as  "liver- 
spots."     The  affection  is  most  frequently  seen  upon  the  face. 

Etiology. — There  are  two  varieties:  idiopathic  chloasma,  due 
to  external  causes,  and  symptomatic  chloasma,  due  to  internal 
causes. 

Under  idiopathic  chloasma  may  be  included  all  the  pigmen- 
tations that  result  from  the  use  of  local  irritants,  such  as  sina- 
pisms, blisters,  scratching,  pressure,  friction,  solar  rays  (tan- 
ning), etc. 

Symptomatic  chloasma  includes  in  its  category  the  pigmenta- 
tion seen  in  association  with  visceral  and  general  diseases,  such 
as  uterine  disease  and  pregnancy,  Addison's  disease,  abdominal 
tuberculosis,  cancer,  malaria,  exophthalmic  goiter,  enlarged  liver, 
etc.  In  these  cases  the  pigmentation  is  usually  diffuse  and  may 
involve  large  areas  of  cutaneous  surface. 

Chloasma  Uterinum. — This  is  most  commonly  seen  during 
pregnancy,  although  it  is  often  observed  in  pathologic  conditions 
of  the  uterus  and  the  ovaries.  The  patches  are  yellowish  or 
brownish  in  color,  and  are  usually  located  about  the  forehead, 
eyelids,  and  cheeks. 

In  exophthalmic  goiter,  or  Graves'  disease,  one  occasionally 
observes  pigmentation  in  small  areas,  larger  patches,  or  as  a 
diffuse  discoloration. 


NiEVUS   PIGMENTOSUS  223 

In  Addison's  disease  the  pigmentation  is  of  a  brownish,  olive- 
greenish,  or  bronze  tint.  It  may  be  general  or  partial.  The 
mucous  membrane  of  the  mouth  is  not  infrequently  discolored 
in  patches.  The  prolonged  administration  of  silver  may  produce 
a  permanent  bluish-gray  or  slate-colored  discoloration  of  the 
skin  (argyria).  A  diffuse  brownish  pigmentation  results  in 
rare  cases  from  the  long-continued  use  of  arsenic. 

Etiology  and  Pathology. — The  only  change  is  an  increased 
deposition  of  pigment  in  the  mucous  layer  of  the  epidermis. 
It  is  not  improbable  that  pathologic  conditions  of  the  sympa- 
thetic nervous  system  play  an  important  r61e  in  symptomatic 
chloasma.  It  is  rather  significant  that  most  of  the  enumerated 
diseases  in  which  pigmentation  occurs  affect  some  abdominal 
organ.  The  compromising  of  the  sympathetic  nerves  or  ganglia 
so  richly  supplied  to  the  abdominal  cavity  might  explain  the 
effect  of  abdominal  growths. 

Diagnosis. — Chloasma  may  be  distinguished  from  tinea 
versicolor  by  the  presence  of  the  former  upon  the  face,  the  pau- 
city of  the  patches,  and  the  absence  of  furfuraceous  scaling  and 
of  a  fungous  parasite. 

Prognosis. — Depends  upon  the  removability  of  the  cause. 
Local  applications  have,  as  a  rule,  but  a  temporary  influence. 

Treatment. — If  the  pigmentation  be  due  to  a  systemic  cause, 
this  should  naturally  be  treated. 

Locally,  the  same  measures  are  employed  as  in  the  treat- 
ment of  lentigo.     Duhring  recommends : 

H  .    Hydrarg.  chlor.  corrosiv gr.  vj ; 

Tinct.  benzoin,  comp Wss; 

Emuls.  amygdal.  amar f^iij. — M. 

Sig. — Apply  night  and  morning. 

Or  the  following  ointment,  recommended  by  Kaposi,  may  be 
employed : 

H  .    Hydrarg.  ammoniat 3j; 

Sodae  biborat 31 ; 

•    Ol.  rosmarin u[x ; 

Ung.  simpl %]. — M. 

NAEVUS  PIGMENTOSUS 

Derivation. — L.,  ncevus,  a  mark.     Synonym. — Pigmentary  mole. 

Definition. — A  circumscribed  pigmentary  depos** 
congenital,  with  or  without  associated  hypertro* 
cutaneous   structures.     The   term    "nevus"   is 


224  DISEASES  OF  THE   SKIN 

y 

many  writers  to  a  growth  which  is  either  congenital  or  which 
appears  shortly  after  birth.  Identical  lesions  may  develop 
many  years  after  infancy;  the  propriety  of  designating  such 
growths  as  nevi  is  questioned  by  some. 

Symptoms. — A  "mole"  may  consist  merely  of  a  circum- 
scribed deposit  of  pigment  or  there  may  be,  in  addition,  hyper- 
trophy of  the  papillae,  of  the  hairs,  and  of  the  connective  tissue. 
Nevi  vary  in  size  from  a  pea  to  the  palm  of  the  hand  or  larger, 
are  rough  or  smooth,  elevated  or  non-elevated,  and  of  a  brown- 
ish or  blackish  color. 

According  to  the  cutaneous  structures  involved,  various 
forms  of  pigmentary  nevi  are  distinguished: 

Ncbvus  spilus  is  a  term  given  to  a  smooth,  flat,  pigmented 
nevus  devoid  of  hair. 

Ncbvus  pilosus  is  a  pigmented  nevus  covered  with  a  growth 
of  downy  or  stiff  hairs. 

Ncbvus  verrucosus  is  a  pigmented  nevus  with  an  irregular  or 
wart-like  surface. 

Ncbvus  lipomatodes  is  an  elevated,  pigmented  nevus  with  con- 
nective-tissue and  fat  hypertrophy. 

Ncbvus  linearis  is  a  variety  in  which  pigmentary  or,  more 
commonly,  warty  lesions  develop  in  lines  or  streaks,  frequently 
following  the  line  of  nerves.  These  nevi  are  often  unilateral — 
ncrvus  unius  lateris.  They  may  be  congenital,  but  not  infre- 
quently develop  during  youth. 

Etiology. — Obscure.  Hairy  moles  are  apt  to  be  congenital, 
non-hairy  ones,  acquired. 

Pathology. — There  is  an  increased  pigment  deposit  in  .the 
cells  of  the  rete  mucosum  and  also  in  the  corium.  In  naevus 
verrucosus  the  papillae  are  greatly  hypertrophied.  There  is 
often  more  or  less  connective -tissue  hypertrophy. 

Treatment. — The  growths  may  be  removed  by  means  of  the 
knife,  caustics,  electrolysis,  or  with  Unna's  microburner,  which 
is  practically  a  needle-pointed  Paquelin  cautery.  For  circum- 
scribed elevated  growths  the  microburner  is  admirable.  Hairy 
moles  may  be  successfully  treated  with  the  x-rays.  Pusey  has 
obtained  excellent  results  with  solid  carbon  dioxid;  liquid  air 
has  also  been  used,  but  the  latter  is  more  difficult  to  obtain  and 
to  preserve. 


CLAVUS  225 


CALLOSITAS 


Derivation. — L.,  callus,  hard  flesh.  Synonyms. — Callus;  Callosity; 
Tylosis. 

Definition. — Callositas  consists  of  hard,  circumscribed  thick- 
enings of  the  horny  epidermis,  usually  involving  the  hands  and 
feet,  and  due  to  hypertrophy  of  the  stratum  corneum. 

Symptoms. — The  condition  occurs  as  slightly  elevated, 
dense,  horny  patches,  of  variable  size,  grayish  or  yellowish  in 
color.  The  favorite  seats  are  the  palms,  soles,  fingers,  and 
toes.  Inflammation  is,  as  a  rule,  absent,  although  it  may  be 
present  and  terminate  in  abscess.  When  located  upon  the 
soles,  considerable  pain  in  walking  is  often  caused,  particularly 
when  a  thin-soled  shoe  is  worn. 

Etiology. — The  cause  of  callus  is  the  continued  or  intermit- 
tent application  of  pressure  or  friction — upon  the  hands,  from 
the  use  of  various  tools;  upon  the  feet,  from  improperly  fitting 
shoes.  In  many  occupation  callosities  the  horny  overgrowth 
is  essential  to  the  continuance  of  the  labor  without  discomfort 
or  injury  to  the  artisan. 

Pathology. — The  condition  is  due  to  a  hypertrophy  of  the 
horny  layer  of  the  epidermis. 

Treatment. — When  treatment  is  desired,  the  hardened  skin 
may  be  pared  off  with  a  sharp  knife  after  preliminary  softening 
by  means  of  hot  water.  Instead  of  this,  a  10  to  25  per  cent, 
salicylic-acid  plaster  may  be  worn  for  some  days.  The  plaster 
should  be  changed  daily  and  the  softened  epidermis  removed. 
Another  treatment  is  cauterization  with  a  stick  of  nitrate  of 
silver,  two  or  three  times  a  week,  the  hardened  skin  being  shaved 
off  at  each  application. 

In  occupation  callosities  change  of  work  is  often  followed  by 
spontaneous  involution. 

CLAVUS 

Derivation. — L.,  clavus,  a  nail.     Synonym. — Corn. 

Definition. — Clavus  is  a  small,  circumscribed,  deep-seated, 
painful  horny  growth,  usually  situated  upon  the  toes. 

Symptoms. — The  usual  seat  of  corns  is  the  dorsal  surface  of 
the  toes.  They  are  pea-sized  or  larger,  rounded,  dense,  horny 
formations  that  may  be  single  or  multiple.  Occurring  between 
the  toes,  maceration  of  the  epidermis  takes  place,  with  the  pro- 
duction of  a  soft  corn.     Corns  are  painful  upon  pressure  and 

15 


226  DISEASE&  OF  THE   SKIN 

often  spontaneously  painful,  being  influenced  by  weather 
changes.  Corns  occurring  upon  the  soles  of  the  feet  give  rise 
to  great  discomfort. 

Etiology. — Continued  pressure  or  friction  from  improperly 
fitting  shoes. 

Pathology. — There  is  hypertrophy  of  the  horny  layer,  as 
in  callus;  but  there  is  also  a  central  conical  core,  the  apex  of 
which  rests  upon  the  papillary  layer  of  the  skin.  It  is  on 
account  of  the  latter  condition  that  pressure  produces  pain. 

Treatment. — The  removal  of  the  cause  and  the  use  of  properly 
fitting  footwear  are  important  therapeutic  measures. 

Corns  may  be  removed  by  paring  off  the  hypertrophied  epi- 
dermis after  having  previously  softened  it  with  soap  and  immer- 
sion in  hot  water.  The  central  core  'mav  be  excised  with  a 
small  scalpel.  To  prevent  return,  a  perforated  felt  plaster 
should  be  worn  and  daily  soaping  of  the  part  resorted  to. 

Instead  of  using  the  knife,  keratolytic  substances,  such  as 
salicylic  acid,  may  be  used.  This  may  be  employed  as  a  25  per 
cent,  plaster  or  in  collodion. 

H  •    Acidi  salicylici 51 ; 

Ol.  ricin'i .' Ylflx; 

Collodii fgj.— M. 

The  collodion  should  be  painted  on  twice  a  day,  a  hot  foot- 
bath being  taken  every  few  days  to  remove  the  softened  epi- 
dermis. Soft  corns  may  be  treated  with  the  stick  of  nitrate  of 
silver  or  acetic  acid  and  the  interposition  of  absorbent  cotton. 

CORNU  CUTANEUM 

Derivation. — L.,  cornu,   a  horn.     Synonym. — Cutaneous  horn. 

Definition. — Cornu  cutaneum  is  a  circumscribed  hornv  out- 
growth  of  the  skin,  of  variable  size  and  shape.  The  condition 
is  rare. 

Symptoms. — Cutaneous  horns  are  hard,  dry,  laminated 
excrescences;  not  differing  materially  from  the  horns  of  lower 
animals.  They  are  grayish,  yellowish,  or  brownish  in  color, 
usually  conical  and  tapering,  and  are  apt  to  be  curved  or 
twisted,  rather  than  straight.  They  are  commonly  small, 
about  one  inch  in  length,  although  horns  twelve  inches  long 
have  been  observed.     They  are  usually  single. 

The  horn  is  concave  at  its  skin  insertion,  the  concavitv  rest- 


CORNU  CUTANEUM  227 

ing  upon  normal  or  hypertrophied  papillae.  There  is,  as  a  rule, 
no  pain  unless  the  part  is  injured,  when  inflammation  and  sup- 
puration may  result.  When  the  horn  is  shed,  as  occasionally 
takes  place,  reformation  usually  occurs.  Quite  a  proportion 
of  cases  terminate  in  epithelioma. 

The  scalp  and  face  are  the  seats  of  predilection.  I  have  seen 
one  grow  from  the  vermilion  border  of  the  lip;  this  terminated 
in  a  buccal  cancer. 

Etiology. — Horns  may  have  their  origin  in  senile  warts. 


sebaceous  cysts,  or  scars.  They  usually  develop  after  the  age 
of  forty,  although  they  may  occur  in  infancy. 

Pathology.— Horns  are  composed  of  densely  laminated 
cornified  cells,  arranged  in  concentric  columns.  There  is  at 
first  a  hypertrophy  of  the  rete  mucosum.  Often  the  papillae 
at  the  base  are  enlarged.  In  about  12  per  cent,  of  horns  epi- 
thelioma develops  at  the  base  of  the  lesion. 

Treatment. — Horns  should  be  surgically  removed;  if  there 
is  thickening  at  the  base,  the  entire  diseased  area  should  be 
included  in  the  area  of  excision. 


228  DISEASES  OF  THE   SKIN 

ACANTHOSIS  NIGRICANS 

Under  the  title  acanthosis  nigricans,  Pollitzer  and,  at  the  same 
time,  Janovsky,  described  a  disease  characterized  by  more  or 
less  generalized  pigmentation  of  the  skin  accompanied  by  warty 
growths.     About  thirty  cases  have  now  been  recorded. 

After  a  rapid  or  slow  evolution  the  cutaneous  surface  gener- 
ally, but  more  particularly  of  the  face,  neck,  abdomen,  back 
of  hands,  and  flexures,  such  as  the  axillae,  groins,  and  nates, 
become  the  seat  of  a  yellowish,  brownish,  or  blackish  pigmenta- 
tion. The  skin  in  these  regions  is  thickened,  and  the  natural 
furrows  exaggerated.  There  soon  appear  warty  growths,  which 
may  be  discrete  or  so  closely  aggregated  as  to  suggest  a  verru- 
cose  nevus.  At  times,  lentiginous  spots  and  lesions  resembling 
seborrheic  warts  are  observed.  The  mucous  membrane  of  the 
mouth  is  often  affected,  the  tongue,  lips,  and  gums  presenting  a 
granular  or  papillomatous  appearance.  Nearly  all  cases  ter- 
minate fatally  after  a  course  of  some  months  or  a  few  years. 

The  disease  has  only  been  observed  in  adult  life.  Carcinoma, 
especially  of  the  stomach  or  uterus,  has  occurred  sufficiently 
often  to  suggest  a  causal  relationship. 

Treatment  is  entirely  unsatisfactory. 

ICHTHYOSIS 

Derivation. — "I,t^'V,  a  fish.     Synonym. — Fish-skin  disease. 

Definition. — A  congenital  chronic  hypertrophic  disease, 
characterized  by  dryness  and  scaliness  of  the  skin  and  a  variable 
amount  of  papillary  hypertrophy. 

Symptoms. — Two  forms  of  the  disease  are  distinguished — 
ichthyosis  simplex  and  ichthyosis  hystrix. 

Ichthyosis  simplex  is  the  variety  ordinarily  encountered. 
It  varies  greatly  in  intensity,  from  merely  an  abnormal  dryness 
of  the  skin  to  a  most  pronounced  and  disfiguring  disease.  In 
the  mildest  grade  the  skin  is  dry  and  harsh,  the  furrows  more 
pronounced  than  normal,  and  a  slight  scaliness  is  present.  To 
this  form  the  term  xeroderma  is  often  applied.  In  some  cases 
there  is  a  prominence  of  the  hair-follicles,  particularly  upon 
the  extremities,  producing  a  keratosis  pilaris. 

Frequently,  however,  the  disease  is  more  pronounced,  exhibit- 
ing variously  sized  reticulated  scales,  which  may  be  small  and 
thin  or  large  and  thick,  resembling  fish-scales.  Upon  the  arms 
and  legs  the  epidermis  forms  diamond-shaped  or  polygonal 


ICHTHYOSIS 


2  29 


plates,  bounded  by  the  natural  furrows  of  the  skin,  and,  in 
severe  cases,  bearing  a  resemblance  to  alligator  skin.  The 
scales  are  often  of  a  brownish  or  greenish  tint. 

Ichthyosis  simplex  involves  more  or  less  of  the  entire  body, 
with  especial  development  upon  the  extensor  surfaces  of  the 
extremities.  The  scalp, 
as  a  rule,  is  dry  and  scaly, 
as  is  also  the  face  when  it 
participates  in  the  pro- 
cess. The  palms  and 
soles  often  show  great 
exaggeration  of  the  lines. 

The  course  of  ichthy- 
osis is  eminently  chronic. 
The  disease  begins  usu- 
ally in  the  first  or  second 
year  of  life,  increases  in 
severity  until  adult  age 
is  reached,  and  then  re- 
mains stationary,  thus 
continuing  throughout 
the  patient's  life. 

Ichthyosis  is  markedly 
influenced  by  the  sea- 
sons. It  is  always  worse 
in  cold  than  in  hot 
weather.  In  the  spring 
and  summer,  when  per- 
spiration is  increased, 
great  improvement  takes 
place.  Itching  is  often 
present  in  mild  form. 
The  skin  is  sensitive,  par- 
ticularly in  cold  weather, 
and  eczema  is  commonly 
engrafted  upon  the  skin 
of  ichthyotic  patients. 

Ichthyosis  hystrix  is 
a  rarer,  more  severe,  and 
more  disfiguring  affection.  It  is  characterized  by  papillary 
and  corneous  hypertrophy,  showing  itself  clinically  as  irregular 
or  linear,  rugous,  warty  or  spinous,  horny  patches.     In  soft** 


7- — Ichthyosis  of  moderate  grade. 


23" 


DISEASES   OF   THE    SKIN 


instances  a  resemblance  to  the  corrugated  bark  of  a  tree  is 
strongly  suggested.  Ichthyosis  hystrix  affects  only  limited 
areas  of  the  skin,  such  as  the  arm,  neck,  axilla?,  umbilicus,  etc. 
Some  of  these  cases  are  entirely  unrelated  to  true  ichthyosis, 
and  should  be  grouped  with  nevi  and  papillomata. 

Ichthyosis  congenita  ("harlequin  fetus  ")  is  a  form  occurring 
in  infants  born  prematurely  or  at  term,  and  exhibiting  at  birth 


Fig.  108. — Ichthyosis. 


a  cracked,  parchment -like  skin,  with  a  tendency  to  form  plates 
separated  by  furrows  or  actual  fissures. 

The  skin  surface  looks  at  times  as  if  it  were  covered  with 
cracked  oiled  paper.  These  infants  are  usually  still  born  or 
die  shortly  afterward. 


ICHTHYOSIS  231 

Etiology. — Ichthyosis  is  a  congenital  disease,  although  it 
does  not,  as  a  rule,  manifest  itself  before  the  first  or  second  year. 
It  is  caused  by  a  developmental  and  nutritional  defect  of  the 
skin,  with  disturbance  of  the  sebaceous  and  sudorific  functions. 
A  hereditary  influence  is  observed  in  many  instances. 

Pathology. — Owing  to  the  congenital  defect,  cornification 
is  abnormal.  The  rete  cells  are  said  to  be  directly  transformed 
into  horny  plates.  The  horny  layer  is  hypertrophic,  producing 
a  hyperkeratosis.  The  rete  is  thickened.  Degenerative  changes 
in  the  sweat-  and  sebaceous  glands  have  been  described.  The 
follicular  orifices  often  contain  horny  plugs. 

Diagnosis. — The  characteristic  features  of  ichthyosis  are: 
the  harsh  dry  skin,  furfuraceous  scales,  and  polygonal  plates, 
the  localization  of  the  eruption,  the  history,  and  the  absence  of 
inflammatory  symptoms.  Mild  cases  might  be  confounded 
with  a  squamous  eczema. 

Prognosis. — The  prognosis  is  unfavorable  as  to  cure.  Con- 
siderable relief,  however,  may  be  afforded  by  proper  treatment. 

Treatment. — Internal  treatment  is  of  little  or  no  value. 
External  treatment  is  to  be  solely  relied  upon.  This  has  for  its 
object  the  removal  of  the  epidermal  scales  and  the  softening 
of  the  skin  with  unguentous  substances. 

Baths  are  of  great  value,  and  are  to  be  employed  frequently. 
Either  a  simple  warm  bath  or  an  alkaline  bath  (sodium  bicar- 
bonate, 4  to  8  ounces  to  bath)  may  be  used.  In  mild  cases 
frequent  bathing,  followed  by  the  inunction  of  some  oily  or 
fatty  substance,  will  be  all-sufficient.  For  this  purpose  cocoa- 
nut  oil,  petrolatum,  adeps,  olive-oil,  oil  of  sweet  almonds, 
diluted  glycerin,  etc.,  may  be  employed.  A  simple  and  effi- 
cient inunction  consists  of: 


R .    Lanolin.  \  -  -    2? w 

Adipis  benzoat.  f   aa  ™      M* 


In  severe  cases  the  following  plan  is  advised:  friction  with 
soft  soap  twice  daily  for  four  or  five  days,  followed  by  a  bath 
and  the  inunction  of  the  following: 


H .  Acid,   salicylici ST-.??' 

Ol.  cocois  (cocoanut  oil) f^viij; 

Ol.  lavand q.  s. — M. 


232  DISEASES   OF   THE    SKIN 

lodiri  of  potassium  in  ointment  form  has  been  highly  spoken 
of: 

B-    Potass,  iodid gr.xx; 

Olei  bubuli  1  ,.   3„„. 

Adipis         /  aa  ^ss, 

Glycerin* f3j.-M. 

Sic— Ft.  ung. 

In  ichthyosis  hystrix,  caustics,  the  Paquelin  cautery,  or  the 
knife  may  be  necessary  to  remove  the  hypertrophic  tissues. 

VERRUCA 

Derivation. — L.,  verruca,  an  excrescence.     Synonym. — Warts. 

Definition. — Verruca  consists  of  a  pin-head-  to  bean-sized, 
circumscribed  elevation  of  the  skin,  due  to  epidermal  and  papil- 
lary hypertrophy- 
Symptoms. — Various  forms  of  warts  are  distinguished. 


Verruca  Vulgaris. — This  is  the  common  wart  seen  upon  the 
hands.  It  isa  pea-sized,  rounded,  rough  or  smooth,  broad-based 
elevation,  yellow  or  brownish  in  color.  It  may  occur  singly  or 
in  numbers. 

Verruca  Plana. — This  is  distinguished  from  the  ordinary 
wart  by  being  flat  and  smooth.     Flat  warts  are  pea-  or  finger- 


VERRUCA 


233 


nail-sized,  but  slightly  elevated,  and  of  a  brownish  or  blackish 
color.  They  occur  in  numbers,  usually  upon  the  backs  of 
elderly  individuals  (verruca  senilis).  Occasionally  numerous 
small  flat  warts  occur  upon  the  face,  particularly  of  young  sub- 
jects, developing  with  considerable  rapidity  (verruca  plana 
juvenilis).  I  have  seen  warts  in  several  patients  develop  upon 
the  lips  and  upon  the  dorsum  of  the  tongue  from  autoinocula- 


Verruca  Filiformis. — These  warts  are  slender,  thread-like 
outgrowths,  about  one-eighth  of  an  inch  in  length,  occurring 
chiefly  upon  the  face,  eyelids,  and  neck. 

Verruca  Digitata.— These  are  slightly  elevated,  pea-  to  finger- 
nail-sized excrescences,  with  numerous  digitations  branching 
out  from  the  base.    The  scalp  is  the  most  common  site. 

Verruca  Acuminata  {Pointed  Condyloma;  Venereal  Warts).- — 
These  are  pinkish  or  reddish,  sessile  or  pedunculated,  pointed 
vegetations,  occurring  about  the  mucocuta*"  *s  (penis, 


234  DISEASES   OF  THE   SKIN 

anus,  labia,  mouth,  etc.)  of  young  individuals.  Occurring 
upon  the  genitals,  they  are  bathed  in  an  offensive  puriform 
secretion.  These  warts  grow  rapidly,  not  infrequently  reaching 
the  size  of  an  egg.  They  bear  at  times  a  strong  resemblance  to 
a  raspberry,  cauliflower,  or  cockscomb. 

Etiology. — It  is  probable  that  most  forms  of  warts,  save 
verruca  senilis,  are  due  to  microorganisms,  and  that  they  are 
autoinoculable  and  contagious. 

Venereal  warts  are  caused  by  contact  with  irritating  secre- 
tions, which  contain,  in  all  probability,  the  causal  microorgan- 
isms. 

Pathology. — Warts  consist  of  a  hyperplasia  of  the  papillae 
of  the  corium  and  the  overlying  layers  of  the  epidermis.  A 
vascular  loop  is  found  in  the  center  of  each  wart. 

In  the  acuminate  variety  the  connective-tissue  and  vascular 
hypertrophy  is  marked,  while  the  horny  layer  is  but  slightly 
hyperplastic. 

Treatment. — Warts  may  be  removed  by  caustics,  excision, 
erasion,  or  electrolysis.  The  best  caustics  to  be  employed  are 
nitric  acid,  caustic  potash,  chromium  trioxid,  or  glacial  acetic 
acid.  These  should  be  cautiously  applied  from  time  to  time 
until  the  wart  disappears.  An  excellent  method  is  to  scrape 
away  the  wart  with  a  curet  under  local  anesthesia  induced  by 
injecting  a  2  per  cent,  solution  of  eucain,  and  then  apply  the 
stick  of  nitrate  of  silver  to  the  base. 

Salicylic  acid  in  collodion  or  alcohol  is  often  successful  in 
causing  the  disappearance  of  warts: 

H .    Acidi  salicylici si ; 

Spirit,  vini  rect *f 3 j . — M. 

Sic — Apply  two  or  three  times  a  day. 

Warts  on  the  scalp  will  sometimes  disappear  after  the  use  of : 

R.    Hydrarg.  ammoniat 3J~iJ; 

Adipis  benzoat ^j. — M. 

The  use  of  1  :  500  corrosive  sublimate  solution  in  50  per  cent, 
alcohol  is  sometimes  efficacious,  as  is  also  an  alcoholic  solution 
of  resorcin,  thirty  grains  to  the  ounce. 

Single  warts  may  be  removed  by  the  application  of  radium  or 
the  high-frequency  current,  often  in  one  treatment.  Filiform 
or  digitate  warts  may  be  snipped  off  with  a  curved  scissors,  the 
base  being  subsequently  cauterized.     Venereal  warts  may  be 


POROKERATOSIS  235 

i  with  solutions  of  alum,  tannin,  or  chlorinated  soda,  and 
then  dusted  with  calomel,  or  they  may  be  cauterized  with  nitric 
acid,  phenol,  or  chromium  trioxid.  Cleanliness  should  be  rigor- 
ously enjoined. 

Warts  upon  the  soles  of  the  feet  are  best  treated  by  using  a 
25  per  cent,  salicylic  plaster  on  them. 

POROKERATOSIS 

Mibelli,  and  later  Resphigi,  made  known,  under  the  name  of 
porokeratosis,  a  hitherto  undescribed  affection,  characterized 
by  eccentrically  spreading  patches  of  hyperkeratosis  with  a 
sharp  elevated  border.  The  disease  prefers  the  extensor  sur- 
faces of  the  hands,  feet,  neck,  and  the  mucous  membrane  of 


Porokeratosis  (courtesy  of  Dr.  G.  W.  Wcnde). 


the  mouth.  It  begins  as  warty-looking  papules  which  slowly 
enlarge  by  peripheral  extension,  producing  plaques  of  various 
size  aiid  shape.  The  plaque  is  surrounded  by  a  rather  sharply 
defined  horny  ridge  or  wall,  the  crest  of  which  often  exhibits 
a  continuous  or  broken  furrow  or  sulcus.  The  bottom  of  the 
furrow  may  contain  a  longitudinal,  cord-like  ridge,  blackish 
dots,  or  conical  corneous  projections.    The  area  within  the  border 


236  DISEASES  OF  THE   SKIN 

may  be  normal  or,  as  occurs  more  commonly,  the  skin  is  either 
thickened  and  callous  or  atrophic  and  glossy.  It  may  be  raised 
or  depressed.  The  patches  vary  in  diameter  from  a  centimeter 
to  the  width  of  a  limb.  The  young  patches  are  usually  cir- 
cular, but  the  older  ones  are  inclined  to  have  an  irregular  wavy 
or  zigzag  outline.  Merely  one  plaque  may  be  present,  but 
usually  they  are  multiple  and  sometimes  numerous. 

The  disease  begins  in  the  first  decade  of  life  in  the  vast 
majority  of  cases.  The  affection  spreads  very  slowly,  occupying 
a  period  of  years.  A  hereditary  influence  is  often  manifest. 
Gilchrist  reported  eleven  cases  occurring  in  four  generations 
of  the  same  family.  The  cause  of  the  disease  is  not  known. 
Under  the  microscope  the  affection  is  seen  to  be  a  hyperkeratosis 
affecting  chiefly  the  deeper  horny  and  upper  rete  strata.  The 
sweat-ducts  are  implicated  in  the  process,  and  to  a  less  extent 
the  sebaceous  glands  and  hair-follicles. 

Lesions  have  been  cured  with  the  electric  needle. 

COMEDO 

Derivation. — L.,  comedo,  glutton,  spendthrift.  Synonyms. — Blackheads; 
Flesh -worms. 

Definition. — Comedo  is  a  condition  characterized  by  black- 
ish, pin-head-sized  plugs  of  sebum  lying  in  the  mouths  of  the 
sebaceous  ducts. 

Comedo  is  an  affection  so  commonly  precedent  to  and  accom- 
panying acne  as  to  belong  to  the  symptomatology  of  that  dis- 
ease. Sabouraud  regards  comedones  as  the  primary  lesions  of 
acne  and  the  connecting  link  between  seborrhea  and  acne. 

Symptoms. — Comedones  appear  as  yellowish,  brownish, 
bluish,  or  blackish  points,  occupying  the  mouths  of  the  seba- 
ceous ducts.  The  "  blackhead  "  is  made  up  of  sebum,  epithelial 
debris,  and  microorganisms.  When  the  sebaceous  material 
is  soft,  pressure  causes  it  to  emerge  from  the  follicle  in  a  long, 
thread-like  filament.  When  it  is  firm  and  inspissated,  it  is 
expressed  as  an  oval,  shining,  somewhat  translucent,  yellowish 
body,  with  a  dark-colored  point  corresponding  to  the  external 
summit  of  the  plug.  This  is  called  by  Sabouraud  the  "sebor- 
rheic cocoon." 

The  dark  color  is  due  partly  to  dust  from  without  and  partly 
to  chemical  changes  in  the  secretion.  At  times  one  sees  bluish- 
black  comedones  with  a  bluish  discoloration  of  the  skin  immedi- 


COMEDO  237 

ately  surrounding  the  plug,  as  if  due  to  the  deposition  of  a 
pigment. 

Comedones  are  extremely  liable  to  undergo  inflammation 
and  give  rise  to  acne  papules  or  pustules. 

The  course  of  the  affection  is  essentially  chronic. 

Etiology. — The  same  causes  which  predispose  to  the  develop- 
ment of  acne,  namely,  puberty,  dyspepsia,  constipation,  anemia, 
menstrual  disturbances,  etc.,  exercise  a  like  influence  in  comedo. 
Unna,  Hodara,  and  Sabouraud  regard  the  microbacillus  found 
in  all  comedones  as  the  cause  of  the  condition.  The  "acarus 
or  demodex  folliculorum,"  an  animal  parasite  occasionally 
discovered  in  the  sebaceous  follicles,  is  without  etiologic  impor- 
tance. Comedones  are  often  produced  artificially  by  deposition 
from  the  atmosphere  of  various  solid  impurities.  Thus  tar, 
brass,  and  iron  workers  are  frequent  sufferers  from  this  affection. 

Pathology. — Unna  claims  that  there  is  a  thickening  of  the 
corneous  layer  of  the  external  surface,  and  consequently  a 
closure  of  the  duct.  The  horny  lining  of  the  ducts  undergoes 
similar  change,  and  scales  are  thrown  into  the  canal  which, 
combining  with  the  sebum,  form  the  comedo. 

Prognosis. — As  a  rule,  the  condition  may  be  remedied  by 
appropriate  treatment. 

Treatment. — The  systemic  treatment,  as  in  acne,  aims  at 
a  correction  of  the  predisposing  causes.  Strychnin,  iron,  cod- 
liver  oil,  and  the  hypophosphites  are  often  required. 

Locally,  applications  designed  to  remove  the  plugs  are  indi- 
cated. The  larger  ones  should  be  squeezed  out  with  a  comedo 
extractor  (Fig.  51).  The  tincture  of  green  soap  (tinctura 
saponis  viridis)  is  an  excellent  remedy  in  sluggish  cases.  Equal 
parts  of  alcohol  and  ether  make  a  nice  sebaceous  solvent. 

Salves  containing  sand  or  chalk  are  sometimes  used.  The 
appended  formula  is  a  useful  example: 

R.    Sulph.  praecip. )  ..  „. 

Saponis  mollis  j    ,->J ' 

Pulv.  cretae 3ss; 

V  aSclllll  .........................    Q  .   S.   clQ     ^J.1^- "JJl. 

Or  the  following  lotion  may  be  used: 

R  .    Acidi  borici gj ; 

Spirit,  vini  rect f^iv. — M. 

The  remedies  in  general  are  much  the  same  as  those  employed 
in  the  treatment  of  acne. 


238  DISEASES  OF  THE  SKIN 

MILIUM 

Derivation. — L.,  milium,  a  millet-seed.  Synonyms. — Grutum;  Stroph- 
ulus albidus. 

Definition. — A  condition  characterized  by  the  formation 
of  small,  round,  yellow  or  pearly-white  sebaceous  bodies  just 
beneath  the  epidermis. 

Symptoms. — The  lesions  are  most  commonly  found  upon 
the  cheeks  in  the  malar  region,  but  may  occur  upon  the  fore- 
head and  other  parts  of  the  face.  They  are  also  occasionally 
seen  elsewhere.  They  consist  of  pin-point-  to  pin-head-sized 
yellowish  or  whitish  elevations,  hard  to  the  touch.  When 
incised  and  expressed,  a  small,  irregular,  whitish,  glistening 
body  is  seen  which  may  be  of  gritty  consistence.  They,  at 
times,  undergo  calcareous  change,  producing  the  so-called 
cutaneous  calculi. 

Etiology. — Milia  occur  in  infants  and  in  young  adults. 
The  cause  is  obscure.  They  develop  at  times  under  scars  and 
in  the  areas  of  former  attacks  of  erysipelas  and  pemphigus. 

Pathology. — Milia  are  believed  to  be  due  to  the  retention 
of  sebaceous  matter  in  superficially  seated  glands.  Under  the 
microscope  they  are  found  to  consist  of  concentric  layers  of 
epithelial  cells  around  a  central  core  of  fat  and  cells  and  sur- 
rounded by  a  thin  capsule. 

Treatment. — In  infants,  the  use  of  soap  and  water  is  all 
that  is  necessarv  to  remove  the  bodies.  In  adults  the  lesions 
should  be  incised  and  the  contents  expressed  with  a  comedo 
remover.  A  small  knife  should  be  used,  the  procedure  being 
practically  painless  and  almost  bloodless.  No  scarring  follows 
the  removal  of  the  milia. 

CYSTIS  SEBACEA 

Derivation. — Zriaft,  fat.  Synonyms. — Wen;  Sebaceous  cyst  or  tumor; 
Atheroma;  Steatoma. 

Definition. — A  wen  is  a  cyst  containing  sebaceous  matter. 

Symptoms. — The  cysts  are  pea-  to  egg-sized,  rounded  or 
oval  tumors,  with  a  doughy  consistence.  Pressure  often  causes 
pitting.  The  seats  of  predilection  are  the  scalp,  face,  neck,  and 
back.  They  are  ordinarily  painless,  and  the  overlying  skin 
is  pale.  When  inflamed,  the  skin  becomes  reddened.  They 
may  remain  for  many  years  without  undergoing  any  change. 


MOLLUSCUM   EPITHELIAL  239 

As  a  result  of  injury  or  without  such  cause,  they  may  suddenly 
take  on  increased  growth.  Under  such  circumstances  inflam- 
mation and  suppuration  commonly  occur.  Before  suppuration, 
incision  and  pressure  will  cause  extrusion  of  a  cheesy -looking 
sebum  in  long  filaments  or  tape-like  masses. 

Pathology. — They  are  due  to  accumulations  of  sebaceous 
matter  in  the  glands;  in  other  words,  they  are  retention  cysts. 

Treatment. — The  overlying  skin  should  be  incised,  and  the 
tumor  with  its  capsule  carefully  dissected  out.  If  the  capsule 
is  allowed  to  remain,  recurrence  usually  follows.  Sometimes 
a  cure  can  be  effected  by  incision,  expression  of  contents,  and 
the  injection  into  the  sac  of  tincture  of  iodin. 


HOLLUSCUH  EPITHELIALE 

Derivation. — L.,  molluscus,  soft.     SjTionytn.— Moll u scum  contagiosum. 

Definition. — Molluscum  epitheliale  is  a  disease  characterized 
by  pin-head-  to  pea-sized  or  larger,  smooth,  semiglobular,  waxy- 
white  or  pinkish  elevations.    The  disease  is  ti 


Fig.  112.— Three 


Symptoms. — The  lesions  are  discrete,  usually  split-pea-sized, 
of  the  color  of  the  skin,  or  pinkish,  with  often  a  distinct  waxy 
appearance.  The  summits  are  somewhat  flattened  and  contain 
a  central,  darkish  opening  from  which  a  cheesy  secretion  may 
be  expressed.  Occasionally,  an  inspissated  plug  of  material 
is  seen  projecting  from  the  central  orifice.    T1  - 

usually  situated  upon  the  face,  particularly 


240 


DISEASES  OP  THE    SKIN 


cheeks,  and  chin.  They  are  also  found  upon  the  genitalia,  the 
chest,  and  elsewhere.  They  increase  slowly  in  size,  often  ter- 
minating in  suppuration  and  thus  spontaneously  disappearing. 
As  a  rule,  no  scarring  is  left.  The  lesions  are  few,  a  half-dozen 
or  more  being  the  usual  number  present. 


Etiology.- — The  disease  occurs  chiefly  in  children.  It  is 
to  an  extent  contagious,  although  under  ordinary  circumstances 
but  feebly  so.  Numerous  examples  of  dissemination  in  families, 
schools,  gymnasiums,  and  asylums  are  on  record.     The  infec- 


KERATOSIS  PILARIS  241 

tion  is  sometimes  transmitted  through  the  use  of  towels.  The 
disease  has  been  successfully  inoculated.  Epithelial  mollusca 
are  seen  at  times  upon  the  eyelids  of  pigeons  and  fowl ;  patients 
sometimes  receive  the  infection  from  pet  feathered  creatures. 

Pathology. — The  growths  consist  of  an  enormous  hyper- 
plasia of  the  cells  of  the  rete  mucosum,  the  process  in  all  prob- 
ability beginning  in  the  hair-follicles.  The  center  of  the  mol- 
luscum  tumor  is  made  up  of  a  number  of  lobules  filled  with 
ovoid  or  rounded,  fatty-looking,  degenerated  epithelial  cells, 
designated  as  "molluscum  bodies." 

Diagnosis. — The  characteristic  features  of  the  disease  are: 
the  size  of  the  lesions,  their  waxy  appearance,  the  presence  of 
a  central  orifice  giving  exit  to  a  whitish  secretion,  and  the 
history  and  course  of  the  affection.  The  secretion  examined 
under  the  microscope  shows  large  ovoid  bodies  which  take  the 
eosin  stain  well. 

« 

Prognosis. — The  condition  sometimes  disappears  spon- 
taneously.    It  is  readily  amenable  to  treatment. 

Treatment. — The  tumors  may  be  destroyed  by  incision, 
expression  of  their  contents,  and  cauterization  of  the  cavity 
with  the  stick  of  nitrate  of  silver  or  carbolic  acid.  Small 
lesions  may  be  bored  with  a  tooth-pick  moistened  in  carbolic 
acid  or  iodin.  Unna's  microburner  is  a  convenient  instrument 
to  effect  their  disappearance. 

Again,  they  may  be  curetted  away  or  snipped  off  with  a  pair 
of  curved  scissors.  Pedunculated  growths  may  be  ligated. 
Where  the  lesions  are  small,  the  following  ointment  may  be 
vigorously  rubbed  in : 

R  .    Hydrarg.  ammoniat ^j; 

Ung.  zinci  oxidi 3J.— M. 

KERATOSIS  PILARIS 

Derivation. — Ktyjaf,  a  horn.  Synonyms. — Lichen  pilaris;  Pityriasis 
pilaris. 

Definition. — Keratosis  pilaris  is  a  hypertrophic  affection 
characterized  by  pin-head-sized  epidermal  accumulations  at 
the  mouths  of  the  hair-follicles.  This  affection  in  its  milder 
forms  is  quite  common  and  often  escapes  notice  or  complaint. 

Symptoms. — The  extensor  surfaces  of  the  arms  and  thighs 
are  the  usual  seats  of  the  eruption.  The  lesions  consist  of 
closely  ag?  *oical,   papulosquamous, 

it 


242  DISEASES  OF  THE   SKIN 

prominences,  corresponding  to  the  orifices  of  the  hair-follicles. 
A  hair  pierces  each  elevation  or  is  buried  within  it.  The  lesions 
are  grayish,  whitish,  or  blackish  in  color,  and  are  made  up  of 
epidermal  cells  and  sebum.  At  times  the  elevations  are  papular 
and  have  a  reddish  tint.  The  skin  is  dry  and  rough  and  feels 
to  the  hand  passed  over  it  not  unlike  a  fine  nutmeg-grater. 

As  a  rule,  itching  is  absent.  The  course  of  the  disease  is 
chronic. 

Etiology. — Puberty  is  regarded  as  an  etiologic  factor,  and 
infrequent  bathing  seems  to  be  causal  in  some  cases.  Hyde 
believes  the  affection  to  be  more  common  in  people  of  unusual 
physical  vigor. 

Pathology. — The  condition  consists  of  an  accumulation  of 
horny  cells  and  sebaceous  material  at  the  orifices  of  the  hair- 
follicles.     Inflammatory  changes  are  sometimes  present. 

Diagnosis. — Keratosis  pilaris  is,  as  a  rule,  easy  of  diagnosis. 
It  may  be  distinguished  from  " goose-flesh* '  (cutis  anserina) 
by  the  permanence  of  the  lesions  as  compared  with  their  evanes- 
cence in  the  latter  affection. 

Pityriasis  rubra  pilaris  is  more  wide-spread,  exhibits  lesions 
upon  the  scalp,  dorsal  surfaces  of  the  phalanges,  etc.,  and  is 
accompanied  by  a  seborrheic  scaling  of  the  surface. 

The  lesions  of  the  small  papular  syphiloderm  are  more  gener- 
ally distributed,  tend  to  group,  are  deeper  seated,  less  scaly 
that  those  of  keratosis  pilaris,  and  are  commonly  associated 
with  pustular  lesions. 

Treatment. — Simple  or  alkaline  warm  baths  with  the  use 
of  ordinary  soap  or  sapo  mollis  will  suffice  for  mild  cases  of 
short  duration.  In  other  cases  this  should  be  followed  by  the 
inunction  of  one  of  the  simple  ointments. 

Daily  cold  sponge-baths  and  friction  should  be  systematically 
employed. 

KERATOSIS  FOLLICULARIS 

Synonym s. — Psorospermosis;  Darier's  disease  (psorospermose  follicu- 
laire  ve'g&ante). 

Definition. — Keratosis  follicularis  is  a  hypertrophic  affection 
characterized  by  pin-head-  to  pea-sized,  dark-colored  or  normal 
tinted  acuminated  or  rounded  papules,  sometimes  with  central 
conical  plugs,  marking  the  sites  of  the  pilosebaceous  follicles. 


HYPERTRICHOSIS  •  243 

Symptoms. — The  disease  is  exceedingly  rare.  The  favor- 
ite seats  of  the  eruption  are  the  scalp,  face,  chest,  loins,  and 
inguinal  region.  The  first  lesions  consist  of  pin-head-sized 
papules  of  the  color  of  the  skin ;  these  gradually  assume  a  deeper 
tint  and  become  covered  with  a  greasy  sebaceous  scale.  On 
close  inspection  some  of  the  papules  are  seen  to  contain  a  fatty 
plug  which  just  projects  from  the  follicular  orifice  and  which 
can  be  removed  with  difficulty,  leaving  a  pit-like  depression. 
The  papules  may  enlarge,  coalesce,  and  form  papillomatous 
vegetations  upon  apposing  skin  surfaces,  as  in  the  inguinal 
region.  These  vegetations  are  bathed  in  a  puriform  secretion 
which  emits  an  extremely  offensive  odor.  The  disease  runs  a 
chronic  and  progressive  course. 

Etiology. — The  disease  is  more  common  in  males  than  in 
females,  and  occurs  chiefly  in  childhood  and  adolescence. 
Heredity  and  contagion  are  possible  causal  factors. 

Pathology. — The  disease  is  primarily  a  hyperkeratosis  of 
the  hair  and  sebaceous  follicles,  with  secondary  hyperplasia 
of  the  interpapillary  projections  of  the  rete  mucosum. 

Prognosis. — No  cures  have  been  reported,  but  improvement 
may  take  place  under  treatment. 

The  disease  was  formerly  believed  to  be  due  to  psorosperms, 
but  this  view  has  been  abandoned. 

Treatment. — Frequent  baths  and  inunctions  with  sapo 
mollis  may  be  employed,  followed  by  the  use  of  a  salicylated 
dusting-powder. 

HYPERTRICHOSIS 

Derivation. — 'TVfp,  in  excess;  0p<f,  hair.     Synonyms. — Hirsuties;  Hairi- 
ness; Hypertrophy  of  the  hair ;  Superfluous  hair. 

Definition. — Hypertrichosis  is  a  condition  characterized 
by  excessive  hair-growth,  either  as  regards  number  or  coarse- 
ness. 

Symptoms. — Hair  may  grow  to  an  unnatural  degree  upon 
parts  normally  the  seat  of  hair,  as  the  mustache,  beard,  head, 
eyebrows,  inside  the  nose,  etc.,  or  there  may  be  an  abnormal 
growth  upon  non-hairy  regions,  or  rather  regions  normally 
covered  by  fine  lanugo  hair. 

Almost  the  entire  cutaneous  surface,  with  the  exception  of 
the  palms  and  soles,  the  last  phalanges  of  the  fingers  and  toes, 
the  glans  penis  and  prepuce,  are  normally  supplied  with  whitish, 


244  *  DISEASES  OP  THE   SKIN 

downy  hair.  Under  certain  circumstances  these  become  hyper- 
trophied  and  pigmented,  increasing  both  in  length  and  in 
diameter. 

Hirsuties  may  be  congenital  or  acquired.  Usually  the  con- 
genital hypertrichosis  is  partial,  being  limited  to  some  special 
region,  as  over  the  sacrum.  In  rare  instances  remarkable  cases 
of  general  hypertrichosis  are  encountered.  A  Russian  named 
Andrian  Jeftichew  and  his  son  Feodor  were  so  covered  as  to 
give  to  their  face  the  appearance  of  a  terrier  dog  (dog-faced 
man). 

The  acquired  variety  of  hypertrichosis  in  girls  and  women 
is  the  form  which  physicians  are  called  upon  to  treat.  The 
excessive  hair-growth  may  involve  the  trunk  and  extremities, 
as  well  as  the  face,  but  ordinarily  the  face  is  chiefly  or  exclusively 
affected.  The  upper  lip,  chin,  cheeks,  and  neck  are  the  usual 
seats  of  the  growth. 

The  amount  of  pilary  development  may  be  but  a  slight  exag- 
geration of  the  normal  down,  or  it  may  be  so  pronounced  as  to 
resemble  masculine  hirsutic  vigor.  The  growth  is  more  visible 
in  brunettes  than  in  blondes.  It  is  common  for  the  hair  of  the 
lip  and  chin  to  take  on  increased  development  as  the  period  of 
the  menopause  is  reached.  Not  infrequently,  however,  we 
see  girls  of  twenty  with  an  undesirable  growth.  The  extent 
of  the  growth,  and  the  amount  of  disfigurement  occasioned 
thereby,  is  often  exaggerated  by  the  patient,  who  becomes 
hypersensitive  and  secludes  herself  to  avoid  attracting  attention. 
In  such  cases  treatment  has  for  its  object  more  than  the  mere 
cosmetic  result,  for  the  mental  condition  and  happiness  of  the 
patient  are  at  stake.  These  patients  commonly  resort  to  the 
use  of  depilatories,  pumice-stone,  or  extracting  with  tweezers, 
all  of  which  procedures  increase  the  intensity  of  the  growth. 

Circumscribed  congenital  hypertrichosis  occurring  upon  a 
pigmented  or  elevated  base  constitutes  a  hairy  nevus  (naevus 
pilosus). 

Etiology. — The  cause  of  hirsuties  is  obscure.  Heredity  is 
an  important  factor  in  many  cases.  Hair-growth  is  a  secondary 
sexual  characteristic;  pilary  activity  accompanies  puberty;  at 
such  times,  and  again  at  the  menopause,  perverted  or  excessive 
innervation  may  cause  superfluous  hair-growth.  Cases  are 
recorded  in  which  menstrual  disorders,  uterine  disease,  preg- 
nancy, etc.,  have  led  to  transient  or  permanent  hypertrichosis. 


HYPERTRICHOSIS  245 

Congenital  hirsuties  may  be  associated  with  structural  defects 
or  anomalies  of  other  organs,  such  as  the  teeth.  The  persistent 
use  of  stimulating  liniments,  of  poultices,  counterirritants,  etc., 
may  lead  to  local  hypertrichosis.  There  is,  however,  little  or 
no  basis  in  fact  for  the  belief  held  by  many  patients  that  the 
use  of  mild  unguents,  such  as  cold-cream  or  petrolatum,  causes 
superfluous  hair-growth. 

Treatment. — The  cases  in  which  treatment  is  usuallv 
demanded  are  women  with  superfluous  facial  hair-growth. 
Superfluous  hair  may  be  temporarily  removed  by  shaving, 
extraction,  or  the  use  of  depilatories,  but  these  procedures  are 
to  be  condemned  for  facial  hirsuties.  The  barium  sulphid 
depilatory,  the  formula  of  which  is  given  by  Duhring,  is  one 
of  the  best : 

R .    Barii  sulphid ^ij ; 

Pulv.  zinci  oxidi  1  . .      ...  __M 

Pulv.  amyli  /    aa  5"J'     M* 

This  is  made  into  a  paste  with  a  little  water  and  spread  on 
the  hairy  region  for  ten  to  fifteen  minutes.  As  soon  as  burning 
is  experienced,  it  should  be  removed  and  followed  by  a  bland 
ointment.  Such  applications  must  be  repeated  every  few  days 
according  to  the  needs  of  the  case. 

The  only  permanent  treatment  of  hirsuties  is  the  use  of 
the  x-rays  or  electrolysis.  The  latter  consists  in  the  insertion 
of  a  fine  needle  into  each  hair-follicle,  and  then  turning  on  an 
electric  current,  to  destroy  the  hair-papilla.  The  operation  is 
somewhat  painful,  but  nearly  always  within  the  limit  of  tolera- 
tion. 

Stiff  hairs  alone  are  to  be  extirpated.  The  removal  of  downy 
or  lanugo  hairs  is  not  to  be  attempted,  as  the  result  is  likely 
to  be  unsatisfactory.  The  operation  is  performed  in  the  follow- 
ing manner:  A  fine  needle  (iridoplatinum  needle  or  a  fine 
jeweler's  broach),  held  firmly  in  a  specially  devised  holder,  is 
attached  to  the  negative  pole  of  a  galvanic  battery.  The  needle 
is  gently  inserted  into  the  hair-follicle  down  to  the  papilla. 
The  patient  holds  a  moistened  sponge  electrode  (positive  pole) 
and  makes  the  current  by  bringing  it  in  contact  with  the  palm 
of  the  other  hand.  In  five  to  ten  seconds  a  frothing  occurs  at 
the  mouth  of  the  follicle.  The  current  is  then  broken  bv  the 
release  of  the  positive  electrode,  and  the  needle  is  withdrawn. 


246  DISEASES  OF   THE   SKIN 

If  the  papilla  has  been  destroyed,  the  hair  will  come  out  upon 
the  slightest  traction  with  a  forceps.  If  it  remains  firm,  the 
operation  must  be  repeated.  A  current  from  one  to  two  mil- 
liamp&res  is  usually  required. 

A  wheal-like  elevation  soon  develops  at  the  site  of  the  opera- 
tion, but  disappears  in  the  course  of  a  few  hours.  Occasion- 
ally pustulation  occurs. 

To  avoid  scarring,  attention  should  be  paid  to  the  following 
points:  (1)  The  use  of  a  fine  needle;  (2)  the  avoidance  of  too 
prolonged  cauterization;  (3)  the  avoidance  of  too  strong  a 
current;  (4)  care  not  to  operate  at  the  same  sitting  upon  hairs 
in  too  close  proximity :  nevertheless,  it  lessens  pain  to  restrict 
one's  operations  to  a  limited  region  rather  than  to  remove  hairs 
here  and  there,  for  a  certain  degree  of  anesthesia  is  produced. 

Hot  water,  calamin  lotion,  or  a  1  :  1000  solution  of  corrosive 
sublimate  sopped  on  after  the  operation  lessens  the  inflammation 
and  the  tendency  to  suppuration  and  scarring. 

The  Depilatory  Effect  of  the  x-Rays. — There  is  no  question 
that  the  x-rays  are  capable  of  producing  a  permanent  falling 
of  hair.  The  depilation  resulting  from  a  few  exposures  is  nearly 
always  temporary.  I  believe  that  the  #-rays  should  be  used  on 
facial  hypertrichosis  only  in  very  severe  and  disfiguring  cases  in 
which  the  extent  of  the  growth  makes  electrolysis  a  hopeless 
task.  The  fact  that  the  hair-papillae  may  be  atrophied  by  the 
rays  in  itself  indicates  that  other  structures  of  the  skin  may 
undergo  similar  change.  The  Rontgen  treatment  requires  a 
fine  adjustment  of  the  dosage  to  produce  the  best  results.  No 
greater  reaction  than  an  erythema  should  ever  be  produced. 
The  technic  of  Freund  is,  I  believe,  to  be  preferred.  Freund 
uses  a  high  tube  and  secures  depilation  in  about  twenty  treat- 
ments; brief  supplementary  courses  are  given  every  six  weeks 
for  a  year  and  a  half,  to  render  the  depilation  permanent. 

The  Rontgen  treatment  is  more  expeditious,  less  painful, 
and  less  tedious  to  the  patient  and  operator  than  electrolysis. 
It  must,  however,  be  employed  with  great  skill  and  caution,  and 
the  patient  should  be  apprised  in  advance  that  some  thinning  or 
wrinkling  of  the  skin  may  be  produced. 


ELEPHANTIASIS 


ELEPHANTIASIS 


s  arabum ; 

Definition. — Elephantiasis  is  a  chronic  hypertrophic  dis- 
ease of  the  skin  and  subcutaneous  tissue,  due  to  obstruction 
of  the  lymphatic  channels,  and  resulting  in  enormous  enlarge- 
ment and  thickening  of  the  part,  with  papillary  outgrowth. 

Symptoms. — The  most  frequent  seats  of  elephantiasis  are 
the  lower  extremities,  although  the  penis,  scrotum,  and  clitoris 
may  be  affected,  and,  more  rarely,  the  arms,  lips,  tongue,  or  ears. 


There  are  two  forms  of  the  disease — the  one  endemic,  para- 
sitic in  origin,  and  indigenous  to  the  tropics;  the  other,  sporadic, 
due  to  inflammatory  obstruction  of  lymphatic  or  blood-vessels, 
and  observed  in  various  countries.  The  tropical  form  is  rare 
in  the  United  States ;  we  will,  therefore,  restrict  our  description 
to  the  ordinary  variety. 

The  affection  usually  begins  as  an  crysipclatoid  inflammation, 
accompanied  by  fever,  redness,  swelling,  I  i  pain.     The 

condition  may  represent  t 


248  DISEASES  OP  THE   SKIN 

phlebitis.  After  some  days  the  inflammatory  phenomena  sub- 
side, but  the  affected  part  is  observed  to  be  larger  than  before. 
Similar  attacks  may  recur  from  time  to  time,  at  intervals  of 
weeks  or  months,  the  affected  part  increasing  in  size  after  each 
attack.  Finally  a  state  of  chronic  hypertrophy  is  reached,  the 
skin  and  subcutaneous  tissue  are  enormously  thickened,  and  the 
member  greatly  increased  in  size. 

The  skin  is  glossy  and  tense,  and  the  deeper  structures  resist- 
ant and  dense;  digital  pressure  produces  but  slight  inden- 
tation or  none  at  all.  The  surface  may  be  pigmented,  and 
exhibit  warty  excrescences  or  thickly  studded  papillomatous 
vegetations.  These  consist  often  of  lymphatic  varicosities, 
the  elevations  occasionally  discharging  a  chylous  or  milky  fluid. 
Between  the  papillary  outgrowths  fissures  of  varying  depths 
are  observed. 

Maceration  of  the  epidermis  and  the  collection  of  decom- 
posing sweat,  sebum,  and  effete  products  give  rise  to  an  offen- 
sive odor.  There  is,  as  a  rule,  no  pain,  although  during  the 
acute  exacerbations  it  may  be  severe.  The  enormous  weight 
of  the  hypertrophied  part  may  make  locomotion  difficult  or 
even  impossible.     The  course  of  the  affection  is  chronic. 

Etiology. — Elephantiasis  is  most  common  in  tropical  coun- 
tries, particularly  Africa,  India,  China,  Japan,  West  Indies,  etc., 
where  it  occurs  chiefly  in  those  subject  to  bad  hygiene  and  poor 
food.  Damp  malarial  districts  are  said  to  produce  the  largest 
number  of  cases.  This  is  explicable  upon  the  theory,  now  pro- 
posed, that  the  mosquito  is  the  intermediate  host  of  the  filaria. 
The  tropical  form  is  due  to  inflammation  and  obstruction  of  the 
lymphatic  vessels  by  the  Filaria  sanguinis  hominis.  The  para- 
sites are  found  in  the  blood  at  night. 

Sporadic  cases  may  be  due  to  inflammatory  obstruction  of 
lymphatic  and  perhaps  other  vessels,  as  a  result  of  repeated 
erysipelas,  cellulitis,  infection  from  ulcers,  syphilis,  pressure 
of  scars  or  tumors,  etc. 

Pathology. — There  is  a  hyperplasia,  participated  in  by  the 
subcutaneous  tissue  and  all  the  layers  of  the  skin.  The  chief 
change  is  in  the  subcutaneous  tissue,  which  is  enormously  hyper- 
trophied and  traversed  by  irregular  bundles  of  connective 
tissue.  Where  the  surface  of  the  skin  is  warty,  the  papillae  are 
greatly  elongated.  Both  blood-vessels  and  lymphatics  are 
enormously  distended,  the  latter  leading  to  dilated  lymph- 
spaces.     The  neighboring  lymphatic  glands  are  enlarged.     In 


DERMATOLYSIS  249 

advanced  cases  the  muscles  undergo  fatty  degeneration  and 
the  bones  become  enlarged. 

Diagnosis. — The  history  of  recurrent  erysipelatous  inflam- 
mation, with  slowly  progressing  hypertrophy,  is  peculiar  to 
elephantiasis.  In  advanced  cases  the  appearances  are  unmis- 
takable. 

Prognosis. — In  the  beginning  the  process  may  at  times  be 
arrested.  When  the  growth  is  far  advanced,  treatment  accom- 
plishes but  little. 

Treatment. — The  erysipelatous  attacks  are  to  be  treated 
by  rest,  hot  or  cold  applications,  and  the  internal  administra- 
tion of  salines  and  quinin. 

Good  food  and  hygiene,  tonics,  and  change  of  climate  are 
important  matters  in  endemic  cases.  Elastic  compression  by 
means  of  a  well-applied  rubber  bandage  is  the  most  efficient 
therapeutic  measure.  Green  soap  and  the  mercurial  ointments 
mav  be  rubbed  into  the  skin. 

In  advanced  elephantiasis  of  the  leg  one  may  resort  to  stretch- 
ing or  partial  exsection  of  the  sciatic  nerve,  to  digital  or  instru- 
mental compression,  or  even  to  ligation  of  the  femoral  artery. 

Elephantiasis  of  the  scrotum  is  best  treated  by  amputation. 

DERMATOLYSIS 

Synonyms. — Cutis  pendula;  Fibroma  pendulum;  Lax  skin;  "Elastic 
skin." 

Definition. — Dermatolysis  is  a  rare  disease,  characterized 
by  hypertrophy  and  laxity  of  the  skin  and  subcutaneous  tis- 
sue, with  a  tendency  to  hang  in  folds. 

Some  wTriters  apply  the  name  dermatolysis  to  an  abnormal 
laxity  and  elasticity  of  the  skin  with  hypertrophy,  as  seen  in 
the  so-called  "elastic-skin  men." 

Symptoms. — The  condition  may  be  congenital,  or  it  may 
follow  the  involution  of  fibromatous  lesions.  The  affected 
area  may  be  limited  or  extensive.  The  subcutaneous  tissue 
and  the  skin,  with  its. component  structures,  hair,  glands,  etc., 
are  all  hypertrophied.  In  marked  cases  the  skin,  which  is 
often  rugose  and  pigmented,  hangs  in  huge  folds  like  a  garment. 

There  are  no  subjective  symptoms  except  the  inconvenience 
occasioned  by  the  size  and  weight  of  the  growth. 

Etiology. — The  etiology  is  obscure.  The  condition  is  allied 
to  fibroma  mol 


25O  DISEASES  OF  THE   SKIN 

Pathology. — There  is  hypertrophy  of  all  the  structures  of 
the  skin  and  subcutaneous  tissue. 

In  the  so-called  "elastic  skin"  the  elastic  tissue  is  normal, 
but  the  connective-tissue  fibers  are  converted  into  a  myxo- 
matous-looking  tissue. 

Treatment. — The  mass  is  to  be  excised  when  its  location 
and  extent  permit.     There  is  no  tendency  to  recurrence. 

ONYCHAUXIS 

Derivation. — "Onf,  a  nail;  art-hiv,  to  grow.  Synonym. — Hypertrophy 
of  the  nail. 

Definition. — Onychauxis  is  an  affection  characterized  by 
an  increase  in  the  size  of  the  nail,  in  length,  in  breadth,  or  in 
thickness. 

Symptoms. — Hypertrophy  of  the  nail  may  be  congenital  or 
acquired,  idiopathic  or  symptomatic,  as  in  ichthyosis  or  syphilis. 
The  nail  may  be  merely  enlarged,  the  quality  and  texture  remain- 
ing normal,  or  there  may  be  coincident  structural  changes. 
Thus,  the  nail  may  become  roughened,  furrowed,  and  opaque, 
and  have  a  yellowish-brownish  or  blackish  hue. 

Lateral  growth  may  result  in  inflammation  of  the  surrounding 
tissues  (paronychia),  or  the  matrix  itself  may  undergo  inflam- 
mation (onychia). 

Onychogry phosis  is  a  term  used  to  denote  nails  which  have 
become  curved  and  claw-like. 

Etiology. — In  acquired  cases  the  condition  is  usually  a 
manifestation  of  psoriasis,  ichthyosis,  leprosy,  syphilis,  eczema, 
etc.  The  condition  may  also  result  from  inflammatory  changes 
in  the  matrix. 

Treatment. — The  excessive  nail  tissue  should  be  removed 
with  a  knife  or  scissors.  Symptomatic  cases  should  be  treated 
in  connection  with  the  associated  disease. 

In  paronychia  the  imbedded  nail-edge  should  be  trimmed 
off  and  a  minute  pledget  of  cotton  packed  in  between  the  nail 
and  the  soft  parts. 

ACROMEGALY 

Derivation. — 'Axpof,  extremity;  prydArj,  great. 

Definition. — Acromegaly  is  a  nutritional  disease,  character- 
ized most  conspicuously  by  an  overgrowth  of  the  bones  and 
soft  tissues  of  the  face  and  extremities. 


ALBINISMUS  251 

Symptoms. — In  well-pronounced  cases  there  are  observed 
thickening  of  the  bones  of  the  hands  and  feet  and  enlargement 
of  the  facial  features.  The  lower  jaw  is  often  hypertrophied. 
The  fingers  are  clubbed,  and  the  ears,  lip,  and  tongue  often 
increased  in  size.  The  skin  may  exhibit  pigmentation,  hyper- 
trichosis, hyperidrosis,  or  sclerous  thickening. 

Etiology  and  Pathology. — Adult  males  are  the  most  fre- 
quent subjects.  The  nature  of  the  disease  is  not  clearly  under- 
stood. Pathologic  changes  in  the  pituitary  body  have  been 
described  which  are  believed  by  many  to  be  the  cause  of  the 
disease. 

Prognosis  and  Treatment. — The  disease  persists  for  an 
indefinite  period  and  is  not  influenced  by  treatment. 

CLASS  VL    ATROPHIAE— ATROPHIES 

ALBINISMUS 

Derivation. — L.,  albus,  white.  Synonyms. — Albinism;  Congenital  achro- 
mia. 

Definition. — Albinism  is  a  congenital  affection,  character- 
ized by  partial  or  complete  absence  of  pigment  in  the  skin, 
hair,  and  eyes. 

Symptoms. — In  complete  albinism  the  skin  is  preternaturally 
white,  or  at  times  rosy- tinted,  and  the  entire  hair  of  the  body 
is  fine,  silky,  and  of  a  whitish  or  yellowish  color.  The  irides 
have  a  pinkish  or  pale-bluish  hue,  and  the  pupils,  owing  to  the 
lack  of  pigment  in  the  choroid,  show  the  orange-red  color  of  the 
fundus.  Photophobia,  nystagmus,  and  nictitation  occur  as 
a  result  of  absence  of  the  protective  pigment  and  are  of  con- 
siderable annoyance  to  the  patient. 

Partial  albinism  occurs  chiefly  in  negroes,  where  it  manifests 
itself  as  variously  sized  and  shaped  depigmented,  milky  white 
patches.  The  hairs  upon  such  patches  are  also  white.  The 
term  "piebald"  is  commonly  applied  to  such  individuals. 
"Albinos"  not  infrequently  exhibit  physical  and  mental  inferi- 
ority. 

Etiology. — Unknown.  Heredity  seems  to  be  a  factor,  inas- 
much as  several  children  in  the  same  family  are  usually  affected. 

Pathology. — The  skin  is  normal,  with  the  exception  that 
there  is  absence  of  pigment  in  the  rete  mucosum. 

Treatment. — Treatment  is  entirely  without  avail. 


DISEASES  OP  THE   SKIN 


Definition. — Vitiligo  is  an  acquired  pigmentary  affection, 
characterized  by  variously  sized  and  sliaped  whitish  patches 
with  hyperpigmented  borders. 

Symptoms. — The  condition  manifests  itself  as  rounded, 
oval,  or  irregular  milk-white  or  pinkish-white  spots  which  tend 


Fig.  115.— Vitiligo 


slowly  or  rapidly  to  spread,  at  times  coalescing  and  producing 
large  patches.  These  are  smooth,  soft,  sharply  denned,  and 
neither  elevated  nor  depressed.  The  surrounding  skin  shows 
increased  pigmentation,  being  usually  brownish  yellow  in  color. 
The  hairs  upon  the  affected  areas  may  or  may  not  turn  white. 

Where  a  vkiliginous  patch  extends  into  the  hairy  scalp,  the 
hair  in  the  area  involved  is  prone  to  turn  white.  Exposure  to 
the  sun,  especially  in  the  summer  months,  leads  to  an  increased 


VITILIGO 


253 


pigmentation  around  the  patches,  and,  therefore,  increases  the 
disfigurement  occasioned. 

The  disease  progresses  slowly,  becoming  conspicuous  only 
after  a  duration  of  years.     In  rare  cases  the  affection  may 


Fig.  116.— Vitiligo  in 


involve  the  greater  part  or,  indeed,  the  whole  of  the  body. 
Vitiligo  lasts,  as  a  rule,  throughout  life. 

The  eruption  may  occur  upon  any  portion  of  the  cutaneous 
surface,  although  it  is  prone  to  elect  the  backs  of  the  hands, 
neck,  face,  and  the  trunk.     There  are  no  subjective  symptoms. 

Etiology. — Vitiligo  occurs  chiefly  in  adult  life;  it  is  more 
common  in  women  than  in  men.  Its  intimate  cause  is  unknown, 
although  it  is  believed  to  be  due  to  involvement  of  nerve  struc- 


254 


DISEASES  OF  THE   SKIN 


ture.  Vitiligo  has  developed  after  injury  to  nerves.  It  is 
occasionally  associated  with  alopecia  areata,  scleroderma,  and 
hyperthyroidism.  I  have  observed  it  several  times  in  associa- 
tion with  Graves'  disease,  and  in  two  patients  who  presented 
merely  a  tachycardia.  In  one  patient  the  vitiligo  developed 
coinci  dentally  with  the  onset  of  a  well -pronounced  exophthalmic 
goiter. 

Pathology. — The  skin  is  normal,  with  the  exception  of  an 
unequal  distribution  of  coloring1  matter.     In  the  white  spots 


Fig.  117. — Vitiligo  upon  the  haniis  in  a  younp  white  woman, 

there  is  a  total  absence  of  pigment,  whereas  in  the  darkened 
borders  the  pigment  is  abnormally  increased. 

Diagnosis.-  -Vitiligo  is  to  be  distinguished  from  chloasma, 
tinea  versicolor,  morphea,  and  leprosy: 


Vitiligo.  Chloasma. 

Patches     are  Patches    are 

sm  o  o  1  h  brownish- 

and    white  yellow;   no 

with  by-  white 

p  e  r  p  i  g  -  spots. 
men  ted 


Morphea.  Lgprosv. 
Thickening  Patches  may 
iU  first,  be  whitish 
followed  or  yellow- 
by  a  tro-  isli.biil  are 
phy.  anesthetic. 


ATROPHIA  CUTIS  255 

Prognosis. — In  rare  cases  spontaneous  recovery  has  been 
observed,  but  the  affection  may  be  said  to  be  practically  incur- 
able. 

Treatment. — From  what  has  been  said,  it  is  evident  that 
the  treatment  is  highly  unsatisfactory.  Duhring  advises  the 
long-continued  administration  of  small  doses  of  arsenic. 
Locally,  lotions  of  corrosive  sublimate  or  acetic  acid,  as  recom- 
mended for  chloasma,  may  be  applied  to  the  pigmented  borders 
with  a  view  to  dissipating  the  color  and  lessening  the  contrast. 

Recently  thyroid  extract  has  been  advised  and  a  cure  has 

been  reported. 

ATROPHIA  CUTIS 

Derivation. — «,  privitive;  rpo^,  nutrition.  Synonyms. — Atrophy  of 
the  skin;  Atrophoderma. 

Definition. — Atrophy  of  the  skin  is  a  condition  characterized 
either  by  diminution  in  .the  bulk  of  the  skin  or  degeneration  of 
its  component  structures. 

Symptoms. — Under  the  general  heading  of  cutaneous  atrophy 
several  varieties  are  to  be  considered. 

ATROPHIA   SENILIS   (SENILE   ATROPHY) 

This  term  is  applied  to  the  degenerative  cutaneous  changes 
that  occur  in  old  age.  The  skin  becomes  thinned,  wrinkled, 
and  furrowed,  and  can  be  readily  raised  from  the  subjacent 
structures  by  reason  of  the  absorption  of  the  subcutaneous 
cushion  of  fat.  Pigmentation  of  a  yellowish  or  brownish  color 
is  often  present.  Not  infrequently  a  dry  branny  scaling  is 
observed.  The  hair  in  atrophic  regions  may  be  lost  or  become 
thinner  and  finer.  Fatty  and  amyloid  degenerative  changes 
may  take  place  in  the  glands  of  the  skin  or  in  the  component 
fibers.  Unna  and  others  have  described  a  change  of  elastic 
fibers  into  elacin  and  the  collagenous  fibers  into  collastin  and 
collacin. 

ATROPHODERMA   NEURITICUM   (GLOSSY   SKIN) 

Glossy  skin  is  a  rare  atrophic  affection  occurring  usually 
upon  the  fingers,  and  characterized  by  a  smooth,  tense,  pinkish, 
shining  appearance,  with  loss  of  hair  and  incurvation  of  the 
nails.  It  is  accompanied  and  preceded  by  considerable  burning 
pain,  and  is  usually  due  to  injury  or  disease  of  a  nerve.  The 
treatment  consists  of  protection  from  cold  and  traumatism 
the  condition  tending  itself  to  spontaneous  recovery. 


256  DISEASES  OF  THE  SKIN 

GENERAL   OR   DIFFUSE   IDIOPATHIC   ATROPHY 

This  is  an  extremely  rare  disease,  involving  large  areas  of 
cutaneous  surface,  such  as  an  entire  limb.  The  skin  is  thinned, 
dry,  wrinkled,  often  scaly,  and  exhibits  a  marbling  of  purplish 
or  reddish-brown  spots  or  streaks,  often  terminating  in  pigmen- 
tation. The  disease  is  slowly  progressive.  It  may  be  congenital 
or  acquired,  partial  or  general. 

In  rare  cases  an  atrophy  of  the  skin  of  one-half  of  the  face 
has  been  observed.  This  condition  has  received  the  designa- 
tion hemi-atrophia  facialis  progressiva. 

STRIAE  ET  MACULAE  ATROPHICAE  (ATROPHIC  LINES  AND  SPOTS) 

This  form  of  atrophy  may  be  idiopathic  or  symptomatic. 
In  the  idiopathic  variety  there  develop,  without  known  cause, 
erythematous  spots  and  lines,  which  after  a  variable  duration 
terminate  in  atrophy.  When  fully  developed,  the  atrophic 
areas  are  from  one  to  two  inches  in  length,  and  are  glistening, 
depressed,  perceptibly  thinned,  and  of  a  whitish  or  bluish-gray 
color.  They  are  usually  seen  about  the  buttocks,  trochanters, 
pelvis,  and  thighs.  The  symptomatic  variety  is  exemplified 
in  the  so-called  linece  albicantes  of  pregnancy.  The  fibers  of 
connective  tissue  are  separated  and  the  papillae  effaced. 

ACRODERMATITIS    CHRONICA   ATROPHICANS 

This  is  a  title  given  by  Herxheimer  and  Hartman  to  an 
inflammatory,  nodular,  chilblain-like  condition  of  the  hands 
and  arms  terminating  in  atrophy.  The  affection  runs  a  chronic 
course  and  is  refractory  to  treatment. 

XERODERMA    PIGMENTOSUM 

Derivation. — Htfpof,  dry;  Mppa,  skin.     Synonyms. — Atrophoderma  pig- 
mentosum; Angioma  pigmentosum  et  atrophicum;  Kaposi's  disease. 

Definition. — Xeroderma  pigmentosum  is  a  rare  congenital 
disease,  characterized  successively  by  pigmentation,  telangiecta- 
sis, cutaneous  atrophy,  and  malignant  papillary  tumors,  ending 
fatally. 

This  rare  disease  was  described  by  Kaposi  in  1870. 

Symptoms. — The  disease  appears  upon  the  face,  neck, 
shoulders,  and  breast  down  to  the  third  rib,  upon  the  arms  and 
dorsa  of  hands,  and  at  times  upon  the  lower  extremities.     The 


XERODERMA    PIGMENTOSUM 


257 


earliest  lesions  consist  of  freckle-like  yellow-brownish  spots 
between  which  the  skin  may  appear  normal  or  show  glazed, 
scar-like  depressions.  Punctate  and  linear  telangiectatic  dila- 
tation of  the  cutaneous  blood- vessels  is  likewise  observed.  The 
epidermis  becomes  thin,  and  in  places  smooth,  whereas  in 
other  areas  there  are  lamella?  and  a  parchment -like  wrinkling. 
Later  the  skin  may  appear  shrunken  and  bound  down  firmly 
upon  the  subadjacent  structures.  In  more  advanced  cases 
eczema*  fissures,  ulcers,  narrowing  of  the  mouth  and  nostrils. 


Fig.  118.— Xerodi 


[gmentosum.     Intense  photophobia 
dren  in  family  similarly  affected. 


Two  other  chil 


and  ectropion  are  prone  to  develop.  Warty  or  other  growths 
finally  appear,  which  take  on  carcinomatous,  angiomatous,  or 
sarcomatous  change.  The  neoplasmata  occur  chiefly  upon  the 
face.     The  disease  terminates  fatally  in  nearly  all  cases. 

Etiology. — A  congenital  predisposition  of  the  tissues  is  the 
only  known  cause.  It  is  common  for  several  children  in  the 
same  family  to  be  attacked.  Cases  are  on  record  in  which  two, 
three,  four,  and  even  seven  children  of  a  family  have  suffered 
from  the  disease.     Usually  the  disease  is  not  present  in  the 


258  DISEASES   OP   THE   SKIN 

parents  of  such  children.  The  disease  usually  begins  in  the 
first  or  second  year  of  life.  The  unfortunate  victims  of  this 
disease  exhibit  a  hypersensibility  to  the  action  of  the  solar  rays. 

Most  writers  regard  the  irritating  influence  of  light  as  a  factor, 
but  Kaposi  did  not  accept  this  view. 

Prognosis. — Nearly  all  cases  terminate  fatally;  at  times 
cancer  of  internal  organs  develops. 

Treatment. — Local  applications  may  be  employed  to  amelio- 
rate the  dry  and  uncomfortable  condition  of  the  skin.  A 
deep-colored  calamine  lotion  may  be  used  to  obstruct  the  pass- 
age of  the  chemic  rays  of  light.  #-Ray  treatment  would  suggest 
itself  when  early  malignant  change  manifests  itself.  \\£hen 
advisable,  the  growths  may  be  removed  surgically. 

SCLEREMA  NEONATORUM 

Derivation. — lK?^nn^l  hard;  vtov,  lately.  Synonyms. — Scleroderma  neo- 
natorum; Sclerema  of  the  newborn. 

Definition. — Sclerema  neonatorum  is  a  disease  occurring  at 
or  shortly  after  birth,  characterized  by  induration  of  the  skin 
and  subcutaneous  tissue  and  local  and  general  circulatory  dis- 
turbance. 

This  disease  was  first  described  by  Underwood  in  1784,  but 
was  by  other  authors  subsequently  confounded  with  oedema 
neonatorum. 

Symptoms. — The  disease  begins  usually  upon  the  legs,  thence 
traveling  upward  to  the  back,  chest,  and  rest  of  the  body;  less 
commonly  it  commences  upon  the  face  and  spreads  downward. 
The  skin  is  of  a  yellowish-white  or  waxy  tint,  later  becoming 
livid.  It  is  hard,  tense,  and  cold,  and  does  not  pit  upon  pres- 
sure. The  rigidity,  which  resembles  "rigor  mortis,"  renders 
motion  of  the  joints  almost  impossible.  Respiration  is  feeble, 
the  pulse  weak,  and  the  temperature  subnormal.  The  infant 
is  unable  to  take  nourishment,  and  death  results  in  a  few  days 
or  weeks.  In  very  rare  instances  recovery  may  spontaneously 
take  place. 

The  disease  may  be  present  at  birth,  or  come  on  secondarily 
within  ten  days. 

Etiology  and  Pathology. — Obscure.  Occurs  chiefly  in 
prematurely  born  children  or  in  those  suffering  from  malnutri- 
tion. The  immediate  cause  appears  to  be  faulty  circulation 
from  pneumonia,  feeble  vitality,  etc.,  or  from  congenital  struc- 


(EDEMA   NEONATORUM  259 

tural  abnormalities.  Langer  believes  sclerema  to  be  due  to  a 
solidification  of  subcutaneous  fat;  Parrott  ascribes  it  to  desic- 
cation of  the  tissues  resulting  from  diarrheal  depletion. 
Ballantyne  notes  the  presence  of  a  perivascular  cell-infiltration. 
He  believes  the  disease  to  be  due  to  overgrowth  of  connective- 
tissue  and  atrophy  of  the  fat-cells.  He  regards  the  disease  as 
a  trophoneurosis. 

Treatment. — The  treatment  consists  of:  (i)  Keeping  up 
the  body  temperature  (by  means  of  an  incubator,  wrapping  in 
wool,  or  hot  baths);  (2)  maintaining  nutrition  (by  feeding 
through  a  tube,  etc.) ;  (3)  centripetal  friction  with  warm  oils. 

OEDEMA  NEONATORUM 

This  is  an  extremely  rare  disease,  and  has  been  confounded 
with  true  sclerema  neonatorum. 

Symptoms. — The  affection  is  encountered  usually  in  prema- 
turely born  infants  or  in  those  of  extremely  feeble  constitution. 
It  begins  at  birth  or  before  the  third  day  of  life.  Drowsiness 
is  one  of  the  first  symptoms,  soon  followed  by  edema,  coldness, 
and  lividity  of  the  dependent  portions  of  the  legs,  genitals,  but- 
tocks, and  hands.  Firm  digital  pressure  produces  pitting,  a 
point  of  distinction  between  edema  and  sclerema.  In  fatal 
cases  the  somnolence  increases,  the  pulse  becomes  feeble,  the 
respiration  shallow,  and  diarrhea  or  convulsions  may  set  in. 

Etiology  and  Pathology. — Premature  birth,  cardiac  weak- 
ness, pulmonary  atelectasis,  malnutrition,  etc.,  have  been 
suggested  as  causes. 

There  is  an  effusion  of  yellowish  serum  into  the  subcutaneous 

tissue. 

Diagnosis. — Congenital  edema  may  usually  be  distinguished 
from  sclerema  by  the  less  generalized  distribution,  by  the  pit- 
ting, lack  of  hardness  of  skin,  absence  of  hidebound  condition, 
and  presence  of  edema,  chiefly  in  dependent  areas. 

Prognosis. — Partial  cases  may  recover,  although  the  mor- 
tality is  about  90  per  cent. 

Treatment. — The  treatment  is  practically  that  of  sclerema 
neonatorum. 


2<5o  DISEASES  OP  THE  SKIN 


SCLERODERMA 

Derivation. — 1k?^p6c,  hard;  6ipfiat  the  skin.  Sjfwmyww. — Hidebound 
disease;  Sclerema  adultorum;  Scleriasis;  Dermatosclerosis. 

Definition. — Scleroderma  is  a  disease  characterized  by  cir- 
cumscribed or  diffuse  induration,  rigidity,  and  stiffening  of  the 
integument,  terminating  in  atrophy. 

Symptoms. — The  disease  is  rare.  The  skin  manifestations 
may  be  preceded  or  accompanied  by  disturbance  of  cutaneous 
sensibility,  such  as  shooting  pain,  prickling,  tingling,  itching, 
formication,  etc.,  and  by  muscular  cramps.  The  disease  begins 
with  the  sensation  of  stiffening  or  hardening  of  the  skin.  To 
the  feel  it  is  tense  and  bound  down  to  the  subjacent  structures, 
so  that  great  difficulty  is  experienced  in  pinching  it  up.  The 
stiffening  or  hardness  progresses  gradually,  or  more  rarely 
rapidly,  until  marked  induration  of  the  integument  results. 
In  some  cases  an  edematous  stage  may  precede  the  induration. 
When  the  disease  is  typically  developed,  the  skin  is  thickened, 
tense,  hard,  and  immovable,  acquiring  in  an  advanced  stage 
the  feel  of  frozen  skin,  leather,  or  even  wood.  A  variable 
amount  of  pigmentation  is  present.  Usually  the  skin  acquires 
a  brownish  tint,  particularly  on  the  arms;  in  other  cases  it  is 
yellowish- white,  suggesting  the  color  of  ivory. 

The  parts  most  affected  in  the  order  of  their  frequency  are 
the  upper  extremities,  trunk,  face,  head,  and  the  lower  extremi- 
ties. The  face  has  an  immobile  expression,  and  in  pronounced 
cases  exhibits  a  contraction  of  the  skin  over  the  nose  and  mouth, 
limiting  the  opening  of  the  latter. 

The  patient  is  often  partially  invalided  by  restriction  of 
motion  in  the  affected  members. 

The  joints,  particularly  of  the  fingers,  are,  through  the  density 
and  contraction  of  the  skin,  kept  in  a  condition  of  ankylosis 
with  semiflexion.  The  skin,  tightly  drawn  over  bony  points, 
often  undergoes  ulceration.  When  the  hands  are  markedly 
involved,  the  condition  is  called  sclerodactylia. 

The  disease  is  chronic,  although  in  rare  cases  it  may  run  an 
acute  course.  Periods  of  alternating  improvement  and  aggrava- 
tion are  not  uncommon.  The  general  health  is,  as  a  rule,  not 
seriously  compromised.  Patients  may  die  in  the  course  of  a 
few  months,  but,  on  the  other  hand,  commonly  live  for  twenty 
or  more  years. 


SCLERODERMA 


261 


Etiology. — Scleroderma  occurs  chiefly  in  early  adult  life. 
Lewin  and  Heller,  who  compiled  and  studied  the  records  of  over 
500  cases,  found  the  three  decades  from  twenty  to  fifty  years  to 
be  most  frequent  periods  in  men,  and  the  decades  from  ten  to 
forty  years  in  women.  The  disease  may  occur  in  childhood, 
records  of  55  cases  having  been  published  in  children  under  fif- 
teen years  of  age.    The  disease  is  distinctly  more  common  in  the 


-Scleroderma  with  sclerodactylia. 


female  sex,  Lewin  and  Heller  having  found  the  rate  to  be  67  per 
cent.  Exposure  to  cold  and  wet,  rheumatism,  nerve-shocks, 
menstrual  disturbance,  traumatism,  etc.,  have  been  assigned 
as  causes. 

Pathology. — Lewin  and  Heller,  from  an  analysis  of  500 
cases,  contend  that  scleroderma  is  an  angiotrophoneurosis,  due 
to  disturbance  of  either  the  peripheral  nerves  or  the  central 
nervous  system.  The  chief  changes  in  the  skin  noted  in  sclero- 
derma are:  an  increase  and  condensation  of   the   connective 


262  DISEASES  OF  THE   SKIN 

tissue  in  the  corium  and  subcutaneous  tissue,  an  increase  in 
the  elastic  tissue,  and  a  diminution  in  the  caliber  of  the  blood- 
vessels.    Later  there  is  atrophy  of  the  subcutaneous  tissues. 

Diagnosis. — The  peculiar  immobile,  indurated,  tightly 
adherent  condition  of  the  skin  is  highly  characteristic  of  the 
disease.  Morphea  is  looked  upon  by  most  writers  as  a  circum- 
scribed form  of  scleroderma. 

Prognosis. — The  prognosis  in  general  is  unfavorable.  The 
disease,  as  a  rule,  persists  throughout  life;  nevertheless,  some 
cases  are  cured  and  others  improved.  Lewin  and  Heller  report 
1 6  per  cent,  of  203  adult  cases,  and  31  per  cent,  of  55  children 
under  fifteen  years,  cured.  Improvement  occurred  in  almost 
a  third  of  the  cases. 

Treatment. — The  patient's  nutrition  should  be  carefully 
kept  up  by  proper  diet  and  hygiene.  Electricity  applied  to  the 
back  of  the  neck  and  spine,  massage,  and  hydrotherapy  are 
often  of  value.  Arsenic,  iron,  quinin,  and  other  tonics  are 
useful  in  some  cases.  Osier  advises  the  use  of  thyroid  extract. 
Some  pronounced  improvements  have  resulted  from  mercurial 
inunctions.     Antirheumatic  remedies  may  be  used  for  pain. 

MORPHEA 

Derivation. — Mop<}>f/t  a  blotch.  Synonyms. — Circumscribed  scleroderma; 
Keloid  of  Addison. 

Definition. — Morphea  is  a  disease  characterized  by  rounded, 
oval  or  linear,  well-defined  indurated  patches  of  a  whitish- 
yellow  surrounded  by  a  violaceous  zone.  Morphea  is  regarded 
as  a  circumscribed  scleroderma,  and  is  included  by  many 
writers  under  that  disease. 

Symptoms. — The  disease  is  characterized  by  one  or  several 
circumscribed  patches  of  a  round,  oval,  or  band-like  configur- 
ation. The  patches  may  be  elevated,  depressed,  or  upon  a 
level  with  the  surrounding  skin.  The  color  is  at  first  pinkish, 
but  later  becomes  dead  white,  ivory  tinted,  or  yellowish;  the 
skin  surrounding  is  of  a  violaceous  or  lilac  hue,  due  to  dilatation 
of  blood-vessels;  the  latter  are  often  visibly  enlarged,  and  may 
be  seen  coursing  through  the  skin  for  some  distance  beyond 
the  patch.  The  skin  of  the  affected  area  is  hard,  shiny,  indu- 
rated, and  bound  down;  later  a  variable  amount  of  atrophy  and 
thinning  of  the  skin  is  noted.     Often  the  patch  bears  a  strong 


MORPHEA  263 

resemblance  to  an  ordinary  large  scar.  In  rare  instances  ulcer- 
ation of  the  patch  may  take  place.  A  single  area  may  be 
involved,  or  there  may  be  several,  in  which  event  the  course 
of  the  distribution  of  a  nerve  is  apt  to  be  followed. 

The  patches  ordinarily  vary  in  size  from  a  coin  to  the  palm  of 
the  hand.  Elevated  linear  patches  may  extend  for  a  number 
of  inches  along  the  arm  or  leg.  The  disease  may  be  located 
upon  the  trunk,  particularly  in  the  region  of  the  breasts,  upon 
the  face,  or  on  the  extremities. 

Subjective  symptoms  are  slight  or  absent;  sometimes  itch, 


Fig.  ik>. — Morphea;  the  patch  is  paper  white  in  color  and  atrophic. 


ing,  pricking,  tingling,  or  pain  is  present.  The  disease  may 
persist  for  many  years,  or  the  patches  may  spontaneously  dis- 
appear. 

Etiology.— The  disease  is  more  frequent  in  women  than  in 
men.  The  cause  is  to  be  looked  for  in  a  lesion  of  nerve-structure. 
In  one  of  my  patients  a  patch  developed  on  the  arm  after  an 
injury  to  the  skin  causing  a  large  ecchymosis. 

Pathology. — Microscopically,  there  is  seen  an  exudation 
around  the  sweat-  and  sebaceous  glands  and  blood-vessels, 
lessening  the  caliber  of  the  latter.     An  atrophy  or  flattening  of 


264  DISEASES  OP  THE  SKIN 

the  papilla,  with  an  increase  and  condensation  of  the  connective- 
tissue,  takes  place,  later  resulting  in  atrophy. 

Diagnosis. — There  should  not  be  much  difficulty  in  dis- 
tinguishing the  patches  of  morphea  from  those  of  vitiligo  and 
nerve  leprosy.  The  patches  of  vitiligo  show  no  structural 
changes;  those  of  nerve  leprosy  are  anesthetic  and  lack  the 
violaceous  zone. 

Prognosis. — Guarded.  Patches  may  disappear  spontan- 
eously, but  are  more  likely  to  persist  indefinitely. 

Treatment. — The  treatment  is  practically  that  of  sclero- 
derma— namely,  tonics,  massage,  and  electricity. 

KRAUROSIS  VULVAE 

Briesky,  in  1895,  described  a  peculiar  atrophic  affection 
involving  the  external  genitalia  of  females.  The  disease  may 
occur  at  any  age,  and  in  both  virgins  and  married  women.  The 
labia  minora,  the  praeputium  clitoridis,  the  vestibule,  and  sur- 
rounding tissues  are  attacked.  The  affected  parts  undergo 
atrophic  change  and  become  shriveled  and  shrunken.  The 
smaller  labia  and  the  prepuce  of  the  clitoris  may  waste  to  such 
an  extent  as  practically  to  disappear.  The  surrounding  integu- 
ment is  often  dry,  glossy,  thickened,  and  of  a  grayish  or  whitish 
hue.  The  posterior  portion  of  the  vulva  is  sometimes  thickened, 
spanned,  and  inelastic,  a  condition  which  may  interfere  with 
coitus  and  childbirth.  The  cause  is  obscure.  Pruritus  has 
preceded  kraurosis  in  some  cases,  and  in  others  there  has  been 
an  actual  eczema  present.  Apart  from  pruritus,  the  only 
other  cause  suggested  is  vaginal  discharge.  In  a  case  recently 
under  my  observation  the  appearances  resembled  leukokeratosis 
of  the  mouth. 

The  affection  is  extremely  obstinate  to  treatment,  and  in 
severe  cases  excision  may  be  necessary.  Cauterization  with 
fuming  nitric  acid  produced  excellent  results  in  a  case  under  my 
care. 

CANITIES 

Derivation. — L.,  canus,  white.  Synonym:. — Grayness  of  the  hair; 
Whitening  of  the  hair. 

Definition. — Canities  is  an  atrophic  pigmentary  affection 
of  the  hair,  characterized  by  circumscribed  or  general  graying 
or  whitening. 


CANITIES  265 

Symptoms. — Canities  is  usually  acquired,  although  in  very 
rare  cases  it  may  be  congenital.  When  occurring  in  advanced 
years,  it  is  to  be  looked  upon  as  a  physiologic  change  accom- 
panying senility  (canities  senilis).  It  is  not  rare  to  observe 
graying  or  whitening  of  the  hair  in  comparatively  young  persons 
(canities  prematura). 

The  loss  of  pilary  pigment  may  be  general,  may  occur  in 
circumscribed  tufts,  or  white  hairs  may  be  interspersed  among 
those  normally  colored.  The  last-named  condition  is  common. 
The  temples  commonly  show  the  first  change,  the  vertex  being 
next  involved. 

The  loss  of  pigment  is  usually  permanent,  although  cases 
are  on  record  in  which  the  color  has  changed  with  the  seasons 
or  with  some  condition  of  health. 

The  graying  or  whitening  of  the  hair  usually  comes  on  gradu- 
ally in  the  course  of  some  years.  In  rare  cases  graying  has 
occurred  in  a  few  months  or  weeks,  and,  indeed,  there  are  authen- 
tic records  of  the  hair  "turning  white  in  a  single  night." 

Ringed  hair  represents  a  condition  in  which  there  are  alternate 
rings  or  bands  of  white  and  colored  hair.  The  affection  is  very 
rare. 

Etiology  and  Pathology. — Canities  is  more  common  in 
men  than  in  women.  Circumscribed  patches  may  accompany 
vitiligo.  Varying  grades  of  whitening  may  follow  fever,  espe- 
cially scarlet  and  typhoid  fever,  psychic  shocks,  intense,  fear  or 
anxiety,  neuralgias,  physical  exhaustion,  etc. 

The  graying  of  later  years  is  a  physiologic  process  due  to 
senile  innervation  of  the  papillae.  Sudden  blanching  of  the 
hair  is  believed  to  be  due  to  the  sudden  presence  of  air-bubbles 
in  the  shaft  of  the  hair,  obscuring  the  pigment. 

Treatment. — Internal  remedies  are  of  little  or  no  value. 
The  whitened  hair  may  be  dyed  with: 

R .    Argent,  nitrat gr.  xv ; 

Ammon.  carb gr.  xxij ; 

Ung.  adipis £j. — M. 

For  black  shade.     (Kaposi.) 

H .    Acidi  pyrogall gr.  xv; 

Ad.  cologn. f^ss; 

Aq.  rosae fSiss. — M. 

For  brown  shade.     (Kaposi.) 


266 


DISEASES  OP  THE   SKIN 


ALOPECIA 

Derivation. — 'AAawr^,  a  fox.     Synonyms. — Baldness;  Calvities. 

Definition. — Alopecia  is  a  physiologic  or  pathologic  deficiency 
or  loss  of  hair,  either  partial  or  complete.  The  forms  of  alo- 
pecia may  be  classified  as  follows: 


I.  Congenital  alopecia. 
II.  Senile  alopecia. 

(a)       Idio- 


III.  Pre- 
mature 

alo- 
pecia. 


pathic. 


1 


(6)  Sympto- 
matic. 


Hereditary 
predispo- 
sition. 

(i)  Local  dis- 
eases. 


(2)  General 
diseases. 


Seborrhea. 

Eczema  seborrhoicum. 

Psoriasis. 

Erysipelas. 

Lupus  erythematosus. 

Syphilodermata. 

Folliculitis. 

Tinea  tonsurans. 

Tinea  favosa,  etc. 


Acute. 


Chronic. 


Typhoid  fever. 
Variola. 
Scarlatina. 
Pregnancy,  etc. 
Syphilis. 
Leprosy. 
Myxedema. 
Neurasthenia. 
Chronic      intoxica- 
tions. 
Anemia. 
Diabetes. 
Cancer. 

Uric-acid  diathesis. 
Phthisis,  etc. 


Congenital  Alopecia. — This  commonly  manifests  itself 
either  as  a  scanty  growth,  a  development  only  in  certain  locali- 
ties, or  as  a  retarded  appearance  of  the  hair.  In  rare  cases 
there  may  be  complete  absence  of  the  hair,  due  to  arrested 
development  of  the  follicles.  In  such  cases  hereditary  pre- 
disposition is  usually  present,  and  there  is  apt  to  be,  in  addition, 
delayed  or  defective  dentition. 

Senile  Alopecia. — As  the  name  indicates,  this  form  of  bald- 
ness is  observed  in  the  aged.  With  the  atrophic  skin  changes 
that  accompany  senility  there  takes  place  a  gradual  thinning 
of  the  hair,  beginning  upon  the  vertex  of  the  scalp,  the  frontal 
and  the  temporal  regions,  and  slowly  leading  to  a  more  or  less 
complete  baldness  of  the  calvarium. 


ALOPECIA  267 

Premature  Alopecia. — This  form  of  alopecia  occurs  in  indi- 
viduals chiefly  between  the  ages  of  twenty  and  thirty-five.  It 
may  be  either  idiopathic  or  symptomatic. 

In  the  idiopathic  variety  the  scalp  presents  no  abnormal  con- 
dition. At  first  only  a  few  hairs  fall  out  from  time  to  time, 
being  replaced  by  a  shorter  or  finer  growth.  Later  these  fall 
and  are  followed  by  still  finer  hairs.  In  this  manner  the  entire 
hair  of  the  scalp  may  be  lost.  The  affection  occurs  in  both 
sexes,  although  much  less  frequently  in  women  than  in  men. 
Heredity  appears  to  be  a  strong  predisposing  factor. 

There  is  a  growing  opinion  that  this  type  of  baldness  is  excep- 
tional, and  that  most  cases  of  premature  alopecia  are  associated 
with  seborrhea  in  some  form.  Of  344  private  cases  of  prema- 
ture alopecia  studied  by  Elliot,  316  had  seborrhea.  Jackson 
found  75  per  cent,  of  300  cases  due  to  seborrhea. 

The  symptomatic  form  results  from  various  local  and  general 
diseases.  Rapid  falling  of  the  hair  (defluvium  capillorum) 
follows  acute  diseases,  such  as  typhoid  fever,  small-pox,  etc. 
Full  regeneration  of  the  hair  follows  the  restoration  to  health. 
Rapid  and  extensive  loss  of  hair  occurs  with  frequency  in  the 
early  stages  of  syphilis. 

Alopecia  Seborrhoica. — Considerable  difference  of  opinion 
exists  as  to  what  constitutes  the  seborrhoic  process;  the  com- 
prehension of  the  relation  of  seborrhea  to  baldness  is  thereby 
embarrassed.  Nearly  all  writers  are  agreed  that  dandruff  is  a 
fertile  caus?  of  loss  of  hair,  but  the  term  dandruff  has  not  the 
same  significance  for  all  observers.  Sabouraud  holds  that  dry 
pityriasis  of  the  scalp  is  not  a  depilating  affection  itself,  but 
that  it  is  frequently  associated  with  true  seborrhea.  Many 
clinicians  speak  of  an  alopecia  pityroides  in  which  there  is  either 
a  seborrhea,  with  fatty  crusts,  or  a  pityriasis,  with  abundant 
scaling.  Crocker  does  not  restrict  alopecia  seborrhoica  to  the 
oily  form;  in  it  there  is  either  "an  excessive  greasiness  of  the 
surface  from  oily  seborrhea,  or  fine,  glistening,  powdery  scales, 
or  greasy  scales  lying  closely  on  the  scalp  and  requiring  to  be 
scraped  off,  or  yellowish,  fatty  matter,  looking  like  pale  yellow 
wax." 

Etiology  and  Pathology. — Dandruff  is  generally  regarded 
as  the  most  potent  cause  of  baldness.  It  is  a  plausible  and 
attractive  theory  to  attribute  the  process  to  microbic  invasion. 
Sabouraud  has  brought  forth  strong  evidence  to  show  that  his 
microbacillus  is  intimately  associated  with,  if  not  the  cause  of, 


268  DISEASES  OP  THE    SKIN 

oily  seborrhea.  He  also  regards  this  organism  as  the  cause  of 
baldness.  The  microbacillus,  according  to  him,  enters  the 
mouth  of  the  hair-follicle,  multiplies,  and  forms  a  thin  microbic 
lamina  which  separates  the  hair-shaft  from  the  follicular  wall. 
Epithelial  irritation  causes  the  encysting  of  the  bacilli  in  a  plug 
or  cocoon.  Then  follow  increased  sebaceous  flow,  hypertrophy 
of  the  sebaceous  gland,  and  progressive  atrophy  of  the  hair- 
papillae.  Sabouraud  recognizes  causes  which  render  the  soil 
favorable,  such  as  city  life,  insufficient  exercise,  excessive  meat 
diet,  gout,  heredity,  etc. 

If  baldness  has  a  microbic  origin,  Sabouraud  is  certainly 
correct  in  regarding  the  above  causes — causes  which  are  oper- 
ative in  the  busy  life  of  great  cities — as  of  vast  importance. 
Baldness  is  rare  or  absent  among  savages,  and  is  much  less 
common  in  country  than  in  city  districts. 

Prognosis. — Alopecia  seborrhoica  progresses  gradually,  unless 
checked  by  treatment,  to  a  denudation  of  the  vertex,  leaving 
a  fringe  of  hair  in  the  temporal  and  occipital  regions.  Appro- 
priate treatment,  particularly  if  instituted  early,  will  sometimes 
check  the  hair-loss  and  lead  perhaps  to  some  regrowth.  If 
systemic  conditions  are  present  which  render  the  scalp  a  favor- 
able nidus,  the  outlook  is  more  unfavorable. 

Treatment. — The  treatment  must  be  directed  toward  the 
existing  seborrhoic  process.  The  measures  employed  relate 
both  to  general  and  local  treatment.  Out-door  life,  exposure 
of  the  scalp  to  sunlight,  a  restricted  meat  diet  (Sabouraud  says 
baldness  is  less  common  in  vegetarians),  the  avoidance  of  exces- 
sive intellectual  labors,  etc.,  are  to  be  recommended. 

Such  tonics  as  iron,  strychnin,  phosphorus,  arsenic,  and  cod- 
liver  oil  may  occasionally  be  prescribed  with  advantage. 

Local  treatment  is  of  great  importance,  particularly  when 
dandruff  is  present.  It  consists  of  the  proper  cleansing  of  the 
scalp  and  the  stimulation  of  the  sebaceous  glands  to  healthy 
action. 

The  tincture  of  green  soap  makes  an  admirable  shampoo 
for  the  removal  of  epithelial  and  sebaceous  debris.  This  may 
be  advantageously  followed  by  such  a  hair-wash  as — 

B .    Resorcin ^ij ; 

Acidi  acetici f.^J-ij '. 

Ol.  ricini f^ss-iss; 

Spirit,  vini  rect q.  s.  ad  f^vj; 

Ol.  bergamot f^j. — M. 


ALOPECIA  AREATA  269 

When  greater  stimulation  is  desired,  the  following  should 
be  used: 

B .    Hydrarg.  bichlorid gr.  xij ; 

Betanaphthol gr.  xxx; 

Ol.  ricini fzj ; 

Spirit,  vini  rect q.  s.  ad  f.^vj; 

Ol.  bergamot ntxxx. — M. 

Sig  . — Hair-wash . 

Ointments  are  often  of  greater  value  than  lotions: 

R .    Sulph.  praecip gr.  xxx-^ij ; 

Adipis 5i ; 

Ol.  bergamot "fjjxxx. — M. 

Sulphur  is  the  best  remedy.  The  ointment  should  be  rubbed 
in  thoroughly  at  night,  but  a  small  quantity  of  salve  being 
employed. 

Daily  digital  massage  of  the  scalp  is  distinctly  useful,  as  is 
also  the  vigorous  use  of  the  hair-brush  to  produce  hyperemia 
of  the  scalp. 

ALOPECIA  AREATA 

Derivation. — 'AP.w7r^,  a  fox.  Synonyms. — Alopecia  circumscripta; 
Area  Celsi. 

Definition. — Alopecia  areata  is  a  disease  of  the  hairy  system, 
characterized  by  the  more  or  less  sudden  occurrence  of  round  or 
oval  circumscribed  bald  patches,  in  rare  cases  coalescing  and 
producing  total  baldness. 

Symptoms. — The  disease  is  usually  limited  to  the  scalp.  The 
lesions  are  circumscribed  and  round,  and  vary  in  size  from  a  coin 
to  the  palm  of  the  hand.  The  skin  is  smooth,  soft,  of  a  dead- 
white  color,  and  totally  devoid  of  hair.  Occasionally  the 
patches  are  pinkish  as  a  result  of  slight  hyperemia.  The  fol- 
licular openings  are  contracted  and  less  prominent  than  in  the 
healthy  scalp.  To  the  feel  the  skin  is  thin,  soft,  and  pliable. 
In  the  beginning  the  patches  are  level  or  slightly  elevated, 
while  later  they  are  sometimes  slightly  depressed. 

The  course  of  the  disease  is  extremely  variable.  In  some 
cases  the  bald  patches  develop  suddenly  in  the  course  of  a  few 
hours.  In  other  cases  the  hair-loss  is  gradual,  extending  over 
a  period  of  a  few  days  or  weeks.  The  areas  then  spread  by 
peripheral  extension  until  they  reach  a  certain  size,  when  they 
remain  stationary. 


270 


DISEASES   OP  THE   SKIN 


The  duration  of  the  disease  varies  greatly.  Recovery  seldom 
occurs  in  less  than  a  few  months,  while  many  cases  last  several 
years.  The  disease  may  occur  at  any  period  of  life.  In  young 
individuals  the  hair  usually  returns  sooner  or  later.  In  adults 
the  baldness  may  persist  and  prove  refractory  to  all  treatment. 
When  regrowth  occurs,  the  patch  is  first  covered  by  fine, 
downy,  whitish  hairs,  which  are  either  shed  or  later  converted 
into  coarse  and  pigmented  hairs.  Not  infrequently  the  hair 
grows  in  and  the  patient  thinks  he  is  on  the  road  to  recovery, 
only  to  have  his  hopes 
shattered  by  the  hair 
falling  out  again.  As  a 
rule,  there  are  no  sub- 
jective symptoms. 

Etiology. — There  are 
two  distinct  theories  of 
the  causation  of  alopecia 
areata.  One  school, 
headed  by  the  French, 
insists  that  the  disease  is 
parasitic,  and  cites  occur- 
rence of  epidemics  in  in- 
stitutions as  proof  of  this 
view.  Epidemics  have 
been  observed  chiefly  in 
France  and  Germany ; 
Bowen  and  Putnam  de- 
scribe an  outbreak  in  an 
institution  in  this  coun- 
try. 

On  the  other  hand, 
there  is  irrefutable  clini- 
cal evidence  of  the  neuropathic  origin  of  cases  of  alopecia  areata. 
Nervous  shocks,  such  as  fright,  prolonged  anxiety,  etc.,  and 
traumatism  to  the  scalp  have  been  directly  followed  by  areate 
loss  of  hair.  I  recently  saw  a  boy  admitted  to  the  Polyclinic 
Hospital  for  fracture  of  the  skull  who  developed  alopecia  areata 
before  leaving  the  institution.  Max  Joseph  has  produced  this 
disease  in  cats  by  excision  of  the  second  cervical  ganglion. 

It  would,  therefore,  appear  that  there  are  two  varieties  of 
alopecia  areata — the  one  trophoneurotic  and  the  other  parasitic. 
In  the  epidemic  observed  by  Bowen  and  Putnam  the  patches 
were  small  and  not  identical  with  those  commonly  observed  in 


ALOPECIA  AREATA  271 

alopecia  areata.     Some  of  the  English  dermatologists  are  of  the 


opinion  that  alopecia  areata  is  prone  to  occur  in  those  who  have 
at  some  previous  period  suffered  from  ring-worm  of  the  scalp. 


.  272  DISEASES  OP  THE   SKIN 

Sabouraud  regards  his  nucrobacillus  as  the  probable  cause  of 
alopecia  areata. 

Pathology. — Both  Giovanni  and  Robinson  found  evidence 
of  inflammatory  disturbance  chiefly  in  the  subpapillary  layer. 
Perivascular  cell-infiltration  was  observed  in  both  early  and 
late  lesions.  Subsequently  atrophic  changes  take  place,  with 
destruction  of  the  hair-papilla;. 

The  characteristic  hair  of  alopecia  areata  has  the  shape  of 
an  exclamation  point.  The  upper  part  is  pigmented  and  normal, 
while  the  lower  portion  is  atrophied  and  without  pigment. 
Sabouraud  describes  an  ampullar  swelling  {the  peladtc  utricle) 
filled  with  the  microbatillus  in  the  upper  third  of  the  follicle. 


Diagnosis. — Alopecia  areata  is  chiefly  apt  to  be  confounded 
with  tinea  tonsurans. 


Alopecia  Areata. 

.   Patches  are: 

(a)  Totally   devoid  of  hair. 

(b)  Pale   or   whitish    in   coloi 

(c)  Smooth    or    soft. 

(d)  Follicles  contracted. 

.   Absence  of  fungus. 
.  Common     in     adolescence     am 
adult  life. 


Ring- worm 

.  Slow,  insidious  onset. 
:.  Patches  are: 

(a)  Covered    with     broken-ofl 

((•)  More  or  less  reddened. 
(cj  Rough  and  scaly 
(d)  Fcllicles  prominent— 

"goose-flesh"    appearance. 
.  Ring-worm  fungus  present. 
.  Occurs    almost     exclusively    in 
childhood. 


ALOPECIA  AREATA  273 

The  baldness  of  early  syphilis  may  bear  some  resemblance  to 
alopecia  areata.  Apart  from  the  presence  of  other  evidences 
of  the  disease,  the  patches  are  moth-eaten  in  appearance  and 
not  sharply  circumscribed.  The  surrounding  hair  and  scalp 
are  lusterless  and  dirty,  whereas  in  alopecia  areata  they  are 
perfectly  normal. 

Prognosis. — In  children  recovery  usually  takes  place.  In 
young  adults  the  prognosis  is  guardedly  favorable,  while  in 
advanced  adults  it  is  unfavorable.  The  longer  the  disease  has 
persisted,  the  more  unfavorable  is  the  prognosis.  The  duration 
of  the  disease  is  uncertain,  and  relapses  are  not  uncommon. 

Treatment. — The  internal  treatment  consists  of  the  use  of 
such  tonics  as  iron,  quinin,  strychnin,  cod-liver  oil,  phosphorus, 
and  arsenic.  Duhring  considers  arsenic  to  be  "especially  ser- 
viceable.' ' 

The  local  treatment  has  for  its  object  the  stimulation  and 
rubefaction  of  the  scalp,  with  the  object  of  increasing  the  blood- 
supply  to  the  follicles.  Many  cases  terminate  in  spontaneous 
recovery,  and  conservatism  is  desirable  in  interpreting  the 
value  of  remedies  employed.  Among  the  many  medicaments 
which  have  been  advised  are  alcohol,  gantharides,  capsicum, 
the  essential  oils,  turpentine,  carbolic  acid,  chrysarobin,  ^am- 
monia, sulphur,  iodin,  mercury,  betanaphthol,  etc. 

The  following  lotion  will  be  found  of  value: 

B.    Tinct.  cantharidis  j _ 

Tinct.  capsici         J  ««^^  , 

01.  ricini fjij ; 

Aq.  cologn fgj  • — M. 

Sic — Apply  to  patches  vigorously  once  or  twice  a  day. 

Instead  of  lotions,  ointments,  such  as  the  following,  may  be 
employed : 

R.    Betanaphthol Jjj; 

Petrolat 5ss; 

01   bergamot TTlxxx.— M. 

Sic — Rub  in  thoroughly  twice  a  day. 

During  the  past  year  I  have  been  employing  an  ointment  of 
chrysarobin,  20  grains,  petrolatum,  1  ounce,  with  most  grati- 
fying results. 
18 


274  DISEASES  OF  THE    SKIN 

An  efficient  treatment  consists  in  the  swabbing  of  the  bald 
areas  once  or  twice  a  week  with: 

H .    Acidi  carbdici     ^  «,  « 

Spirit,  villi  reel,   j  ■  • 

or  50  per  cent,  trikresol  may  be  employed. 

The  faradic  current,  applied  with  a  wire  brush  electrode,  is 
often  useful,  as  is  likewise  high-frequency  electricity.  In  obsti- 
nate cases  blistering  of  the  affected  areas  may  be  resorted  to. 

Phototherapy. — Many  writers,  including  Finsen,  Hyde  and 
Montgomery,  Kromayer,  and  others  have  testified  to  the  value 
of  actinic  light  rays  in  this  disease.     It  is  admitted  that  many 


Vif-  115. — Tol»l  tlofwii 

cases  in  which  light  is  used  might  have  recovered  spontaneously. 
Kromayer's  results,  however,  in  cases  of  extensive  and  even 
total  alopecia  of  years'  standing,  indicate  that  light  therapy  is 
one  of  the  must  useful  measures  in  the  treatment  of  this  disease. 
The  iron  arc  or  carbon  are  may  be  employed.  The  ordinary 
London  Hospital  t>-pe  of  lamp  suffices  for  this  purpose,  and 
jiermiis  of  the  exposure  of  an  area  the  size  of  a  silver  dollar. 
Tne  accompanying  photograph  Fi;;.  1;*  shows  hyperemie 
areas  resulting  from  thirty-minute  exposures. 


ATROPHIA   PILORUM   PROPRIA  275 


FOLLICULITIS  DECALVANS 


Quinquaud  described  a  from  of  folliculitis  more  particularly 
involving  the  scalp,  and  followed  by  destruction  of  the  pilous 
elements,  with  scarring  and  baldness.  The  disease  occurs  in 
irregular  patches  from  the  size  of  a  pea  to  that  of  a  silver  quarter- 
dollar,  over  which  there  is  a  complete  or  partial  alopecia. 
Scattered  through  the  patches,  or  occurring  upon  the  spreading 
border,  are  papules,  pustules,  or  merely  reddish  spots  which 
represent  the  inflammatory  process  which  ends  in  follicular 
destruction.  The  papules  and  pustules  are  usually  penetrated 
by  hairs  which  fall  out.  Small  patches  are  often  irregularly 
scattered  throughout  the  scalp. 

Histologically,  the  process  is  a  perifolliculitis.  Micrococci 
have  been  found  in  the  lesions. 

The  disease  is  a  form  of  cicatricial  alopecia,  perhaps,  of 
coccogenous  origin,  and  doubtless  belonging  in  the  same  group 
with  lupoid  sycosis. 

Treatment. — Quinquaud  advised  painting  with  tincture  of 
iodin  and  using  a  bichlorid  of  mercury  lotion.  I  have  secured 
good  results  with  ointments  of  tar  and  ammoniated  mercury. 
The  loss  of  hair  is,  of  course,  irremediable. 

ATROPHIA  PILORUM  PROPRIA 

Synonym. — Atrophy  of  the  hair. 

Definition. — An  idiopathic  or  symptomatic  atrophy  of  the 
hair,  characterized  by  diminution  of  size,  dryness,  brittleness, 
and  tendency  to  splitting. 

Symptoms. — Symptomatic  atrophy  of  the  hair  occurs  in 
seborrhea,  ring- worm,  phthisis,  syphilis,  the  various  fevers,  etc. 

The  idiopathic  form  is  exemplified  in  the  following  affections: 

FRAGILITAS    CRINIUM 

This  condition  is  characterized  by  a  splitting  or  longitudinal 
fission  of  long  hairs  into  two  or  more  fibrillae.  The  splitting 
is  most  often  seen  upon  the  long  hairs  of  the  female  scalp,  and 
usually  affects  scattered  hairs.  Sometimes  all  the  hairs  of  an 
affected  region  are  attacked.  The  cleft  hairs  spread  apart  or 
curl  up.  The  beard  is  also  at  times  involved.  Duhring  has 
described  a  condition  of  the  beard  in  which  the  cleavage  affected 


276 


DISEASES  OP  THE  SKIN 


the  intrafollicular  portion  of  the  hair,  not  infrequently  the  hair, 
bulb.  The  hair-root  was  split  into  two  or  four  stalks;  atrophy 
of  the  bulb  occurred.  The  hair  in  fragilitas  crinium  is  drier 
and  more  brittle  than  normal. 

Etiology. — The  disease  is  probably  a  nutritional  disorder, 
dependent  upon  nerve  disturbance.  Some  writers  believe  the 
use  of  sharp  hair-pins  may  operate  as  a  cause  upon  the  feminine 
scalp. 

Treatment. — Proper  hygiene  of  the  scalp  and  the  use  of 
stimulating  lotions  and  bland  ointments  are  advised.  The 
split  ends  of  the  hair  should  be  cut  off;  the  beard  should  be 
dailv  shaved. 


TRICHORRHEXIS    NODOSA 

This  condition  is  most  frequently  observed  in  the  beard  and 
mustache.  It  is  characterized  by  spindle-shaped,  bulbous, 
translucent  swellings  along  the  hair-shaft.  Rupture  takes 
place  at  the  points  of  distention,  the  hairs  frequently  breaking 

off  and  leaving  brush-like  stumps. 

The  fractures  arc  nearly  always  trans- 
verse to  the  axis  of  the  hair.  The  nodes 
present  roughly  a  resemblance  to  the  ova 
pediculi.  When  numerous  frayed  ends  of 
are  seen,  the  beard  looks  as  if  it  had 
been  recently  singed.  One  hair  may 
present  several  nodes.  The  pubic  and 
axillary  hairs  may  likewise  be  affected. 
Etiology  and  Pathology. — Hodara, 
Essen,  and  Spiegler  have  found  micro- 
organisms which  they  regard  as  the  cause 
of  the  disease.  Other  competent  investi- 
gators have  failed  to  confirm  these  re- 
sults. Future  research  is  necessary  to 
establish  the  cause. 

Treatment. — The  results  of  treatment 
are  far  from  satisfactory.  Repeated  shav- 
ing has  been  the  most  efficient  measure. 
Besnier  advises  plucking  the  hairs  out.  Various  antiseptic 
lotions  and  ointments  have  been  advised. 


Fig.    126. — Trichorrhexis 
nodosa. 


PIEDRA  277 


MONILETHRIX 


This  is  a  rare  affection  of  the  hair  in  which  the  entire  hair- 
shaft  consists  of  alternating  nodular  or  fusiform  swellings  and 
narrow  atrophic  portions.  The  spindle-shaped  nodes  are 
darker  than  the  intervening  portions,  and  thus  a  ringed  appear- 
ance is  produced.  The  hair  is  brittle  and  prone  to  break  in  the 
internodular  areas,  the  resulting  fracture  having  frayed  or 
brush-like  ends.  The  brittleness  may  be  so  pronounced  as  to 
cause  most  of  the  affected  hair  to  break  off  near  the  scalp  and 
thus  produce  bald  patches  looking  somewhat  like  tinea  ton- 
surans. 

The  disease  is  regarded  as  a  congenital  defect  in  the  nutrition 
of  the  hair.     The  treatment  is  unsatisfactory. 

LEPOTHRIX 

'  Lepothrix  is  a  condition  involving  the  hairs  of  the  axillae 
and  scrotum,  and  characterized  by  the  presence  of  an  irregular 
sheath  produced  by  microorganisms.  The  hair,  either  in  cir- 
cumscribed areas  or  throughout  its  entire  length,  is  surrounded 
by  concretions  which  give  it  a  ragged  "wet-string"  appearance 
when  held  up  to  the  light.  The  hair  becomes  brittle  and  breaks 
upon  slight  traction.  The  masses,  particularly  upon  axillary 
hairs,  are  often  red,  owing  to  the  presence  of  the  organism  pro- 
ducing "red  sweat."  Under  the  microscope  the  whole  or  part 
of  the  hair  is  seen  to  be  ensheathed  in  a  mass  which  has  often 
the  appearance  of  a  feather ;  at  other  times,  nodular  concretions 
are  attached  to  the  hair.  The  condition  appears  to  be  bacterial 
in  origin,  and  both  bacilli  and  micrococci  have  been  found. 

Treatment. — The  hair  should  be  shaved  and  the  parts 
sponged  with  antiseptic  solutions,  such  as  bichlorid  of  mercury. 

PIEDRA 

Piedra  is  a  disease  of  the  hair  occurring  among  the  natives 
of  Colombia,  South  America.  The  hair-shaft  is  the  seat  of  a 
number  of  black,  intensely  hard,  pin-head-sized  nodules,  which 
rattle  during  the  process  of  combing  the  hair.  Women  alone 
are  affected,  as  a  rule,  but  occasionally  the  beard  and  scalp  of 
men  are  involved.  The  concretions  are  due  to  the  presence  of 
a  fungus  which  has  been  studied  by  Juhel-Renoy. 


278  DISEASES  OF  THE  SKIN 


TINEA  NODOSA 

Tinea  nodosa,  so  named  by  Morris  and  Cheadle,  is  an  affec- 
tion characterized  by  nodular  incrustations  occurring  upon 
the  hair  of  the  scalp  and  beard.  The  hair  is  ensheathed  in  con- 
cretions which  give  the  shaft  an  irregular  appearance  and  cause 
it  to  become  brittle.  The  mass  is  made  up  of  mycelium  and 
spores,  rather  smaller  than  those  in  tinea  tonsurans. 

The  treatment  consists  of  shaving  and  the  use  of  antiseptics. 

PLICA  POLONICA 

This  is  a  condition  due  to  uncleanliness  and  neglect,  and 
resulting  in  the  matting  of  the  hair  into  inextricable  strands. 
In  plica  neuropafhica,  apparently  as  a  result  of  nutritional 
alteration  of  the  hair,  hard  lumps  or  rope-like  masses  occur, 
the  latter,  at  times,  growing  to  considerable  length. 


ATROPHIA  UNGUIUM 
Synonyms. — Onychatrophia;  Atrophy  of  the  nail. 

Definition. — A  congenital  or  acquired  condition,  charac- 
terized by  decreased  size  or  thickness  of  the  nail,  softening, 
splitting,  crumbling,  and  discoloration. 

Symptoms. — In  congenital  atrophy  the  nails  may  be  absent, 
defective,  or  distorted.  In  acquired  atrophy,  which  is  more 
common,  the  nail  may  be  thin,  opaque,  narrow,  friable,  fur- 
rowed, laminated,  or  otherwise  distorted.  Acquired  atrophy 
results  from  wasting  general  diseases,  syphilis,  nerve  injuries, 
etc.,  and  from  such  local  disorders  as  psoriasis  and  eczema. 
When  the  nail  is  invaded  by  the  fungus  of  ring-worm  or  favus, 
it   is   termed   onycJwmycosis, 

Etiology. — Dystrophy  of  the  nails  and  hair  has  been 
observed  to  occur  in  several  generations  of  families;  occasionally 
there   is  associated   mental   weakness. 

Treatment. — The  treatment  varies  according  to  the  cause. 
Syphilis  and  other  constitutional  diseases  must  receive  their 
appropriate  treatment.  In  other  cases  trimming  and  scraping 
of  the  nails  and  friction  with  green  soap,  followed  by  protection 
with  wax  or  a  rubber  stall,  are  often  of  value.  In  onychomyco- 
sis mercurial  preparations  are  of  particular  efficiency. 


MOR VAN'S  DISEASE  279 

A1NHUM 
Derivation. — From  a  native  term  meaning  "to  saw." 

Definition. — Ainhum  is  a  tropical  endemic  disease  charac- 
terized by  a  slow,  spontaneous  amputation  of  the  little  toe. , 

Symptomatology. — The  disease  begins  as  a  circular  furrow 
in  the  digitoplantar  fold  of  the  little  toe.  Other  toes  may 
occasionally  be  attacked.  There  is  no  pain  and  likewise  no 
evidence  of  inflammation.  Very  slowly,  occupying  a  period  of 
years,  the  furrow  increases  in  depth  until  the  digit  is  constricted 
as  if  by  a  ligature.  The  distal  portion  of  the  toe  swells  up  from 
circulatory  obstruction,  and  gradually  undergoes  dry  gangrene 
and  spontaneous  amputation.  This  may  occur  without  ulcera- 
tion, or  the  fissure  may  be  moist  and  discharge  a  foul-smelling 
secretion. 

The  course  of  the  disease  is  extremely  slow,  the  process  run- 
ning over  five  to  ten  years  or  more. 

Etiology. — Obscure.  The  disease  occurs  chiefly  in  negroes 
in  Africa,  South  America,  and  the  West  Indies.  It  is  also 
observed  in  India.     The  affection  is  probably  a  trophoneurosis. 

Treatment. — Early  transverse  incision  of  the  constricting 
band  may  check  the  course  of  the  disease.  Later  nothing 
remains  save  amputation. 

MORVAN'S  DISEASE  (SYRINGOMYELIA) 

This  disease  belongs  rather  to  the  domain  of  neurology,  but 
brief  mention  is  here  made  because  of  certain  cutaneous  mani- 
festations, which  bring  the  affection,  at  times,  into  diagnostic 
conflict  with  leprosy. 

The  disease  is  due  to  structural  changes  in  the  spinal  cord, 
with  resultant  sensory  disturbances  and  trophic  alterations, 
particularly  involving  the  upper  extremities. 

The  onset  of  the  disease  is  insidious,  with  pain  in  one  or  both 
arms,  accompanied  by  a  loss  of  muscular  power.  Analgesia 
may  occur  early  or  later  in  the  course  of  the  disease.  Later, 
trophic  changes,  particularly  in  the  form  of  recurring  whitlows, 
develop,  with  subsequent  phalangeal  necroses  and  mutilations. 
Large  blebs,  sometimes  with  hemorrhagic  contents,  ulcerations, 
muscular  atrophy,  glossy  skin,  and  claw-like  deformity  of  the 

hands  are  tv**  *~* *    ,v  observed.     One  or  both  hands  may 

be  invtt**  *he  lower  extremities. 


DISEASES  OP  THE  SKIN 


There  is  preservation  of  the  tactile  sense,  with  loss  of  sen- 
sation to  heat,  cold,  and  pain.  The  disease  may  last  many 
years. 

The  differential  diagnosis  from  leprosy  is  considered  under 
the  head  of  the  latter  disease. 

CLASS  VIL    NEOPLASMATA— NEW-GROWTHS 
KELOID 

Derivation.— X'M,  a  daw-     Sj-homjw.— Cheloid ;  Keloid  of  Alibert. 

Definition.— Keloid  is  a  connective-tissue  new-growth, 
appearing  as  variously  sized  and  shaped,  smooth,  firm,  reddish, 
cicatriform  elevations. 

Symptoms. — The  disease  usually  begins  as  a  small  pea-sized 
nodule  which,  during  the  course  of  years,  slowly  increases  in 
size.  The  shape  is  extremely  variable:  it  may  be  round,  oval, 
cylindric,  stellate,  or  linear.  Very  commonly  claw-like  proc- 
esses extend  out  from  the  major  portion  of  the  growth  to  the 
surrounding  skin.  Keloids  vary  in  size  from  a  pea  to  the  palm 
of  the  hand  or  larger.  The  growth  is  sharply  defined,  firmly 
implanted  in  the  skin,  smooth,  firm,  and  dense,  with  a  shining 


FIBROMA  28l 

pinkish  or  reddish  color.  They  may  occur  in  any  region,  but 
are  most  common  upon  the  trunk,  especially  over  the  sternum 
and  the  face,  particularly  in  negroes.  Pain  and  tenderness 
are  occasionally  experienced. 

It  is  now  believed  that  most  all  keloids  are  of  traumatic 
origin,  and  that  the  so-called  spontaneous  keloids  result  from 
trivial  and  unrecognized  bruises  and  injuries. 

Cicatricial  keloids  have  their  origin  in  obvious  scars,  such 
as  those  resulting  from  vaccination,  variola,  syphilis,  surgical 
incisions,  burns,  etc.  The  size  and  shape  of  the  keloid  are 
largely  determined  by  the  character  of  the  preceding  cicatrix. 

Etiology. — All  that  can  be  said  as  to  the  cause  of  keloid  is 
that  it  is  due  to  a  peculiar  tissue  tendency  to  the  development 
of  fibrous  connective  tissue.  This  tendency  is  strongly  marked 
in  the  negro  race  who  develop  keloidal  growths  with  great 
frequency. 

Pathology. — Keloid  is  made  up  of  dense  bundles  of  white 
fibrous  tissue  running  parallel  with  the  axis  of  the  tumor. 
These  fibers  are  in  the  middle  or  lower  strata  of  the  corium ;  the 
papillary  layer  is  usually  preserved  intact. 

Prognosis. — Spontaneous  involution  occurs  in  rare  cases. 
Ordinarily  the  growth,  untreated,  persists  throughout  life. 

Treatment. — Surgical  treatment  alone  is  entirely  unsatis- 
factory, excision  being  almost  invariably  followed  by  recur- 
rence. Surgical  ablation,  preceded  and  followed  by  x-ray 
treatments,  has  given  good  results  in  many  cases,  and  would 
appear  at  the  present  time  to  be  the  best  treatment.  The 
jc-rays  may  be  used  alone,  but  must  be  pushed  to  the  point  of 
producing  a  dermatitis.  Multiple  scarification,  followed  by 
the  use  of  a  mercurial  or  lead  plaster,  has  been  advised. 

FIBROMA 

Derivation. — L.,  fibra,  a  fiber.  Synonyms. — Molluscum  fibrosum; 
Fibroma  molluscum;  Molluscum  pendulum. 

Definition. — Fibroma  is  a  connective-tissue  growth  situated 
in  the  corium  and  subcutaneous  tissue,  characterized  by  sessile 
or  pedunculated,  soft  or  firm,  rounded,  painless  tumors,  varying 
in  size  from  a  split-pea  to  an  egg  or  larger. 

Symptoms. — Fibromata  occur  either  singly  or  more  com- 
monly in  numbers,  when  they  are  distr"*  **• 
part  of  the  body.     In  some  instance 


282 


DISEASES   OP    THE    SKIN 


hundreds.  They  commonly  vary  in  size  from  a  r>ea  to  a  cherry 
or  even  a  pear.  In  rare  cases  huge  pendulous  growths  may  be 
present;  these  occasionally  undergo  ulceration.  Fibromata 
have  a  uniformly  soft  consistence  and  are  frequently  peduncu- 
lated. The  overlying  skin  may  be  normal,  pinkish  or  reddish, 
stretched,  hypertrophied,  or  atrophied.  The  tumors  are  pain- 
less. 

Etiology.' — Obscure.  Some  peculiar  tissue  tendency  must 
be  operative.  Heredity  appears  to  play  a  part  in  some 
instances. 


Fig.  uS.— Fibroma  (fi 


Pathology. — Recent  tumors  are  made  up  of  gelatinous 
young  connective  tissue;  old  tumors,  of  dense,  closely  packed, 
fibrous  tissue.  The  growths  are  situated  in  the  corium  and 
subcutaneous  tissue. 

Dia gnosis. — Molluscum  fibrosum  is  to  be  distinguished 
chiefly  from  lipoma  and  neuroma.  Lipomata  are  tabulated 
and  not  pedunculated,  and  neuromata  are  accompanied  by 
pain. 

Prognosis. — The  tumors  tend  to  increase  in  size  and  number 
and  persist  throughout  life. 


.  f+. .  _i- 


XANTHELASMA  283 

Treatment. — Pedunculated  tumors  may  be  removed  by 
means  of  a  ligature  or  galvanocautery.  Others,  if  not  too 
numerous,  may  be  excised  with  the  knife. 

NEUROMA 
Derivation. — 'Sevpcv    a  nerve.     Synonym. — Nerve  tumor. 

Definition. — Neuroma  of  the  skin  is  an  affection  character- 
ized by  one  or  more  pin-head-  to  hazel-nut-sized  tubercles, 
made  up  of  connective  and  elastic  tissue  and  nerve-fibers,  and 
accompanied  by  severe  paroxysmal  pain. 

Symptoms. — The  condition  is  exceedingly  rare.  The  nodules 
are  purplish  or  pinkish,  elastic  and  immovable,  both  painful 
and  tender  on  pressure.  The  accompanying  paroxysmal  pain 
is  often  excruciating.  The  few  cases  reported  have  all  been 
middle-aged  men. 

Pathology. — The  growths  are  really  neurofibromata,  con- 
sisting of  a  mixture  of  connective  tissue  and  medullated  and 
non-medullated  nerve-fibers.  The  tumors  are  seated  in  the 
corium. 

Treatment. — Excision  of  the  nerve-trunk  leading  to  the 
growths  has  been  twice  tried,  resulting  in  one  case  in  temporary, 
and  in  the  other  case  in  permanent  amelioration. 

XANTHELASMA 

Derivation. — Earffc,  yellow,  and  ?Xa<r/ia,  lamina.  Synonyms. — Xanthoma 
planum  palpebrarum;  Vitiligoidea. 

Xanthelasma  is  a  degenerative  condition  of  the  skin,  char- 
acterized by  circumscribed,  flat  or  slightly  raised,  yellowish 
patches,  usually  affecting  the  eyelids. 

This  affection  is  classed  in  many  text-books  as  a  new  growth 
under  the  title  of  Xanthoma  Planum,  but  the  researches  of 
Pollitzer,  of  New  York,  clearly  indicate  that  the  pathologic 
process  is  not  neoplastic,  but  degenerative.  Pollitzer  prefers 
the  designation  "  xanthelasma,"  first  proposed  by  Erasmus 
Wilson. 

Symptomatology. — Xanthelasma  occurs  usually  upon  the 
eyelids  as  pea-sized  or  larger,  rounded  or  oval,  soft,  smooth,  flat 
or  slightly  elevated,  circumscribed  patches  of  a  yellowish  or 
4#jJWHiMki&f!.i0olor.     They  are  commonly  situated  near  the 

*se  of  touch  the  patches  cannot  be 
ling  unaltered  skin .    The  patches 


284  DISEASES  OP  THE  SKIN 

may  extend  in  the  direction  of  the  long  fibers  of  the  orbicu- 
laris palpebrarum  muscle. 

Xanthelasma  develops  at  or  after  middle  life,  and  the  lesions 
never  disappear  spontaneously. 

Pathology. — According  to  Pollitzer,  the  structures  of  the  skin 
of  the  eyelid  are  normal,  but  the  greater  part  of  the  cutis  is 
filled  with  the  peculiar  cell-like  bodies  called  "  xanthoma  cells/ ' 
These  are  due  to  degeneration  of  the  muscle-fibers  and  the  for- 
mation of  a  peculiar  lipoid  substance.  Groups  of  "  xanthoma 
cells  "  are  really  degenerated  muscle-fibers  seen  in  cross-section. 
In  advanced  cases  little  or  no  muscle  tissue  is  found  in  the 
affected  area. 

Prognosis. — After  progressing  to  a  certain  size  the  lesions 
remain  stationary  for  an  indefinite  period. 

Treatment. — Whenever  desired  fcr  cosmetic  reasons,  the 
patches  may  be  removed  by  means  of  the  knife,  cautery,  or 
electrolysis.  The  painting  of  the  patches  with  trichloracetic 
acid  is  often  followed  by  a  fading  of  the  discoloration  and  some- 
times by  their  disappearance. 

XANTHOMA  TUBEROSUM 

Derivation. — ZavOos,  yellow. 

Xanthoma  tuberosum  occurs  upon  the  neck,  body,  or  extrem- 
ities as  pea-  to  cherry-sized,  rounded,  hard,  yellowish  nodules 
or  infiltrations.  They  are  distinctly  raised  above  the  level  of 
the  skin.  The  larger  patches  are  made  up  of  closely  set  aggre- 
gations of  smaller  nodules.  The  favorite  seat  of  the  eruption 
is  about  the  elbows  and  knees,  where  the  lesions  are  usually 
grouped.  The  face  remains  exempt.  Occasionally  it  is  seen 
upon  the  knuckles,  buttocks,  palms,  and  soles.  The  mucous 
membrane  of  the  mouth,  pharynx,  esophagus,  and  respiratory 
tract  may  exhibit  lesions.  Nodules  have  also  been  found  in  the 
liver.  Indeed,  hepatic  disease  may  bear  some  causative  rela- 
tion to  the  disorder.  The  disease  occurs  most  frequently  in 
youth  and  early  adult  life.  The  eruptive  elements  develop 
with  rapidity  and  persist  many  years,  but  in  most  cases  ultim- 
ately disappear. 

When  the  lesions  are  numerous  and  wide-spread,  the  desig- 
nation xanthoma  multiplex  is  employed. 

Xanthoma  tuberosum  is  an  exceedingly  rare  disease. 

Pathologically,  xanthoma  is  a  new  growth  made  up  of  pro- 


MYOMA  285 

liferated  endothelial  or  connective-tissue  cells.  Pollitzer  and 
Wile  have  recently  demonstrated  the  presence  of  cholestrin  in 
the  connective- tissue  cells;  they  believe  that  this  substance  is 
carried  through  the  blood  stream,  deposited  in  the  skin,  and 
then  taken  up  by  the  cells. 

Treatment. — The  underlying  causes,  when  ascertainable, 
should  be  treated.  The  lesions  may,  when  desired,  be  removed 
by  means  of  the  knife,  galvanocautery,  or  electrolysis. 

XANTHOMA  DIABETICORUM 

This  disease  is  separate  and  distinct  from  the  preceding 
varieties  of  xanthoma.  It  occurs  in  subjects  of  glycosuria, 
and  is  characterized  by  numerous  pin-head-  to  pea-sized, 
obtusely  conical  papules  or  tubercles  of  a  peculiar  orange-red 
color.  The  apical  center  of  the  lesion  is  usually  yellowish, 
with  a  small  reddish  areola.  They  appear  upon  the  extensor 
surfaces  of  the  extremities,  upon  the  buttocks,  loins,  neck, 
and  elsewhere.  A  variable  amount  of  itching  and  . burning 
may  be  present. 

The  eruption  develops  comparatively  acutely;  it  may  dis- 
appear spontaneously  and  recur  at  a  later  period.  It  is  most 
common  in  corpulent,  florid,  middle-aged  persons. 

The  lesions  microscopically  show  more  inflammatory  change 
than  in  the  ordinary  form  of  xanthoma.  Large  xanthoma 
giant-cells  are  present. 

The  treatment  should  be  directed  toward  the  underlying 
glycosuria.  Under  proper  dietetic  and  medicinal  treatment 
the  eruption  usually  disappears. 

MYOMA 

Derivation. — MvAvt  muscle.  Synonyms. — Myoma  cutis;  Dermato- 
myoma;  Liomyoma  cutis. 

Definition. — Myoma  cutis  is  a  rare  affection,  characterized 
by  single,  or  more  rarely  multiple,  smooth,  pale  red,  pea-  to 
bean-sized  tumors,  made  up  of  smooth  muscle-fibers. 

Symptoms. — Simple  myoma  (liomyoma)  is  rare  and  appears 
as  small,  pea-sized,  pale-red,  elastic  growths,  occurring  most 
frequently  upon  the  upper  extremities.  About  twenty  cases 
are  on  record;  most  of  them  were  men  past  middle  life. 

Dartoic  myoma  is  the  commoner  form,  and  appears  usua11" 
as  a  solitary  hazel-nut-  to  orange-sized,  sessile  or  pedf 
tumor,  occurring  upon  the  breasts,  scrotum,  or  la 


286 


DISEASES  OP  THE   SKIN 


Pathology. — The  tumors  consist  chiefly  of  unstriped  muscle- 
fibers,  but  may  contain  fibrous  connective  tissue  (fibromyoma), 
vascular  tissue  ( an  gio  myoma,  myoma  telangiectodes),  or  lym- 
phatic tissue  (lymphangiomyoma). 

Treatment. — When  practicable,  excision  may  be  advised. 

NAEVUS  VASCULOSUS 

Synonyms. — Naevus  sanguineus;  Angioma. 

Definition.— Vascular  nevi  are  congenital  formations  com- 
posed chiefly  of  blood-vessels,  having  their  seats  in  the  skin 
and  subcutaneous  tissue. 


Symptoms. — Nevi  are  either  present  at  birth  or  are  prone 
to  appear  during  the  first  month  or  two  of  life.  There  are  two 
varieties : 


PORT-WINE    MARK    (NAEVUS  FI.AMMEUS  t   ANGIOMA  SIMPLEX) 

This  occurs  as  flat  patches  of  a  deep-red  or  purplish  color, 
varying  in  size  from  the  palm  of  the  hand  to  an  entire  side  of 
the  head.  The  surface  may  be  smooth  or  studded  with  small, 
erectile,  pea-sized  tumors.  The  head  aod  neck  are  the  areas 
usually  affected.  Great  disfigurement  is  occasioned  by  these 
growths. 


ANGIOMA  SERPIGINOSUM  287 

Mild  instances  of  angioma  simplex  are  seen  in  infants,  who 
present  more  or  less  circumscribed,  pinkish  patches  about  the 
face,  head,  or  neck.  Crying  or  other  exertion  temporarily 
intensifies  the  redness.  These  patches  are  often  seen  at  birth, 
but  may  appear  at  a  later  period. 

ANGIOMA    CAVERNOSUM    (NAEVUS    TUBEROSUS) 

This  variety  is  characterized  by  circumscribed,  elevated, 
erectile,  pulsating,  purplish  tumors  with  a  smooth,  rugose, 
or  tabulated  surface.  This  form  may  occur  upon  the  face, 
but  is  also  common  about  the  nates,  pudenda,  and  elsewhere. 

Etiology  and  Pathology. — Whether  vascular  nevi  are 
present  at  birth  or  appear  later,  they  are  the  result  of  con- 
genital malformation. 

In  the  flat  or  simple  angioma  there  is  a  new-growth,  involving 
chiefly  the  capillaries  of  the  corium.  In  angioma  cavernosum 
there  is  a  hypertrophy  of  the  blood-vessels  (both  arteries  and 
veins)  of  the  corium  and  of  the  subcutaneous  tissue,  with  a 
variable  amount  of  connective-tissue  overgrowth. 

Treatment. — Pin-head-sized  nevi  are  best  treated  by  destruc- 
tive cauterization.  For  this  purpose  electrolysis,  the  thermo- 
cautery, or  nitric  acid  applied  upon  a  pointed  wooden  stick 
have  been  advised.  I  have  found  the  use  of  Unna's  micro- 
burner  (a  needle-pointed  Paquelin  cautery)  to  be  superior  to  all 
other  methods  for  small  nevi. 

For  the  large  port-wine  stains  no  treatment  has  hitherto 
proved  entirely  satisfactory.  Actinic  light  treatment  with  the 
Finsen  lamp  and  electrolysis  have  produced  amelioration.  Most 
encouraging  results  are  at  the  present  time  being  obtained  from 
the  use  of  liquid  air  and  solid  carbon  dioxid  in  vascular  nevi. 

For  circumscribed  elevated  angiomata  Wyeth,  of  New  York, 
recommends  the  forcible  distention  of  the  growth  with  hypo- 
dermic injections  of  boiling  water  under  general  anesthesia. 
These  angiomata  may  also  be  treated  by  ligation,  galvano- 
cautery,  electrolysis,  or  excision. 

ANGIOMA  SERPIGINOSUM 

This  rare  affection,  first  described  by  Jonathan  Hutchinson, 
is  characterized  by  small  groups  of  1^t» 

resembling  * 'grains  of  Cayenne  pc 


288  DISEASES  OP  THE  SKIN 

a  centimeter  in  diameter,  and  usuallv  round  or  oval.  The  center 
of  the  patch  clears  up.  producing  a  circular  or  circulate  arrange- 
ment. Spreading  takes  place  upon  the  periphery  by  the  appear- 
ance of  new  puncta :  these  reddish  points  represent  the  summits 
of  vascular  loops.  The  enlargement  of  patches  and  the  peri- 
pheral extension  lead  to  the  production  of  gyrate  figuration. 
The  Hwm^p  spreads  very  slowly.  The  extremities  are  usually 
preferred-  Most  of  the  cases  described  were  in  young  children; 
some  started  from  nevi. 

Treatment. — Destruction    bv    electrolysis    or    the    micro- 
Paquehn  cautery. 


Definition. — Telangiectasis  is  a  term  applied  to  a  vascular 
new-growth  or  enlargement  of  capillaries  developed  after  the 

infantile  period. 

Telangieciases  are  acquired  growths;  nevi  are  congenital. 

Symptoms. — Telangiectasis  may  be  either  diffuse  or  circum- 
scribed: the  latter  is  far  more  common.  The  naevus  araneus, 
or  spider  nevus,  is  the  form  ordinarily  seen.  This  most  often 
appears  upor  the  face,  and  consists  of  a  pin-head-  or  larger 
sized  red  central  elevation,  with  enlarged  capillaries  radiating 
therefrom.  The  size  of  the  affected  area  varies,  but  it  usually 
covers  about  one-half  inch. 

Small  circumscribed  angiomata  simulating  the  spider  nevus 
develop  commonly  upon  the  trunk  of  aged  persons. 

Dilatation  of  blood-vessels  may  occur  upon  scars,  over  malig- 
nant growths,  in  the  vicinity  of  inflammatory  dermatoses, 
after  vigorous  x-ray  treatments,  etc.  Osier  states  that  telangi- 
ectases frequently  occur  in  persons  suffering  from  hepatic  dis- 
ease. 

The  term  rosacea  is  applied  to  enlargement  of  the  blood- 
vessels of  the  face  resulting  from  repeated  flushing;  it  is  com- 
monly associated  with  acne  lesions. 

Etiology. — Telangiectasis  sometimes  develops  as  a  result 
of  a  slight  injury  to  the  skin  which  leads  to  the  formation  of 
new  blood-vessels,  A  pin-prick  or  insect-bite  may  act  in  the 
same  manner.  Acute  and  inflammatory  diseases  may  likewise 
lead  to  telangiectases.  I  have  seen  erysipelas  produce  per- 
manent vascular  dilatation. 


LYMPHANGIOMA  289 

Treatment. — Telangiectatic  vessels  may  readily  be  destroyed 
by  electrolysis,  or,  preferably  and  less  painfully,  by  the  use  of 
Unna's  microburner  (a  needle  Paquelin  cautery). 

ANGIOKERATOMA 

Angiokeratoma  is  a  name  given  by  Mibelli,  in  1889,  to  a 
peculiar  affection  involving  particularly  the  hands  and  feet, 
and  characterized  by  telangiectatic  elevations  with  subsequent 
warty  overgrowths. 

Symptoms. — The  affection  is  prone  to  develop  in  persons 
who  are  much  exposed  to  cold.  Indeed,  the  early  lesions  are 
chilblains — dark-red  macules,  often  with  a  central  deeper 
colored  point,  which  largely  disappear  upon  pressure.  The 
central  punctum  consists  of  a  vascular  capillary  loop;  often 
several  telangiectatic  points  representing  capillary  varicosities 
are  clustered  in  an  elevated  papule  or  nodule.  The  nodule  is 
of  a  deep-red,  violaceous,  or  purplish  color.  The  overlying 
epidermis  is  thickened  and  horny,  so  that  the  lesions  present 
the  appearance  of  a  wart.  Pressure  discloses  to  view  the 
vascular  dilatation,  and  pricking  is  followed  by  rather  free 
bleeding.  The  eruption  prefers  the  hands  and  feet,  particularly 
the  dorsal  surfaces.  Lesions  may  also  occur  upon  the  ears, 
scrotum,  and  elsewhere.  The  distribution  may  be  one-sided 
or  symmetric.  The  eruption  begins  in  childhood;  in  a  few 
instances  the  lesions  have  appeared  later  in  life. 

Pathologically,  the  process  appears  to  originate  in  capillary 
enlargement  with  subsequent  hyperkeratosis  as  a  result  of  the 
vascular  engorgement. 

Treatment. — For  the  early  lesions,  stimulating  applications, 
as  in  chilblains.  The  vascular  warts  may  be  destroyed  with 
the  electrolytic  needle. 

LYMPHANGIOMA 

Derivation. — 'Ayyeiov,  vessel;  L.,  lympha,  lymph. 

Symptoms. — The  disease  is  extremely  rare.     There  are  two 

varieties. 

Lymphangioma   circumscriptum    (lymphangiectodes)    is 

by  numerous  small,  closely  aggregated,  deep- 

des,  which  have  either  the  normal  tint 


290  DISEASES  OP   THE    SKIN 

of  the  skin  or  are  yellowish  or  pinkish.  They  vary  in  size  from 
a  pin-point  to  a  hemp-seed.  The  lesions  are  usually  arranged 
irregularly  in  small  groups  with  healthy  intervening  skin. 
They  run  a  chronic  course,  and  often  recur  after  removal.  The 
chest  and  upper  extremities  are  the  seats  of  predilection.  The 
disease,  as  a  rule,  makes  its  appearance  in  infancy  or  early 
childhood. 

Lymphangioma  tuberosum  multiplex  appears  as  numerous 
scattered,  pea-  to  bean-sized,  elevated,  brownish-red,  glistening 


tubercles,  occurring  most  frequently  upon  the  trunk.  The 
tubercles  arc  somewhat  painful  on  pressure.  The  disease  is 
extremely  rare. 

Pathology.  Lymphangioma  shows  under  the  microscope 
both  dilatation  of  preexisting  lymph-channels  and  formation  of 
new  lymphatic  vessels  and  spaces. 

Treatment. — When  desirable,  extirpation  by  means  oi 
electrolysis  or  excision. 


ADENOMA  SEBACEUM  29 1 

COLLOID  DEGENERATION  OF  THE  SKIN 

Synonym. — Colloid  milium. 

This  affection  is  ordinarily  regarded  as  very  rare.  In  my 
experience  it  is  not  so  infrequent  as  the  paucity  of  recorded 
cases  would  indicate.  The  condition  is  usually  limited  to  the 
upper  part  of  the  face,  particularly  the  forehead.  It  is  charac- 
terized by  numerous  disseminated  or  closely  studded  grayish- 
yellow  or  yellowish- white,  pin-point-  to  pin-head-sized  papules 
imbedded  in  the  skin  and  slightly  elevated  above  it.  The 
elevations  are  flat  topped,  irregular,  firm  to  the  touch,  and  some- 
what glistening.  On  puncture  a  small  quantity  of  gelatinous 
fluid  exudes.  The  condition  is  progressive  and  of  slow  develop- 
ment. It  occurs  chiefly  in  middle  or  advanced  adult  life.  The 
condition  was  well  marked  in  a  patient  of  mine  with  a  pro- 
nounced lupoid  sycosis  with  bleb  formation  and  essential 
shrinking  of  the  conjunctivae. 

Pathologically,  the  process  is  a  colloid  degeneration  of  the 
connective  tissue  of  the  corium  and  the  elastic  fibers.  The 
sebaceous  glands  are  not  involved. 

Diagnosis. — The  disease  is  to  be  distinguished  from  milium, 
xanthoma,  hydrocy stoma,  and  adenoma  sebaceum. 

Treatment. — Electrolysis  and  curetting  have  been  success- 
fully employed. 

ADENOMA  SEBACEUM 

Adenoma  of  the  sebaceous  glands  may  be  present  at  birth 
or  appear  shortly  afterward ;  the  growths  are  prone  to  take  on 
increased  development  around  the  age  of  puberty.  The  lesions 
are  usually  situated  upon  the  face,  particularly  about  the  sides 
of  the  nose,  upper  lip,  and  chin.  They  consist  of  pin-head-  to 
pea-sized,  rounded  tumors,  usually  with  a  smooth  epidermal 
covering.  The  color  may  be  of  the  normal  skin  tint,  waxy,  or 
reddish,  the  last  named  hue  being  often  influenced  by  the 
presence  of  visibly  enlarged  capillaries.  The  tumors  are  fre- 
quently grouped  about  the  alae  of  the  nose  in  a  symmetric 
manner.  There  are  usually  other  congenital  cutaneous  defects, 
such  are  nevi,  comedones,  fibromata,  and  pigment  spots.  The 
disease  is  more  common  in  asylum  children  who  are  mentally 
deficient. 

Pathologically,  the  essential  change  is  a  1 
sebaceous  glands. 


292  DISEASES  OP  THE   SKIN 

Spiradenoma  or  adenoma  of  the  sweat-glands  is  a  rarer  con- 
dition. Many  of  the  cases  formerly  described  under  this  title 
were  cases  of  multiple  benign  cystic  epithelioma.  Spiradenoma 
is  apt  to  be  a  single  growth,  larger  than  sebaceous  adenoma. 
Puncture  may  show  the  presence  of  a  clear  fluid. 

Treatment. — Electrolysis  in  small  lesions  and  excision  in 
larger  growths  are  advised. 

RHINOSCLEROMA 

Derivation. — P*c,  or  />''v,  the  nose;  oK7.rjp6^t  hard. 

Definition. — Rhinoscleroma  is  a  disease  affecting  the  skin 
and  mucous  membrane  of  the  nose,  and  characterized  by 
irregularly  shaped,  flattened  new-growths  of  almost  stony 
hardness. 

Symptoms. — The  disease  was  described  by  Hebra  and  Kaposi 
in  1870.  It  occurs  chiefly  in  Galicia  in  Austria,  southwestern 
Russia,  and   Brazil.     In  the  United  States  it  is  extremely  rare. 

The  growth,  which  begins  usually  in  the  mucous  membrane 
of  the  septum  of  the  alae  of  the  nose,  consists  of  circumscribed, 
dense,  hard,  flattish  nodules  or  raised  plaques,  which  tend  to 
become  confluent.  The  overlying  skin  is  glistening  and  cither 
of  normal  tint  or  brownish  red.  Dilated  blood-vessels  at  times 
course  over  the  growth.  The  skin  is  firmly  attached  to  the 
tumors;  the  epidermis  is  tense  and  sometimes  fissured,  when 
it  gives  issue  to  a  viscid  secretion  which  dries  in  the  form  of 
crusts. 

The  disease  begins  insidiously  as  a  painless  induration  and 
thickening  of  the  mucous  membrane  of  the  nasal  alae,  the  sep- 
tum, or  the  upper  lip.  The  neoplasm  slowly  extends,  causing 
broadening  or  flattening  of  the  nose  and  contraction  of  the 
nasal  orifices,  at  times  to  complete  occlusion.  The  process 
may  involve  the  lips  or  extend  along  the  nose  to  the  velum 
palati.  The  pharynx,  larynx,  and  trachea  may  become  in- 
volved. Less  commonly  the  disease  begins  in  the  pharyngeal 
vault  or  larynx. 

The  disease  runs  a  progressive  course  without  tendency  to 
involution.  When  excised,  the  growth  recurs.  The  disease, 
however,  is  local,  and  does  not  affect  the  general  health. 

Etiology. — The  disease  is  most  common  in  the  poor.  Both 
sexes  are  equally  attacked.  The  age  limits  thus  far  have  been 
from  nine  to  forty  years.  Rhinoscleroma  is  practically  an 
endemic  disease,  and  is  comparatively  common  in  a  few  coun- 
tries and  extremely  rare  elsewhere. 


i: 


MULTIPLE  CUTANEOUS  TUMORS  ASSOCIATED  WITH  ITCHING    293 

Pathology. — Frisch  found  a  short,  thick,  ovoid  bacillus, 
which  is  generally  regarded  as  the  cause  of  the  disease. 
Rhinoscleroma  belongs  to  the  infectious  granulation  neoplasms. 

Diagnosis. — The  diagnosis  is  usually  easy;  the  stony  indura- 
tion involving  the  mucous  membrane  and  skin  of  the  nose,  the 
progressive  painless  course,  the  absence  of  spontaneous  ulcera- 
tion or  tendency  to  involution  make  a  characteristic  picture. 

Prognosis. — Unfavorable.  The  growth  usually  persists 
throughout  life.  Through  involvement  of  the  throat  and 
larynx  suffocation  may  result. 

Treatment. — The  result  of  treatment  has  hitherto  been 
unsatisfactory.  Excision  is  promptly  followed  by  recurrence. 
As  patients  live  a  long  time  unless  their  air-supply  is  cut  off, 
efforts  have  been  directed  to  prevent  closure  of  the  nostrils. 
Boring  with  the  stick  of  caustic  potash  and  the  use  of  sponge- 
tents  was  a  method  employed  by  Kaposi.  Recently  remark- 
able results  have  been  obtained  with  the  #-rays:  the  disease 
has  not  only  been  arrested  in  its  course,  but  improvement, 
amounting  almost  to  cure,  has  been  achieved. 

MULTIPLE  CUTANEOUS  TUMORS  ASSOCIATED  WITH  ITCHING 

Three  cases  of  this  affection  have  been  recorded— one  by 
Hardaway,  in  1880,  and  two  by  Schamberg  and  Hirschler,  in 
1905- 

The  eruption  consists  of  pea-  to  bean-sized,  elevated  nodules, 
covered  with  a  thickened,  horny  epidermis.  The  tumors  are 
blackish  in  color  (in  the  negro),  firm  to  the  touch,  distinctly 
elevated,  and  sharply  circumscribed.  The  eruption  in  one  case 
appeared  in  the  course  of  two  weeks,  no  new  lesions  developing 
after  that  time.  The  arms  and  legs  were  chiefly  affected ;  lesions, 
however,  were  present  also  on  the  trunk.  There  is  no  tendency 
to  confluence  of  the  nodules.  About  170  lesions  were  present 
in  each  of  the  two  cases  reported.  In  Hardaway's  case  there 
were  60  present.  Itching  is  a  pronounced  feature  of  the  dis- 
ease, being  limited,  as  a  rule,  to  the  nodular  growths.  In 
Hardaway's  case  there  was  also  itching  of  the  skin  between 
the  tumors,  the  intervening  integument  becoming  thickened, 
rough,  and  pigmented.  Itching  is  severe  and  leads  to  scratch- 
ing of  the  lesions,  with  the  production  of  excoriations  and 
fissures. 

■■■  all  the  cases  are— (i)  The  develop- 


294  DISEASES  OP  THE  SKIN 

ment  of  tubercles  and  tumors  in  the  skin,  particularly  of  the 
extremities,  accompanied  by  more  or  less  severe  itching;  (2)  the 
horny  character  of  the  epidermis  overlying  the  growths;  (3)  the 
persistence  of  the  tubercles  and  itching  for  many  years:  the 
duration  in  the  three  cases  reported  has  been  twenty-two  years, 
fourteen  years,  and  fifteen  years  respectively ;  (4)  recurrence 
of  the  nodules  after  extirpation.     AH  the  patients  were  women. 


Fig.   131.   -  Multiple  tumor-like  sir™ 


Pathologically,  the  sequence  of  changes  appears  to  be  as 
follows:  dilatation  of  the  culaneous  blood-vessels;  cell-infil- 
tralion,  chiefly  in  sharply  circumscribed  masses;  proliferation 
of  the  fixed  connective -tissue  elements;  formation  of  new  col- 
lagenous fibers.  In  the  largest,  and  presumably  the  oldest, 
tumors,  there  is  more  pronounced  vascular  dilatation,  and,  as 
a  result  thereof,  an  enormous  overgrowth  of  the  horny  layer  of 
the  epidermis,  a  condition  much  like  that  seen  in  angiokeratoma. 
A  feature  of  more  than  passing  interest  is  the  great  abundance 
of  mast -cells  present. 

The  cause  of  the  affection  is  unknown  and  treatment  is  with- 
out much  avail, 

LUPUS  ERYTHEMATOSUS 


Definition. — Lupus  erythematosus  is  a  disease  characterized 
by  well-defined  reddish  patches  covered  with  yellowish  or  gray- 
ish adherent  scales  and  tending  to  atrophy. 


LUPUS  ERYTHEMATOSUS 


295 


Symptoms. — The  disease  occurs  in  several  forms  with  quite 
marked  clinical  differences. 

There  are  three  chief  varieties:  (1)  Discoid;  (2)  disseminated; 
(3)  telangiectatic. 

Discoid  Variety  (Lupus  Erythematosus  Discoidea). — 
This  is  the  variety  most  frequently  encountered.  It  exhibits 
a  predilection  for  the  face,  particularly  the  nose,  cheeks,  and 
ears,  and  is  usually  symmetric  or  nearly  so.  The  scalp  may 
also  be  attacked,  producing  circumscribed  loss  of  hair.  More 
rarely  the  arms,  hands,  and  other  portions  of  the  body  are 
affected. 


The  disease  appears  first  as  small,  pea-sized,  isolated  or 
grouped,  reddish  spots  which  have  a  grayish  or  yellowish, 
tightly  adherent  scale  or  crust.  When  this  is  removed,  it  shows 
upon  its  nether  surface  small,  spike-like  projections  which  repre- 
sent sebaceous  casts  of  the  follicular  ducts.  This  feature  is 
most  pronounced  in  patches  upon  the  nose.  The  patches 
slowlv  increase  in  size  by  peripheral  extension,  several  neighbor 
ing  lesions  commonly  coalescing  and  producing  larger  patches. 
The  border  of  the  patch  is  sharply  defined  and  elevated  above 


296  DISEASES  OF   THE    SKIN 

the  level  of  the  skin.  Central  involution  commonly  proceeds 
with  peripheral  spreading,  the  center  undergoing  partial  resorp- 
tion and  flattening  or  sinking  in."  Complete  involution  may 
take  place,  in  which  event  the  center  exhibits  a  thin,  whitish, 
atrophic,  or  cicatricial  appearance.  Or  if  the  resorption  be 
not  complete,  the  center  is  somewhat  reddened  and  still  scaly. 
The  border  is  red  or  violaceous,  and  studded  with  patulous 
and  enlarged  sebaceous  orifices  or  horny  plugs. 

The  patches  run  an  extremely  slow  course,  covering  months 
or  years.     They  may  disappear  spontaneously,  with  or  with- 


out atrophic  scarring;  or  they  may  persist,  gradually  increasing 
in  size  until  large  areas  are  involved.  Occasionally  patches 
on  the  nose  and  cheek  coalesce,  producing  the  so-called  "butter- 
fly" appearance,  the  body  represented  by  the  nose,  and  the  cheek 
patches,  the  wings.  The  union  of  patches  may  also  lead  to 
gyrate  figurations. 

Disseminated  Variety  (Lupus  Disseminatus  of  Hebra). — 
This  is,  as  a  rule,  a  more  acute  form,  and  is  much  less  common 
than  the  discoid  variety.  It  begins  usually  upon  the  face,  in 
much  the  same  manner  as  the  discoid  form.  i.  c,  with  the 
formation  of  small  reddish  patches,  but  the  latter  are  more 


LUPUS  ERYTHEMATOSUS  297 

numerous  and  are  prone  to  develop  upon  the  extremities  and 
elsewhere.  They  are  ordinarily  erythematous  and  super- 
ficially scaly,  but  may  at  times  resemble  the  lesions  of  erythema 
multiforme,  urticaria,  syphilis,  etc.  The  eruption  may  be 
extremely  acute  and  involve  large  surfaces,  in  some  cases 
becoming  almost  universal. 

In  other  cases  serious  succeeding  crops  may  follow  a  com- 
paratively mild  initial  outbreak.  From  a  score  to  a  hundred 
or  more  lesions  may  be  present.     In  rare  cases  the  subjective 


Fig.    134—  Lupus  erythematosus  it 

pigment. 

symptoms  may  be  severe,  and  vesiculation  or  pustulation  may 
occur.  Acute  and  wide-spread  cases  may  be  accompanied  by 
intermittent  fever,  headache,  joint  and  bone  pains,  diarrhea, 
and  may  terminate  fatally.  Kaposi  has  described  cases  com- 
plicated bv  persistent  erysipelas-like  swelling  of  the  face,  with 
high  fever  and  great  mortality. 

Telangiectatic  Variety. — In  this  form  there  are  patches  of 
pin-head,  pea,  finger-nail,  or  much  larger  size,  which  appear 
upon  various  portions  of  the  face.     They  are  of  a  pin1 


298  DISEASES  OF  THE  SKIN 

deep-red  tint,  and  often  show  no  change  in  the  skin  save  the 
appearance  of  fine  enlarged  capillaries.  The  color  disappears 
under  digital  pressure.  Scaling  and  patulous  glandular  orifices 
are  absent,  although  there  may  be  some  thickening  of  the  skin 
and  elevation  of  the  border.  Upon  involution  of  the  patches 
some  atrophic  scarring  may  be  visible. 

The  subjective  symptoms  in  lupus  erythematosus  are,  as  a 
rule,  mild  or  absent.     Itching  is  seldom  complained  of. 

Etiology. — The  disease  is  much  more  common  in  females 
than  in  males,  the  former  comprising  two-thirds  of  the  cases. 
Any  age  may  be  attacked,  but  the  disease  begins  usually  in  the 
third  decade  of  life.  It  is  rare  in  childhood,  although  Kaposi 
has  described  a  case  in  a  child  of  three.  I  have  observed  and 
recorded  the  disease  in  a  four-year-old  girl.  Many  dermatol- 
ogists regard  the  disease  as  due  to  the  toxins  of  the  tubercle 
bacillus — therefore,  a  so-called  toxi-tuberculid.  Both  Boeck 
and  Roth  claim  to  have  found  recent  or  remote  ^tuberculous 
manifestations  in  over  50  per  cent,  of  their  cases.  It  is  not, 
however,  generally  concurred  in  that  lupus  erythematosus  is 
essentially  and  invariably  a  tuberculous  affection.  The  evidence 
for  this  assumption  is  stronger  in  the  disseminated  variety. 
Crocker  regards  a  feeble  circulation,  prolonged  exposure  to 
great  heat  or  cold,  and  superficial  inflammations,  such  as 
follow  erysipelas  or  scarlet  fever,  as  favoring  factors.  Dis- 
orders of  the  sebaceous  glands  not  infrequently  precede  the 
development  of  lupus  erythematosus. 

Pathology.  -Considerable  difference  of  opinion  exists  as 
to  the  characteristic  histopathologic  changes  in  the  skin.  The 
disease  is  variously  regarded  as  a  chronic  inflammatory  der- 
matosis, as  a  local  infective  granuloma,  and  as  a  tuberculo toxic 
process.  There  is  a  pronounced  infiltration  of  embryonic 
cells  in  the  upper  half  or  third  of  the  coriuni.  proliferation  of 
the  fixed  connective -tissue  cells,  hypertrophy  of  the  sebaceous 
glands,  followed  by  degeneration  and  atrophy  and  degenerative 
changes  in  the  collagen  and  elastin.  Kordyce  and  Holder 
believe  the  process  to  orginate  in  embolic  or  thrombotic  obstruc- 
tion of  ca  pill  Aries.  Schoonheid  claims  that  the  rete  is  first 
affected,  and  that  this  is  followed  by  a  perivascular  cell-infiltra- 
tion around  the  subepithelial  blood- vessels.  In  contradistinc- 
tion from  lupus  vulgaris  then.*  are  no  circumscribed  cell-nests 
and  no  giant -cells* 

Diagnosis.     Lupus    erythematosus     may     be     confounded 


LUPUS  ERYTHEMATOSUS  299 

with  lupus  vulgaris,  eczema,  psoriasis,  seborrhoic  dermatitis, 
rosacea,  etc.  The  differentiation  from  lupus  vulgaris  is  as 
follows : 

Lupus  Erythematosus.  Lupus  Vulgaris. 

1.  As   a   rule,    develops   in    adult       1.  Develops  in  childhood  or  youth. 

life. 

2.  Disease  is  usually  superficial.  2.  Disease  is  deep  seated. 

3.  The     lesions     are     wellrdefined       3.  The  lesions  are  discrete  papules 

scaly  patches.  and  tubercles. 

4.  Sebaceous   ducts   patulous   and       4.  Sebaceous  system  not  involved. 

often  plugged. 

5.  Ulceration  never  occurs.  5.  Ulceration    with    scarring   com- 

monly present. 

6.  Scarring  smooth   and   fine.  6.  Scarring     irregular     and     con- 

spicuous. 

Eczema  does  not  produce  sharply  defined  erythematous 
patches  lasting  long  periods  of  times;  furthermore,  tightly 
adherent  scaling  with  sebaceous  plugs  and  comedones  are 
absent.  Eczema  causes  much  greater  itching  and  does  not 
scar.  Psoriasis,  seborrhoic  dermatitis,  and  rosacea  may  be 
likewise  excluded  by  attention  to  the  foregoing  points. 

Prognosis. — The  prognosis  is  invariably  guarded.  Its 
capricious  course  renders  spontaneous  disappearance  and 
relapses  frequent  possibilities.  Many  cases  are  extremely 
obstinate;  ultimately,  however,  cure  may  take  place.  The 
tendency  to  scarring  should  be  borne  in  mind  in  forecasting 
the  result. 

Treatment. — No  known  drug  has  any  constant  influence 
upon  the  disease,  although  such  remedies  as  iodin,  arsenic, 
cod-liver  oil,  etc.,  are  occasionally  of  value.  Quinin,  in  10-  to 
1 5 -grain  doses  daily,  has  been  found  of  distinct  service  in  some 
cases.  Crocker  advises  the  use  of  salicin,  15  to  20  grains  three 
times  a  day. 

The  local  treatment  consists  of  the  use  of  sedative  or  stimu- 
lating applications,  caustics,  or  surgical  manipulation,  accord- 
ing to  the  nature  of  the  case. 

There  are  two  distinct  types  of  cases  which  require  entirely 
different  treatment.  The  superficial,  very  red  patches  with 
dilated  blood-vessels  must  be  treated  with  mild  measures, 
whereas  the  infiltrated  patches  with  horny  crusts  and  sebaceous 
plugs  cannot  be  successfully  treated  save  by  stimulating  and 
even  escharotic jMlfe 

Inasi  of  cases  get  spontaneously 

well  *  *er  remedies  should  always 


300  DISEASES  OF  THE   SKIN 

be  given  a  fair  trial  before  proceeding  to  the  use  of  caustics  or 
other  destructive  measures.  In  cases  attended  by  a  consider- 
able degree  of  inflammation,  mild  astringent  applications  should 
be  used.     The  following  is  often  of  value : 

H.    Zinci  sulphat.     \  --  . 

Potass,  sulphid.  i   aa  gr.  xi, 

Glycerini f 3  j ; 

Spirit,  vini  rect 13 vj ; 

Aq.  rosae q.  s.  ad  f^vj. — M. 

Sic. — Apply  three  or  four  times  a  day. 

A  lotion  containing  2  per  cent,  of  resorcinol  and  boric  acid 
with  zinc  oxid  and  calamin  may  also  be  used. 

Many  cases  do  well  under  stimulating  applications.  An 
admirable  method  is  to  rub  into  the  part  vigorously  every  day 
or  every  other  day  the  tincture  of  green  soap.  This  may  be 
followed  by  the  use  of  a  soothing  ointment.  The  above  treat- 
ment is  applicable  to  cases  with  horny  adherent  crusts. 

The  more  thickened  the  patches,  the  more  vigorously  are 
they  to  be  treated.  A  25  per  cent,  salicylic-acid  plaster  often 
acts  admirably.  In  obstinate  infiltrated  patches  a  20  to  50 
per  cent,  solution  of  caustic  potash  may  be  applied  for  a  few 
minutes  and  then  washed  off  with  vinegar.  The  surroundings 
must  be  carefully  protected.  A  soothing  ointment  should  then 
be  applied. 

Some  cases  do  well  under  an  ointment  of  sulphur,  one  to  two 
drams  to  the  ounce.  Preparations  of  tar  are  also  advised.  The 
following  combination  makes  a  useful  formula : 

H  .    Sulph.  praecip 3j  i 

Olei  eadini f  3  j ; 

Lanolini  )  . .    _• 

,  f      ,  •   •   >    aa  3> v  I 

Ol.  bergamot TTlxl. — M. 

Sio. — Apply  once  or  twice  a  day. 

Collodion  is  advised  by  Crocker  to  effect  pressure  upon  the 
blood-vessels.  Payne  advises  a  3  to  6  per  cent,  salicylic-acid 
collodion,  and  Unna,  a  10  per  cent,  resorcinol  collodion  which 
acts  most  vigorously  and  must  be  used  with  care.  Ethyl  chlorid 
spray  acts  well  at  times,  as  does  a  mentholated  alcohol  fre- 
quently applied.  Stronger  applications,  such  as  pure  carbolic 
acid,  trichloracetic  acid,  etc.,  may  be  used  in  rebellious  cases. 

Electrolysis  has  been  used  with  good  results.  I  have  found 
the  microburner  of  Unna  (needle  Paquelin  cautery)  of  distinct 


TUBERCULOSIS  CUTIS  301 

value,  particularly  in  small  patches  of  the  telangiectatic  variety. 
Linear  scarification,  as  advised  by  Squire,  may  be  resorted  to 
when  other  measures  fail. 

Solidified  carbon  dioxidt  applied  with  moderate  pressure 
for  ten  to  thirty  seconds,  has  given  splendid  results  in  some 
cases.  Carbon  dioxid,  however,  is  not  of  value  in  all  cases. 
Where  it  fails,  it  will  not,  if  properly  employed,  do  any  harm. 

Phototherapy. — The  use  of  actinic  rays  of  light  applied  by 
means  of  the  Finsen  lamp  or  the  London  Hospital  type  of  lamp 
is  often  of  distinct  value.  This  treatment  is  more  especially 
useful  in  the  vascular  forms  of  the  disease. 

Radiotherapy. — The  #-rays  may  at  times  be  employed  with 
benefit  in  the  thickened  forms  of  lupus  erythematosus.  In 
the  vascular  variety  the  treatment  is  rarely  of  value.  In  all 
cases  the  x-rays  must  be  used  with  the  greatest  care  and  cir- 
cumspection, if  used  at  all,  for  cases  unsuccessfully  treated  by 
the  x-rays  are  thereafter  much  more  difficult  to  cure  by  other 
means. 

TUBERCULOSIS  CUTIS 

Tuberculosis  cutis  is  due  to  infection  of  the  skin  with  the 
tubercle  bacillus.  It  may  be  primary  or  may  occur  secon- 
darily to  involvement  of  some  other  organ. 

Five  principal  varieties  of  tuberculosis  of  the  skin  are  recog- 
nized: (1)  Lupus  vulgaris;  (2)  tuberculosis  verrucosa  cutis; 
(3)  tuberculosis  cutis  orificialis;  (4)  scrofuloderma;  (5)  miliary 
tuberculosis  of  the  skin. 

LUPUS    VULGARIS 

Derivation. — L.,  lupus,  a  wolf.  Synonyms. — Lupus  exedens;  Lupus 
exulcerans;  Noli  me  tangere;  Tuberculosis  of  the  skin  (one  form). 

Definition. — Lupus  vulgaris  is  a  tuberculous  cellular  new- 
growth,  characterized  by  reddish  or  brownish  patches  consisting 
of  papules,  nodules,  and  flat  infiltrations,  usually  terminating 
in  ulceration  and  scarring. 

Symptoms. — The  disease  commonly  begins  as  one  or  several 
pin-head-  to  lentil-seed-sized  grouped  or  disseminated  flat 
papules.  The  color  is  dull  red,  with  often  an  admixture  of 
brown  or  yellow.  The  papules  are  softer  than  the  surrounding 
skin,  and  can  be  readily  indented  or  penetrated  by  pressure 
with  a  blunt  or  sharp  instrument.  Their  soft  consistence  and 
brownish-red  color  have  caused  Hutchinson  to  liken  their 
appearance  to  "apple  jelly." 


DISEASES  OF   THE    SKIN 


These   papules  develop  gradually   into  pea-sized  or  larger 
tubercles  or  nodules,  which  ultiniaU'lv  become  aggregated  in 


■iity  years  of  age;  duration,  fa 


Tuberculosis  cutis 


variously  sized  and  shaped 
patches,  covered  with  im- 
perfectly formed  epider- 
mis. After  a  variable 
duration  the  nodules  coal- 
esce, chiefly  by  individual 
extension,  forming  dull- 
red,  raised,  soft  patches. 

Lupus  nodules  are  often 
flat  and  imbedded  in  the 
skin.  At  other  times  they 
are  raised  above  the  level 
of  the  surrounding  integu- 
ment. But  a  single  tu- 
bercle may  be  present,  al- 
though usually  a  number 
of  scattered  grouped  or 
eo  ale  scent  nodules  are 
seen.  Central  involution 
or  ulceration  of  patches 
may  occur,  leaving  a 
scarred  area,  surrounded 
by  an  elevated,  dark -red, 
lupus  border,  spreading  in 
a  gyrate  or  serpiginous 
manner.  Small  lupus  nod- 
ules are  prone  to  spring  up 
in  the  cicatricial  tissue. 

One  of  the  distinguish- 
ing features  of  lupus  vul- 
garis is  the  remarkable 
indolence  and  chronicity 
of  the  lesions.  Nodules 
may  remain  for  months 
or  years  without  increas- 
ing in  size  or  undergoing 
retrogressive  change.  In 
many  cases,  however,  a 
slow  extension  takes  place 
by  peripheral  spreading 
or  the  appearance  of 
nodules.     Ultimately 


(courtesy  of  Dr.  M.  B.  Hamdl). 


304  DISEASES  OF  THE   SKUf 

retrogiessive  or  degeneiative  change  takes  place.  Tbe  nodules 
may  be  resorbed,  leaving  a  smooth  or  scaly  scarred  surface 
(lupus  exjoHativus),  or,  as  is  more  commonly  the  case,  break 
down  and  ulcerate  (lupus  ardms;  lupus  exuUrraus). 

Lupus  ulcers  are  irregular  in  outline,  comparatively  shallow, 
have  but  a  scant  secretion,  and  tend  readily  to  bleed.  Tbe 
resultant  crusts  are  often  of  a  brownish  color  from  the  san- 
guineous contents.  At  times  exuberant  granulations  spring 
up  upon   the  border  of  the  ulcer   [lupus  kvpiirtr&pkicus),  or 


Fig.    1J&— iVr^ipi 


there  may  develop  papillomatous  outgrowths     .'ti^».;  fvp£&~ 

The  most  frequent  seat  of  lupus  is  tbe  ;*.¥.  partkutxrly  the 
nose,  cheeks,  and  ears.  The  disease  may  be  hrnittd  in  area 
or  may  involve  almost  the  entire  face.     When  the  tip  and  ake 

of  the  nose  are  attacked,  tbe  pan?  ultimately  become  shrunken 
from  absorption  or  ulceration,  and  marked  cicatricial  contrac- 
tion of  the  nostrils  occurs.  The  same  process  aK'-u:  :he  eye- 
lids mav  (ead  to  a  pronounced  ectropion.  The  tars  are  com- 
monly deformed  and  contracted,      in  the  worst  cases  the  pai- 


TUBERCULOSIS   CUTIS  305 

pebral,  nasal,  and  oral  orifices  are  narrowed  to  small  apertures 
or  slits,  and  the  features  are  disfigured  almost  beyond  human 
semblance.  The  mucous  membranes,  cartilage,  and  bone  may 
in  the  end  undergo  destruction. 

Etiology.— Lupus  vulgaris  is  essentially  a  disease  originat- 
ing in  childhood  and  youth;  over  one-half  of  the  cases  develop 
before  the  age  of  fifteen.  It  is  distinctly  uncommon  to  observe 
it  to  begin  after  the  age  of  thirty.  Females  are  considerably 
more  prone  to  it  than  males.  It  is  now  well  recognized  that 
lupus  vulgaris  is  a  tuberculosis  of  the  skin,  due,  therefore,  to  the 
invasion  of  the  tubercle  bacillus.  Lupus  patients  react  almost 
uniformly  to  the  influence  of  tuberculin.  It  is  common  to 
note  tuberculous  disease  in  other  members  of  the  family.     Many 


.■-•£ 


Fig-  139.— 
iniillrated  with 
Dr.  J.  T.  Bowt 


patients  have  tuberculous  foci  elsewhere.  All  causes  (debility, 
bad  hygiene,  filth,  etc.)  which  lower  the  resisting  power  of  the 
individual  thereby  render  the  cutaneous  tissues  a  more  favor- 
able soil.  Direct  inoculation  from  without  appears  to  be  the 
mode  of  infection. 

Pathology.-  Microscopic  examination  may  show,  deep  in 
the  corium,  either  sharply  circumscribed  nests  of  mononuclear 
leukocytes  surrounded  by  a  collagenous  capsule,  or  an  infiltra- 
tion of  these  cells,  evenly  diffused  throughout  the  lymph- 
channels  and  surrounding  tissues.  Giant-cells  with  peripherally 
arranged  nuclei  are  constantly  observed.  There  are  also  plasma- 
cells,  mast -cells,  and  large  multi  nuclear  cells  present.    T 


306 


DISEASES  OF  THE   SKIN 


bacilli  are  few,  and  discoverable  only  by  laborious  examination 
of  many  sections.  They  may  be  found  between  the  cells,  but 
are  usually  discovered  in  the  giant-cells.  Inoculation  of  lupus 
tissue  into  a  guinea-pig  will  commonly  produce  a  generalized 
tuberculosis. 

Diagnosis. — The  diseases  most  apt  to  be  confounded  with 
lupus  vulgaris  are  the  tubercular  syphilid,  lupus  erythematosus, 
epithelioma,  and  leprosy.  The  first-named  disease  may  often 
closely  simulate  lupus;  the  differentiation  is  as  follows: 


Lupus  Vulgaris. 

i.  Develops  usually  before  the  age 
of  puberty. 

2.  Course  extremely  slow. 

3.  History,   perhaps,  of  tuberculo- 

sis in  family. 

4.  Concomitant    signs  of   tubercu- 

lous disease. 

5.  Nodules  soft. 

6.  Ulcers  are  comparatively  super- 

ficial, with  irregular  undermined 
edges;  discharge  slight;  crusts 
scant  and  reddish  brown. 

7.  Scars  yellowrish,  shrunken,  and 

hard. 

8.  Refractory  to  all  but  destructive 

measures. 


Tubercular  Syphilid. 

1.  Develops  after   the   age  of  pu- 

berty. 

2.  Course  rapid. 

3.  History  of  infection. 

4.  Concomitant  signs  of  syphilis. 

5.  Nodules  firm. 

6.  Ulcers  are  deep,  with  sharp-cut 

edges;  discharge  copious;  crusts 
bulky  and  greenish. 

7.  Scars  whitish,  soft,  and  smooth. 

8.  Rapid  healing  under  the  iodids 

and  mercury. 


Epithelioma  begins  much  later  in  life,  often  develops  upon 
warts,  moles,  etc.,  and  is  characterized  by  a  central  ulcera- 
tion with  a  hard,  raised,  pearly,  vascular  border.  In  leprosy 
the  eruption  is  more  generalized  and  abundant  and  develops 
later  in  life.  When  macular  patches  are  present,  they  are 
anesthetic. 

Prognosis. — The  disease  runs  an  eminently  chronic  course. 
The  prognosis  depends  upon  the  age  of  the  patient  and  the  form, 
extent,  and  duration  of  the  disease.  Occurring  in  small,  cir- 
cumscribed patches,  the  prognosis  is  favorable.  Some  cases 
are  practically  incurable.  The  possibility  of  generalized  tuber- 
culosis resulting  should  be  borne  in  mind. 

Treatment. — General  hygienic  measures,  such  as  nutritious 
diet,  fresh  air,  exercise,  etc.,  should  receive  attention.  In 
manv  cases  the  administration  of  such  remedies  as  cod-liver 
oil,  iodid  of  iron,  etc.,  is  indicated,  although  no  direct  curative 
influence  is  to  be  expected  from  their  use.  Tuberculin  has  been 
used   in   some   cases   with  encouraging   results.     Its   curative 


TUBERCULOSIS  CUTIS  307 

value,  however,  is  at  the  present  time  not  definitely  deter- 
mined. 

Local  treatment  has  for  its  object  the  destruction  of  the  lupus 
tissue,  with  as  little  resultant  scarring  as  possible.  In  some 
cases  of  an  inflammatory  type  mild  measures  may  at  first  be 
indicated. 

In  hyperemic  cases  the  condition  is  sometimes  improved  by 
the  continued  application  of  calamin  lotion.  Mercurial  plaster 
occasionally  exerts  a  beneficial  influence  on  the  disease.  A 
salicylic-acid  (20  per  cent.),  creasote  (40  per  cent.),  or  resorcinol 
plaster  may  be  used  with  good  results.  Most  cases,  however, 
require  more  heroic  treatment. 

The  solid  stick  of  nitrate  of  silver  is  useful  in  the  treatment 
of  small  discrete  lesions.  It  is  bored  into  the  tissue  until 
the  nodule  is  destroyed.  Every  few  days  new  lesions  are 
attacked. 

Pyrogallic  acid  is  a  slow  but  practically  painless  caustic. 
It  may  be  used  in  a  25  per  cent,  ointment  or  as  a  paint. 

Brocq  advises  the  following: 

4i  .    Acidi  pyrogallici  \  5 5  err  1 

Acidi  salicylici     j aa  gr.  1. 

Collodii f|j  — M. 

Sic — Paint  on  the  part  every  day  until  a  slough  is  produced. 

Personally,  I  prefer  to  use  pyrogallol  in  ointment  form: 

K  .    Acidi  pyrogallici jij ; 

Cerati  resinae q.  s.  ad    3J. — M. 

Sig. — Apply  on  piece  of  muslin. 

After  several  days'  continuous  application,  changed  daily, 
the  necrotic  tissue  is  removed  by  hot  fomentations  and  the 
pyrogallic-acid  treatment  resumed. 

Arsenious  acid  is  a  rapid  caustic,  exerting  a  selective  action 
upon  diseased  tissue.  It  is,  however,  very  painful,  and  can 
be  used  only  over  small  areas  on  account  of  the  danger  of 
absorption. 

R .    Acidi  arseniosi irr.  xx; 

Pulv.  acaciae '  -"n; 

Aquae 

Ft.  past. 

Sig. — Spread  on  lint  and  f 
tice  until  slough  comes  away* 


308  DISEASES  OF  THE    SKIN 

Chlorid  of  zinc  is  an  efficient  caustic,  not  so  painful  as  arsenic. 
It  does  not,  however,  select  diseased  tissue. 

H.    Zinci  chloridi .1?*^ » 

Pulv.  opii Siss; 

Acidi  hydrochlorici fgvj ; 

Aq.  bullientis ^3xx. — M. 

Sig. — To  one  ounce  of  the  solution  add  two  drams  of  wheaten  flour. 
Spread  the  paste  upon  lint  and  apply  for  twenty-four  hours. — {Middlesex 
Hospital  formula.) 

Curetting  is  an  extremely  valuable  procedure.  It  is  often 
supplemented  by  the  use  of  a  caustic,  such  as  a  pyrogallic-acid 
ointment,  or  the  application  of  the  Paquelin  cautery. 

Scarification  is  a  most  useful  measure,  particularly  in  diffuse 
superficial  patches.  Numerous  parallel  incisions,  crossed  at 
right  angles  by  others,  are  made  through  the  skin  by  means 
of  a  sharp  scalpel  or  scarifier.  This  is  often  advantageously 
followed  by  the  application  of  an  iodoform  ointment  or  a 
bichlorid  of  mercury  lotion. 

The  galvanocautery  and  the  Paquelin  cautery  find  a  distinct 
field  of  usefulness  in  the  treatment  of  forms  of  the  disease  char- 
acterized by  discrete  nodules. 

Actinotherapy  and  Radiotherapy. — The  employment  of  con- 
centrated sunlight  and  electric  light  with  an  apparatus  specially 
devised  by  Finsen  has  given  most  excellent  results,  both  as 
regards  permanence  of  cure  and  subsequent  cosmetic  appear- 
ance.    The   treatment   is  long  and   tedious,   and   requires  an 
expensive  outfit,  but  gives  the  best  results  in  lupus  of  any 
treatment  thus  far  advocated.      Within  recent  years  encourag- 
ing results  in  the  treatment  of  selected  cases  of  lupus  have  been 
reported  from  the  use  of  the  x-rays;  one  advantage  of  the  latter 
treatment  is  that  a  large  portion  or  the  entire  diseased  area  may 
be  exposed  to  the  rays  at  one  time,  thus  greatly  shortening  the 
period    of    treatment.     (See    chapter    on    Radiotherapy    and 
Actinotherapy.) 

Surgical  ablation  of  patches  of  lupus  has  been  extensively 
practised  by  Lang;  the  excision  is  followed  by  skin-grafting, 
and  the  results  are  said  to  be  most  satisfactory. 

TUBERCULOSIS  VERRUCOSA  CUTIS 

There  are  several  clinical  varieties  of  warty  tuberculosis  of 
the  skin.  The  condition  is  due  to  the  invasion  of  the  tubercle 
bacillus. 


TUBERCULOSIS  CUTIS 


309 


Tuberculosis  verrucosa  cutis  is  characterized  by  one  or 
several  circumscribed  patches  of  variable  size  and  shape,  occur- 
ring particularly  upon  the  arms  or  legs.  They  are  of  a  brownish 
or  violaceous  color,  and  usually  have  a  warty  or  vegetating 
surface;  sometimes  small  pustules  are  present.  The  condition 
occurs  in  butchers,  dissecting-room  attendants,  and  other 
persons  handling  dead  or  liv- 
ing bodies.  It  may  be  con- 
founded with  blastomycetic 
dermatitis. 

Verruca  Necrogenia(Post- 
mortem  Wart;  Anatomic 
Tubercle).— This  is  a  tuber- 
culous disease,  due  to  local 
inoculation,  and  character- 
ized by  the  development  of 
one  or  several  verrucous  nod- 
ules. 

Symptoms. — The  affection 
begins  at  the  site  of  an  abra- 
sion as  an  inflammatory  ves- 
icopustule;  this  slowly  in- 
creases in  size  and  is  attended 
by  burning  and  itching.  The 
fully  developed  lesion  is  usu- 
ally bean-sized,  flattened,  and 
covered  with  a  horny  or  warty 
surface  or  with  crusts.  The 
fingers  and  knuckles  are  the 
favorite  seats. 

Etiology.  — The  affection 
occurs  in  physicians,  dis- 
secting-room attendants,  and 
those  coming  in  contact  with 
the  cadaver. 

Pathology. — The  disease 
is  produced  by  inoculation 
with  the  tubercle  bacillus. 
This  organism   may  or  may   not  be   found  in   the   tissues. 

Prognosis.— Unless  proper  treatment  is  instituted,  the  dis- 
ease is  progressive.    General  tuberculous  infection  is  of  rare 


DISEASES  OP  THE   SKIN 


Treatment. — The  treatment  consists  of  destruction    of  the 
diseased  tissues  by  means  of  the  curet,  knife,  or  such  caustics 


as  nitric  acid,  caustic  potash,  etc.  The  preliminary  applica- 
tion of  a  25  per  cent,  salicylic-acid  plaster  facilitates  the  treat- 
ment. 


TUBERCULOSIS   CUTIS  311 

TUBERCULOSIS  CUTIS  ORIFICIALIS 
This  form  of  tuberculosis  of  the  skin  is  characterized  by 
indolent,  discrete,  round  or  oval,  shallow,  granulating  ulcers, 
often  covered  with  thin  crusts,  occurring  in  the  neighborhood 
of  the  orifices  of  the  body  (anus,  vulva,  nose,  and  mouth). 
The  ulcers  are  painless,  exhibit  no  tendency  to  heal,  and  pursue 
a  slow,  progressive  course.  There  is  nearly  always  visceral 
tuberculosis  present,  and  frequently  there  are  lesions  of  the 
adjacent  mucous  tracts,  which  show  yellowish;  miliary  papules. 
The  condition  is  very  rare.  Chiari  observed  but  5  cases  among 
3000  to  4000  autopsies  on  tuberculous  subjects. 

SCROFULODERMA 

Derivation. — L.,  scrofa,  a  sow. 

Definition. — Scrofuloderma  is  a  tuberculous  affection  of 
the  skin  and  subcutaneous  tissues,  originating  in  the  lymph- 
glands  and  terminating  in  ulceration  of  the  integument. 

Symptoms. — The  affection  begins  in  one  or  more  lymph- 
glands,  which  become  swollen,  constituting  variously  sized 
tumors  unaccompanied  by  redness  or  pain.  Later  these  glands 
undergo  caseation  and  suppuration,,  the  overlying  skin  becom- 
ing tense,  violaceous,  and  riddled  with  sinuses  which  permit 
the  escape  of  a  caseous,  sanious  pus. 

The  scrofulous  ulcer  is  usually  almond  shaped,  with  thin, 
violaceous,  undermined  edges,  and  an  uneven  base  made  up 
of  pale,  flabby  granulations. 

The  course  is  slowly  progressive.  When  cicatrization  occurs, 
the  scars  are  seen  to  be  irregular,  knotty,  and  hard. 

The  most  common  seat  of  the  disease  is  about  the  face  and 
neck. 

Conjunctivitis,  keratitis,  blepharitis,  rhino rrhea,  otorrhea, 
bone  trouble,  etc.,  are  at  times  associated  with  the  lymphatic 
and  cutaneous  involvement. 

Etiology. — Scrofuloderma  is  a  form  of  cutaneous  tuberculosis 
and  is  due  to  the  tubercle  bacillus. 

Diagnosis. — From  lupus  vulgaris  scrofuloderma  mav  be 
distinguished  by  the  absence  of  outlying  tubercles  and  patches. 
From  syphilis  it  may  l>e  distinguished  l>v  the  peculiar  character 
of  tin  si-Toi'iilny.  ulcer,  the  history,  the  slow -course .  and  pn  -..  tn-- 
of  other  signs  of  struma. 

Treatment.— The  c 


DISEASES  OF   THE   SKIN 


Fig.   i4j. — Scrofulodrrm  (tuberculosis)  having  its  origin  in  a  lymphatic  gland. 


food,  proper  hygiene,  and  the  use  of  such  tonics  as  cod-liver  oil 
and  iodid  of  iron. 


Fig.    1*4- — Scrofulodci 


DERMATOSES  ASSUMED  TO  BE  RELATED  TO  TUBERCULOSIS   313 

The  local  treatment  has  for  its  object  the  destruction  of  the 
ulcers.  This  may  be  accomplished  by  the  use  of  the  curet,  knife, 
or  caustics,  or  preferably  by  the  use  of  the  x-rays. 

MILIARY    TUBERCULOSIS    OF    THE    SKIN 

An  acute  miliary  tuberculosis  of  the  skin  has  been  observed 
chiefly  in  children.  It  usually  accompanies  a  general  miliary 
tuberculosis.  The  condition  may  follow  the  exanthematic 
fevers.  The  lesions  consist  of  small,  brownish-red,  conical  pap- 
ules, suggesting  acne  lesions.  They  may  later  break  down  and 
form  sharply  cut  ulcers,  upon  the  periphery  and  base  of  which 
miliary  tubercles  may  be  seen. 

A  dermatitis  tuberculosa  acuta  has  been  described  by  Heller 
and  Gaucher,  in  which  a  variety  of  lesions,  macules,  papules, 
pustules,  vesicles,  or  blebs  may  develop,  terminating  in  ulcers 
and  associated  with  glandular  caseation. 

DERMATOSES   ASSUMED   TO   BE   RELATED   TO   TUBER- 
CULOSIS 

There  are  a  number  of  dermatoses  described  by  various 
authors  under  diverse  names,  some  of  which  appear  to  be 
related  to  tuberculosis.  Darier  designated  these  "tubercu- 
lides," and  Hallopeau,  believing  them  to  be  caused  by  the  toxins 
of  the  tubercle  bacillus,  called  them  "toxituberculids."  Con- 
siderable difference  of  opinion  exists  as  to  the  identity  of  these 
variously  titled  eruptions.  Several  of  the  more  common  affec- 
tions will  be  briefly  described. 

ACNITIS  (Barthclemy) 

Acnitis  is  identical  with  Crocker's  acne  agminata,  but  is  dis- 
tinct from  folliclis.  Tilbury  Fox  described  three  cases  of  this 
disease  in  1878  as  a  form  of  lupus.  The  eruption  is  usually 
confined  to  the  face,  but  may  occur  later  on  the  limbs.  The 
lesions  consist  of  pin-point-  to  pin-head-sized,  firm,  brownish- 
red  papules  and  nodules,  tending  at  times  to  form  pustules. 
A  distinguishing  feature  is  the  tendency  to  grouping  about  the 
chin,  cheeks,  or  temples.  The  nodules  are  lupoid  in  appear- 
ance. Occasionally  several  lesions  coalesce  into  a  nodular 
patch.     The    eruption    is  indolent  and   persistent,   and   not 


DISEASES   OF   THE   SKIN 


affected  by  the  usual  treatment  for  acne.  After  involution, 
small  pigmented  scars  are  often  left.  In  a  case  under  the 
author's  care  guinea-pig  inoculations  and  the  tuberculin  test 
were  negative . 

FOLL1CLIS    (B.rthatmy) 

The  eruption  in  folliclis  is  more  apt  to  attack  the  hands, 
forearms,  feet,  and  legs,  although  the  face  may  also  be 
affected. 

The  lesions  begin  as  red  spots,  but  soon  inflammatory  reddish 
papules  are  formed  which  tend  to  vesiculate  at  the  summit  and 
become,  pustular.  A  dark-colored,  tightly  adherent  horny 
center  is  often  observed,  and  is  quite  characteristic.  There 
is  no  tendency  to  grouping.  The  lesions  may  run  their  course 
in  a  few  weeks,  but  new  crops  appear,  and  the  affection  may 
last  for  years,  with  seasonal  interruptions.  The  affection  occurs, 
as  a  rule,  in  tuberculous  subjects  or  in  the  offspring  of  such 
persons.  I  have  seen  several  series  of  cases  in  which  three  or 
four  children  in  a  family  simultaneous! v  presented  the  eruption 


BLASTOMYCOSIS    CUTIS 


upon  the  hands  and  face.  In  these  patients  the  eruption  dis- 
appeared in  the  summer  months  and  returned  as  the  cold 
season  approached. 


Fig.  146. -Tuberculid  (follidls)  or  sir 
patient  only  in  the  winter  months.     Followed  by  si 


This  affection  appears  to  be  closely  related  to,  if  not  identical 
with,  the  "small  pustular  scrojuloderm  "  described  by  Duhring. 


BLASTOMYCOSIS  CUTIS 

Synonyms. —  Dermatitis  blast  omycotica;  Blaslomycelic  dermatitis. 

Definition. — Blastomycosis  is  a  chronic  infectious,  inflam- 
matory disorder,  due  to  the  invasion  of  blastomycetes  (patho- 
genic  yeast   fungus),   and  characterized  by   sharply  1 


316  DISEASES  OF  THE   SKIN 

elevated,  warty  or  papillomatous  patches,  the  borders  of  which 
are  studded  with  minute  abscesses  which  exude  a  puriform 
secretion. 

Blastomycetic  dermatitis  was  first  described  by  Gilchrist 
and  Stokes  in  1897.  Since  that  time  about  50  cases  have 
been  observed.  The  disease  is  common  in  Chicago,  where 
it  has  been  thoroughly  studied  by  Hyde,  Montgomery,  and 
others. 

Symptoms. — The  disease  begins  as  a  papule  or  papulopustule 
which  becomes  crust-covered  and,  enlarging,  acquires  a  warty 
surface.  The  eruption  spreads  by  peripheral  extension  or  by  the 
appearance  of  new  lesions.  When  a  coin  or  larger-sized  patch 
is  developed,  the  appearances  are  as  follows:  The  patch  is 
distinctly  elevated,  with  a  sharply  margined  border;  it  is 
covered  with  papillary  excrescences  which  give  it  a  warty  or 
cauliflower  appearance.  Young  patches  are  comparatively 
dry;  older  patches  have  a  soft,  pus-infiltrated  base,  frequently 
covered  with  crusts.  The  granulations  are  often  vascular  and 
readily  disposed  to  bleed.  The  border  exhibits  a  characteristic 
appearance:  it  is  dark  red  or  violaceous,  and  slopes  from  the 
elevated  plaque  to  the  healthy  skin.  It  is  studded  with  minute 
abscesses,  sometimes  visible  only  with  the  aid  of  a  magnifying 
lens.  Other  portions  of  the  patch  may  also  exhibit  miliary 
abscesses.  When  punctured  with  a  fine  needle,' a  glairy  muco- 
pus  is  evacuated  in  which  the  yeast  organism  is  found.  Parts 
of  larger  patches  may  heal  and  become  covered  with  an  irregu- 
lar, pinkish,  shining  scar.  Miliary  abscesses  may  develop  in 
the  cicatricial  tissue.  The  face,  hands,  and  arms  are  the  areas 
most  frequently  attacked,  but  the  disease  may  occur  upon 
any  portion  of  the  body.  The  disease  is  indolent  in  its  course, 
a  patch  one  inch  in  diameter  usually  requiring  months  to 
develop. 

A  number  of  fatal  cases  of  systemic  blastomycosis  have  been 
reported.  Pyemia,  with  subcutaneous  abscesses  or  pulmonary 
involvement,  may  develop. 

Etiology. — The  disease  is  due  to  local  infection  with  a 
pathogenic  yeast  fungus.  A  cutaneous  wound  favors  the  inva- 
sion of  the  organism.  One-half  of  the  patients  have  been  over 
forty  years  of  age.  The  disease  appears  to  be  much  more 
common  in  the  United  States  than  abroad. 

Pathology. — There  is  an  enormous  downgrowth  of  the  rete 
projections,  which  assume  various  irregular  shapes.     In  these 


ACTINOMYCOSIS  317 

are  found  the  characteristic  miliary  abscesses  filled  with  poly- 
morphonuclear leukocytes,  occasionally  giant-cells  and  yeast- 
organisms.  The  blastomyces  are  also  found  between  epithelial 
cells  and  in  the  corium.  They  are  round,  oval,  or  irregular, 
with  a  double  contoured  capsule  and  granular  protoplasm, 
often  containing  a  vacuole.  Unequal  pairs  of  organisms  or 
budding  forms  may  be  seen.  Cultures  on  agar  or  glucose-agar 
produce  a  white,  cotton-like  growth. 

Diagnosis. — The  disease  is  principally  to  be  differentiated 
from  tuberculosis  verrucosa  cutis,  which  it  may  strongly 
resemble.  Often  microscopic  and  cultural  examinations  are 
necessary  to  establish  the  diagnosis.  A  border  showing  miliary 
abscesses  is  strongly  suggestive  of  blastomycosis;  pus  from 
these  macerated  in  20  to  30  per  cent,  potassium  hydroxid 
solution  commonly  shows  budding  organisms  in  this  disease. 

Prognosis. — Favorable  unless  septicemia  or  other  systemic 
infection  has  taken  place. 

Treatment. — Potassium  iodid  in  large  doses  restrains  or 
arrests  the  disease.  This  drug,  with  the  use  of  the  x-rays,  has 
proved  curative  in  a  number  of  cases.  Complete  excision  has 
been  successful  in  several  cases,  but  cureting  alone  is  apt  to 
be  followed  by  recurrence. 

ACTINOMYCOSIS 

Derivation. — 'Anc-ic,  ray;  ^i'*w,  mushroom.     Synonym. — Lumpy -jaw. 

Definition. — Actinomycosis  is  a  parasitic  disease  occurring 
in  the  lower  animals  and  man,  due  to  the  ray-fungus,  and  char- 
acterized by  deep  subcutaneous  tumQrs  or  swellings  which 
break  down  and  suppurate. 

Symptoms. — The  face  and  neck  are  the  parts  usually 
involved,  the  parasite  in  such  cases  gaining  entrance  to  the 
tissues  around  carious  teeth.  The  onset  of  the  disease  is  insidi- 
ous, weeks  or  months  elapsing  before  the  appearance  of  cuta- 
neous manifestations. 

The  lesions  consist  of  deep-seated  tumors  or  swellings  which, 
approaching  the  surface,  become  red  or  livid  in  color,  and, 
breaking  down,  discharge  a  bloody  seropus  containing  char- 
acteristic yellow  granules.  These  granules  are  made  up  almost 
exclusively  of  fungus.  Sinuses  with  uneven  nodular  edges 
persist  for  an  indefinite  period.  The  tumors  may  roughly 
suggest  the  appearance  of  sarcoma. 


3l8  DISEASES   OP   THE    SKIN 

Etiology  and  Pathology. — The  disease  is  due  to  the  invasion 
of  the  organism  by  the  actinomyces  or  "ray-fungus."  The 
fungus  consists  of  club-shaped  threads  radiating  from  a  common 
center.  It  is  uncommon  for  the  infection  to  gain  entrance 
through  the  skin. 


Treatment. — The  administration  of  large  dose?  of  potassium 
iodid  has  proved  successful  in  many  cases,  and  should  be  given 
thorough  trial.  Locally,  irrigation  with  corrosive  sublimate 
solutions  is  advised.  In  obstinate  cases  the  parts  should  be 
thoroughly  cureted.  The  use  of  the  .i-rays  would  seem  to  be 
indicated. 

MYCETOMA 

Derivation — Mp»vr,  a  fungus.  Synonyms. —  Podelconia :  Fungus  foot 
of  India;   Madura  foot. 

Definition. — Mycetoma  is  an  endemic  disease,  due  to  the 
presence  of  a  vegetable  fungus,  characterized  by  disintegration 
of  the  tissues,  chiefly  of  the  foot  and  hand. 

Symptoms.— The  disease  occurs  most  frequently  in  India, 
In  a  typical  case  the  foot  is  swollen  and  infiltrated  and  beset 
with  pea-  to  nut-sized  tubercles  or  nodules.     These  break  down 


SPOROTRICHOSIS  319 

with  the  formation  of  sinuses,  which  connect  with  the  deeper 
structures  and  which  give  exit  to  a  thin,  seropurulent  fluid 
containing  whitish  or  blackish  granules.  Bony  structures  may 
become  involved.  The  course  is  chronic,  the  disease  lasting  for 
years.  The  disease  is  chiefly  encountered  in  India  and  neighbor- 
ing eastern  countries,  although  a  few  cases  have  been  reported 
in  this  country. 

Treatment. — Complete  removal  by  means  of  the  knife  or 
curet  is  the  only  successful  treatment.  The  use  of  the  iodid  of 
potassium  has  been  suggested. 

SPOROTRICHOSIS 

Definition. — Sporotrichosis  is  a  chronic  or,  more  rarely,  an 
acute,  infectious  process,  characterized  by  the  formation  of  a 
local  inoculation  lesion  followed  by  multiple  cutaneous  and 
subcutaneous  nodules,  which  undergo  suppuration  and  ulcera- 
tion. 

The  disease  in  man  was  first  described  by  Schenck  in  1898, 
under  the  title  "  Refractory  Subcutaneous  Abscesses  caused  by 
a  Fungus,  Probably  Related  to  the  Sporothrix." 

Since  then  Hektoen  and  Perkins,  de  Beurmann,  and  his 
associates  in  France,  Brayton,  Dor,  Stein,  Hyde,  and  others 
have  reported  cases.  De  Beurmann's  name  is  intimately 
associated  with  the  disease  because  of  his  clinical  and  patho- 
logic studies.     About  100  cases  have  thus  far  been  reported. 

Symptoms. — The  period  of  incubation  following  accidental 
inoculation  with  the  causative  sporothrix  is  quite  uniformly 
between  six  and  twelve  days.  The  hand  and  forearm  are  the 
sites  most  often  infected,  although  the  face,  thigh,  leg,  foot, 
and  other  regions  may  be  the  seat  of  the  primary  infection. 

Following  the  infection,  firm  indolent  cutaneous  and  sub- 
cutaneous nodules  and  tumors  develop,  which  in  the  course  of 
four  to  six  weeks  undergo  softening  and  ulceration  and  give 
exit  to  a  seromucoid  discharge.  Fistulous  tracts  may  com- 
municate with  deep-seated  abscesses.  The  abscesses  and  ulcers 
are  surrounded  by  a  reddish -violet  coloration.  These  so-called 
sporotrichotic  gummata  are  usually  multiple,  and  have  been 
observed  to  number  as  many  as  four  score  or  more.  They 
commonly  develop  along  the  line  of  the  lymphatic  vessels  near 
the  site  of  infection.  At  other  times  the  tumors  are  scattered. 
There  is  associated  enlargement  of  the  neighboring  lymphatic 


320  DISEASES   OF   THE   SKIN 

glands.  Other  tissues  than  the  skin  may  be  exceptionally 
affected,  such  as  the  mucous  membranes,  the  muscles,  the 
joints,  the  bones,  the  testes,  and  the  spinal  marrow. 

Clinically,  there  are  two  groups  of  cases,  the  chronic  and  the 
acute  cases.  Most  cases  run  a  chronic,  afebrile  course,  without 
serious  disturbance  of  the  general  health.  In  rare  instances 
there  are  acute  cases  which  run  a  rapid  course,  with  high  fever, 
prostration,  emaciation,  and  digestive  disturbances.  Leuko- 
cytosis is  usually  present  in  sporotrichosis. 

Etiology. — Two-thirds  of  the  cases  reported  have  been  in 
men.  The  usual  age  is  from  the  third  to  the  sixth  decade. 
Hyde  and  Davis  state  that  some  of  the  American  cases  of 
"mycotic  or  epizootic  lymphangitis"  in  horses  is  due  to  the 
sporotrichum  Schenckii,  and  that  it  is  probable  that  human 
cases  have  been  derived  from  the  equine  disease.  The  mold  is, 
however,  not  uncommon  about  barnyards  and  untilled  fields, 
and  may  infect  both  horses  and  men. 

Pathology. — The  gummata  exhibit  an  intense  inflammatory 
reaction  of  the  connective  tissue,  most  marked  about  the  blood- 
vessels, with  plasma  cells  and  lymphocytes  in  the  peripheral 
zone,  epithelioid  and  giant-cells  in  the  middle  zone,  and  abscess 
in  the  center.  Caseation,  such  as  is  seen  in  tuberculosis,  is 
absent. 

The  sporothrix  examined  in  the  hanging  drop  from  cultures 
several  days  old  exhibits  abundant  mycelia,  with  oval  or  pyri- 
form  spores  attached  by  fine  pedicles.  The  spores  are  3  to 
5  /1  in  length  and  2  to  3  ,«  in  width.  The  mold  grows  best  upon 
media  containing  sugar,  but  will,  nevertheless,  flourish  on  ordi- 
nary culture-media  at  room  temperature.  The  parasite  has, 
up  to  the  present,  not  been  found  in  the  microscopic  sections 
of  human  tissues.  Experimentally,  the  fungus  can  be  inocu- 
lated successfully  into  guinea-pigs,  mice,  rats,  cats,  and  mon- 
keys.    The  rat  is  the  most  susceptible. 

Diagnosis. — The  disease  is  most  apt  to  be  confounded  with 
tertiary  syphilis  or  tuberculosis  of  the  skin.  Occasionally  deep 
trichophytosis  may  be  simulated.  Syphilitic  gummata  are  less 
numerous,  of  slower  development,  and  do  not  form  large  ab- 
scesses. Syphilitic  ulcers  are  circular,  with  borders  that  are 
lined  with  a  necrotic  covering,  and  are  not  undermined. 

The  sporotrichotic  gummata  develop  more  rapidly  and  un- 
dergo suppuration  sooner  than  tuberculous  lesions;  the  dis- 
charge is  mucoid  instead  of  thin  and  granular ;  the  scars  are 


SYPHILODERMA  32 1 

not  elevated  and  seamed;  general  lymphatic  enlargement  is 
usually  absent. 

Cultures  from  the  pus  readily  disclose  the  presence  of  the 
characteristic  fungus. 

Prognosis. — Most  cases  of  sporotrichosis  recover  under  ap- 
propriate treatment. 

Treatment. — The  sovereign  remedy  against  this  disease  is 
iodid  of  potassium  in  increasing  doses,  beginning  with  10  grains 
three  times  a  day.  Locally,  for  the  abscesses  and  ulcers, 
diluted  Lugol's  solution  has  been  advised. 

VERRUGA  PERUANA 

Verruga  is  a  specific  febrile,  infectious  disease,  endemic  in 
certain  valleys  of  the  Peruvian  Andes. 

It  is  characterized  by  an  intense  anemia,  muscular  and  joint 
pains,  fever,  and  later  by  a  peculiar  eruption.  It  is  transmis- 
sible by  inoculation,  the  incubaticm  period  varying  between  eight 
and  forty  days.  The  cutaneous  symptoms  appear  from  twenty 
days  to  six  months  after  the  onset  of  symptoms.  The  erup- 
tion begins  upon  the  face  and  extremities,  later  spreading  to 
other  parts.  The  mucous  membranes  participate  in  the  proc- 
ess. The  early  lesions  are  itching  red  spots  or  vesicles;  later, 
vegetative  growths  resembling  warts,  both  sessile  and  pedun- 
culated, appear  upon  these  sites.  The  granulations  may  be 
small  or  large,  discrete  or  confluent.  Ultimately  these  warts, 
during  the  stage  of  retrogression,  become  desiccated  and 
horny. 

Microscopically,  the  disease  is  a  connective-tissue  new-growth 
resembling  sarcoma. 

SYPHILODERMA 

Derivation. — 2i»c,  and  $&oct  a  companion  of  swine.  Synonyms. — Syph- 
ilis cutanea;  Dermatosyphilis;  Syphilis  of  the  skin;  Lues. 

SYPHILIS 

Definition. — Syphilis  is  a  chronic,  systemic,  infectious  disease, 
due  to  inoculation  with  the  spirochaeta  pallida.  It  is  character- 
ized by  eruptive  manifestations  involving  the  skin  and  mucous 
membranes,  but  any  tissue  or  organ  may  be  affected.  The 
disease  is  not  infrequently  transmitted  to  progeny. 

Symptoms. — Chancre. — At  the  site  of  infection  or  entrance 
21 


322  DISEASES  OF    THE   SKIN 

of  the  spirochetes  into  the  body  (save  in  hereditary  syphilis) 
certain  tissue  changes  take  place  which  give  rise  to  a  lesion 
recognized  clinically  as  a  chancre.  This  initial  lesion  of  the 
disease  develops  after  'a  primary  incubation  period  which 
averages  three  weeks,  but  which  ordinarily  varies  from  twelve 
to  thirty  days,  and  in  exceptional  cases  extends  to  forty  or 
sixty  days. 

There  are  a  number  of  clinical  varieties  of  the  chancre  depend- 
ent upon  the  physical  appearance  of  the  lesion.  The  three 
chief  varieties  are :  the  chancrous  erosion,  the  chancrous  ulcera- 
tion, and  the  dry  papule.  In  addition,  there  are  initial  sores 
occasionally    encountered    which    present    certain    deviating 


characteristics,  among  these  may  be  mentioned  the  multiple 
herpetijorm  chancre  of  Dubuc,  the  silvery  spot  described  by 
Taylor,  of  New  York,  and  the  injecting  balanoposthitis  of 
Mauriac.  Space  will  not  permit  a  detailed  description  of  these 
various  forms. 

Induration  is  an  important  diagnostic  feature  of  the  chancre; 
by  this  is  meant  a  sclerotic  hardening  of  the  tissues  beneath 
and  around  the  sore.  It  is  essential  to  recognize  that  indura- 
tion is  not  a  feature  of  chancres  in  their  early  incipiency. 
Fully  ten  to  fourteen  days  or  longer  are  necessary  to  develop 
the  characteristic  hardness.  The  secretion  of  the  chancre  is 
serous  in  character,  although  as  a  result  of  adventitious  causes 
it  may  become  purulent  or  seropurulent.     Chancres  are  usu- 


SYPHILODERMA 


323 


ally  single,  but  occasionally  two,  three  or  more  lesions  may  be 
present.  After  the  healing  of  a  chancre  a  more  or  less  well- 
developed  scar  remains;  at  times  this  is  depressed,  at  other 
times  it  is  elevated. 

In  all  cases  of  true  chancre  an  adenopathy  or  enlargement  of 
the  neighboring  lymphatic  glands  develops.  There  is  also 
commonly  an  induration  of  the  lymphatics,  or,  more  properly 
speaking,  of  the  perivascular  lymph-spaces. 

Chancres,  for  obvious  reasons,  appear  usually  upon  or  in  the 
neighborhood  of  the  genital  organs.  They  may  develop,  how- 
ever, upon  any  portion  of  the  cutaneous  surface  or  in  any 
of  the  adjacent  mucous  cavities.     The  sites  of  extragenital 


chancres,  in  the  order  of  their  frequency,  are  as  follows:  lips, 
breasts  (in  female),  buccal  cavity,  fingers  and  hand,  eyelids 
and  conjunctivae,  tonsils,  throat,  tongue,  chin,  cheek,  trunk, 
arms,  legs  and  thigh,  neck,  gums,  etc. 

Stages  of  Syphilis. — For  purposes  of  simplicity  in  teaching 
syphilis  has  been  divided  into  three  stages:  primary,  secondary, 
and  tertiary.  This  classification  of  Ricord  is  open  to  objection 
if  interpreted  as  representing  definite  and  determinate  periods 
of  the  disease  applicable  to  all  patients.  It  must  be  remembered 
that  the  boundaries  of  these  periods  are  artificial,  and  that 
symptoms  ordinarily  observed  in  the  early  intermediate  or 
late  stage  may,  in  certain  individuals,  be  noted  earlier  or 
later  than  usual.     Syphilis  is  an  uninterrupted,  morbid  process, 


324 


DISEASES  OF  THE   SKIN 


but  is  characterized  by  a  fair  degree  of  uniformity  in  the  chro- 
nology of  its  manifestations. 

The  chancre  and  the  associated  adenopathy  represent  the 
primary  stage.     The  secondary  stage  is  characterized  by  a  series 


of  constitutional  symptoms,  including  the  appearance  of  a 
generalized  eruption.  In  the  late  tertiary  period  we  note  certain 
cutaneous  outbreaks  and  involvement  of  various  organs  and 
tissues. 


SYPHILODERMA 


The   eruption  of  syphilis  may  be  macular  (erythematous), 
papular,  vesicular  (rare),  pustular,  bullous,  tubercular,  gum- 


3^6  DISEASES   OP   THE   SKIN 

matous,  ulcerative,  or  mixed.  The  macular,  papular,  vesicular, 
and  pustular  eruptions  belong  to  the  secondary  period,  and  the 
tubercular,  bullous,  gummatous,  and  ulcerative  to  the  late 
stage. 

General  Characteristics  of  Syphilitic  Eruptions. — Dis- 
tribution.-— The  early  or  secondary  eruptions  are  generalized 
and  more  or  less  symmetric.  The  late  or  tertiary  eruptions 
are  circumscribed,  and,  as  a  rule,  asymmetric.  Syphilids  are 
commonly  seen  on  the  scalp,  particularly  upon  the  hairy  border, 
about  the  commissures  of  the  mouth,  the  ate  of  the  nose,  the 
genitalia,  anus,  palms,  and  soles. 

Color. — Too  much  importance  has  been  attached  to  the  color- 
ation  of   syphilitic   eruptions.     In   the   beginning,   the   early 


lesions  have  usually  a  pinkish-red  hue,  but  are  colder  and  more 
subdued  in  color  than  in  most  inflammatory  dermatoses.  As 
they  persist,  they  assume  more  of  a  brownish  or  yellowish-red 
color,  and  ultimately  fade,  leaving  a  yellowish -brown  pigmenta- 
tion. The  large  papular  and  tubercular  lesions  have  commonly 
the  so-called  "ham  or  copper  color,"  but  this  same  hue  may  be 
noted  at  times  in  psoriasis,  lupus,  and  other  diseases.  Syphilitic 
scars  are  apt  to  be  smooth  and  pigmented. 


SYPHILODERMA  327 

Polymorphism. — The  coincident  appearance  of  various  types 
of  cutaneous  lesions  is  commonly  observed  in  the  early  erup- 
tions of  syphilis.  Thus  macules  and  papules  or  papules  and 
pustules  are  frequently  noted  at  the  same  time.  This  is  doubt- 
less due  to  the  comparative  chronicity  of  the  process  and  the 
development  of  lesions  in  crops. 

Configuration. — The  early  symptoms  are  generally  distributed. 
In  negroes,  especially,  there  is  a  pronounced  tendency  to  annular 
arrangement  of  lesions  (Fig.  151).  Nodular  eruptions  are  prone 
to  take  on  circular,  crescentic,  or  serpiginous  outlines. 

Absence  of  Subjective  Symptoms. — Syphilitic  eruptions  are 
remarkably  free  from  itching,  burning,  or  painful  sensation. 
This  applies  to  the  vast  majority  of  cases,  but  is  not  without 
exception.  Early  eruptions  that  develop  with  great  rapidity 
may  cause  some  itching;  decided  itching,  too,  may  occur  in 
the  small  papular  syphilids,  particularly  when  they  scale. 
Syphilitic  ulcers  are  distinctly  less  painful  than  corresponding 
lesions  from  other  causes. 

General  Symptoms  of  Secondary  Syphilis. — At  the  ter- 
mination of  the  secondary  period  of  incubation,  which  lasts  on 
an  average  about  six  weeks,  a  train  of  constitutional  distur- 
bances is  commonly  noted.  These  are — (a)  General  enlarge- 
ment of  the  superficial  and  deep  lymphatic  glands;  (b)  moderate 
fever,  the  evening  temperature  commonly  reaching  ioo°  to 
1010  F.,  although  it  may  be  higher;  (c)  lassitude  and  anorexia; 
{d)  articular  and  muscular  pains  (these  are  apt  to  be  worse  at 
night);  .(e)  anemia;  (/)  alopecia,  producing  irregular  streaky 
or  moth-eaten  patches  of  hair-loss;  (g)  congestion  and  ulcer- 
ation of  throat,  and  mucous  patches;  (h)  eruptions  upon  the 
skin. 

WASSERMANN  REACTION 

The  biologic  test  known  as  the  "  Wassermann  test  "  was 
first  brought  to  the  attention  of  the  medical  profession  by 
Wassermann,  Neisser,  and  Bruck  on  May  10,  1896.  Two 
weeks  later  Detre,  working  independently,  published  similar 
observations. 

The  Wassermann  reaction  is  employed  both  as  a  diagnostic  test 
and  as  a  therapeutic  index.  It  is  based  on  the  "  complement 
deviation  reaction  "  elaborated  by  Bordet  and  Gengou. 

Briefly,  the  principles  are  as  follows: 

Repeated  injections  of  red  blood-cells  of  one  animal  into  an 
alien  species  develop  in  the  blood-serum  of  the  latter  a  defensive 


3^8  DISEASES  OF  THE    SKIN 

substance  called  "  amboceptor,"  which  has  a  specific  affinity 
for  these  erythrocytes,  and  in  the  presence  of  "  complement  " 
prepares  them  for  solution  by  the  latter. 

In  the  Wassermann  test  guinea-pig  serum  is  used  as  comple- 
ment, while  the  amboceptor  is  rabbit's  blood,  immunized  against 
sheep's  corpuscles.  The  sheep's  red  blood-cells,  altered  by  the 
amboceptor,  absorb  the  complement  and  undergo  hemolysis. 

Now,  if  the  blood-serum  of  a  syphilitic  subject  (presumably 
containing  antibodies)  is  mixed  under  certain  conditions  with 
extract  of  syphilitic  liver,  called  "  antigen  "  (or  of  certain  anti- 
gens made  of  alcoholic  extracts  of  normal  organs),  a  specific 
union  occurs  which,  in  the  presence  of  the  "  complement," 
will  absorb  or  fix  the  latter.  When  the  amboceptor  and 
sheep's  corpuscles  are  later  added,  the  complement  having  been 
absorbed,  hemolysis  will  not  take  place.  If  the  suspected 
patient's  serum  is  not  syphilitic,  then  the  complement  remains 
unabsorbed,  and  is  left  free  to  dissolve  the  sheep's  erythrocytes 
sensitized  by  the  amboceptor. 

In  the  positive  test  (hemolysis  restrained)  the  corpuscles  settle 
at  the  bottom  of  the  test-tube :  when  the  test  is  negative  (hemo- 
lysis), the  fluid  in  the  test-tube  is  diffusely  stained  with  the  free 
hemoglobin. 

A  positive  test  (with  the  following  reservations)  indicates 
active  syphilis,  i.  e.,  the  presence  of  living  spirochetes.  (Positive 
reactions  may  be  obtained  in  yaws  and  in  a  proportion  of 
cases  of  scarlet  fever,  malaria,  leprosy,  etc.,  and  within  a  period 
of  twenty-four  to  forty-eight  hours  after  the  administration 
of  ether.) 

A  negative  reaction  is  presumptive,  but  not  absolute,  evi- 
dence of  the  absence  of  syphilis. 

The  Wassermann  test  is  of  great  value  in  the  diagnosis  of 
obscure  cases  of  syphilis,  particularly  of  visceral  lesions.  It 
is  also  of  importance  in  determining  the  extinction  of  the  spiro- 
chetes in  the  system.  Permanent  negative  Wassermann  reac- 
tions indicate  the  cure  of  the  disease. 

In  primary  syphilis  the  reaction  develops  only  in  from  five 
to  thirty  days  after  the  appearance  of  the  chancre.  It  is 
present  in  nearly  all  cases  of  secondary  syphilis,  and  in  a  large 
percentage  of  tertiary  cases. 

Modifications  of  the  Wassermann  reaction,  with  a  view  to 
simplification,  have  been  made  by  a  number  of  workers;  the 
best  known  of  the  modified  tests  is  that  of  Noguchi. 


SYPHILODERMA 


329 


The  value  of  the  Wassermann  reaction  depends  in  large 
measure!  upon  the  perfection  of  the  delicate  technic  and  the 
skill  of  the  laboratory  worker. 

A  further  word  of  caution  is  necessary :  a  positive  Wassermann 
reaction  means  that  the  patient  whose  blood  is  examined  has 
active  syphilis;  it  does  not  prove  that  the  cutaneous  eruption 
or  other  lesion  under  suspicion  is  syphilitic  in  character.  A 
person  suffering  from  syphilis  may  happen  to  be  the  subject  of 
herpes  zoster,  psoriasis,  cancer,  or  any  other  dermatosis. 

The  early  eruptions  of  syphilis  may  be  distinguished  from  the 
late  eruptions  as  follows: 


Early  Eruptions. 

1.  Accompanied   by  constitutional 

disturbances,  sore  throat,  alo- 
pecia, etc. 

2.  Eruption  generalized  and  sym- 

metric. 

3.  Lesions  comparatively  superficial 

and   not   destructive. 

4.  Eruption   macular,    papular,   or 

pustular. 


3- 


Late  Eruptions. 

Frequently  accompanied  by 
osteocopic  pains  and  stigmata 
of  former  manifestations. 

Eruption  circumscribed  and 
asymmetric. 

Lesions  deep-seated  and  destruc- 
tive. 

Eruption  nodular,  gummatous* 
or  ulcerative. 


SYPHILODERMA    ERYTHEMATOSUM    (MACULAR    SYPHILODERMt 

ROSEOLA) 

The  macular  syphilid  is  the  most  frequent  form  assumed 
by  the  early  eruption.  It  develops,  usually,  from  six  to  eight 
weeks  after  the  initial  lesion,  and  requires  a  week  to  ten  days 
for  its  full  development.  It  is  characterized  by  rounded,  oval 
or  irregular,  pea-  to  finger-nail-sized,  ill-defined  macules,  which 
are  at  first  of  a  rose-red  color,  later  becoming  violaceous,  brown- 
ish, or  yellowish.  The  trunk,  particularly  the  anterior  surface, 
and  the  extremities  are  most  frequently  involved.  In  the 
beginning  the  lesions  disappear  under  pressure  of  the  finger; 
later  similar  manipulation  discloses  the  presence  of  a  brownish- 
yellow  pigment  in  the  skin.  The  face  is  usually  exempt.  The 
eruption  lasts  from  one  to  four  weeks.  Papular  and  pustular 
lesions  may  later  appear,  particularly  in  untreated  cases. 
Occasionally  a  roseola  may  partially  relapse  after  disappearing. 

Diagnosis. — The  macular  syphiloderm  is  to  be  differentiated 
from  measles,  tinea  versicolor,  and  the  rashes  due  to  copaiba  and 
other  drugs. 


330 


DISEASES   OF  THE   SKIN 


Macular 
Syphiloderm. 

(i)  Associated 
symptoms  of 
syphilis — mu- 
cous patches, 
alopecia,  en- 
larged glands, 
remains  of 
chancre,  etc. 

(2)  Fever  occa- 
sionally and 
usually  moder- 
ate. 


(3)  Eruotion 
chiefly  on 
trunk  and  ex- 
tremities; face 
usually  free. 

(4)  Eruption 
consists  of  pea- 
to  finger-nail- 
sized,  oval  or 
rounded  mac- 
ules, at  first 
rose-red,  later 
violaceous, 
brownish,  or 
yellowish. 

(5)  Itching  ab- 
sent. 

(6)  Wassermann 
reaction,  posi- 
tive. 


Measles. 


Tinea 
Versicolor. 


Dermatitis 

Medicamentosa 

(Copaiba,Ql  inin)  . 


(2)  Considerable 
fever  and  ca- 
tarrhal symp- 
toms, involv- 
i  n  g  eyes, 
throat,  and 
chest. 

(3)  Face  first  in- 
volved ;  later 
trunk  and  ex- 
tremities. 

(4)  Eruption 
consists  of 
pinkish-red 
irregular  mac- 
ules or  mac- 
ulopapules,  at 
times  crescen- 
t  i  c  a  1 1  y  ar- 
ranged; ap- 
pearance 
"blotchy." 

(5)  Itching  mod- 
erate. 


(2)  Fever     occa- 
sionally. 


(3)  Eruption  con- 
fined to  chest, 
shoulders,  and 
back. 

(4)  Eruption  con- 
sists of  large, 
irregular  yel- 
lowish-brown- 
ish macules. 
Furfuraceous 
scaling.  Fun- 
gus present. 


(5)  Itching  slight. 


(3)  Face  often  in- 
volved. 


(4)  Eruption  ery- 
thematous or 
urticarial. 


(5)   I  t  c 
severe. 


h  i  n  g 


SYPHILODERMA    PAPULOSUM 


The  papular  syphilid  may  represent  the  first  cutaneous  out- 
break of  the  disease,  or  it  may  follow  in  the  wake  of  the  roseola, 
developing  at  the  site  of  disappearing  macules. 

Several  varieties  of  papular  eruptions  are  distinguishable, 
depending  upon  the  size,  shape,  and  course.  In  general,  there 
are  two  types — the  conical  or  acuminate,  which  develop  about 
hair-follicles,  and  the  non-follicular,  or  flat  form.  Of  the  former, 
there  are  two  varieties — the  large  and  the  small  {miliary  papular 
syphilid).     The  flat  syphilid  has  also  a  large  and  a  small  variety. 

The  large  papular  syphiloderm  (lenticular  papular  syphi- 
lid) is  a  frequent  form  of  the  disease,  associated  with  or  follow- 


SYPHILODERMA  33 1 

jug  the  macular  eruption.  It  is  characterized  by  pea-  to  finger- 
nail-sized, rounded  or  oval,  convexly  flat,  shining  papules. 
The  color  is  at  first  pinkish  red,  but  soon  changes  to  a  brownish- 
red  or  raw-ham  tint.  The  lesions  develop  slowly,  and  are 
primarily  firm  and  smooth,  but  later  scaly.  The  eruption  is 
usually  extensive,  the  forehead,  nape  of  the  neck,  chin,  arms, 
genitals,  etc.,  often  being  particularly  beset  with  lesions.  The 
palms  and  soles  commonly  show  lesions.  Some  of  the  eruptive 
elements  are  so  large  as  to  be  appropriately  termed  tubercles. 
The  eruption  persists  for  several  weeks  or  months,  responding 
rather  readily  to  treatment. 


Fig.  iS4- — Maculopapular  syphilid  of  face — eruption  also  on  body. 

During  the  stage  of  involution  the  papules  undergo  desqua- 
mation and  produce  a  papulosquamous  syphilid. 

In  the  papulosquamous  syphilodenn  (squamous  syphilid) 
the  lesions  are  flattened  and  covered  with  thin,  scanty,  dirty- 
grayish  scales.  These  lesions  show  a  predilection  for  the  palms 
and  soles  (palmar  and  plantar  syphihderm),  where  it  constitutes 
an  obstinate  manifestation.  When  both  palms  and  soles  are 
affected,  the  eruption  is  probably  an  early  one;  when  unilateral, 
it  is  late. 

The  large  fiat  syphilid  may  also  undergo  change,  giving  rise 
to  the  moist  papule. 


33* 


DISEASES  OF   THE   SKIN 


The  moist  papule  (flat  condyloma)  is  a  modified,  large 
papular  syphilid,  occurring  upon  opposing  skin  surfaces,  such 
as  the  nates,  perineum,  genitalia,  etc.  It  differs  from  the  dry 
papule  in  being  moist,  softer,  and  flatter,  and  covered  with  a 
grayish,  mucoid  pellicle  made  up  of  macerated  epidermis. 
Large  flat  patches  are  occasionally  formed  through  the  coal- 
escence  of   neighboring   lesions.     Moist   papules   occasionally 


Vig-  IJS.— Papuloi 


become  hypertrophic  and  covered  with  warty,  papillary  growths 
(hypertrophic  or  vegetating  papules). 

The  acuminate  papular  syphiloderm  (follicular  syphilid  ; 
miliary  syphilid)  occurs  at  the  sites  of  hair-follicles.  It  may 
appear  early  or  late  in  the  first  year  of  infection.  It  is  not  so 
common  as  the  flat  papular  eruption.  A  large  and  small  form 
are  distinguished.  The  latter  is  characterized  by  a  profuse 
eruption,  most  abundant  upon  the  trunk,  arms,  and  thighs, 
consisting  of  pin-head-  to  millet-seed-sized,  rounded  or  acumin- 


SYPHILO  DERMA 


ated,  firm  papules,  with  vesicular,  pustular,  or  scaly  summits. 
The  color  is  at  first  bright  red,  later,  brownish  red. 


Fig.    1 5<>.— Squamous  syphilid  of  palm. 

One  of  the  most  characteristic  features  of  the  eruption  is  a 
distinct  tendency  to  grouping  of  the  lesions  in  clusters;  this 


is  at  times  most  conspicuous,  while  at  other  times  it  is  less 
well  pronounced.     The  eru  '"  appear  unless 


DISEASES   OF   THE   SKIN 


vigorously  treated.  Stains  or  slight  depressions  at  the  mouths 
of  the  hair-follicles  are  seen  after  the  disappearance  of  the 
eruption.     It  is  quite  common  to  find  interspersed  pustules 


Fig.   158. — Extensive  small  papular  (follicular)  syphilid. 


present;  indeed,  the  miliary  pustular  syphilid  is  a  follicular 
syphilid  in  which  the  lesions  generally  undergo  suppuration. 
The  miliary  papulopustular  syphilid  is  far  m< 
negroes  than  in  the  white  race. 


SYPHILODERMA  335 

Diagnosis  of  the  Papular  Syphilid.— The  lesions  in  the 
large  flat  syphilid  are  so  characteristic  as  scarcely  to  be  con- 
founded with  any  other  disease.  Leprosy  may  be  excluded  by 
the  history,  the  more  chronic  course  of  the  eruption,  and  the 
absence  of  associated  symptoms  of  syphilis.  The  miliary 
syphilid  may  readily  present  difficulties  in  diagnosis.  The 
lesions  bear  a  close  resemblance  to  lichen  scrofulosus,  but  the 


Fig.    '50 — Miliar;   papulopuslular  syphilid   in   a  negress;   grouping  well  marked. 

latter  occurs  only  in  youth  and  is  largely  limited  to  the  trunk. 
Psoriasis  punctata,  keratosis  pilaris,  and  lichen  ruber  may  be 
excluded  by  the  distribution  and  extent  of  the  eruption,  the 
grouping  of  the  lesions,  the  presence  of  interspersed  pustules, 
and  the  associated  symptoms  o* 

The  papulosquamous  sypkit  may 

be  confounded  with  psora*  be 

elbows  and  knees,  the  df*1 


336  DISEASES  OP  THE  SKIN 

infiltration  of  the  patches,  the  involvement  of  the  palms  and 
soles,  the  history,  and  the  presence  of  other  than  cutaneous 
lesions  should  clarify  the  diagnosis.  The  Wassermann  test  is 
of  great  importance  in  doubtful  cases.  The  test  is  often  positive 
in  leprosy,  a  fact  that  must  be  borne  in  mind.. 

SYPHILODERMA    VESICULOSUM 

The  vesicular  syphilid  is  by  far  the  rarest  of  all  the  cutaneous 
manifestations  of  syphilis.  It  occurs  as  small  miliary  or  larger, 
pea-sized  (varicelliform  syphilid),  occasionally  umbilicated  ves- 
icles, developing  usually  upon  regions  where  the  skin  is  thin. 
Papules  and  pustules  may  also  be  present.  The  eruption  is  a 
comparatively  early  one  and  runs  a  rapid  course.  Not  in- 
frequently the  vesicles  surmount  a  papular  base. 

SYPHILODERMA  PUSTULOSUM 

Syphiloderma  pustulosum  may  be  divided  into  four  sub- 
varieties:  (i)  Small  acuminated  pustular  syphilid;  (2)  large 
acuminated  pustular  syphilid;  (3)  small  flat  pustular  syphilid; 
(4)  large  flat  pustular  syphilid. 

The  small  acuminated  pustular  syphiloderm  (miliary 
pustular  syphilid)  may  occur  as  the  first  eruption  of  syphilis, 
or  may  follow  the  macular  or  papular  outbreak.  It  is  usually 
profusely  generalized,  consisting  of  small,  pin-head-  to  millet- 
seed-sized,  acuminated  pustules,  seated  upon  a  dull-red  papular 
base.  There  is  frequently  a  tendency  to  group  in  clusters. 
The  lesions  are  located  at  the  mouths  of  hair-follicles,  and  are 
seen  to  be  perforated  by  hairs.  They  soon  dry  to  crusts,  which 
fall  off,  leaving  a  fringe-like,  annular  epidermal  exfoliation 
around  the  base,  which  has  been  termed  the  "collaret."  Miliary 
papules  may  also  be  present.  The  favorite  regions  are  the 
arms,  thighs,  chest,  and  back. 

The  large  acuminated  pustular  syphiloderm  (acneiform 
syphilid ;  varioliform  syphilid)  is  a  rather  uncommon  mani- 
festation, occurring  early  and  running  a  rapid  course.  It 
consists  of  split-pea-sized  or  larger,  acuminated  pustules,  some- 
what resembling  acne  or  variolous  lesions.  At  times  the  erup- 
tion runs  progressively  through  the  stages  of  papule,  vesicle, 
and  pustule.  The  pustules  dry  to  crusts,  beneath  which  super- 
ficial ulceration  may  take  place.  The  regions  attacked  are 
the  scalp,  face,  trunk,  and  extremities.  The  eruption  may 
be  preceded  by  moderate  fever. 


SVPHILODERMA 


Diagnosis.— A  cne  and  small-poi 
from  this  form  of  syphilis: 

Papulopustule  Syphilodbrm. 

i.  Concomitant   signs  of  syphilis. 

2.  Occurs  usually  in  adult  life. 

3.  Course  acute. 


4.  Distribution  general. 

5.  Color  brownish  red. 

6.  Tendency  to  ulceration. 

7.  Wassermann  reaction  positive 


are   to  be   differentiated 


2.  Occurs  at  sge  of  puberty. 

3.  Course  chronic,  with  exacerba- 

4.  Limitation  of  lesions  largely  to 

5.  Color  light  or  dark  red. 

6.  No  tendency  to  ulceration. 


Small-pox  may  be  more  closely  simulated  by  the  pustular 
syphilid  than  by  any  other  disease — during  epidemics  of  small- 


pox many  errors  of  diagnosis  are  made.  In  small-pox  there 
are  pronounced  fever  and  prostration  forty-eight  to  seventy- 
two   hours  before  the  appearance  of  the  eruption;  the  early 


338  DISEASES   OF   THE   SKIN 

papules  are  "shotty,"  the  vesicles  much  firmer  than  those  of 
syphilis,  and  the  evolution  from  papule  to  crust  much  more 
rapid  than  in  syphilis.  In  the  latter  disease  the  remains  of 
the  chancre  and  associated  symptoms  are  present. 

The  small  flat  pustular  syphiloderm  (impetigoform  syphi- 
lid) is  characterized  by  small,  flat,  pea-sized  pustules,  grouped  in 


Fig.  ifii. 


irregular  clusters,  and  occurring  in  the  first  year  of  the  disease. 
Crusting  occurs  early  and  is  profuse  (!>ustuloaustaccous  syphilid), 
the  color  being  yellowish,  greenish,  or  brownish.  Beneath 
the  crusts,  superficial  or  deep  ulceration  occurs.  The  favorite 
seats  are  the  nose,  mouth,  beard,  scalp,  and  genitals. 


SYPHILODERMA  339 

Diagnosis. — The  small  flat  pustular  syphilid  may  be  differ- 
entiated from  contagious  impetigo  and  pustular  eczema  by 
the  history  and  course  of  the  disease,  the  occurrence  of  ulcer- 
ation, and  the  concomitant  signs  of  syphilis. 

The  large  flat  pustular  syphiloderui  (ecthymaform 
syphilid)  occurs  as  a  generalized  eruption,  consisting  of  large, 


Fig.  i6j. — Ulcerative  syphilid;  this  began  as  a  papular  eruption,  which  was  at 
it  mistaken  for  small-pox.  Patient  later  developed  lever,  sloughing  of  soft  palate, 
■■■■ :-':  —   -■-.,  and  barely  escaped  a  fatal  outcome. 


finger-nail- sized,  flat  pustules,  seated  upon  a  dark-red  base. 
The  pustules  tend  rapidly  to  crust. 

There  are  two  varieties— the  superficial  and  the  deep.  The 
superficial  form  is  characterized  by  flat,  roundish  or  oval, 
brownish  crusts,  beneath  which  is  a  superficial  ulceration. 
This  is  a  common  and  benign  manifestation,  occurring  during 
the  first  year  of  the  disease.  The  favorite  seats  are  the  back, 
shoulders,  and  extremities. 

In  the  deep  form,  or  rupia,  the  crusts  are  more  bulky,  conical, 
of  a  greenish  or  blackish  color,  and  concentrically  stratified, 


340  DISEASES  OF  THE  SKIN 

like  the  layers  of  an  oyster-shell.  Beneath  the  crusts  is  a 
deep,  punched-out  ulcer,  covered  with  a  greenish -yellow,  auri- 
form secretion.     This  is  a  later  and  more  malignant  form. 

SYFHILODEKMA  TUBERCULOSUM  (TUBERCULAR  SYPHILID) 
This  is  a  late  or  tertiary  manifestation,  occurring  usually 
between  two  and  ten  years  after  infection.  It  is  characterized 
by  disseminated  or  grouped,  pea-  to  hazel-nut-sized,  rounded, 
smooth,  firm,  deeply  seated  nodules.  The  color  is  brownish 
red,  bluish  red,  coppery,  or  yellowish  brown.     The  lesions  are. 


as  a  rule,  comparatively  few,  and  tend  to  become  aggregated 
in  groups,  arranging  themselves  in  circles  or  segments  thereof. 
The  coalescence  of  neighboring  groups  may  produce  patches 
of  serpentine  configuration  (serpiginous  tubercular  syphilodcrm). 
The  eruption  develops  most  frequently  upon  the  face,  par- 
ticularly about  the  forehead  and  nose,  but  may  appear  upon 
the  arms,  trunk,  legs,  or  elsewhere. 

Tubercles  disappear  cither  by  absorption,  leaving  a  brownish 
stain,  or  by  ulceration,  with  the  production  of  scars.     Syphilitic 


SVPHILODERMA 


Fig-   163. — Ulcerated  tubercular  syphilid  of  nose  and  chin. 

ulcers  are  deeply  punched  out,  with  sharp-cut  edges,  often 
crescentic  in  snape,  and  covered  with  a  grayish-yellow,  gummy 


DISEASES   OP  THE    SKIN 


secretion  which  dries  into  brownish  or  greenish  crusts.     There 
is  often  an  offensive  odor. 


.66. — Syphilitic  ulcer  on  the  tongue.     Late  manifestation. 


Diagnosis. — The  tubercular  svphiloderm  is  to  be  differ- 
entiated from  lupus  vulgaris,  leprosy,  and  epithelioma,  par- 
ticularly the  first  named  disease. 


Tu: 


i.   Develcps     after     the     age     of 
puberty. 

2.  Course  more  or  less  rapid. 

3.  History  of  infection. 

4.  Concomitant    signs   of    syphilis. 

5.  Nodules  firm. 

6.  Ulcers  are  deep,  with  sharp-cut 

edges.       Discharge       copious, 
crusts  bulky  and  greenish. 

.7.  Scars  whitish,  soft,  and  smooth. 

8,  Rapid  healing  under  iodids  and 

mally 


Lupus  Vulgaris. 

1.  Develops   usually   at    or   l>efore 

puberty. 

2.  Course  extremely  slow. 

3.  History  i>f  infccliun.  negative. 

4.  Concomitant   signs.   |>*rliaps,   of 

tulieiculnus  diathesis 

5.  Nudities  soft 

6.  Ulcers  superficial,   Kith  soft,  ir- 

regular, undetmmed  edges. 
Discharge  slight,  crusts  scanty 
ami  reddish  twiiwn 

7.  Scars   yellowish,   shrunken,  and 

8.  Refractory    to   all    liul    destruc- 


SYFHILODERMA    GUMMOSUM    (GUMMATOUS    SYPHILID 

This  is  a  tertiary  manifestation,  occur ring,'pas  a  rule,  some 
years  after  the  contraction  of  the  disease.  It  is  characterized 
by  a  circumscribed  infiltration  in  the  subcutaneous  tissue,  mani- 


SYPHILODBRHA 


343 


testing  itself  clinically  as  one  or  several  slightly  raised,  rounded 
or  flat,  painless  tumors  (gumma,  gummy  tumor,  syphiloma). 

The  overlying  skin  is,  in  the  beginning,  normal,  becoming 
pinkish  or  reddish  only  when  ulceration  is  threatened.  The 
deposit  is  at  first  pea-sized,  but  in  the  course  of  several  weeks 
or  months  reaches  the  dimensions  of  a  hazel-nut  or  walnut. 
Untreated,  it  softens,  breaks  down,  and  ulcerates,  destroying 
the  skin,  subcutaneous  tissue,  and  at  times  other  structures. 
Under  treatment  it  may  undergo  absorption  and  disappear. 
Even  after  softening  occurs,  vigorous  specific  treatment  may 


Fig.  167. — Ulcerated  gumma  of  foot. 


lead  to  disappearance  without  ulceration.  The  scalp  and  fore- 
head  are  favorite  sites  for  gummata,  although  they  may  occur 
anywhere.  In  malignant  syphilis  gummata  may  develop 
much  earlier  in  the  course  of  the  disease — *ven  during  the 
first  year.  The  healing  of  a  gumma  is  followed  by  less  dis- 
figuring scarring  than  would  be  anticipated  from  its  appear- 
ance during  the  ulcerative  stage. 

Diagnosis  .—The  gumma  may  be  distinguished  from  fur- 
uncle, carbuncle,  abscess,  fibroma,  lipoma,  etc.,  by  the  origin, 
course,  and  appearance  of  the  lesion  and  the  associated  history. 


344  DISEASES  OF  THE   SKIN 

SYPHILODERMA    BULLOSUM    (BULLOUS    SYPHILID;    PEMPHIGUS 

SYPHILITICUS) 

This  occurs  as  an  early  symptom  in  hereditary  syphilis  and, 
more  rarely,  as  a  late  manifestation  in  the  acquired  form.  The 
blebs  are  discrete,  disseminated,  round  or  oval,  pea-  to  walnut- 
sized,  and  surrounded  by  a  slight  areola.  The  contents  are 
at  first  serous,  rapidly  becoming  purulent,  and  drying  into 
brownish  or  greenish  crusts.  The  crusts  may  be  large,  bulky, 
and  raised  or  rupial,  as  seen  in  the  large  flat  pustular  syphilo- 
derm.  Beneath  the  crusts  are  erosions  or  ulcers,  which  heal 
with  the  formation  of  pigmented  cicatrices.  The  bullous 
syphilid  usually  occurs  in  broken-down,  cachectic  individuals. 

A  pigmentary  syphilid  is  occasionally  seen  about  the  back 
of  the  neck  in  women,  particularly  in  brunettes.  In  rare 
instances  it  mav  occur  in  men,  and  in  other  localities.  It  con- 
sists  of  faint  "cafe  au  lait,"  rounded  or  oval  spots  of  finger- 
nail size,  with  intervening  areas  of  skin  which  appear  to  be 
lighter  than  the  normal  skin  tint.  In  many  cases  it  is  difficult 
to  determine  whether  one  is  dealing  with  hyperpigmented 
patches  or  a  "leukoderma  syphilitica.*'  Considerable  difference 
of  opinion  exists  with  regard  to  this  eruption. 

The  pigmentation  or  staining  of  the  skin  so  common  after 
various  syphilitic  eruptions  should  not  be  confounded  with  the 
above-described  condition. 

HEREDITARY    OR    CONGENITAL    SYPHILIS 

Syphilis  may  be  transmitted  from  either  father  or  mother 
to  offspring,  although  it  is  surer  to  be  conveyed  by  the  latter. 
Even  if  the  mother  be  infected  with  the  disease  some  months 
subsequent  to  conception,  the*  disease  is  transmitted.  A  woman 
may  be  free  of  manifestations  of  syphilis  and,  nevertheless, 
give  birth  to  a  syphilitic  infant.  Syphilitic  infection  in  utero 
is  extremely  apt  to  cause  miscarriage  or  the  birth  of  stillborn 
children. 

While  infants  are  occasionally  born  with  the  syphilitic  erup- 
tion upon  them,  it  is  far  more  common  for  it  to  develop  some 
weeks  after  birth.  The  majority  of  infected  infants  manifest 
an  eruption  during  the  first  month.  Nearly  all  cases  exhibit 
the  secondary  outbreak  before  the  end  of  the  second  month, 
and  only  rarely  is  it  delayed  after  the  third  month.  The  most 
common  eruptions  are  the  macular,  papular,  and  bullous. 

The  macular,  or  erythematous,  eruption,  consists  of  finger-nail- 


SYPHILODERMA  345 

to  palm-sized,  indistinct,  yellowish,  brownish-red  or  copper- 
colored,  erythematous  patches,  covered  with  a  shining  and 
wrinkled  epidermis.  The  palms,  soles,  buttocks,  thighs,  and 
genitalia  are  frequently  attacked.  The  patches  may  be  dry 
or  moist,  the  latter  resembling  at  times  erythema  intertrigo 
or  eczema. 

The  papular  eruption  often  develops  from  the  macular,  the 
combination  constituting  the  commonest  syphilid  observed  in 
the  infant.  The  papules  are  pea-  to  finger-nail- sized,  smooth, 
glazed,  and  usually  of  a  brownish  or  yellowish-red  color.  Occur- 
ring in  the  folds  of  the  skin,  they  often  degenerate  into  moist 


Fig.    168.— Annulopapular  syphilid  in  a  negro  infant  suffering  from  hereditary  syphilis. 


papules.     Where  skin  surfaces  are  in  contact,  as  around  the 
anus,  flat  condylomata  or  moist  papules  are  prone  to  develop. 

The  bullous  syphilid  is  not  infrequently  present  at  birth 
or  develops  soon  afterward.  It  is  a  comparatively  common 
form  in  hereditary  syphilis,  occurring  in  about  one-quarter 
of  the  cases.  Its  occurrence  is  an  evidence  of  severe  in- 
fection. The  palms,  soles,  and  face  are  the  most  frequent 
seats  of  the  blebs.  The  eruption  consists  of  variously  sized, 
lobular  bulls,  situated  upon  an  unhealthy 
*n  rupture  takes  place,  an  excoriated 
L 
•lotions  are  comparatively  rare, 


346  DISEASES  OF  THE  SKIN 

particularly  the  former.  Pustules  may  occur  upon  the  apices 
of  small  papules,  or  the  ecthymatous  form  may  be  present; 
the  latter  is  a  severe  form,  and  is  usually  associated  with  pro- 
found cachexia. 

The  tubercular  and  gummatous  syphilid  is  uncommon  in  heredi- 
tary infection.  It  is  a  late  manifestation,  and  when  present, 
develops  usually  some  years  after  birth.  There  are  other 
highly  suggestive  manifestations  of  syphilis.  Kaposi  regarded 
the  brownish -Ted,  dry,  fissured,  and  glazed  appearance  of  the 
palms  as  specially  characteristic. 


-S& 


Syphili- 


is  (jcumina)h  1 


<syphili= 


The  syphilitic  infant  presents  a  weazened,  senile,  emaciated 
facies,  which  at  first  glance  suggests  the  disease. 

Coryza  or  snuffles,  is  an  early  and  prominent  symptom  of 
hereditary  infection. 

Rhagades  or  fissures,  are  commonly  observed  about  the 
commissures  of  the  mouth  and  other  orifices.  The  frontal 
and  parietal  bones  may  be  thickened  in  the  form  of  circum- 
scribed bossy  swellings.  The  hair  is  often  scanty,  particularly 
over  the  temples.  The  long  bones  at  times  exhibit  an  inflam- 
mation about  the  epiphyses.  Syphilitic  dactylitis  may  also 
be  present.  In  later  years,  often  around  the  age  of  six,  keratitis 
and  other  eye-lesions  may  develop,  as  well  as  ear  troubles. 
The  Hutchinson  teeth,  so  characteristic  of  hereditary  syphilis, 


SVPHII.ODKKMA  347 

are  observed  in  the  second  or  permanent  teeth.  The  upper 
central  incisors,  which  are  the  most  diagnostic,  are  peg  shaped 
with  the  cutting-edge  smaller,  and  ere  seen  tically  notched. 
Enlargement  of  the  spleen  with  an  associated  anemia  is  com- 
monly observed. 

Etiology  and  Pathology. — Syphilis  is  an  infectious  granu- 
loma, due  to  the  invasion  of  a  specific  parasite.  It  would 
appear  at  the  present  time  that  the  causative  agent  is  the 
Spiroch&ta  pallida,  discovered  by  Schaudinn  and  Hoffman. 
This  organism  is  found  in  the  initial  lesion,  in  nearly  all  the 
morbid  lesions  of  the  secondary  period,  and  frequently  in  late 
lesions,  such  as  gumma ta.  In  congenital  syphilis  it  is  demon- 
strable not  only  in  the  skin,  but  in  most  of  the  inner  organs. 


Fig.  170. — Hutchinson's  teeth  in  a  child  with  hereditary  syphilis. 

The  syphilitic  process  is  characterized  by  a  distinctly  cir- 
cumscribed and  homogeneous  cell-infiltration,  tending  to 
spread  upon  the  periphery,  at  the  same  time  undergoing  central 
involution.  The  cell- in  filtration  exhibits  a  characteristic  ten- 
dency to  surround  blood-vessels  and  lymphatics;  it  is  alleged 
that  the  veins  and  perivascular  lymph-spaces  are  chiefly  impli- 
cated. The  infiltrate,  which  lies  in  the  conum  and  subcuta- 
neous tissue,  disappears  either  by  absorption  or  ulceration. 

Prognosis. — The  prognosis  of  acquired  syphilis  is,  in  the 
majority  of  cases,  favorable.  Syphilis  is,  however,  a  large  factor 
in  determining  late  degenerative  changes  in  visceral  organs  and 
tissues.  Malignant  cases  in  rare  instances  prove  fatal.  In 
hereditary  syphilis  the  prognosis  is  guarded,  many  infants 
succumbing  to  the  disease. 


348  DISEASES  OF  THE   SKIN 

Treatment. — The  treatment  of  syphilis  should  be  begun  as 
soon  as  the  diagnosis  is  established.  ^This  can  often  be  deter- 
mined during  the  primary  stage  by  the  finding  of  spirochetes 
in  the  serum  of  the  initial  sclerosis.  Where  facilities  for  such 
an  examination  are  not  at  hand,  the  early  diagnosis  may  be 
facilitated  by  a  Wassermann  test,  which  is  often  positive  late  in 
the  primary  stage. 

It  is  regarded  as  good  practice,  at  the  present  time,  to  excise 
the  initial  lesion,  if  it  be  recognized  early  and  be  located  in  some 
region  that  can  be  readily  ablated.  Even  though  constitutional 
infection  is  not  prevented,  the  number  of  spirochetes  entering  the 
body  is  lessened.  Various  substances  have,  in  similar  manner, 
been  injected  beneath  and  around  the  chancre  to  destroy  the 
spirochetes. 

The  treatment  of  syphilis  has  been  revolutionized  by  the 
introduction  of  the  Wassermann  test,  and  by  the  elaboration, 
by  Ehrlich,  of  dioxydiamido-arsenobenzol. 

Before  the  introduction  of  the  Wassermann  test,  it  was  the 
general  practice  to  treat  sufferers  from  syphilis  for  three  or 
four  years,  and  then  cease,  provided  that  no  further  evidence  of 
the  disease  manifested  itself. 

In  the  light  of  our  present  knowledge  a  patient  must  be 
treated  until  he  becomes  permanently  Wassermann  negative. 

It  must  not  be  forgotten,  in  the  general  enthusiasm  for  the 
new  medicament,  that  we  possess  other  drugs  which  are  capable 
of  exerting  a  specific  influence  upon  syphilis  and  its  manifes- 
tations.    These  we  shall  consider  first: 

Mercury  has  been  used  for  centuries  in  the  treatment  of 
syphilis.  It  has  doubtless  cured  thousands  of  syphilitic  sub- 
jects. It  is  not  always  well  borne,  and  in  some  individuals 
it  fails  to  effect  a  disappearance  of  existing  lesions  in  doses  that 
can  be  tolerated. 

Mercury  may  be  administered  by  mouth,  by  inunction,  by 
fumigation,  and  by  hypodermic  and  intravenous  injection. 

By  Mouth. — Treatment  by  mouth  is  regarded  with  much 
less  favor  than  by  some  of  the  more  intensive  methods.  Its 
convenience,  however,  makes  it  the  most  employed  route, 
certainly  in  the  hands  of  the  general  practitioner.  While  its 
influence  on  the  disease  is  distinctly  less  vigorous  than  hypo- 
dermic injections  or  inunctions,  yet  I  have  known  patients 
exclusively  treated  by  mouth  to  be  cured  of  the  disease,  as 
demonstrated  by  the  Wassermann  test. 


SYPHILODERMA  349 

The  preparation  most  often  prescribed  is  the  protiodid  or 
green  iodid  of  mercury.  This  may  be  given  in  doses  of  J  to  J  of 
a  grain  three,  four,  or  fiv%  times  a  day.  A  little  colicky  pain 
is  often  produced  at  first,  but  tolerance  is  usually  established. 

Mercury  with  chalk  (hydrargyrum  cum  creta)  is  better  borne, 
and  is  less  apt  to  cause  looseness  of  the  bowels.  It  may  be 
employed  in  one-  or  two-grain  doses  three  or  four  times  a  day. 
Calomel  in  doses  of  one-half  to  two  grains,  thrice  daily,  may  also 
be  used.  The  bichlorid  of  mercury  (gr.  -fa  to  ry)»  either  in  pill 
or  in  liquid  form,  is  preferred  by  some. 

Inunctions. — Inunctions  are  of  great  efficiency,  and  may 
always  be  relied  upon  to  produce  a  rapid  effect.  They  are 
extensively  used  in  Germany,  where  courses  of  thirty  rubbings 
are  employed  periodically.  One  dram  of  the  50  per  cent, 
mercurial  ointment  (unguentum  hydrargyri  fortior)  is  carefully 
rubbed  in  daily.  The  duration  of  the  rubbing  is  a  most  import- 
ant consideration.  Twenty  minutes  should  be  the  minimum 
duration  of  the  inunction.  Longer  periods  are  necessary  when 
the  skin  is  not  particularly  absorbent.  The  areas  usually 
employed  are  the  insides  of  the  thighs,  the  lateral  surfaces  of  the 
chest  and  abdomen,  and  the  insides  of  the  arms  and  forearms. 
When  the  rubbing  is  carried  out  by  a  masseur,  the  back  consti- 
tutes a  convenient  expanse  of  surface  for  the  broad  sweep  of 
the"  hands.  A  hot  bath  shortly  before  the  rubbing  increases  the 
absorbing  power  of  the  skin.  Mercury  for  inunctions  is  usually 
dispensed  in  the  dose  to  be  used  in  wax-papers. 

Hypodermic  Injections. — Mercury  is  used  hypodermatically, 
both  in  the  form  of  soluble  and  insoluble  salts.  The  chief 
disadvantage  of  hypodermic  injections  is  the  pain  produced. 
This  varies  greatly  in  different  subjects,  but  in  some  is  sufficient 
to  cause  them  to  refuse  to  continue  the  treatment.  The  insol- 
uble salts  produce  much  greater  and  more  persistent  pain  than 
the  soluble  preparations. 

The  bichlorid  of  mercury  is  one  of  the  most  frequently  em- 
ployed soluble  salts: 

K .  Hydrargyri  bichloridi gr.  viij ; 

Sodii  chloridi gr.  iv; 

Aquae  destillatae Jj- — M. 

Sig. — Inject  15  to  20  minims  two  or  three  times  a  week  into  the 
gluteal  muscles. 

Among  the  insoluble  salts  are  the  salicylate  of  mercury, 
calomel,  metallic  *«*«*       (oleum  cinereum),  etc. 


350  DISEASES  OF  THE   SKIN 

The  following  formula  is  much  employed  : 

H  .  Hydrargyri  salicylat 10  gm; 

Lanolini 3  gm. ; 

Olei  olivae   30  gm. — M. 

(1  c.c.  =  3  grains  of  salicylate  of  mercury.) 

Sic — 1  to  3  grains  injected  deep  into  the  gluteal  muscles  every  five 
to  seven  days. 

The  injections  commonly  cause  inflammatory  nodulations, 
and  in  rare  instances  abscesses  and  necrosis.  If  employed  un- 
skilfully, serious  salivation  and  poisoning  may  result. 

The  advantages  of  hypodermic  injections  are  the  accuracy  of 
the  dosage,  their  cleanliness,  the  rapidity  of  effect,  and  the 
general  efficiency  of  their  influence  upon  the  lesions  and  the 
underlying  disease. 

Fumigations  or  mercurial  vapor-baths  are  useful  in  appropri- 
ate cases;  they  are  especially  valuable  in  ulcerative  lesions  of  the 
body.  Calomel  (20  to  30  grains)  is  vaporized  in  a  receptacle, 
the  body  of  the  patient  being  in  a  cabinet  or  surrounded  by  a 
tent  of  some  kind. 

The  dose  of  mercury  for  different  patients  varies  considerably. 
When  it  is  well  borne,  no  matter  how  administered,  it  should  be 
carefully  increased  until  it  produces  an  effect  upon  the  manifest- 
ations of  the  disease  present  or  upon  the  patient. 

Iodids. — The  potassium  salt  is  the  drug  usually  administered. 
It  is  of  particular  value  in  late  eruptions,  and  should  be  com- 
bined with  mercury.  The  iodids  are  often  necessary  in  the 
early  stages  of  syphilis  to  combat  fever,  headache,  or  bone 
pains.  The  iodids  are  ordinarily  given  in  from  5-  to  15-grain 
doses.  At  times  much  larger  doses  are  necessary.  The  follow- 
ing makes  a  palatable  combination: 

H .  Hydrarg.  chlor.  corrosiv gr.  i-ij ; 

Potass,  iodid 3*J_*V » 

Tinct.  cardamomi  comp q.  s.  ad  f,5iij. — M. 

Sic. — One  teaspoonful  in  water  after  meals. 

When  the  iodids  are  not  well  borne  by  the  stomach,  it  is  well 
to  administer  them  in  saturated  solution,  well  diluted  in  milk, 
given  immediately  after  meals. 

The  iodids  are  of  little  or  no  value  in  the  treatment  of  squam- 
ous syphilis  of  the  palms  and  soles,  and  of  syphilitic  glossitis. 

Arsenobenzol  or  Salvarsan. — In  1910  Ehrlieh,  aided  by  Hata 
and  Bertheim,  introduced  a  synthetic  arsenical  compound  of 


SYPHILODERMA  35 1 

complicated  formula  in  the  treatment  of  syphilis.  The  chemic 
name  of  the  drug  is  dioxydiamido-arsenobenzol  (C12H1202N2- 
AS23).  It  is  dispensed  as  a  dichlorhydrate,  a  yellowish  powder 
containing  34  per  cent,  of  arsenic.  It  oxydizes  on  exposure  to 
air,  and  is  on  this  account  put  up  in  air-free  tubes.  The  peculiar 
molecular  form  in  which  the  arsenic  is  held  prevents  it  from  com- 
bining with  the  tissues,  and  this  prevents  arsenical  poisoning. 
The  drug  has  a  specific  affinity  for  spirilla,  which  are  experi- 
mentally demonstrated  to  be  destroyed  by  it. 

There  are  several  methods  of  administration.  While  at  the 
present  time  the  intravenous  method  is  generally  preferred,  it  is 
impossible  to  know  what  the  ultimate  sanctioned  mode  of  admin- 
istration will  be. 

Subcutaneous  Administration. — The  contents  of  the  dispensing 
vial,  usually  containing  0.6  gram  of  salvarsan,  are  emptied 
into  a  sterile  mortar  and  carefully  rubbed  up  with  9  to  10  drops 
of  a  15  per  cent,  sterile  caustic  soda  solution.  There  is  then 
added,  with  constant  stirring,  the  desired  amount  of  sterile 
distilled  water  (5  to  ioc.c).  A  fine  suspension  is  formed,  which 
should  be  tested  with  litmus  paper  to  determine  whether  it  is 
exactly  neutral.  If  it  is  not,  a  drop  of  caustic  soda  solution  or 
of  acetic  acid  may  be  added,  as  the  reaction  demands.  With 
an  appropriate  sterile  syringe  and  a  needle  of  large  caliber  the 
suspension  is  injected  deep  into  the  subcutaneous  tissues  to 
the  inner  side  of  the  scapula.  The  site  of  the  injection  must  be 
rendered  surgically  aseptic. 

The  subcutaneous  injections  are  commonly  very  painful,  and 
require  the  use  of  an  anodyne  for  a  day  or  two.  An  infiltra- 
tion is  often  formed  which  may  last  months,  and  which  in  some 
cases  forms  a  sterile  abscess  as  a  result  of  the  necrosis  of  tissue. 
This  method  of  administration,  while  commonly  satisfactory 
as  to  its  influence  on  lesions,  is  the  least  efficacious  mode  of 
giving  the  drug. 

Intramuscular  Injections. — The  salvarsan  is  rubbed  up  in  a 
small,  sterile  mortar  with  a  15  per  cent,  solution  of  sodium  hy- 
drate added  drop  by  drop  until  the  drug  is  completely  dissolved. 
From  time  to  time  a  few  drops  of  sterile  water  may  be  added  to 
aid  in  the  solution.  Ordinarily,  it  will  require  from  1  c.c.  to 
1.2  c.c.  of  the  sodium  hydrate  solution.  Hot  sterile  water  is 
then  added  to  bring  the  quantity  up  to  6  or  8  c.c.  The  injection 
is  given  intramuscularly  in  the  outer  side  of  the  buttock.     The 


3$Z  DISEASES  OP  THE  SKIN 


should  be  pointed  downward.    Massage  of  the  site  helps 
to  diffuse  the  injected  fluid. 

Intravenous  Injections. — The  entire  contents  of  the  vial  con- 
taining salvarsan  are  deposited  in  a  sterile  mixing  jar  of  250  cc 
capacity.  Hot  sterile  distilled  water  is  poured  upon  this,  and  the 
jar  is  thoroughly  shaken  until  the  salvarsan  is  completely  dis- 
solved* There  is  then  added  drop  by  drop  about  23  ™««"« 
(sometimes  less)  of  a  sterile  15  per  cent,  solution  of  caustic  soda. 
At  first  a  fine  precipitation  is  produced,  but  when  the  fluid 
becomes  alkaline,  this  dears  up.  The  entire  amount  is  now  in- 
creased to  250  c.c.  by  the  addition  of  sterile  distilled  water. 
It  is  highly  important  that  the  solution  should  be  absolutely  clear 9 
otherwise  its  injection  may  cause  alarming  symptoms.  It  is 
essential  to  use  distilled  water  in  the  preparation  of  the  drug, 
otherwise  it  may  be  impossible  to  obtain  a  clear  solution. 
The  solution  is  now  filtered  through  sterile  gauze  into  the  cylin- 
dric  container  (Weintraud  apparatus)  to  which  a  rubber  tubing 
and  needle  are  attached.  (This  apparatus  should  be  boiled 
before  each  injection.) 

The  forearm  is  rendered  surgically  aseptic,  and  a  tourniquet 
is  applied  to  the  arm.  The  detached  needle  is  inserted  into  a 
distended  vein.  When  the  flowing  of  blood  indicates  that  the 
needle  is  in  the  vein,  the  tubing  with  the  fluid  flowing  from  it 
should  be  adjusted  to  the  needle,  the  tourniquet  quickly  removed, 
and  the  solution  allowed  to  run  in  by  gravity  pressure.  The 
injection  should  require  about  eight  minutes. 

There  is  another  method  which,  to  my  mind,  is  preferable. 
Prior  to  pouring  the  salvarsan  solution  into  the  Weintraud 
cylindric  funnel,  about  50  c.c.  of  warm  sterile  physiologic  salt 
solution  (made  with  distilled  water)  is  poured  in.  The  needle 
attached  to  the  tubing  is  inserted  into  a  vein,  and  the  solution 
allowed  to  flow.  If  the  needle  is  not  in  the  vein,  a  subcutaneous 
swelling  occurs,  and  the  needle  must  be  withdrawn  and  inserted 
into  another  vein.  After  the  salt  solution  has  fallen  in  level  to 
the  bottom  of  the  cylindric  funnel,  the  salvarsan  solution  is 
added.  This  procedure  prevents  the  possibility  of  the  salvarsan 
being  injected  outside  the  vein,  a  most  unfortunate  accident, 
as  it  causes  intense  and  persistent  pain,  and  commonly  leads  to 
the  formation  of  an  abscess  and  sometimes  contracture.  It  is 
good  practice  to  follow  the  salvarsan  solution  with  25  to  50  CC.^ 
of  physiologic  salt  solution  in  order  to  wash  out  all  of  th* 
varsan  in  the  tubing. 


SYPHILODERMA  353 

After-effects. — Various  reactive  symptoms,  such  as  chills, 
moderate  rise  of  temperature,  nausea,  vomiting,  abdominal  pain, 
or  diarrhea,  may  occur  in  from  one  to  six  hours  after  the  injec- 
tion, more  particularly  after  the  intravenous  administration. 
These,  however,  are  of  short  duration. 

Injections  of  Oil  Suspensions. — The  drug  may  be  rubbed  up  in 
some  sterile  thin  oil,  as  sesame  oil,  oil  of  sweet  almonds,  liquid 
paraffin,  etc.  No  alkali  is  used.  These  oil  suspensions  are 
injected  into  the  buttocks.  The  full  dose  may  be  administered 
or  fractional  doses  of  o.  i  gram  may  be  given  at  intervals  of  three 
to  seven  days  until  0.6  gram  has  been  received.  The  injection 
of  o.  1  gram  of  1  c.c.  of  oil  is  practically  painless,  and  is  a  conve- 
nient method  of  treating  outdoor  hospital  patients. 

Relative  Merits  of  the  Different  Modes  of  Administration. — 
The  subcutaneous  method  is  usually  very  painful,  and  is  not 
infrequently  followed  by  tumefaction  and  necrosis.  It  is  the 
least  efficacious.  The  intragluteal  injection  of  alkaline  solution 
is  usually  painful,  and  often  produces  tumefactions.  It  is  more 
efficient  than  the  subcutaneous  method,  but  less  intensive  in  its 
effect  than  the  intravenous  administration.  The  intravenous 
method  is  practically  painless,  and  does  not  produce  inflamma- 
tory indurations.  The  drug  is  more  rapidly  eliminated,  but, 
nevertheless,  has  the  most  rapid  influence  on  existing  lesions. 
It  is  the  method  of  choice. 

Indications  for  Salvarsan. — Sufficient  is  known  concerning 
the  effects  of  salvarsan  to  justify  its  use  in  all  cases  of  syphilis 
when  no  distinct  contraindications  exist.  It  is  especially 
indicated  in — (a)  Cases  of  malignant  and  precocious  syphilis; 
(6)  cases  resistant  to  mercury  or  those  in  which  an  idiosyncrasy 
against  this  drug  exists;  (c)  cases  in  which  mercury  fails  to  pre- 
vent relapses;  (d)  in  ulcerative  lesions  of  the  mucous  mem- 
branes; (e)  in  visceral  and  nerve  syphilis;  (/)  in  syphilitic 
cachexia;  (g)  in  latent  syphilis  with  persistent  positive  Was- 
sermann  reactions;  (h)  in  the  early  stages  of  tabes  dorsalis  and 
paresis ;  (i)  in  primary  syphilis  with  a  view  to  aborting  the  dis- 
ease; (7)  in  hereditary  syphilis. 

Contraindications. — The  following  conditions  contraindicate 
the  use  of  salvarsan:  (a)  Myocarditis  or  other  grave  cardiac  dis- 
ease; (b)  severe  renal  disease  of  a  non-syphilitic  character;  (c) 
advanced  dffiBiNUWtiye       iditions  of  the  central  nervous  sys- 

•  (d)  profound  debility  or  cachexia 


s.ya&  .£;-. 


354  DISEASES   OF  THE   SKIN 

Outline  of  Treatment  of  Syphilis  with  Salvarsan. — In  the  light 
of  our  present  knowledge  one  of  the  best  methods  of  treating 
early  syphilis  is  to  give  the  patient  two  or  three  intravenous 
injections  of  salvarsan  at  intervals  of  about  a  week.  This 
should  be  followed  by  a  course  of  30  mercurial  inunctions  or  20 
injections  of  an  insoluble  mercury  salt.  After  this  the  blood 
should  be  tested  at  intervals  of  a  month,  and  further  treatment 
guided  by  the  result  of  the  Wassermann  reactions.  There  is 
reason  to  believe  that  such  a  course  will  cure  a  considerable 
percentage  of  cases  in  a  relatively  short  time. 

Treatment  of  Hereditary  Syphilis, — As  in  acquired  syphilis, 
the  best  remedies  are  salvarsan  and  mercury.  Owing  to  the 
fact  that  the  internal  organs  in  hereditary  syphilis  swarm  with 
spirochetes,  salvarsan  should  be  used  unless  the  infant  is  too 
weak  and  puny.  It  is  almost  impossible  to  give  intravenous 
injections  to  infants,  owing  to  the  minute  size  of  the  veins. 
Intragluteal  injections  are  best  used.  For  a  new-born  infant 
one  may  give  0.005  to  0.03  gram  of  salvarsan.  When  the 
infant  is  extremely  weak,  the  mother  may  be  injected  and  the 
child  obtain  the  benefit  of  the  treatment  through  the  maternal 
milk.  If  mercury  is  preferred  in  the  beginning,  it  should  be 
used  in  the  form  of  inunctions.  They  may  be  prescribed  as 
follows : 

R.    Ung.  hydrargyri  \  --    -iv  __vT 

lanohni  I  J 

M.  et  in  partes  No.  viii  div. 

SiG. — Spread  one  portion  upon  abdominal  binder  each  day  or  rub 
into  skin. 

Mercury  may  also  be  administered  internally  in  the  form  of 
calomel,  gr.  j±  to  ,\  thrice  daily,  or  mercury  with  chalk,  one- 
half  grain  three  times  a  day. 

The  Wassermann  reaction  and  the  clinical  symptoms  should 
be  the  guides  as  to  the  duration  of  treatment. 

LEPRA 

Derivation. — At-pot,  rough  or  scaly.  Synonyms. — Leprosy;  Elephantia- 
sis graecorum. 

Definition. — Leprosy  is  a  chronic  infectious  disease  due 
to  a  specific  bacillus,  affecting  with  predilection  the  skin  and 
nervous  system,  with  the  production  of  infiltrations,  ulcer- 
ations, anesthesia,   paralysis,  and  gangrene. 


LEPRA  355 

Leprosy  is  distributed  over  almost  a  quarter  of  the  habitable 
globe.  It  occurs  not  only  in  the  tropics,  but  also  in  the  cold 
regions  of  the  north.  It  is  a  common  disease  in  China,  Japan, 
India,  the  Philippine  Islands,  and  in  parts  of  Africa.  In  Europe 
it  is  chiefly  observed  in  Norway,  Russia,  Spain,  Portugal.  It 
is  found  in  Iceland,  New  Brunswick,  Canada,  West  Indies,  Cen- 
tral and  South  America,  and  the  Hawaian  Islands.  Within  the 
borders  of  the  United  States  it  has  principally  been  noted  in 
Louisiana,  California,  and  among  those  of  Scandinavian  origin 
in  Minnesota  and  Wisconsin. 

Symptoms. — The  period  of  incubation  is  most  difficult  to 
establish,  as  the  time  and  manner  of  infection  are  generally 
unknown.  It  has  been  estimated  by  various  observers  to  be 
between  a  few  weeks  or  months  and  two,  five,  ten,  or  more 
years. 

For  convenience  of  description  three  varieties  of  the  disease 
are  recognized:  (i)  Nodular  or  tegumentary  leprosy;  (2) 
anesthetic  or  nerve  leprosy;  (3)  the  mixed  type. 

Nodular  Leprosy  (Lepra  Tuberculosa). — Prodromal 
symptoms,  such  as  mental  depression,  languor,  malaise,  ano- 
rexia, nausea,  and  bone  pains,  may  precede  the  characteristic 
manifestations  of  the  disease  by  several  weeks,  months,  or 
years.  Febrile  symptoms  commonly  occur  in  the  prodromal 
stage  of  tubercular  leprosy.  The  fever  is  intermittent,  often 
accompanied  by  prostration,  and  preceded  by  chills.  It  may 
recur  with  each  new  outbreak  of  tubercles. 

Eruptive  Stage. — This  is  commonly  characterized  by  the 
appearance  of  smooth,  reddish,  yellowish,  or  brownish,  bean- 
sized,  infiltrated  spots  or  macules.  The  color  depends  some- 
what upon  the  race  and  complexion  of  the  subject. 

The  spots  may  disappear  and  reappear  several  times  before 
the  characteristic  tubercles  of  the  disease  develop.  The  latter 
may  appear  upon  t£e  previously  "healthy  integument  or  may 
develop  upon  the  pigmented  sites  of  old  macular  patches. 

The  nodules  begin  as  pin-head-  to  pea-sized  papules  of  a 
pinkish-red  or  yellowish-brown  color.  They  gradually  increase 
in  size  and  may  reach  the  dimensions  of  a  hickory-nut  or  walnut. 
They  are  usually  rounded  in  shape,  and  in  consistence  are 
relatively  soft.  When  the  nodules  are  in  close  juxtaposition, 
they  run  together  and  form  infiltrated  patches  with  an  irregular 
or  mammilated  surface. 

The  face  is  a  favorite  seat  of  the   eruption.     'r* 


DISEASES  OF  THE   SKIN 


most  attacked  are  the  forehead  (particularly  in  the  region  of 
the  eyebrows),  cheeks,  ears,  nose,  chin,  lips,  and  the  backs  of 


the  forearms  and  hands.     The  eruption  is  extremely  rare  upon 
the  scalp,  glans  penis,  and  the  palms  and  soles. 


LBPRA  357 

In  an  advanced  case  of  tubercular  leprosy  the  entire  face 
is  beset  with  tubercles  and  leprous  infiltrations.  There  are 
marked  thickening  of  the  forehead  and  an  exaggeration  of  the 
natural  furrows  of  the  skin.  This  produces  the  so-called 
"leonine'*  expression.  The  nose  and  ears  are  swollen  and 
studded  with  nodules;  the  lips  are  thickened  and  everted;  the 
eyebrows  are  scant  or  entirely  lost;  the  voice  is  hoarse  and 
raucous;  the  lymphatic  glands  are  swollen.  The  patient  loses 
all  semblance  of  his  former  self,  and  presents  a  terrible  picture 
of  disfigured  humanity.  The  mucous  membranes  of  the  mouth, 
nose,  eyes,  pharynx,  larynx,  and  vagina  may  become  the  seat 
of  small  tubercles. 

Course. — Leprous  nodules  may  persist  unchanged  for  months 
or  years,  or  they  may  undergo  resorption  or  ulceration.  The 
softening  and  breaking  down  of  the  nodules  lead  to  the  for- 
mation of  leprous  ulcers ;  these  are  shallow,  indolent  ulcers  with 
defined  borders  and  a  viscid  surface  discharge,  which  dries  in 
the  form  of  thick  crusts.  At  times  ulceration  may  be  extensive 
and  lead  to  a  great  loss  of  tissue,  exposing  ligaments  and  bony 
structures.  Ulceration  occurs  must  frequently  upon  the  extrem- 
ities. 

Leprosy  tends,  like  syphilis,  to  the  production  of  sterility; 
as  the  disease  advances,  atrophy  of  the  testicles  and  impotence 
develop. 

Duration  of  the  Disease. — Leprosy  is,  in  most  cases,  a 
progressive  disease.  Patients  may  live  for  many  years  unless 
carried  off  by  intercurrent  maladies.  A  very  large  number 
die  of  lung,  kidney,  or  intestinal  complications. 

Anesthetic  Leprosy. — The  nerve  type  of  leprosy  presents 
quite  a  different  picture  from  tubercular  leprosy.  The  prodro- 
mal period  is  longer,  and  there  is  an  absence  of  fever.  The 
symptoms  are  largely  those  of  a  multiple  neuritis,  with  pro- 
nounced trophic  changes. 

The  primary  eruption  begins  either  as  blebs  or  erythematous 
spots.  Disturbances  of  sensation,  such  as  burning  or  itching,  may 
precede  the  outbreak  of  the  cutaneous  lesions.  The  macular 
patches  are  of  a  bluish-red  or  reddish-brown  color,  later  becom- 
ing yellowish,  brownish,  or  sepia  tinted.  They  are  round  or 
oval  in  shape,  and  tend  to  spread  upon  the  periphery  and  heal 
in  the  center.  Coalescence  of  neighboring  patches  leads  to 
the  formation  of  large  gyrate  or  serpentine  figurations,  with 
reddish,  sharply  defined  borders,  and  pale,  achromic  centers. 


358  DISEASES  OP  THE  SKIN 

During  the  period  of  increased  coloration  the  patches  are  hyper- 
esthetic;  as  they  clear  up  in  the  center  they  are  prone  to  become 
anesthetic.  The  loss  of  sensation  is,  however,  not  limited  to 
these  patches,  but  extends  over  the  area  of  distribution  of 
affected  nerve -trunks. 


As  a  result  of  the  anesthesia  the  patient  often  burns  or  scalds 
himself  through  absence  of  sensory  warning.  Karly  in  the 
disease  tactile  sensation  may  be  preserved,  when  appreciation 
of  pain  and  temperature  sense  are  destroyed;  later  all  sensory 
function  is  abolished. 

The  macular  patches  are  observed  chiefly  upon  the  trunk 


lepra  359 

and  extremities;  the  hair  over  affected  patches  is  apt  to  whiten 
or  fall  out.  As  a  result  of  cessation  of  perspiration  over  the 
parts  involved  the  skin  becomes  dry  and  scaly,  or  smooth, 
glistening,  and  atrophic  in  appearance. 

The  bullous  eruption  occurs  chiefly  upon  the  extremities, 
in  the  form  of  blebs  of  variable  size,  containing  clear,  serous 
fluid.  The  loss  of  the  epidermal  covering  exposes  areas  resemb- 
ling in  appearance  burns  or  scalds.  Upon  healing,  cicatrices 
or  pigmented  spots  are  left. 


Nerve  Manifestations. — As  has  been  stated,  the  symptoms 
of  nerve  leprosy  are  those  of  a  multiple  neuritis.  There  are 
neuritic  pains,  often  paroxysmal,  with  accompanying  hyper- 
esthesia. Later,  loss  of  sensation,  more  or  less  pronounced, 
is  observed.  Paralysis  and  atrophy  of  muscles  are  frequent 
expressions  of  the  leprous  nerve  process.  It  is  not  uncommon 
for  a  one-sided  facial  paralysis  to  occur.  Paralysis  of  the  arm, 
with  atrophy  of  the  muscles  of  the  hand  and  tendinous  con- 
tractions,  produce   the    "leper  claw,"    so  suggeV'— 


36o 


DISEASES   OP    THE   SKIN 


disease.  Pronounced  deformities  of  the  feet  may  also  result 
from  paralysis  and  contractures. 

The  occurrence  in  lepers  of  a  deep  ulceration  (plantar  ulcer) 
upon  the  sole  of  the  foot  is  highly  characteristic. 

The  bones  of  the  fingers  and  toes  undergo  a  rarefying  osteitis 
and  become  absorbed,  leading  to  shortening  or  loss  of  the 
digits  without  ulceration.  The  terminal  members  may,  how- 
ever, be  lost  as  a  result  of  gangrene,  spontaneous  amputation 
taking  place.  When  healing  occurs,  deformed  stumps  of  the 
hands  and  feet  remain  {lepra  mutilans).  This  horrible  mutila- 
tion is  quite  painless,  as  all  sensation  is  gone. 


The  leprous  process  manifests  a  predilection  for  the  ulnar 
and  peroneal  nerves.  A  valuable  diagnostic  sign  is  the  palp- 
able bulbous  or  fusiform  enlargement  of  the  ulnar  nerve  felt 
behind  the  olecranon  process.  This  occurs  quite  early  in  the 
disease.  Anesthesia  of  the  soft  palate,  uvula,  and  pharynx 
is  also  observed. 

Patients  with  anesthetic  leprosy  live  longer  than  tubercular 
cases.  They  commonly  die  from  intercurrent  diseases  or 
intestinal  complications. 


LEPRA  361 

Mixed  Leprosy. — This  represents  a  combination  of  the 
anesthetic  and  nodular  forms,  and  in  this  country  is  more 
common  than  the  pure  types.  In  some  instances  the  symptoms 
of  nodular  leprosy  develop  first,  thosa  of  nerve  leprosy  being 
later  engrafted;  in  other  instances,  the  order  of  development  is 
reversed. 

Etiology. — Leprosy  is  caused  by  the  invasion  of  the  body 
by  the  Bacillus  lepra  of  Hansen.  The  disease- is  but  feebly 
contagious,  and  appears  to  require  particular  conditions  of  soil 
to  render  infection  possible.  Hereditary  transmission  of 
leprosy  does  not  take  place,  although  it  is  possible  that  a  pre- 
disposition to  the  disease  may  be  inherited.  Leprosy  is  prac- 
tically never  seen  in  infant  life,  and  is  rare  under  the  age  of 
ten.  Climatic  conditions  influence  the  spread  of  the  disease — 
hot,  moist  localities  and  damp,  cold  regions  favoring  dissemi- 
nation. The  temperate  climate  of  the  United  States  and  Europe 
is  unfavorable  to  the  development  of  leprosy.  The  individual 
may  become  infected  with  leprosy  through  any  wound  or  abra- 
sion of  the  skin.  The  upper  respiratory  tract,  particularly 
the  nasal  mucous  membrane,  is  now  suspected  of  being  the  usual 
avenue  of  infection. 

Pathology. — The  nodular  lesions  are  produced  by  deposits 
of  cells  in  the  corium  and  subcutaneous  tissues  similar  to  those 
seen  in  lupus  and  syphilis. 

The  specific  bacillus  is  found  in  the  tubercles,  the  infiltra- 
tions, the  mucous  membranes,  the  lymphatic  glands,  spleen, 
liver,  kidneys,  etc.  In  nerve  leprosy  the  bacilli  are  found  in 
the  nerves,  particularly  in  the  connective  tissue  surrounding 
them. 

Clegg  has  grown  lepra  bacilli  in  symbiotic  relation  with  the 
amoeba  coli,  and  Duval  has  succeeded  in  obtaining  pure  cul- 
tures of  the  lepra  bacillus.  He  also  claims  to  have  successfully 
inoculated  Japanese  dancing  mice. 

Diagnosis. — Advanced  cases  of  leprosy  are  readily  recognized 
by  those  who  have  had  any  experience  with  the  disease.  Incip- 
ient or  atypical  cases  may  present  difficulties  of  diagnosis. 
The  diseases  which  may  resemble  leprosy  are  syphilis,  lupus, 
mycosis  fungoides,  morphea,  vitiligo,  syringomyelia,  etc. 

The  nodules  of  syphilis  are  usually  smaller,  rounder,  and 
redder  than  those  of  leprosy;  they  are  prone  to  circular  arrange- 
ment and  run  a  more  rapid  course.     Lupus  vulgaris  is  apt  to 


362  DISEASES  OF  THE   SKIN 

be  more  circumscribed  in  extent:  the  nodules  are  apple-jelly 
colored,  very  soft,  and  often  set  in  scar  tissue.  Mycosis  fun- 
goides  may  in  its  early  stages  closely  simulate  leprosy,  but  the 
patches  are  redder  and  more  eczematous  in  appearance;  later 
fungating  ulcerating  growths  develop  upon  them. 

In  all  doubtful  cases  of  nodular  leprosy  excision  of  a  lesion 
and  examination  for  the  lepra  bacilli  should  prove  decisive. 

In  anesthetic  leprosy  the  loss  of  sensation  is  a  most  important 
diagnostic  symptom.  This  will  readily  differentiate  the  dis- 
ease from  morphea,  vitiligo,  and  various  pigmentations.  Syrin- 
gomyelia presents  at  times  a  close  resemblance  to  nerve  leprosy; 
it  may  be  distinguished  by  the  absence  of  cutaneous  discolor- 
ations,  the  loss  of  heat  and  pain  sensation  with  preservation 
of  the  tactile  sense  and  tlje  exemption  of  the  facial  muscles. 
A  valuable  sign  of  nerve  leprosy  is  the  enlargement  of  the 
ulnar  nerve  behind  the  olecranon. 

Prognosis. — The  prognosis  of  leprosy  is  usually  unfavor- 
able, most  cases  progressing  to  a  fatal  termination.  It  is  not 
entirely  hopeless,  as  symptomatic  cures  are  effected  in  a  small 
percentage  of  cases. 

Treatment. — Nutritious  food,  good  hygiene,  general  tonics, 
and  removal  to  a  healthful  temperate  climate  are  important 
therapeutic  considerations.  Daily  hot  baths  are  of  distinct 
value. 

Internally,  the  most  important  remedies  are  chaulmoogra 
oil,  gurjun  oil,  and  strychnin.  Chaulmoogra  oil  appears  to 
have  given  more  consistent  results  in  tubercular  leprosy  than 
any  other  medicament.  It  is  given  in  capsule  or  emulsion, 
in  doses  beginning  with  three  minims,  three  times  a  day,  and 
increasing  to  thirty  or  more  if  the  patient's  stomach  will  bear 
it.  Gurjun  oil  is  also  highly  recommended.  Crocker  has 
obtained  good  results  with  hypodermic  injections  of  mercurials. 
Strychnin  is  principally  of  value  in  nerve  leprosy,  and  should 
be  given  in  ascending  doses. 

Locally,  friction  with  oils,  such  as  chaulmoogra  oil,  gurjun 
oil,  or  any  other  oil,  is  advantageous.  Nodules  may  be  treated 
with  the  electrocautery  or  thermocautery,  or  exposed  to  the 
#-rays,  often  with  good  results. 


FRAMBESIA  363 


FRAMBESIA 

Derivation. — Fr.,  framboise,  a  raspberry.  Synonyms. — Yaws;  Pian; 
Peruvian  wart. 

Definition. — Frambesia  is  an  infectious  disease,  endemic 
in  certain  tropical  countries,  characterized  by  papules,  tubercles, 
and  tumors  having  the  appearance  of  raspberries. 

Symptoms. — The  eruptive  phenomena  of  the  disease  are 
preceded  by  a  prodromal  stage  which  may  last  one  or  two 
weeks.  There  is  often  moderate  fever,  which  is  prone  to  be 
followed  by  glandular  intumescence,  rheumatoid  pains,  and 
the  appearance  of  the  eruption.  Several  varieties  of  cutaneous 
lesions  are  described.  The  .yaws  tubercles  vary  in  size  from 
a  pin-head  to  a  cherry  or  larger.  -They  are  smooth  at  first, 
but  later  acquire  an  irregular  surface,  due  to  warty  excres- 
cences; these  are  often  pinkish,  suggesting  the  appearance 
of  a  raspberry;  therefore  the  name,  frambesia.  The  vegeta- 
tions are  covered  with  an  exuding  secretion  which  dries  in  the 
form  of  crusts  resembling  yellow  beeswax.  Ulceration  may 
occur,  with  the  discharge  of  a  thin,  fetid,  yellowish  fluid. 
Lesions  may  develop  in  the  mouth,  looking  somewhat  like 
mucous  patches. 

In  other  cases  small  or  large  patches  of  branny  desquamation 
may  be  present,  beneath  which  papillary  overgrowth  takes 
place.  The  face,  upper  and  lower  extremities,  and  genitalia 
are  the  parts  most  attacked. 

The  disease  lasts  two  to  six  months  in  mild  cases,  and  several 
years  in  severe  forms  in  debilitated  individuals. 

Frambesia  is  confined  to  tropical  countries,  and  is  observed 
chiefly  on  the  west  coast  of  Africa. 

The  disease  is  contagious,  and  one  attack  protects  against 
future  infections.  By  some  observers  the  affection  is  regarded 
as  a  tropical  form  of  syphilis. 

Castellani  has  found  in  yaws  a  spirochete  closely  resemb- 
ling the  parasite  of  syphilis,  which  he  has  named  Spirochete 
per  tenuis. 

Treatment. — Salvarsan  has  been  found  to  be  a  specific  in 
yaws.  Local  mild  parasiticides,  and  quinin,  iron,  and  strychnin, 
are  used  with  good  effect. 


364  DISEASES  OF  THE  SKIN 

EPITHELIOMA 

Synonyms. — Epithelial  cancer;  Carcinoma  epitheliale;  Rodent  ulcer. 

Definition. — Epithelioma  is  a  chronic,  progressive  new- 
growth  having  its  origin  in  the  epithelium  of  cutaneous  or 
mucous  structures,  and  exhibiting  a  destructive  or  ulcerative 
tendency. 

Symptoms. — Nearly  all  cases  of  epithelioma  may  be  classified 
under  three  varieties:  the  superficial,  deep,  and  papillary 
epithelioma. 

Superficial  Epithelioma  (Flat  or  Discoid  Variety). — The  early 
lesions  present  varied  clinical  appearances,  according  to  the 
anatomic  structure  whence  they  spring.  They  make  their 
appearance  as  one  or  more  grouped,  yellowish,  reddish,  or  pearly 
papules,  or  as  flat  infiltrations,  warty  outgrowths,  or  degenerative 
seborrheic  patches.  These  show  a  tendency  to  become  excori- 
ated and  covered  with  reddish,  brownish,  or  yellowish  crusts. 
When  the  crust  is  removed,  bleeding  takes  place  and  a  new 
serosanguineous  crust  is  formed.  In  the  course  of  several 
months  or  years  the  deposit  increases,  or  new  lesions,  which 
undergo  degeneration,  with  the  formation  of  superficial  ulcers, 
appear. 

The  ulcer  is  usually  roundish,  with  a  sharply  defined,  rounded, 
indurated,  pearly  edge.  Often  waxy-looking  papules  stud 
the  border.  The  base  is  hard,  reddish,  uneven,  easily  disposed 
to  bleed,  and  secretes  a  scanty  yellowish  fluid.  Spreading 
takes  place  both  upon  the  periphery  and  into  the  deeper 
structures.  When  scraped  with  a  curet,  the  border  and  base 
are  found  to  be  extremely  friable. 

This  form  of  epithelioma  is  found  chiefly  upon  the  face, 
although  it  may  appear  upon  the  neck,  scalp,  trunk,  or  hands. 
It  may  remain  for  many  years  without  causing  lymphatic 
involvement  or  impairing  the  general ,  health.  Usually  there 
is  but  slight  pain. 

Rodent  ulcer  is  a  term  applied  to  a  form  of  epithelioma 
having  rather  distinct  clinical  features.  It  commonly  has  its 
origin  in  a  soft  brownish  tubercle  that  has  existed  for  a  long 
time  upon  the  face.  Ulceration  takes  place  and  progresses 
into  the  depth,  causing  a  considerable  excavation  of  tissue.  In 
untreated  cases  great  destruction  may  occur,  the  bones  even 
becoming  involved  ultimately.  A  rodent  ulcer  does  not  build 
up  a  neoplasm,  but  rather  eats  out  and  destroys.  The  favorite 
seat  is  about  the  eyelids,  nose,  and  temples. 


EPITHELIOMA 


Deep-seated  Epithelioma  (Nodular  or  Infiltrating  Variety). — 
This  form  develops  from  the  superficial  variety  or  from  a  nodule 
having  its  seat   in  the   corium   and  subcutaneous  tissue.     It 


Fig.   176. — Rodcnl  ulcer  (epithelioma)  of  nose.     Chnmcterislic  pear 


3*6  DISEASES  OF   THE   SKIN 

may  also  develop  from  the  extension  of  a  cancer  from  a  neighbor- 
ing mucous  membrane.  The  nodule  is  pea-  to  walnut-sized, 
firm,  indurated,  rounded  or  flat,  shining,  and  of  a  reddish  or 
purplish  color.  After  a  lapse  of  some  months  ulceration  takes 
place.  The  ulcer  is  deep,  rounded,  or  irregular  in  shape,  with 
an  uneven,  reddened,  easily  bleeding  base,  and  hard,  everted, 
waxy,  or  purplish  edges.  An  areola  of  redness  and  infiltration 
indicates  the  spreading  border.  This  form  of  epithelioma  runs 
a  much  more  rapid  course  than  the  superficial  form. 


The  lymphatic  glands  become  involved,  the  pain  is  severe 
and  of  a  lancinating  character,  and  the  patient  slowly  succumbs 
through  marasmus,  hemorrhage,  or  exhaustion. 

Papillary  Epithelioma. — This  form  may  develop  from  the 
superficial  or  deep  variety  or  from  an  ordinary  wart.  Il  appears 
either  as  a  pea-  to  linger -nail -si  zed  verrucous  elevation,  or  a 
larger,  coin-sized,  lobulated,  spongy,  papillary  growth.  The 
surface  may  be  dry  and  covered  with  homy  yellow  scales,  or 
moist  and  covered  with  uneven,  exuberant  granulations  secret- 


EPITHELIOMA  367 

ing  a  sanguineous  or  translucent  fluid.  Disintegration  occurs, 
with  the  production,  first,  of  fissures  and,  later,  of  ulcers.  The 
course  is  progressive  and,  as  a  rule,  malignant. 


Fig.  178.— Deep- 


Epithelioma  involves  with  predilection  the  face,  particularly 
the  lower  lip,  eyelids,  and  nose.     The  penis,  labia,  and  other 


Fig.  I7g. — Deep-seated  epithelioma. 


parts  of  the  body  are  not  infrequently  affected, 
variety  occurs  most  frequently    ' 


The  papillary 
~kin  and 


368  DISEASES   OP  THE    SKIN 

mucous  membranes.     It  is  also  occasionally  seen   upon  the 
back  of  the  hand. 

Etiology. — The  cause  of  cutaneous  cancer  is,  like  the  entire 
question  of  the  origin  of  neoplasms,  involved  in  obscurity. 
Accumulated  experience  points  strongly  toward  continuous 
or  frequently  repeated  irritation  as  the  most  important  factor 
in  the  production  of  epithelioma.  Cancer  of  the  lower  lip  is 
almost  exclusively  a  disease  of  males,  because  pipe-smoking 
is  largely  limited  to  that  sex.  The  friction  of  a  jagged  tooth 
against  the  tongue,  the  continued  pinching  of  eye-glasses,  and 
like  causes  may  evoke  the  development  of  an  epithelioma. 
Chemic  rays  of  light  are  certainly  a  factor  in  the  production 


Fig.  iBo. — Epithelioma  of  craUrifoim  type. 

of  many  skin  cancers,  particularly  those  which  begin  as  keratoses. 
Skin  cancer  is  far  more  common  on  the  face  and  hands— parts 
exposed  to  light — than  elsewhere.  Cancer  of  the  skin  of  the 
face  in  negroes  is  extremely  rare.  Among  about  3000  negroes 
with  skin  diseases  I  have  seen  a  facial  cancer  only  once,  and  this 
was  in  a  mulatto  woman.  The  dark  pigment  acts  as  a  protective 
barrier  against  the  irritative  actinic  rays  of  light.  ar-Ray 
cancers  are  produced  perhaps  in  an  analogous  manner.  Cancer 
"of  the  skin  is  not  rare  in  those  who  work  in  tar  and  crude  par- 
affin for  many  years.  The  long-continued  ingestion  of  arsenic 
may,  in  rare  instances,  lead  to  the  development  of  multiple  skin 
cancer.     Skin  cancers  most  commonly  occur  after  middle  age; 


EPITHELIOMA 


369 


it  is  not  rare,  however,  to  observe  small,  superficial,  pearly  epi- 
.theliomata  in  comparatively  young  persons.  I  have  seen 
epithelioma  in  three  patients,  aged  twenty-one  years,  and  in  a 
girl  thirteen  years  old  in  the  practice  of  a  colleague. 

Pathology. — The  essential  process  in  epithelioma  is  the  pro- 
liferation of  epithelial  cells  and  their  extension  into  structures 


not  normally  the  seat  of  these  cells.  Epithelioma  cutis  must 
have  its  origin  in  the  epithelium  of  the  epidermis  or  in  the 
epithelial  lining  of  glandular  structures  in  the  skin.  In  many 
cases  the  process  consists  of  an  abnormal  downgrowth  into  the 
corium  of  the  interpapillary  projections  of  the  rete  mucosum, 
a  proliferation  of  the  rete  cells,  and  their  isolation  in  the  corium 
in  the  form  of  nests.  In  the  center  of  these  nests  "pearly 
bodies"  are  commonly  found.  Epithelioma  may  also  spring 
from  the  wall  of  a  hair-follicle  or  from  the  epithelium  of  seba- 
ceous or  sweat-glands.  Secondary  inflammatory  changes  in 
the  skin  follow. 

Diagnosis. — Epithelioma  may  be  confounded  with  warts, 
the  ulcerating  tubercular  syphiloderm,  and  lupus  vulgaris. 


37°  DISEASES  OP  THE  SKIN 

The  age  of  the  patient,  the  occurrence  of  ulceration,  the  general 
appearance  of  the  growth,  and  the  course  will  usually  enable 
one  to  distinguish  epithelioma  from  a  wart. 

From   syphiloderm,   epithelioma  may  be   differentiated  as 

follows : 

Epithelioma.  Tubercular  Ulcerating 

Syphilid. 

i.  Occurs  in  late  life.  i.  Occurs  usually   in  middle   and 

early  life. 

2.  History,  perhaps,  of  chronic  irri-       2.  History  of  early  and  concomi- 

tation.  tant  signs  of  syphilis. 

3.  Evolution  slow.  3.  Evolution  rapid. 

4.  Ulceration  single.  4.  Ulceration  usually  multiple. 

5.  Edges  of  ulcer  hard  and  pearly.  5.  Edges  of  ulcer  not   indurated. 

Discharge  scanty.  Discharge    abundant,    yellow- 

ish, and  creamy. 

6.  Lancinating  pain.  6.  No  pain. 

7.  Yields  only  to  destructive  mea-       7.  Heals  under  the  use  of  iodids 

sures.  and  mercury. 

1 

The  differential  diagnosis  from  lupus  vulgaris  will  be  found 
under  that  disease. 

Prognosis. — The  superficial  form  resulting  from  seborrheic 
degeneration  may  be  permanently  cured  by  early  and  thorough 
destruction.  In  some  of  the  other  forms  the  prognosis  is  more 
grave,  and  will  depend  upon  the  age  of  the  patient,  the  extent 
of  the  disease,  the  rapidity  of  the  process,  and  the  existence 
of  glandular  enlargement.  Cancers  of  mucous  membranes  run 
a  particularly  malignant  course. 

Treatment. — No  internal  remedies  have  any  influence  upon 
epithelioma.  The  only  means  of  curing  the  process  is  by 
removing  or  destroying  the  growth.  Most  surgeons  regard 
excision  as  the  best,  if  not  the  exclusive,  course  to  pursue. 

In  deep  growths,  in  those  associated  with  glandular  enlarge- 
ment, and  in  those  situated  upon  the  lip  or  some  other  mucous 
surface,  there  can  be  no  question  as  to  the  wisdom  of  employing 
the  knife.  There  are  many  superficial  growths,  however,  in 
which  it  is  entirely  unnecessary  to  use  such  heroic  treatment: 
not  only  can  these  epitheliomata  be  cured  without  the  use  of 
the  knife,  but  the  resultant  cosmetic  effect  is  much  better 
when  treated  by  other  means.  The  freedom  from  recurrence 
is  no  greater  after  surgical  ablation  than  after  other  treatments 
to  be  described.  There  are  many  aged  and  timid  persons  who 
will  shrink  from  the  use  of  the  knife,  but  who  will  gladly  sub- 
mit to  treatment  by  other  means. 


EPITHELIOMA  371 

For  small  superficial  growths  one  of  the  most  efficacious 
and  rapid  methods  of  treatment  is  erasion  with  a  dermal  curet. 
This  can  be  accomplished  in  a  minute,  and  almost  without  pain; 
if  desired,  local  anesthesia  by  the  injection  of  eucain  may  be 
employed.  After  curetting,  the  area  is  cauterized  with  the 
stick  of  nitrate  of  silver ;  this  stops  bleeding  and  seals  the  wound 
with  a  coagulum.  When  the  process  is  deeper,  a  pyrogallic- 
acid  ointment  is  applied : 

R  .    Acidi  pyrogallici 3  j~*J "» 

Cerati  resinse 3nJ- — M. 

Sig. — Apply  on  muslin. 

This  ointment,  which  is  a  slow  and  practically  painless 
caustic,  may  be  used  on  ulcerated  epitheliomata  without  pre- 
vious curetting.  A  black  slough  is  produced  in  a  few  days, 
which  is  removed  by  moist  fomentations;  the  ointment  is 
then  reapplied  if  necessary. 

Arsenic  has  long  been  highly  prized  as  a  caustic  for  cutaneous 
cancer.  It  exerts  a  selective  destructive  effect  upon  diseased 
cells.  Its  disadvantage  is  the  severe  pain  that  it  causes,  often 
requiring  the  use  of  an  anodyne.  On  account  of  the  possibility 
of  absorption  it  should  not  be  applied  over  an  area  more  than 
one  inch  square.  It  acts  best  upon  ulcerated  surfaces;  when 
the  overlying  skin  is  unbroken,  its  use  should  be  preceded  by 
curetting.     The  following  formula  is  frequently  used: 

R.    Pulv.  acidi  arseniosi  (arsenic  trioxid) 3ij — iij ; 

Pulv.  acaciae 3ij. — M. 

Make  into  a  paste  with  a  saturated  solution  of  cocain,  and 
apply  to  the  affected  part,  covering  the  same  with  a  single 
thickness  of  gauze.  Allow  it  to  remain  for  twelve  to  twenty- 
four  hours,  according  to  the  endurance  of  the  patient  and  the 
degree  of  destructive  effect  produced.  Considerable  edema 
occurs,  particularly  if  the  growth  is  located  near  the  eyelids. 

Caustic  potash  is  a  valuable  but  powerful  caustic,  and  must 
be  used  with  great  care.  It  readily  permeates  tissues,  both 
diseased  and  sound,  and  destroys  more  deeply  than  is  expected. 
When  scarring  is  not  a  matter  of  moment  and  rapid  destruc- 
tion of  a  growth  is  desired,  caustic  potash  may  be  used.  It  acts 
in  a  minute  or  two,  producing  a  soft  black  necrotic  mass.  Its 
use  is  extremely  painful.  ation ;  the 

area  to  be  treated  After 


■/ 


372  DISEASES   OP   THE    SKIN 

cauterization,  neutralization  should  be  effected  with  compresses 
saturated  with  vinegar. 

Electrocautery  and  thermocautery  are  of  great  value  in  treat- 
ing small  epitheliomatous  growths,  particularly  when  circum- 
scribed and  elevated. 

The  ar-rays  and  radium  have  within  recent  years  been  exten- 
sively employed  in  the  treatment  of  epithelioma,  with  most 
gratifying  results.  This  treatment  is  detailed  in  the  special 
chapter  devoted  to  Radiotherapy. 

MULTIPLE    BENIGN    CYSTIC    EPITHELIOMA 

Under  the  above  title  Fordyce  classifies  many  of  the  cases 
formerly  recorded  as  instances  of  epithelioma  adenoides  cysti- 
cum,  syringocystadenoma,  hydradenomes  eruptifs,  etc.  The 
disease  is  most  commonly  seen  upon  the  face,  although  it  may 
occur  also  on  the  neck  and  upper  portion  of  the  trunk.  The 
^^^^^^  lesions  consist  of  pin-head- 

-*-^^^|  ^^^  to    pea-sized,   pearly,   pink- 

ish, reddish,  or  pale-yellow 
^^H  ^H  tumors.       They    arc    tense, 

4M  ^         shining,  oval  or  round,  and 

painless  to  the  [ouch.     The 
i        number  varies  from  two  or 
'    L     ^^  three    to   a    score    or  more. 

f  They  are  usually  discretely 
scattered,  but  occasionally 
neighboring  lesions  may  run 
together.  They  slowly  in- 
^^^^^"■^^^^~*  crease  in  size,  reaching  the 

' ■"  |,|:l'':i  ™tic  epi-     sizeofapea.     Exceptionally 


iwlhs  on  tlu- 


Modt-ra 

iif acattpTcd  |.in-  thev  mav  grow  larger  ana 
ulcerate,  as  is  seen  in  the 
accompanying  illustration.  The  course  is  usually  benign;  the 
glands  are  not  involved,  and  the  general  health  is  not  com- 
promised. 

The  growths  are  usually  observed  at  or  before  puberty  or 
a  little  later. 

Pathology. — The  tumors  are  derived  in  nearly  all  cases 
from  dovvngrowths  of  the  retc  mucosum  and  from  the  walls 
of  hair-follicles.  Cysts  arc  commonly  formed,  and  colloid 
change  is  not  infrequently  noted. 

Treatment. — Large  tumors  may  be  curetted  or  excised. 


PAGBT'S  DISEASE  OF  THE   NIPPLE  373 

PAGETS  DISEASE  OF  THE  NIPPLE 
Synonym. — Malignant  papillary  dermatitis 

Definition. — Paget's  disease  is  a  malignant  affection  of  the 
nipple  and  areola,  characterized  at  first  by  an  eczematoid 
process  which  later  terminates  in  carcinoma  of  the  skin  and 
mammary  gland. 

Symptoms. — The  disease  attacks  women,  usually  between 
the  ages  of  forty  and  sixty.  But  one  breast  is,  as  a  rule, 
involved,  and  this  is  usually  the  right  breast. 

In  the  beginning  firm  crusts  are  noted  upon  a  reddened 
base.     A  typical  case  exhibits  a  sharply  defined,   red,  raw, 


:8j.— Paget's  disease  of  the  nipple. 


granulating  surface,  copiously  exuding  a  clear,  viscid  secretion. 
Scattered  throughout  the  patch  are  frequently  seen  small 
islets  of  epidermized  skin;  these  may  represent  either  efforts 
at  repair  or  areas  that  have  escaped  destruction.  This  appear- 
ance is  quite  suggestive  of  the  disease.  Early  in  the  course  of 
the  affection  the  nipple  becomes  retracted  and  surrounding 
induration  occurs.  The  infiltration  present  has  been  aptly 
likened  to  the  feel  of  a  button  or  coin  through  a  handkerchief. 
Burning,  itching,  and  pain  are  present,  and  are  usually  severe. 
Later,  in  untreated  cases,  cancerous  involvement  of  the  skin 
and  mammary  gland  takes  place.  Paget's  disease  has,  in  a 
few  instances,  been  recorded  as  occurring  upon  the  penis,  scro- 
tum, and  other  regions. 

Pathology. — Under  the  microscope  there  is  visible  a  pro- 


374  DISEASES  OP  THE  SKIN 

liferation  of  cells  of  the  mucous  layer,  with  edema  and  vacuo- 
lation,  prolongation  of  the  rete  pegs,  formation  of  epithelial 
nests,  dilatation  of  papillary  blood-vessels,  perivascular  cell- 
infiltration,  and  loss  of  the  superficial  epiderm. 

A  sharp  line  of  demarcation  separates  the  disease  tissue  from 
the  healthy  border. 

Diagnosis. — Paget's  disease  may  be  distinguished  from 
eczema  by  the  more  advanced  age  of  the  patient,  the  sharp 
definition  of  the  patch,  the  peculiar  raw  granular  appearance, 
the  button-like  infiltration,  and  the  course  of  the  disease. 

Prognosis. — If  the  disease  is  recognized  before  mammary 
cancer  is  developed,  cure  may  result  from  properly  applied 
measures. 

Treatment. — If  there  is  doubt  as  to  the  diagnosis,  such 
remedies  as  are  employed  in  eczema  should  be  tried.  When 
the  nature  of  the  disease  is  firmly  established,  treatment  of  a 
positive  character  should  be  employed.  Caustics  are  not  to 
be  used,  as  they  may  cause  extension  of  the  process  to  the 
glands.  The  jc-rays  have  been  used  with  success  by  a  number 
of  dermatologists.  Whenever  doubt  exists  as  to  the  advis- 
ability or  necessity  of  surgical  ablation,  the  more  radical  treat- 
ment had  better  be  adopted. 

SARCOMA 

Derivation. — 2dp£,  flesh. 

Definition. — Sarcoma  is  a  malignant  disease,  characterized 
by  variously  sized,  shaped,  and  colored  tumors,  occurring  in  the 
skin  and  subcutaneous  tissues  either  as  primary  or  secondary 
growths. 

Symptoms. — Sarcoma  may  be  primary  in  the  skin  or  second- 
ary to  the  same  process  in  some  other  organ  or  tissue.  Several 
varieties  are  described. 

Primary  melanotic  sarcoma  or  melanosarcoma  is  one  of 
the  most  common  and  most  malignant  forms  of  the  disease. 
It  usually  has  its  origin  in  an  irritated  pigmented  nevus, 
although  other  pigmented  patches  may  be  the  site  of  develop- 
ment. The  lesion  is  usually  single  at  first ;  it  varies  in  size  from 
a  pea  to  a  cherry  or  walnut.  It  is  soft  or  firm  to  the  touch, 
usually  sessile,  round  or  oval  in  shape,  and  of  a  bluish,  brownish, 
or  blackish  color.  New  lesions  soon  develop  in  the  neighbor- 
hood of  the  original  growth,  and  later  at  a  distance.  They 
may  remain  unchanged  for  a  considerable  period;  some  tend 


SARCOMA  375 

to  break  down  and  ulcerate.  Visceral  metastasis  occurs,  and 
a  fatal  termination  results. 

Hutchinson  has  described  a  condition  under  the  name  of 
melanotic  whitlow  in  which  there  is  an  onychia,  with  pigmenta- 
tion suggesting  silver-nitrate  stains,  terminating  in  tumor  for- 
mation and  generalization  of  the  process. 

Primary  non-pigmented  sarcoma  occurs  both  in  localized 
and  generalized  form.  The  localized  form  develops  commonly 
upon  an  irritated  nevus  or  wart,  and  is  usually  encountered 
upon  the  extremities.  It  is  firm  and  of  normal  skin  tint;  later 
it  breaks  down,  ulcerates,  and  acquires  the  appearance  of  a 
fungoid  growth. 

In  the  generalized  form  the  lesions  are  few  or  numerous, 
and  usually  situated  upon  the  extremities,  particularly  the  legs. 
At  first  they  are  of  the  color  of  the  normal  skin,  with,  perhaps, 
a  reddish  or  bluish  cast,  but  later  are  apt  to  become  dark 
blue  or  purplish.  They  vary  in  size  from  a  pin-head  to  a  cherry 
or  egg.  As  the  disease  progresses  the  intervening  skin  becomes 
tense,  swollen,  painful,  and  erysipelatoid  in  appearance.  Some 
of  the  lesions  may  undergo  ulceration.  The  disease  is  rapidly 
progressive  and  leads  to  metastasis  in  various  viscera.  The 
termination  is  nearly  always  fatal. 

Idiopathic  multiple  hemorrhagic  sarcoma  is  a  form  first 
described  by  Kaposi.  It  occurs  usually  in  males  between  the 
ages  of  forty  and  sixty.  It  is  preceded,  upon  the  feet,  hands, 
or  face,  by  edema  and  itching.  Later  brownish,  bluish,  or 
purplish  spots  appear,  upon  which  there  develop  raised  or 
flat  nodules  varying  in  size.  The  skin  of  the  affected  part 
becomes  infiltrated  and  ultimately  elephantiasic  in  character. 
The  disease  lasts  from  three  to  five  years  or  longer.  In  some 
instances  recovery  takes  place. 

Multiple  benign  sarcoid  (Boeck)  appears  in  typical  cases  as 
an  extensive  eruption  of  firm  nodules  upon  the  head,  trunk,  and 
extremities.  The  lesions  are  at  first  bright  red,  later  yellowish 
or  brownish,  and  in  size  vary  from  a  hemp-seed  to  a  bean.  A 
tendency  to  peripheral  spreading  and  central  healing  is  exhibited. 
On  the  face  the  lesions  have  a  blue  center  and  yellow  border. 
Under  the  use  of  arsenic,  or  at  times  without,  the  lesions  tend 
to  disappear.  The  affection  is  usually  benign,  although  some 
cases  run  an  unfavorable  course. 

Etiology. — We  are  in  complete  darkness  as  to  the  cause 
of  sarcoma.     It  occurs  at  all  ages,  and  is  at  times  congenital. 


376  DISEASES  OF  THE   SKIN 

Pathology. — Sarcoma  is  a  connective-tissue  growth  made 
up  of  round  or  spindle-shaped  cells.  The  pigmented  sarcomata 
are  regarded  by  many  workers  as,  in  reality,  carcinomata,  as 
they  have  their  origin  in  the  epithelial  cells  of  nevi.  In  the 
multiple  idiopathic  pigmented  sarcoma  the  color  is  due  to 
hemorrhagic  extravasation. 

Diagnosis. — Sarcoma  may  be  confounded  with  fibroma, 
carcinoma,  mycosis  fungoides,  and  gumma ta.  The  coloration, 
the  course  of  the  disease,  and  the  microscopic  appearances 
determine    the    diagnosis. 

Prognosis. — The  prognosis  is  always  grave,  most  cases 
terminating  fatally. 

Treatment. — When  lesions  are  single,  they  should  be  excised. 
When  the  lesions  are  numerous,  ablation  is  neither  feasible  nor 
advisable.  Hypodermic  injections  of  diluted  Fowler's  solution 
in  ascending  doses  has  effected  some  cures.  The  #-rays  have  also 
done  well  and  are  certainly  worthy  of  trial. 

.  GRANULOMA  FUNGOIDES 

Synonyms. — Mycosis  fungoides;  Inflammatory  fungoid  neoplasm; 
Lymphodermia  perniciosa. 

Definition. — A  chronic,  malignant  disease,  characterized 
primarily  by  an  eruption  of  an  urticarial,  eczeinatoid,  or 
lichenoid  appearance,  and  later  by  ulcerating  fungoid  tumors. 

Symptoms. — In  the  early  "premycosie"  or  prefungoid 
stage  the  disease  may  manifest  itself  by  eruptions  of  varied 
character;  usually  an  eczematoid  or  lichenoid  appearance  is 
presented,  although  in  some  cases  erythema,  urticaria,  psoriasis, 
or  pityriasis  rubra  may  be  closely  simulated.  It  is  thus  seen 
that  in  the  beginning  the  affection  has  most  varied  forms  of 
expression. 

Commonly,  the  first  symptom  is  the  appearance  of  one  or 
more  reddish,  sharply  marginated,  round,  circinate  patches, 
either  on  a  level  with  the  skin  or  slightly  elevated.  The  surface 
may  be  smooth,  or  scaly  enough  to  suggest  psoriasis.  Itch- 
ing is  usually  a  pronounced  symptom.  The  plaques  vary  in 
size,  shape,  and  distribution.  The  trunk  is  usually  first 
involved.  The  patches  tend  to  spread  upon  the  periphery 
and  clear  up  in  the  center.  Large  circinate  or  gyrate  lesions 
may  thus  be  formed.  As  the  disease  progresses,  the  skin  becomes 
more  infiltrated.     The  lesions  referred  to  may  disappear  and  be 


GRANULOMA   FUNGOIDES  377 

followed  by  new  patches.  This  stage  lasts  several  months  to 
several  years.  Later  the  lesions  take  on  a  more  distinctly 
infiltrated  and  nodular  character.  Pea-sized  nodules  and 
finger-nail-  to  palm-sized  plaques  are  now  seen ;  these  are  prone 
to  assume  a  circinate,  semilunar,  or  gyrate  shape.  They  are 
distinctly  elevated  and  infiltrated,  and  vary  in  color  from  Hi 
pinkish  to  a  bluish  red.  After  lasting  for  months  or  years, 
the  fungoid  stage  develops. 

Fungoid  Stage. — Fungoid  tumors  may  appear  upon  the 
patches  described  or  rise  from  the  healthy  skin.  They  vary 
in  size  from  a  cherry  to  an  orange,  are  sessile  or  pedunculated, 
reddish  or  normal  skin  tinted,  and  usually  hemispheric.  The 
growths  are  moderately  firm,  the  overlying  skin  being  tense 
*  and  sometimes  crusted.  The  tumors  may  disappear  and 
reappear. 

Finally,  some  undergo  ulceration,  producing  characteristic 
mushroom-like  growths.  The  trunk  is  first  affected;  later, 
the  extremities  and  face.  The  lymphatic  glands  become 
greatly  swollen. 

The  general  health  is,  in  the  beginning,  not  affected,  but 
as  the  disease  progresses  and  ulceration  takes  place,  the  patient's 
vitality  is  seriously  compromised  and  a  fatal  termination 
ultimatelv  occurs. 

Etiology  and  Pathology. — Mycosis  fungoides  occurs  most 
often  in  corpulent  men  beyond  the  age  of  forty.  The  disease 
is  believed  to  be  an  infectious  granuloma,  due,  it  is  presumed, 
to  a  microparasite. 

The  microscopic  picture  in  the  tumor  stage  strongly  re- 
sembles round-cell  sarcoma.  Early  in  the  disease  the  pres- 
ence of  compact  masses  of  multiform  cells, — round,  cuboidal, 
and  irregular, — set  in  a  delicate  fibrous  stroma,  is  charac- 
teristic. 

Diagnosis. — The  chronicity,  sharp  circumscription,  and 
circinate  character  of  the  early  plaques  are  highly  suggestive, 
although  a  positive  diagnosis  at  this  time  is  often  impossible. 
The  proneness  of  the  patches  to  undergo  resorption,  with  sub- 
sequent reappearance,  is  highly  diagnostic.  When  the  tumors 
develop,  the  nature  of  the  disease  becomes  clear.  Eczema 
and  psoriasis  are  the  affections  to  be  differentiated. 

Prognosis. — The  disease  is  usually  fatal,  although  several 
recoveries  have  taken  place.  The  affection  may  last  many 
years. 


378  DISEASES  OP  THE   SKIN 

Treatment. — The  itching  in  the  early  stages  is  to  be  treated 
in  the  same  manner  as  in  eczema.  From  present  indications 
the  most  important  therapeutic  remedy  appears  to  be  the  use 
of  the  x-rays.  In  a  number  of  cases  the  disease  has  been  kept 
in  abeyance  as  long  as  the  rays  were  applied. 


CLASS  VIIL    ANOMALIES  OF  SECRETIONS  OF 

GLANDS 

HYPERIDROSIS 

Derivation. — "Twp,  in  excess;  ifyoK,  sweat.  Synonyms. — Idrosis;  Hy- 
drosis;  Ephidrosis;  Sudatoria;  Polydrosis;  Excessive  sweating. 

Definition. — Hyperidrosis  is  a  functional  disorder  of  the 
sweat-glands  characterized  by  an  excessive  secretion  of  sweat. 

Symptoms. — Hyperidrosis  may  be  generalized  or  localized; 
it  may  likewise  be  in  some  cases  unilateral.  General  excessive 
sweating  need  not  be  discussed  here,  as  it  is  usually  the  expres- 
sion of  a  constitutional  disturbance. 

Localized  sweating  is,  as  a  rule,  symmetric,  and  confined  to 
special  regions,  as  the  palms,  soles,  axillae,  genitalia,  nose,  fore- 
head, etc.  The  condition  is  observed  most  typically  upon 
the  hands,  which  are  moist,  clammy,  and  cold;  in  its  mild 
forms  this  is  a  very  common  affection.  When  more  pronounced, 
the  hands  are  constantly  wet,  and  sweat  may  drip  from  the 
skin  in  droplets.  This  is  a  most  annoying  trouble,  as  gloves 
are  rapidly  ruined  and  patients  often  incapacitated  for  manual 
occupations.  When  the  feet  are  affected,  the  skin  of  the  soles 
becomes  macerated  and  sodden.  The  epidermis  has  a  whitened 
appearance,  owing  to  infiltration  with  moisture;  just  above 
the  whitened  border,  on  the  lateral  surface  of  the  foot,  is  a 
narrow,  reddish,  inflammatory  border.  The  feet  become 
extremely  tender  upon  walking. 

Excessive  sweating  in  the  axilla?  is  not  uncommon;  it  is 
greatly  increased  by  mental  excitation.  During  medical 
examinations  the  sweat  from  the  axillae  not  infrequently  trickles 
down  the  sides  of  the  chest.  Hyperidrosis  of  the  feet,  axillae, 
and  genitalia  is  apt  to  be  associated  with  bromidrosis. 

Unilateral  hyperidrosis  is  usually  seen  upon  the  face.  It 
is  sometimes  accompanied  by  a  faint  erythema. 

Etiology. — The  disease  is  due  to  a  disturbance  of  the  nervous 
mechanism   governing   the    vasomotor   and   sweat   apparatus. 


BROMIDROSIS  379 

Vasomotor  weakness,  cardiac  disease,  nerve  lesions,  etc.,  are 
the  most  common  underlying  causes.  In  unilateral  hyperidro- 
sis  there  is  usually  some  structural  nerve  disease. 

Prognosis. — Excessive  sweating  of  the  hands  is  a  most 
refractory  affection;  when  the  feet  are  affected,  the  condition 
is  frequently  cured. 

Treatment. — In  general  hyperidrosis  constitutional  remedies 
are  to  be  employed — belladonna  or  atrcpin,  ergot,  nux  vomica, 
mineral  acids,  quinin,  etc.  Crocker  speaks  highly  of  sulphur, 
given  in  dram  doses  twice  daily,  for  both  general  and  local 
sweating.  For  the  local  forms  the  remedies  are,  for  the  greater 
part,  to  be  applied  to  the  affected  regions.  Upon  the  palms 
this  condition  is  much  more  refractory  to  treatment  than  upon 
the  soles.  The  following  will  be  found  of  great  value  in  the 
treatment  of  sweating  feet: 

R.    Acidi  salicylici gr.  xx-xxx; 

Acidi  borici 3 j ; 

Petrolati  } aa  S"--*- 

Sig. — To  be  rubbed  in  well  at  bedtime. 

The  feet  ought  not  to  be  washed  more  than  once  a  week. 
It  is  well  also  to  strew  boric  acid  in  the  stockings.  Hebra's 
plan  was  to  wrap  up  the  feet  in  unguentum  lithargyri  (diachylon 
ointment),  and  continue  the  treatment  for  a  fortnight. 

Crocker  recommends  the  use  of  a  belladonna  ointment. 
Immersion  in  a  i  per  cent,  solution  of  permanganate  of  potash 
is  advocated.  All  these  remedies  will  be  found  more  efficient 
in  sweating  feet  than  in  sweating  hands. 

To  check  sweating  of  the  axillae  for  a  few  hours  apply  a  sponge 
soaked  in  very  hot  water. 

Faradization  and  galvanization  are  sometimes  of  value  in 
hyperidrosis.  I  have  seen  marked  lessening  of  perspiration 
follow  the  long-continued  use  of  the  x-rays. 

BROMIDROSIS 

Derivation. — Bp&fioc,  a  stench.     Synonym. — Osmidrosis. 

Definition. — Bromidrosis  is  a  functional  disorder  of  the 
sweat-glands,  characterized  by  sweat  secretion  of  an  offensive 
odor. 

Symptoms. — The  term  bromidrosis,  strictly  speaking,  should 


380  DISEASES  OF  THE   SKIN 

be  applied  only  to  that  condition  in  which  the  sweat  when 
secreted  has  an  unnatural  odor;  by  common  acquiescence, 
however,  bromidrosis  refers  also  to  the  stinking  odor,  caused 
by  decomposition  of  the  sweat  after  transudation.  In  negroes 
a  general  malodorous  sweat  is  more  or  less  physiologic.  It 
may  be  symptomatic,  as  in  uremia,  rheumatism,  etc. 

More  commonly  the  bromidrosis  is  local,  and  limited  to 
such  localities  as  the  feet,  axillae,  and  genitocrural  region;  it 
is  usually  associated  with  an  excessive  sudoriparous  secretion. 
At  times,  although  the  amount  of  sweating  may  be  normal, 
the  odor  is  so  penetrating  as  to  unfit  the  sufferer  for  society. 

Etiology  and  Pathology. — Thin  has  described  a  micro- 
organism, the  bacterium  fcetidum,  in  decomposing  and  mal- 
odorous sweat.  The  stockings  and  shoes  become  saturated 
with  sweat  and  emit  an  offensive  odor.  Bromidrosis  of  the 
feet  does  not  occur  in  those  who  walk  barefooted.  General 
bromidrosis  may  occur  in  hysteria,  neurasthenia,  gout,  chronic 
alcoholism,  etc. 

Treatment. — In  local  bromidrosis  the  treatment  is  essentially 
that  of  hyperidrosis.  Immersion  in  a  r  per  cent,  solution  of 
permanganate  of  potash  or  in  a  2  to  5  per  cent,  solution  of 
formalin  is  of  great  value.  For  general  bromidrosis  the  under- 
lying condition  must  be  studied  and  treated.  I  have  found 
the  internal  use  of  carbolic  acid  in  1-  to  3-minim  doses  of  value. 
Osier  cured  a  patient  by  the  administration  of  alkalis. 

ANIDROSIS 

Derivation. — 'A,  privative,  and  <ffy>wff  sweat.  Synonym. — Decrease  or 
absence  of  sweating. 

Definition. — A  disorder  of  the  sweat-glands  characterized 
by  diminution  or  suppression  of  sweat.  Like  hyperidrosis, 
anidrosis  may  be  local  or  general. 

Symptoms. — It  may  be  the  symptomatic  expression  of 
general  disease,  such  as  fevers,  diabetes,  Bright 's  disease,  etc. 
It  is  observed  in  ichthyosis  as  a  congenital  condition.  It  may 
also  be  due  to  faulty  innervation.  There  may  be  but  slight 
diminution  of  sweat  secretion  or  total  absence. 

Treatment. — In  congenital  cases  nothing  is  of  avail.  In 
acquired  cases  one  may  employ  massage,  electricity,  vapor 
and  alkaline  baths,  etc. 


HEMATIDROSIS  38 1 

CHROMIDROSIS 

Derivation. — Xp&fia,  color;  i<Jpwf,  sweat. 

Definition. — A  disorder  of  the  sweat-glands  characterized 
bv  an  abnormal  coloration  of  the  sweat. 

Symptoms. — There  are  two  forms — idiopathic  and  accidental 
(color  due  to  certain  substances  taken  into  the  system).  The 
color  in  the  idiopathic  form  is  ordinarily  black  or  sepia.  The 
orbital  region  is  usually  affected. 

The  affection  occurs,  as  a  rule,  in  hysteric  women.  At  times 
the  discoloration  is  self-produced. 

Red  sweat  is  not  uncommonly  seen  in  the  axillae,  where  it 
stains  the  undershirt.  It  is  not  infrequently  accompanied  by 
itching.  The  axillary  hairs  exhibit  a  reddish  color,  and  are 
surrounded  by  a  rough  sheath,  made  up  of  bacteria  in  zooglea 
masses.  Green  sweat  may  occur  in  copper  workers,  or  in  those 
who  have  ingested  considerable  quantities  of  this  drug.  Blue 
sweat  has  occurred  from  the  adminstration  of  iron. 

Etiology  and  Pathology. — The  subjects  of  chromidrosis, 
save  the  red  axillary  form,  are  usually  hysteric  or  neurasthenic 
women. 

Treatment. — The  treatment  is  based  upon  broad  general 
principles.  In  red  chromidrosis  of  the  axillae  antiseptic  soaps 
are  indicated. 

URIDROSIS 

Derivation. — Ovpnv,  urine;  M/>«f,  sweat.     Synonym. — Sudor  urinosus. 

Definition. — A  condition  characterized  by  the  secretion, 
through  the  sweat-glands,  of  constituents  of  the  urine  in  con- 
siderable quantity. 

Symptoms. — The  sweat  normally  contains  small  quantities 
of  urea.  In  suppression  of  the  urine,  as  in  B  right's  disease, 
cholera,  etc.,  urinary  products  are  eliminated  through  the  sweat- 
glands.  There  is  a  urinous  odor  to  the  skin,  and  sometimes 
a  deposition  of  salts  in  the  form  of  minute  whitish  crystals 
upon  the  cutaneous  surface. 

HEMATIDROSIS 

Derivation. — Alua,  blood;  M/jwf,  sweat.     Synonym. — Bloody  sweat. 

Definition. — A  condition  characterized  by  hemorrhage  from 
the  sweat-pores. 


382  DISEASES  OF  THE   SKIN 

Symptoms. — Very  rare.  Occurs  in  young  hysteric  women. 
It  may  sometimes  represent  a  vicarious  menstruation.  It 
has  occasionally  been  encountered  in  the  new-born. 

PHOSPHORIDROSIS 

Derivation. — ^oxj(j>6poct  phosphorus;  Mp6f,  sweat. 

Definition. — A  rare  condition,  characterized  by  phosphor- 
escent sweat.  Has  been  observed  after  the  ingestion  of  phos- 
phorus and  of  fish,  but  is  probably  due  to  a  species  of  photo- 
bacterium.  Koster  observed  a  patient  whose  body  linen 
became  phosphorescent  after  violent  exercise. 

GRANULOSIS  RUBRA  NASI 

In  1 90 1  Jadassohn  described,  under  this  title,  seven  cases  of 
a  peculiar  affection  of  the  nose  occurring  in  children.  Upon 
a  more  or  less  defined  area  of  redness  upon  the  tip  and  sides 
of  the  nose  there  are  studded,  numerous,  pin-point-  to  pin- 
head-sized,  dark-red  maculopapules.  These  may  be  made 
to  disappear  under  pressure,  unlike  lupus  nodules,  which  they 
otherwise  resemble.  The  eruption  is  usually  limited  to  the 
nose,  but  may  rarely  occur  upon  the  upper  lip  and  cheeks. 
Between  the  lesions  the  skin  is  moist  and  covered  with  drop- 
lets of  perspiration.  Indeed,  hyperidrosis  of  the  nose  is  a 
pretty  constant  accompaniment  of  the  disease.  The  patients 
were  all  children  under  the  age  of  sixteen ;  many  of  them  suffered 
from  cold  extremities,  evidencing  poor  peripheral  circulation. 
The  disease  lasts  for  years.  Microscopically,  the  sweat-glands 
are  implicated  in  the  process. 

HYDROCYSTOMA 

Derivation. — 'Ifipox;,  sweat. 

Definition. — A  condition  characterized  by  the  formation, 
upon  the  face,  of  firm,  discrete,  translucent,  pin-head-  to  split - 
pea-sized,  deep-seated  vesicles.  This  affection  has  been  care- 
fully studied  and  described  by  A.  R.  Robinson. 

Symptoms. — The  lesions  are  usually  confined  to  the  face, 
especially  the  nose  and  cheeks,  although  they  may  occasionally 
appear  upon  the  neck.  They  are  discrete,  although  when 
numerous,  closely  crowded  together.  They  vary  in  number 
from  half  a  dozen  to  a  hundred  or  more.     The  individual  lesions 


SUDAMEN  383 

appear  as  tense,  shining,  translucent,  obtusely  rounded  vesicles, 
varying  in  size  from  a  pin-head  to  a  pea.  They  are  deep  seated 
and  firm  to  touch.  Small  lesions  bear  a  resemblance  to  a  sago 
grain.  Larger  vesicles  have,  upon  the  periphery,  a  faint 
bluish  or  purplish  color,  which  is  quite  characteristic.  Upon 
puncture  of  the  vesicle  a  clear  fluid,  acid  in  reaction,  exudes. 

In  their  later  stages,  through  desiccation  of  the  contents, 
a  whitish,  milium-like  appearance  may  be  presented. 

The  affection  is  almost  entirely  limited  to  women,  par- 
ticularly middle-aged  women.  It  is  produced  by  excessive 
perspiration,  especially  in  persons  exposed  to  warm  vapor ;  the 
subjects  of  the  disorder  have  nearly  all  been  washerwomen. 
The  lesions  greatly  improve  or  disappear  in  the  winter  months, 
but  are  prone  to  return  in  the  summer. 

Pathology. — The  vesicle  is  caused  by  a  cystic  dilatation 
of  the  sweat-duct  in  the  corium;  as  the  vesicle  increases  in 
size,  the  cyst-wall  approaches  the  epidermis. 

Treatment. — Those  affected  should  avoid  occupations  that 
promote  perspiration.  Residence  in  a  cool  climate  is  eminently 
desirable.  The  results  of  treatment  are  not  very  brilliant. 
Robinson  advises  friction  with  sapo  mollis  and  water,  and 
puncturing  the  vesicles  with  a  needle.  Mild  astringent  lotions, 
such  as  the  one  advised  for  miliaria,  may  be  used. 

SUDAMEN 
Derivation. — L.,  sudor,  sweat.     Synonym. — Miliaria  crystallina. 

Definition. — An  ephemeral  eruption  characterized  by  the 
formation  of  numerous  superficial,  pin-head,  transparent  ves- 
icles, occurring  during  the  course  of  febrile  diseases. 

Symptoms. — The  eruption  consists  of  pin-point-  to  pin-head- 
sized  non-inflammatory  vesicles.  They  have  been  aptly 
described  as  resembling  "dew-drops."  The  vesicles  are  dis- 
cretely scattered  over  the  trunk  and  neck.  They  contain 
clear  contents,  and  are  situated  upon  a  normal  skin  that  shows 
no  redness  whatsoever.  The  vesicles,  which  are  extremely 
thin  roofed,  rupture  readily  and  disappear  in  a  few  days, 
leaving  behind  a  slight  desquamation.  There  are  no  subjective 
symptoms.  The  condition  occurs  in  general  febrile  disorders, 
accompanied  by  sweating,  such  as  typhoid  and  typhus  fever, 
rheumatism,  septicemia,  etc. 

Pathology. — The  vesicles  are  due  to  a  collection  of  sweat 


384  DISEASES  OF  THE   SKIN 

in  the  upper  layers  of  the  epidermis,  as  a  result  of  obstruction 
of  the  mouth  of  the  sweat-ducts. 

Treatment. — The  affection  undergoes  spontaneous  involu- 
tion and  requires  no  treatment. 

MILIARIA 

Derivation. — L.,  milium,  millet.  Synonyms. — Prickly  heat ;  Lichen  tropi- 
cus; Red  gum;  Strophulus. 

Definition. — A  mild  inflammatory  affection  characterized  by 
discrete  but  closely  set,  pin-point-  to  pin-head-sized  papules 
and  vesicles  occurring  at  the  mouths  of  the  sweat-ducts,  and 
accompanied   by  itching  and   burning. 

Symptomatology. — Miliaria  is  essentially,  although  not 
exclusively,  a  disease  occurring  during  the  hot  season.  The 
eruption  appears  suddenly,  usually  after  pronounced  physical 
exertion,  the  ingestion  of  hot  beverages,  or  some  other  cause 
provocative  of  sweating.  The  patient  experiences  a  feeling 
of  heat  and  itching  over  parts  of  or  the  entire  trunk.  On 
inspection,  the  skin  exhibits  great  numbers  of  discrete  but 
closely  studded,  pin-point-  to  pin-head-sized,  reddish  papules 
{miliaria  papulosa).  The  papules  are  surrounded  by  a  reddish 
halo.  The  summits  of  many — indeed,  at  times,  of  most — of 
the  papules  are  capped  with  small  vesicles  containing  a  clear 
fluid  {miliaria  vesiculosa).  In  a  few  days  the  serum  becomes 
milky  or  yellowish-white.  The  vesicles  show  no  tendency  to 
rupture. 

When  the  eruption  is  copious,  the  inflammatory  zone  around 
the  lesions  gives  the  skin  an  appearance  of  generalized  redness; 
this  has  led  to  the  designation  miliaria  rubra.  The  eruption 
appears  in  crops,  and  the  duration  of  the  affection  depends 
upon  the  frequency  of  repetition  of  the  outbreaks.  At  times 
the  eruption  consists  of  but  one  crop,  and  the  affection  then 
lasts  about  a  week. .  The  recurrence  of  crops  may  perpetuate 
the  disorder  throughout  the  entire  summer.  The  advent  of 
cool  weather  or  removal  to  a  colder  climate  produces  a  rapid 
disappearance  of  the  eruption.  In  children,  particularly  in 
the  summer  months,  miliaria  is  very  prone  to  be  complicated 
by  the  development  of  furuncles.  Marked  burning  and  itching 
are  usually  complained  of. 

Etiology  and  Pathology. — The  eruption  is  caused  by  free 
perspiration  as  a  result  of  exposure  to  heat,  the  use  of  hot 
drinks,    particularly    alcoholic    beverages,    violent    exertion, 


MILIARIA  385 

vapor  baths,  excessive  clothing,  etc.  I  believe  that  intestinal 
disorders,  with  absorption  of  toxic  products,  is  often  an  impor- 
tant factor;  I  have  not  infrequently  seen  miliaria  in  the  winter 
months,  apparently  from  the  elimination  of  irritating  substances 
through  the  sweat-ducts. 

Under  the  microscope  minute  sweat-cysts  are  seen  scattered 
throughout  the  epidermis.  Some  investigators  believe  these 
to  be  due  to  obstruction  of  the  sweat-ducts,  but  Torok  concludes 
that  the  process  is  inflammatory  and  due  to  the  irritation  of 
the  sweat  on  the  surface. 

Diagnosis. — Miliaria  may  be  distinguished  from  eczema 
by  the  sudden,  profuse  outbreak  of  the  eruption  following 
sweating,  by  the  discreteness  and  absence  of  coalescence  of 
the  lesions,  by  the  absence  of  weeping,  and  by  the  spontaneous 
cure  under  appropriate  weather  conditions.  I  have  seen 
miliaria  so  abundant  as  to  call  into  question  the  possibility 
of  the  existence  of  scarlet  frier. 

Treatment. — The  prophylactic  treatment  of  miliaria  is 
concerned  with  the  avoidance  of  those  factors  known  to  pro- 
duce the  disorder.  Children  should  be  lightly  clad  in  thin 
woolens  in  summer,  and  should  be  kept  in  cool  places,  sheltered 
from  the  torrid  heat.  Constipation  should  be  guarded  against, 
as  should  also  all  intestinal  disturbances. 

The  local  treatment  consists  in  the  use  of  mild  sedative 
lotions  and  dusting-powders.  I  have  found  the  following 
lotion  to  act  in  an  admirable  manner ;  indeed,  I  know  of  no  better 
combination : 

R.    Resorcin.      )  --      . 

Acidi  borici  j dJ ' 

Glycerini jj ; 

Aquae  hamamelidis f 3J ; 

Spirit,  vini  rcct f^vj ; 

Zinci  oxidi Jjij ; 

Aquae q.  s.  ad  f^vj. — M. 

Sig. — Sop  on  frequently. 

Or  the  following  dusting-powder  may  be  used: 

R .    Menthol gr.  v ; 

Acidi  boriei Sj ; 

Talci  Venet 3J.— M. 

One  may  sop  on  a  saturated  solution  of  boric  acid  and  follow 

this  with  a  dusting- powder.     When  the  entire  body  is  involved, 

bran,  starch,  or  alkaline  baths  may  be  employed  with  good 

results.     Ointments  are  best  avoided. 
*5 


386  DISEASES  OF  THE   SKIN 

SEBORRHEA 

Derivation. — L.,  sebum,  suet;  p«j,  to  flow.  Synonyms. — Dandruff;  Pity- 
riasis; Ichthyosis  s£bac6;  Eczema  seborrhceicum  of  some  authors. 

Definition. — A  disorder  of  the  fat-producing  glands,  char- 
acterized by  an  increased,  decreased,  or  altered  secretion  of 
sebum,  producing  an  oily,  crusted,  or  scaly  condition  upon  the 
skin. 

Considerable  difficulty  arises  in  the  presentation  of  this  sub- 
ject, owing  to  the  diverse  views  held  as  to  what  should  be 
included  within  the  designation  seborrhea.  Most  writers, 
following  the  teachings  of  Hebra,  describe  two  distinct  forms — 
seborrhea  oleosa  and  seborrhea  sicca  (pityriasis  simplex). 

In  the  former  condition  there  is  a  seborrheal  flux  or  excessive 

* 

flow  of  sebum,  while  in  the  latter  form  it  is  assumed  that  there 
is  a  diminished  secretion,  with  an  exfoliation  of  cells.  Sabou- 
raud,  whose  careful  researches  upon  this  subject  have  attracted 
general  attention,  denies  the  existence  of  a  seborrhoea  sicca. 
He  holds  that  pityriasis  simplex  may  and  does  frequently 
coexist  with  an  oily  seborrhea,  particularly  upon  the  scalp, 
but  that  it  is  a  condition  apart. 

Seborrhoea  Oleosa. — This  form  manifests  itself  as  an  inor- 
dinate oiliness  of  the  part.  Upon  the  scalp  the  hair  and  skin 
are  seen  to  be  greasy,  glistening,  moist,  and  sticky;  the  hair 
often  becomes  matted  together.  Even  after  thorough  washing 
a  reaccumulation  of  oil  soon  manifests  itself.  When  the  scalp 
is  not  kept  clean,  the  fatty  matter  may  become  rancid  and 
emit  a  disagreeable  odor. 

Upon  the  face,  seborrhea  may  occur  as  an  independent  affec- 
tion, or  may  be  associated  with  a  similar  condition  upon  the 
scalp.  It  usually  attacks  the  middle  third  of  the  face — the 
forehead,  nose,  chin,  and  adjacent  portions  of  the  cheeks.  The 
skin  is  preternaturally  oily,  and  presents  a  dirty,  begrimed 
appearance,  owing  to  the  adhesion  of  particles  of  dust.  The 
mouths  of  the  sebaceous  follicles  are  dilated  and  frequently 
obstructed  with  dark-colored  plugs.  Sometimes  an  oily  secre- 
tion is  seen  exuding  from  the  follicular  openings.  There  is 
often  an  enlargement  of  the  superficial  blood-vessels,  partic- 
ularly about  the  alae  of  the  nose. 

The  same  appearances  may  at  times  be  noted  in  the  sternal 
and  interscapular  region  and  elsewhere. 

Acne  often  coexists  with  oily  seborrhea.  Sabouraud  regards 
the  seborrhea  as  a  necessary  forerunner  to  the  development 


SEBORRHEA  387 

of  acne.  In  the  same  manner  this  author  holds  that  alopecia 
prematura  is  in  large  part  due  to  the  organism  which  produces 
oily  seborrhea. 

Seborrhcea  Sicca  (of  Hebra). — This  is  the  pityriasis  simplex 
so  commonly  seen  upon  the  scalp  and  face.  Upon  the  scalp 
it  takes  the  form  of  dandruff,  occurring  as  fine,  branny,  whitish 
or  grayish  scales.  The  scales  are  loose  and  drop  readily  from 
the  hair  to  the  coat-collar  and  shoulder  covering  of  the  patient. 
The  scalp  is  usually  dry  and  pale,  although  in  some  cases  a 
certain  degree  of  redness  may  be  present.  The  hair  is  apt  to 
be  dry  and  lusterless  and  show  a  tendency  to  splitting. 

When  the  face  is  affected,  the  regions  preferred  are  the  eye- 
brows, root  of  nose,  nasolabial  furrow,  and  beard.  Commonly, 
a  certain  degree  of  the  redness  is  present;  when  inflammatory 
change  is  clinically  recognizable,  the  condition  is  included  in 
the  category  of  seborrheic  dermatitis  or  eczema. 

The  so-called  pityriasiform  seborrhoea  sicca  may  spread 
over  the  entire  face. 

At  times  crusted  forms  of  seborrhea  are  observed  upon  the 
face,  scalp,  sternum,  pubic  region,  umbilicus,  or  elsewhere. 
There  is  a  greasy  secretion  of  a  grayish,  yellowish,  or  brownish 
color,  consisting  of  scales  and  dried  sebaceous  matter,  more  or 
less  adherent  to  the  subjacent  surface.  Kaposi  classifies  the 
milk-crust,  or  crusta  lactea,  of  infants  with  this  affection. 

This  variety  may  also  occur  upon  the  male  genitalia,  par- 
ticularly in  the  balanopreputial  fold.  The  smegma  prceputii 
is  a  normal  secretion,  which,  as  a  result  of  decomposition,  often 
leads  to  a  balanitis.  Vernix  caseosa  is  an  intra-uterine  sebor- 
rhea, physiologic  in  character.  The  seborrhoea  corporis  of 
Duhring  is  considered  under  the  head  of  Seborrheic  Dermatitis. 

Etiology  and  Pathology. — There  is  considerable  diversity 
of  opinion  as  to  the  cause  of  seborrhea.  Oily  seborrhea  has 
been  held  to  be  due  to  such  causes  as  digestive  troubles,  faulty 
nutrition,  constipation,  anemia,  etc.,  occurring  chiefly  around 
the  age  of  puberty.  Sabouraud  makes  out  a  strong  case  for 
the  pathogenicity  of  the  microbacillus  studied  by  him.  If 
his  conclusions  are  true,  then  oily  seborrhea  in  various  grades 
is  almost  a  universal  disease,  for  the  microbacillus  may  be  found 
in  the  sebaceous  matter  expressed  from  the  nasal  follicles  of 
almost  all  subjects.  It  is  possible  that  the  general  disturbances 
above  mentioned  render  the  skin  a  favorable  soil  for  the  develop- 
ment of  this  organism. 


388  DISEASES  OF  THE   SKIN 

As  regards  the  pityriasic  form,  many  writers,  including 
Auspitz,  Piffard,  McCall  Anderson,  Elliott,  and  Sabouraud, 
view  it  as  an  epidermic  affection  unrelated  to  the  oil-glands. 
Unna,  Elliott,  Sabouraud,  and  others  believe  it  to  be  of  para- 
sitic origin,  the  result  of  coccic  infection. 

Diagnosis. — Oily  seborrhea  is  readily  recognized  by  the 
diffuse  greasy  appearance  of  the  skin  and  the  enlarged  pores. 
The  pityriasic  form  may  be  confounded  with  eczema,  but  the 
absence  of  the  inflammatory  element  will  enable  one  to  make 
the  diagnosis. 

Prognosis. — The  prognosis  is,  generally  speaking,  favor- 
able. The  eruption  yields  to  treatment,  but  there  is  a  pro- 
nounced tendency  to  relapse.  Long-standing  involvement 
of  the  scalp  leads  to  baldness. 

Treatment. — The  general  treatment  of  seborrhea  concerns 
itself  primarily  with  the  proper  regulation  of  the  patient's 
hygiene — therefore,  outdoor  life,  exercise,  bathing,  etc.,  are  to  be 
advised.  An  effort  should  be  made  to  correct  any  departure 
from  normal  activity  of  any  organs  or  tissue.  In  view  of  the 
excellent  local  effects  of  sulphur,  this  remedy  has  been  counseled 
as  an  internal  medicament.  Duhring  advises  it  in  the  form 
of  calcium  sulpKid,  £  of  a  grain,  three  times  a  day.  Sabouraud 
has  used  natural  sulphur  waters  (those  of  Luchon  and  Calles) 
with  good  effect.  Cod-liver  oil,  iodin,  phosphorus,  iron,  and 
arsenic  are  also  recommended. 

Local  Treatment. — The  indications  are,  first,  to  remove  the 
crusts  and  scales,  and  then  to  use  stimulating  and  astringent 
applications,  with  a  view  favorably  to  influence  the  glandular 
secretions. 

To  soften  crusts  upon  the  scalp,  one  may  employ  the  follow- 
ing: 

H .    Acidi  salicylici ,^j ; 

Olei  olivae f,5 vj.  — M. 

This  may  be  followed  by  the  use  of  the  tincture  of  green  soap 
to  remove  the  epithelial  debris.  When  the  hair  is  greasy,  the 
green  soap  is  used  without  preliminary  oiling.  Care  should 
be  taken  not  to  irritate  the  scalp  unduly  by  violent  friction, 
as  these  patients  are  often  predisposed  to  eczema.  Instead 
of  the  tincture  of  green  soap,  ordinary  soap  may  be  used,  or 
medicated  soaps  containing  resorcin,  sulphur,  and  salicylic  acid. 


SEBORRHEA  389 

Sulphur  is  the  most  valuable  remedy  in  seborrhea;  it  is  to 
be  used  in  ointment  form: 

& .    Sulphur  praecip jj ; 

Adipis  ben-oat ^j. — M. 

This  should  be  rubbed  into  the  scalp;  but  a  small  amount 
should  be  employed,  as  otherwise  the  hair  will  become  dis- 
agreeably greasy. 

For  seborrhea  of  the  scalp,  I  am  very  fond  of  using  this 
pomade,  in  conjunction  with  resorcin  lotions.  The  pomade 
is  used  two  or  three  times  a  week,  and  on  alternate  nights  the 
following  lotion  is  applied: 

R  .    Resorcini sjij ; 

Spirit,  vini  rect.  ] 

Aq.  eologniensis  > aa fjij. — M. 

Aquae  j 

Sig. — Rub  into  the  scalp. 

One-half  to  one  dram  of  glycerin  may  be  added  if  the  scalp 
becomes  too  dry.  If  a  greater  degree  of  stimulation  is  desired, 
thirty  grains  of  ^-naphthol  should  be  added  to  the  lotion, 

Elliott  advises  the  use  of  resorcin  ointment  upon  the  scalp. 

In  addition  to  sulphur  and  resorcin,  the  mercurials  and  tar 
are  also  valuable,  the  latter,  however,  being  unpleasant  on 
account  of  its  odor  and  color. 

One  may  use  a  mercurial  ointment  and  lotion  upon  the  scalp; 
the  mercurials  should  not  be  used  with  sulphur :     . 

H .    Hydrarg.  bichloridi gr.  j-iij ; 

Glycerini f  xj ; 

Spirit,  myrcia  (bay -rum) f*vJ- — M. 

Sig. — Use  on  the  scalp. 

Thirty  or  forty  grains  of  the  ammoniate  or  nitrate  of  mercury 
may  be  incorporated  in  an  ounce  of  benzoinated  lard. 

For  oilv  or  crusted  seborrhea  of  the  face  ointments  and  lotions 
are  employed.     During  the  day  one  may  use: 

R  .    Resorcini 3 j ; 

Acidi  borici 3J ; 

Spirit   vini  rect.  \ aafgi 

Aq.  eologniensis   (  ° 

Aqua? q.  s.  ad  f.^vj. — M. 

Sig. — Wet  upon  absorbent  cotton  and  wipe  affected  regions. 


39°  DISEASES  OF  THE  SKIN 

At  night-time  a  sulphur,  resorcin,  or  mercurial  ointment  may 
be  used.  These  remedies  must  be  employed  in  milder  strength 
upon  the  face  than  upon  the  scalp.  The  following  formula  is 
useful : 


Lanolini 
Ung.  aq.  rosae 


Lanolini  } aa3iv.-M. 


ASTEATOSIS 

Derivation. — 'A,  privative;  oriap,  fat. 

Definition. — Asteatosis  is  a  condition  characterized  by  a 
diminution  or  suppression  of  the  sebaceous  secretion. 

Symptoms. — The  skin,  as  a  result  of  the  loss  of  the  lubri- 
cating and  softening  oily  secretion,  is  harsh,  dry,  and  frequently 
desquamating.  The  epidermis  may  be  thickened  and  fissures 
may  develop. 

Idiopathic  cases  are  rare.  The  condition  often  accompanies 
psoriasis,  leprosy,  ichthyosis,  prurigo,  scleroderma,  and  lichen 
ruber.  It  may  also  result  from  the  use  of  substances  which 
deprive  the  skin  of  its  natural  oil,  as  alcohol,  strong  soaps,  etc. 

Treatment. — Inunctions  of  fatty  substances. 


CLASS  DC    NEUROSES  OF  THE  SKIN 

HYPERESTHESIA 

Hyperesthesia  is  a  condition  characterized  by  an  increased 
sensibility  of  the  skin.  The  condition  may  be  localized  or 
generalized,  mild  or  severe.  In  well-pronounced  cases  the 
mere  pressure  of  the  clothes  gives  rise  to  great  distress.  Patients 
shrink  from  contact  with  all  objects.  The  affection  may  be 
persistent  or  of  short  duration.  Hyperesthesia  may  occur  in 
various  functional  and  organic  nervous  diseases,  such  as  hys- 
teria, leprosy,  meningitis,  etc. 

DERMATALGIA 

Synonyms. — Neuralgia  of  the  skin;  Dermalgia;  Rheumatism  of  the  skin. 

Definition. — Dermatalgia  is  characterized  by  pain  in  the 
skin,  not  the  result  of  structural  changes,  and  without  contact 
with  any  object. 


PRURITUS  391 

Symptoms. — The  symptoms  are  entirely  subjective.  The 
surface  of  the  skin  is  normal.  The  pain  is  spontaneous,  but 
is  increased  by  pressure,  friction  of  clothing,  etc.  The  painful 
sensation  may  be  of  a  burning,  stinging,  or  darting  character. 

Small,  circumscribed  areas,  particularly  hairy  regions,  are 
affected.     The  affection  occurs  most  frequently  in  adult  females. 

Etiology. — Rheumatism  is  looked  upon  as  causative  in 
most  cases.     It  may  also  occur  in  hysteria  and  chlorosis. 

Treatment. — General  treatment  is  to  be  directed  to  the 
cause.  Locally,  counterirritants  and  the  galvanic  current 
are  of  value. 

Meralgia  paraesthetica  is  a  term  given  to  a  rare  condition  in 
which  the  outer  lower  two-thirds  of  the  thigh,  supplied  by  the 
external  femoral  cutaneous  nerve,  is  the  seat  of  disturbances 
of  sensation.  This  may  take  the  form  of  tingling,  formication, 
burning,  cold,  tension,  throbbing  pain,  etc.  The  condition 
is  due  to  various  causes — neuritis,  alcoholism,  gout,  rheumatism, 
etc.  The  affection  is  persistent,  although  it  is  usually  benefited 
by  massage. 

Erythromelalgia,  described  by  Weir  Mitchell,  is  a  painful 
condition,  affecting  the  terminal  members  of  the  extremities. 
It  is  characterized  by  a  burning  or  neuralgic  pain  in  the  fingers 
and  toes.  One  or  both  sides  may  be  involved.  The  fingers 
or  toes  are  observed  to  be  very  red,  and  at  times  somewhat 
swollen.  Pressure  or  traumatism  of  any  kind  may  provoke 
an  attack  of  pain.  The  affection  is  probably  due  to  structural 
change  in  the  central  nervous  system  or  in  the  peripheral  nerves. 
It  is,  as  a  rule,  refractory  to  treatment.  Arsenical  poisoning 
may  produce  similar  symptoms. 

PRURITUS 

Derivation. — L.,  prurire,  to  itch. 

Definition. — Pruritus  is  a  functional  cutaneous  disease 
characterized  by  itching,  without  structural  alteration  of  the 
skin.  There  are  many  diseases  of  the  skin  which  are  accom- 
panied by  more  or  less  severe  itching,  particularly  eczema, 
scabies,  urticaria,  and  lichen  planus.  The  itching  referred  to 
here  is  the  essential  feature  of  the  disease,  and  is  unassociated 
with  any  primary  cutaneous  efflorescence. 

Symptoms. — The  disturbed  sensation  may  partake  of  the 
character  of  itching,  tickling,  pricking,  crawling,  tingling,  etc. 


392  DISEASES  OF  THE  ^KIN 

The  intensity  of  the  itching  varies  greatly;  at  times  it  is  slight, 
and  the  attack  is  of  short  duration.  In  other  instances  it  may 
be  so  severe  and  unremitting  as  to  render  the  life  of  the  patient 
miserable.  Indeed,  persons  have  been  known  to  attempt 
self-destruction  rather  than  bear  a  suffering  more  unendurable 
than  pain. 

In  most  instances  the  itching  comes  on  in  paroxysms,  but 
in  the  worst  cases  the  intervening  periods  of  freedom  are 
extremely  brief.  The  maximum  intensity  of  itching  is  usually 
at  night,  and  the  slumber  of  the  patient  is  often  seriously 
compromised. 

The  sufferer  is  invariably  prompted  to  scratch  and  rub  the 
affected  parts,  for  this  manipulation,  at  least,  purchases  tem- 
porary relief.  As  a  result  of  long-continued  and  frequently 
repeated  scratching  and  friction,  excoriations,  papules,  and 
thickening  of  the  skin  result.  An  eczema  is  not  infrequently 
produced  which  masks  the  underlying  condition. 

When  the  itching  is  generalized,  it  is  termed  pruritus  uni 
versalis,  although  the  disturbed  sensation  seldom  affects  the 
entire    integumentary    surface.     Generalized    itching   is   most 
frequently  encountered  in  the  aged,  in  whom  beginning  senile 
changes  in  the  skin  are  observed  {pruritus  senilis). 

Itching  is  often  confined  to  a  single  locality.  The  most 
common  regions  are  the  genitalia  and  anus,  although  the 
palms,  the  soles,  face,  nape  of  the  neck,  and  other  areas  may 
be  affected. 

In  pruritus  ani,  a  not  uncommon  condition,  the  itching  is 
localized  to  the  mucous  and  cutaneous  surfaces  of  the  anus. 
The  itching  may  be  intense,  and  the  parts  may  become  the 
seat  of  an  eczema  by  reason  of  the  scratching.  This  is  occa- 
sionally associated  with  pruritus  scroti,  or  the  latter  condition 
may  occur  independently.  The  scrotum  and  the  perineum  are 
the  seat  of  the  pruritus,  which  may  be  distressing  in  its  severity. 
Abrasions  and  excoriations  are  usually  present,  and  consider- 
able eczematous  infiltration  of  the  skin  may  result. 

Pruritus  imlvce  represents  the  corresponding  condition  in  the 
female  sex.  The  scratching  and  consequent  pleasurable  relief 
obtained  may  lead  to  the  development  of  obnoxious  practices. 

Duhring  has  called  attention  to  a  form  of  itching  occurring 
in  the  cold  months  of  the  year — pruritus  hicmalis,  or  winter 
itch.  The  itching  is  usually  confined  to  the  lower  extremities; 
it  is  worse  at  night-time,  when  the  patient  disrobes.     It  com- 


pruritus  393 

monly  persists  throughout  the  winter  months,  disappearing 
in  the  spring,  although,  in  some  cases,  it  ceases  after  lasting  a 
few  weeks.     There  are  usually  yearly  recurrences. 

Some  persons  suffer  an  itching  of  the  skin  after  bathing 
(bath  pruritus).  The  pruritus  lasts  from  a  few  minutes  to 
a  half-hour.  Young  adults  with  dry  skin  are  most  subject  to 
this  disturbance. 

Etiology. — Pruritus  may  be  caused  by  functional  or  organic 
nervous  diseases,  or  through  nutritive  and  metabolic  disorders 
exerting  a  secondary  influence  upon  the  sensory  nerves.  There 
is  developed  a  great  hypersensitiveness  of  the  cutaneous  nerves. 

Among  the  most  important  causes  of  generalized  itching 
are  the  various  psychic  neuroses,  neurasthenia,  diabetes, 
cholemia,  lithemia  and  the  uric-acid  diathesis,  Bright 's  disease, 
utero-ovarian  disorders,  constipation,  digestive  and  liver 
troubles,  pregnancy,  etc.  The  excessive  use  of  tobacco,  coffee, 
tea,  alcohol,  opium,  etc.,  may  be  causative.  In  senile  pruritis 
degenerative  changes  in  the  skin  are  probably  responsible  for 
the  condition. 

The  condition  of  the  liver  should  always  be  determined  when 
generalized  pruritus  exists.  I  observed  a  case  of  generalized 
severe  itching  of  three  years*  duration,  with  bile  acids  and  pig- 
ment in  the  urine,  but  without  discoloration  of  the  skin. 
Later  the  patient  developed  jaundice. 

Pruritus  ani  may  have  its  origin  in  such  local  causes  as 
hemorrhoids,  fissures,  fistula,  intestinal  worms,  or  may  be 
due  to  constipation,  lithemia,  etc.  Pruritus  scroti  occurs 
commonly  in  tailors,  who  sit  with  crossed  legs;  it  may  be 
reflexly  caused  by  a  vesical  calculus  or  urethral  stricture. 
Pruritus  vulvae  is  common  in  diabetic  subjects,  but  may  also 
result  from  uterine  disease,  pregnancy,  and  from  leukorrheal 
and  other  discharges.  Long-continued  itching  from  eczema, 
pediculosis,  and  other  causes  may  develop  the  pruritic  habit, 
so  that  the  itching  persists,  although  the  primary  cause  be 
cured.  Pruritus  hiemalis  is  due  to  the  action  of  cold  upon  the 
peripheral  nerves. 

Diagnosis. — The  diagnosis  of  generalized  pruritus  is  more 
often  made  than  is  warranted ;  the  itching  is  often  discovered 
subsequently  to  be  caused  by  pediculosis,  urticaria,  or  a  mild 
eczema.  All  these  affections  must,  therefore,  be  carefully 
excluded  before  the  diagnosis  of  pruritus  is  established. 
Difficulty  will  at  times  arise  from  the  presence  of  eczematoid 


394  DISEASES  OF  THE   SKIN 

lesions  from  scratching;  it  is  important  to  determine  whether 
the  itching  has  antedated  the  appearance  of  these. 

Prognosis. — This  depends  upon  the  removability  of  the 
underlying  cause.  Although  the  disease  is  usually  obstinate, 
many  cases  can  be  cured,  and  nearly  all  can  be  given  a  con- 
siderable measure  of  relief. 

Treatment. — The  internal  treatment  must  largely  be  guided 
by  the  detection  of  the  disorders  believed  to  bear  an  etiologic 
relationship  to  the  pruritus.  Constipation,  digestive  disorders, 
hepatic  disease,  diabetes,  lithemia,  nervous  debility,  etc., 
must  receive  special  treatment.  In  some  cases  no  flagrant 
deviation  from  health  will  be  discovered.  In  these  patients 
the  treatment  must  be  more  or  less  empiric.  I  have  seen  good 
results  from  the  administration  of  the  tincture  of  cannabis 
indica  in  ascending  doses,  beginning  with  five  to  ten  minims. 
The  tincture  of  gelsemium  may  be  employed  in  the  same  dosage. 
Salicylate  of  soda,  carbolic  acid,  phenacetin,  antipyrin,  bromids, 
chloral,  and  valerian  have  all  been  recommended.  Opium 
should  be  avoided. 

Woolen  undergarments  should  not  be  worn,  as  they  often 
excite  itching. 

Local  applications  give  a  large  measure  of  relief,  and  are  of 
great  importance  in  the  treatment.  Warm  soda  baths,  con- 
taining four  to  five  ounces  of  washing-soda  to  twenty  gallons 
of  water,  are  often  grateful  to  the  patient.  A  pound  of  starch 
added  makes  the  bath  more  soothing.  Baths  should  be  taken 
immediately  upon  retiring.  When  the  skin  is  dry  and  scaly, 
ointments  are  indicated  rather  than  lotions.  The  following 
has,  in  my  experience,  proved  generally  useful: 

H  .    Menthol gr.  x-xx ; 

Pulv.  camphone gr.  xx-xxx ; 

Acidi  phenici gr.  xx-xxx ; 

Adipis  benzoat 31J. — M. 

Bulkley  advises  a  salve  containing  chloral  and  camphor: 

K.    Chloralis     \  ..   „       . 

Camphors  J   aa  -~>ss~i; 

Ung.  aq.  rosae Jjj. — M. 

Bronson  counsels  the  use  of  the  following  oil : 

H  .    Acidi  phenici £j ; 

Liq.  potassac f^j; 

Oleilini 15  j.— M. 


PRURITUS  395 

In  generalized  itching  lotions  will  usually  be  found  prefer- 
able to  ointments,  as  they  are  far  more  cleanly.  A  combina- 
tion which  has  given  me  excellent  results  is  the  following: 

R .    Acidi  phenici 3J ; 

Liq.  car  bonis  detergent  is 

(tincture  of  mineral  tar) f£  j-ij; 

Glycerini 3j ; 

Pulv.  zinci  oxidi 31J; 

Aquae q.  s.  ad  f 3 vii j . — M. 

In  other  cases,  particularly  where  there  are  no  scratch  abra- 
sions, the  following  will  be  found  most  useful: 

R .    Menthol gr.  xx; 

Pulv.  camphorae gr.  xl ; 

Acidi  phenici fjj ; 

Aq.  hamamelidis 13  j; 

Glycerini fjij; 

Spirit,  vini  rect f  5ij ; 

Aquae q.  s.  ad  f^viij. — M. 

Crocker  advises  a  thymol  lotion  made  up  as  follows: 

R.    Thymol £ij ; 

Liq.  potassae f 3 j ; 

Glycerini ^5"J. » 

Aquae f^viij. — M. 

Cider  vinegar  has  been  advocated  as  a  local  application. 

Numberless  applications  have  been  used  in  pruritus  ani. 
Care  must  be  taken  not  to  use  too  strong  remedies,  particularly 
if  a  tendency  to  eczema  be  present.  The  ointment  that  has 
given  me  better  results  than  any  other  contains  the  following 
ingredients: 

R .    Acidi  phenici gr.  x-xv; 

Picis  hquidae 13 j ; 

}?no,ini  l aa3iv.-M. 

Ung.  aq.  rosae  j  ° 

Some  patients  object  to  the  tar  on  account  of  the  discolor- 
ation of  the  undergarments.  The  mercurials  are  often  valu- 
able, and  may  be  used  in  combination  with  cocain  as  follows: 

R .    Cocain.  hydrochlorat gr.  x ; 

Hydrarg.  chlor.  mit gr.  xx; 

Ung.  aq.  rosae 5J. — M. 

Care  must  be  taken  that  the  cocain  habit  is  not  acquired. 


3!j6  '  llfTIUHnBS  OP  THE  SKIN 

Liveing  long  ago  advised  the  use  of  morphin  and  bismuth : 

R.    Morphinae  hydrochlorat gr.  ij; 

Bismuth,  nitratis ,jj; 

Ung.  aq.  rosae 3J. — M. 

Liquids  are  more  cleanly  to  apply,  and  often  give  relief. 
I  have  seen  some  good  results  from  a  i  :  iooo  solution  of  bichlo- 
rid  of  mercury.  The  compound  tincture  of  benzoin  is  also 
at  times  valuable.  Some  writers  have  claimed  good  results 
from  painting  with  nitrate  of  silver  (argentum  nitratis,  gr.  xv; 
spiritus  aetheris  nitrosi,  fSj).  Bathing  with  very  hot  water 
will  give  temporary  relief  during  severe  attacks  of  itching. 

Adler  advises  rectal  injections  of: 

R .    Fluidext.  hamamelidis f  Jj ; 

Fluidext.  ergot f.^ij ; 

Fluidext.  hydrastis fjij ; 

Tinct.  benzoin,  comp f^ij; 

Ol.  olivae  carbolat f^j. — M. 

Sig. — Inject  one  to  two  drams  daily. 

In  pruritus  scroti  and  vulvae  the  same  remedies  as  advised 
in  pruritus  ani  may  be  used.  In  the  first-named  condition 
the  wearing  of  a  well-fitting  suspensory  sometimes  gives  relief. 

In  obstinate  cases  of  pruritus  ani,  scroti,  and  vulvae  I  have 
obtained  brilliant  results  from  the  use  of  the  x-ravs.  as  have 
some  other  writers.  A  few  treatments  will  often  give  great 
relief.  The  rays  should  not  be  used  upon  the  scrotum  except 
in  elderly  persons,  in  whom  the  destruction  of  spermatozoa 
is  a  matter  of  indifference.  High-frequency  currents  are  also 
beneficial  in  these  localized  forms  of  pruritus. 

In  pruritus  hiemalis  the  use  of  linen  or  silk  underwear  is 
advised.  A  sojourn  in  a  warmer  climate  is,  of  course,  advan- 
tageous. 

ANESTHESIA 

Anesthesia  is  characterized  by  impairment  or  entire  loss  of 
cutaneous  sensibility.  It  is  usually  circumscribed,  and  is 
observed  in  functional  and  organic  nerve  diseases.  It  is  a 
characteristic  feature  of  anesthetic  leprosy.  Anesthesia  is  a 
condition  which  comes  much  more  frequently  within  the  domain 
of  neurology  than  of  cutaneous  medicine. 


LEUKOKERATOSIS   BUCCALIS  397 

DISEASES  OF  THE  MUCOUS  MEMBRANES 

LEUKOKERATOSIS  BUCCALIS 

Synonyms. — Leukoplakia  buccalis;  Leukoma;  Leukoplasia. 

Definition. — Leukokcratosis  buccalis  is  a  disease  of  the 
mucous  membrane  of  the  mouth,  more  particularly  of  the 
tongue,  characterized  by  the  formation  of  whitish  patches, 
running  a  chronic  course,  and  sometimes  terminating  in  epi- 
thelioma. 

Symptoms. — The  disease  begins  insidiously  as  a  reddish 
patch  or  patches,  often  unobserved  by  the  patient.  After  a 
duration  of  weeks  or  months,  attention  is  attracted  to  the 
presence  of  whitish  or  bluish-white  discoloration  of  the  mucous 
membrane  of  the  tongue  in  roundish,  oval,  or  irregular  patches. 
The  border  of  the  affected  area  is  fairly  well  defined.  The 
surface  of  the  patch  is  commonly  dry  and  rough,  exhibiting 
a  thickening  of  the  epithelial  covering.  On  spontaneous  or 
forcible  removal  of  the  thickened  epithelium  a  smooth,  red, 
sensitive,  and,  at  times,  bleeding  surface  is  left. 

As  the  disease  progresses  the  patches  extend  in  dimensions, 
and  a  greater  degree  of  hypertrophy  of  the  superficial  layers 
of  the  tongue  takes  place. 

The  process  may  be  limited  to  small  circumscribed  foci,  or 
a  considerable  area  of  the  tongue  may  be  affected.  Patches 
or  trails  of  leukokeratosis  are  commonly  observed  upon  the 
mucous  lining  of  the  cheeks,  particularly  along  the  interdental 
line.  The  mucous  membrane  of  the  lip  is  also  frequently 
involved ;  occasionally  patches  are  seen  upon  the  gums. 

The  horny  layer  may  become  greatly  thickened  and  exhibit 
a  frayed  or  loosened  edge,  which  the  patient  is  tempted  to 
detach  with  the  teeth.  Fissures  and  furrows  may  develop, 
giving  the  tongue  somewhat  the  appearance  of  the  cerebral 
convolutions.  At  times  hypertrophy  of  the  papillae  takes 
place,  with  the  production  of  a  circumscribed  or  diffuse 
warty  appearance.  Firm  nodulations  or  ulcers  may  ultimately 
form.  It  is  from  the  warty,  nodular,  and  ulcerative  lesions  that 
secondary  cancer  of  the  tongue  originates. 

In  rare  cases  leukokeratosis  has  been  noted  about  the  vulva 
and  on  the  glans  penis. 

The  subjective  symptoms  experienced  in  mouth  lesions  are 
sensitiveness,  and  pain  upon  the  ingestion  of  acids,  sweets,  and 
hot  or  cold  beverages. 


398  DISEASES  OF  THE  SKIN 

Etiology  and  Pathology. — The  affection  is  seen  almost 
exclusively  in  the  male  sex,  and  after  the  age  of  thirty.  Syphilis 
has  been  accused  of  being  the  most  important  etiologic  factor. 
Perhaps  the  causative  influence  of  syphilis  has  been  exag- 
gerated. In  my  experience  smoking  and  the  gouty  diathesis 
have  been  the  most  potent  etiologic  factors.  Other  influences 
invoked  as  playing  a  causal  role  are  the  use  of  alcoholic  bev- 
erages and  highly  seasoned  food,  gastrointestinal  disorders, 
the  irritation  of  rough  teeth  or  plates,  etc 

Microscopically,  there  is  noted  an  inflammatory  cell-infil- 
tration in  the  papillary  layer,  hyperplasia  of  the  rete,  and 


Fig.   184. — LeukoberatosU   of   the   tongue.      Subsequently 
terminating  fatally. 

hyperkeratosis  of  the  epithelium.  Malignant  changes  result 
from  the  downgrowth  of  epithelial  cells. 

Prognosis. — The  condition  is,  as  a  rule,  obstinate,  but  some 
cases  get  well.  The  liability  to  ultimate  malignant  change 
must  always  be  remembered. 

Treatment. — Antisyphilitic  treatment  in  the  vast  majority 
of  cases  is  of  no  avail.  The  use  of  tobacco  must  be  interdicted. 
I  have  seen  patches  disappear  after  the  cessation  of  smoking, 
reappear  upon  resumption  of  tobacco,  and  again  disappear 
upon  its  withdrawal.  Condiments,  highly  seasoned  foods, 
alcoholic  drinks,  and  hot  beverages  should  be  avoided.  Rough 
teeth  or  plates  should  be  corrected,  and  a  proper  hygiene  of 
the  mouth  carried  out.    The  gouty  and  lithemic  state  and 


ACTINOTHERAPY  399 

gastrointestinal  disturbances  should  receive  appropriate  atten- 
tion. 

Mild  mouth-washes  containing  such  substances  as  sali- 
cylic acid,  boric  acid,  bicarbonate  of  soda,  etc.,  are  useful. 
Sometimes  pastils  with  these  ingredients  are  to  be  preferred. 

When  cauterants  are  used,  they  should  be  used  boldly,  with 
the  idea  of  destroying  the  affected  tissues.  Mild  superficial 
caustics  are  apt  to  do  harm  rather  than  good.  I  am  opposed 
to  the  use  of  the  x-rays  for  this  condition.  The  galvano- 
cautery  or  thermocautery,  acid  nitrate  of  mercury,  trichlor- 
acetic acid,  etc.,  have  given  good  results.  Circumscribed, 
rebellious,  thickened  patches  may  be  excised.  Upon  the  first 
evidence  of  malignancy  surgical  measures  should  be  applied. 

ACTINOTHERAPY,  RADIOTHERAPY,  OPSONO- 
THERAPY, AND  REFRIGERATION 

ACTINOTHERAPY 

In  1896  Dr.  Niels  R.  Finsen,  of  Copenhagen,  published  a 
report  upon  the  use  of  concentrated  actinic  rays  of  light  in 
the  treatment  of  diseases  of  the  skin,  particularly  lupus  vul- 
garis. The  therapeutic  virtues  of  light  have  since  been  con- 
firmed by  numerous  observers.  Both  the  light  from  the  sun 
and  from  a  powerful  arc-lamp  may  be  employed,  although  the 
uncertainty  attending  the  use  of  the  solar  rays  and  the  equal 
or  greater  efficiency  of  those  from  the  latter  source  have  led 
to  the  almost  exclusive  adoption  of  the  electric  arc-lamp  in  the 
application  of  this  treatment. 

The  rationale  of  the  so-called  Finsen-light  treatment  is 
based  upon  three  propositions:  (1)  The  property  of  concen- 
trated rays  of  light  to  destroy  bacteria;  (2)  the  power  of  light- 
rays,  under  certain  conditions,  to  penetrate  living  tissues; 
(3)  their  ability  to  bring  about  certain  inflammatory  struc- 
tural changes. 

The  Finsen  apparatus  consists  of  a  powerful  arc-lamp  armed 
with  telescopic  tubes  with  condensing  lens  of  rock-crystal  or 
quartz,  between  which  are  compartments  for  distilled  and 
flowing  water  to  absorb  the  heat-rays.  Glass  lenses  cannot 
be  employed,  for  they  absorb  too  large  a  proportion  of  the 
actinic  or  chemical  rays,  which  constitute  the  chief  factor  in 
the  production  of  the  therapeutic  effects. 


400  DISEASES   OF  THE    SKIN 

The  area  of  cutaneous  surface  to-be  treated  must  be  rendered 
anemic,  so  that  the  blood  contained  in  the  skin  shall  not  act  as 
a  red  screen  and  filter  out  the  chemical  rays.     This  is  accom- 


plished by  the  use  of  compressors,  which  consist  of  two  rock- 
crystal  lenses  set  into  a  frame,  so  that  running  water  may  flow 


ACTINOTHERAPY  4OI 

between  them.  These  compressing  lenses  are  of  different 
sizes  and  shapes,  which  render  them  adaptable  to  different  parts 
of  the  body.  They  are  held  by  an  attendant,  or  are  applied 
firmly  to  the  surface  by  means  of  elastic  bands.  The  area  to 
be  treated  is  brought  just  within  the  focal  point  of  the  distal 
condensor  of  the  tube,  the  light  covering  a  surface  of  one -half 
to  three-quarters  of  an  inch.  Depending  upon  the  effect 
desired,  the  stance  lasts  from  twenty  minutes  to  one  hour  or 
longer.  In  from  eight  to  twenty-four  hours  an  inflammatory 
reaction  is  induced  in  the  area  treated,  varying  from  an  ery- 
thema to  the  production  of  blebs  and  swelling.  The  frequency 
of  the  treatments  and  their  duration  depend  upon  the  nature 
of  the  disease,  the  extent  of  the  cutaneous  involvement,  and 
individual  susceptibility.  For  deep-seated  conditions,  such 
as  lupus  vulgaris,  the  stance  is  usually  an  hour  or  more.  Other 
patches  may  be  treated  on  consecutive  days.  The  treated 
parts  are  covered  with  a  boric-acid  or  zinc  ointment,  and  are 
permitted  to  heal.  Such  areas  may  be  treated  again,  if  neces- 
sary, at  the  end  of  two  or  three  weeks. 

Actinotherapy  has  found  its  chief  field  of  usefulness  in  lupus 
vulgaris,  for  this  rebellious  disease  is  caused  by  the  presence 
of  tubercle  bacilli  in  the  skin,  and  these  may  be  destroyed  by 
concentrated  rays  of  light.  A  large  percentage  of  the  cases 
treated  in  Copenhagen  has  been  cured  by  the  Finsen  treatment ; 
the  scars  are  smooth,  as  a  rule,  and  the  general  cosmetic  effect 
excellent.  Lupus  cases  exhibiting  much  pigmentation,  fibrous 
thickening,  or  involvement  of  the  mucous  membranes  are  dis- 
tinctly less  favorable.  It  is  also  difficult  or  impossible  to  treat 
lupus  ulcerations  by  this  means,  as  the  necessary  pressure 
cannot  be  made.  These  cases  can  be  treated  with  better  results 
by  means  of  the  x-rays. 

Lupus  erythematosus  has  likewise  been  treated  with  con- 
centrated actinic  rays,  with  a  fair  measure  of  success.  Indeed, 
actinotherapy  appears  to  give  as  good  results  in  this  capricious 
dermatosis  as  any  other  known  method  of  treatment.  The 
seances  need  not  be  so  protracted  as  in  lupus  vulgaris,  and 
simpler  and  smaller  lamps  may  be  employed.  Those  cases 
that  exhibit  enlargement  of  blood-vessels  seem  to  be  the  most 
favorable. 

Alopecia  areata  has  been  treated  with  concentrated  actinic 
light,  and  a  considerable  portion  of  the  cases  thus  treated  has 
been  cured,  but  it  must  be  remembered  that  this  affection  dis- 


402  DISEASES  OF  THE  SKIN 

appears  tinder  many  and  varied  therapeutic  measures,  and  not 
infrequently  spontaneously.  Nevertheless,  the  results  obtained 
by  Kromayer  and  others  demonstrate  that  phototherapy  is 
one  of  the:  most  valuable,  methods  of  treatment  in  this  disease. 

Vascular  nevi  have  been  reported  by  Finsen  -  and  other 
observers  to  have  been  greatly  improved  by  actinotherapy,  but 
complete  cures  do  not  appear  to  have  been  achieved.  Those 
cases  in  which  the  cutaneous  blood-vessels  are  not  greatly 
enlarged,  as  in  the  port-wine  stain,  give  the  best  chances  of 
success. 

Acne  and  various  subacute  inflammatory  dermatoses  have 
been  treated  with  light-rays,  with  alleged  good  result^. 

The  small  area  that  can  be  treated  by  the  Finsen  method, 
and  consequently  the  large  number  of  treatments  required  and 
the  expense  of  operation  of  the  apparatus,  all  tend  to  circum- 
scribe the  field  of  usefulness  of  this  therapeutic  procedure. 

A  smaller  and  simpler  lamp  than  the  large  Finsen  apparatus 
is  the  Lortet  and  Genoud  or  London  Hospital  type.  This  is 
an  arc-lamp,  shielded  by  a  metallic  jacket,  through  which  water 
constantly  circulates.  The  condensing  lens  is  brought  within 
two  inches  of  the  arc.  The  patient  presses  the  area  to  be  treated 
against  the  lens,  which  is  made  of  various  sizes  and  contours, 
so  as  to  permit  adaptation  to  different  parts.  An  area  of  4 
or  5  cm.  in  diameter  may  be  treated.  With  this  lamp  reaction, 
varying  in  degree  from  an  erythema  to  bleb  formation,  may  be 
produced  by  a  thirty-minute  exposure.  The  penetration  of 
the  chemical  frequencies  is,  however,  extremely  limited.  The 
lamp  is,  therefore,  but  poorly  adapted  to  the  treatment  of  deep 
nodules  of  lupus  vulgaris;  it  is  useful,  however,  in  the  treat- 
ment of  alopecia  areata,  lupus  erythematosus,  and  conditions 
in  which  a  pronounced  surface  reaction  is  desired. 

Within  recent  years  the  mercury  vapor  lamp  has  been  used 
for  therapeutic  purposes.  The  light  emitted  from  incandescent 
mercury  vapor  is  exceedingly  rich  in  blue,  violet,  and  ultra- 
violet rays.  The  ultra-violet  rays  are  almost  completely 
absorbed  by  the  enveloping  glass  tube. 

In  the  "Uviol"  lamp  (ultra-violet  light  lamp),  made  by 
Schott,  a  glass-like  material,  said  to  be  a  barium-phosphate- 
chrome  combination,  is  used.  This  is  pervious  to  the  ultra- 
violet frequencies.  A  distinct  erythema  may  be  produced 
by  a  five-  to  ten-minute  exposure  at  6  to  10  cm.     The  lamp 


ACTINOTHERAPY  403 

is  useful  wherever  it  is  desired  to  produce  a  superficial  cutaneous 
reaction.     The  degree  of  reactive  inflammation   may  be  pre- 


FLr.  1S6.— London  Hospital  lamp  in  use  at  the  Polyclinic  Hospital.  Philadelphia. 


determined  by  the  distance  and  duration  of  the  exposure.  I 
have  found  this  lamp  useful  in  the  treatment  of  acne,  alopecia 
areata,  and  certain  forms  of  eczema. 


404  DISEASES  OF  THE  SKIN 

THE  ROENTGEN  OR  x-RAYS 

In  1895  Professor  Roentgen,  of  Wurzburg,  found  that  when 
a  Crookes  tube  was  excited  by  an  electric  current  of  high  poten- 
tial, peculiar  rays  were  given  off,  which  he  modestly  designated 
x-rays,  because  of  their  unknown  character.  These  rays  were 
at  first  employed  alone  for  diagnostic  purposes,  but  the  acci- 
dental production  of  structural  changes  in  the  skin  led  to  their 
trial  in  cutaneous  diseases  by  Freund  and  Schiff,  of  Vienna. 
x-Ray  treatment  lias  a  wide  field  of  usefulness  in  cutaneous 
diseases,  and  has  been  accorded  an  important  place  in  the 
therapeutics  of  these  disorders. 

x-Rays  may  be  generated  from  an  induction  coil  run  either 
by  a  storage  battery  or  by  ordinary  current  from  a  dynamo,  or 
a  static  machine  may  be  used.  In  general,  a  coil  will  be  found 
more  satisfactory,  as  in  warm,  moist  weather  the  efficiency  of 
a  static  machine  may  be  considerably  impaired. 

x-Ray  tubes  have  different  properties,  depending  chiefly  upon 
the  degree  of  vacuum  in  the  tube.  A  hard  tube,  or  one  of  high 
vacuum,  offers  great  resistance  to  the  passage  of  the  electric 
current,  and  gives  off  rays  which  penetrate  to  considerable 
depth  and  exert  but  a  minimal  influence  upon  the  superficial 
tissues.  A  soft  tube,  or  one  of  low  vacuum,  on  the  other  hand, 
gives  off  rays  which  do  not  penetrate  to  great  depth,  but  exert 
a  maximum  influence  upon  the  superficial  tissues.  Inter- 
mediate tubes,  termed  "medium  soft"  and  "medium  hard," 
have  varying  grades  of  penetration,  proportionate  to  the  degree 
of  the  vacuum. 

Hard  tubes  show  but  little  contrast  in  the  fluoroscopic  shadow 
between  the  bones  and  soft  tissues  of  the  hand,  whereas  the 
reverse  is  true  of  soft  tubes. 

Inasmuch  as  the  therapeutic  effect  of  the  x-rays  is  propor- 
tionate to  the  amount  of  the  rays  absorbed  by  any  given  tissue, 
it  is  obvious  that  soft  or  medium  soft  tubes  should  be  used  for 
superficial  cutaneous  disorders,  and  hard  or  medium  hard  tubes 
for  deep  affections,  such  as  those  involving  the  subcutaneous 
tissues,  lymphatic  glands,  or  viscera.  Soft  tubes  are  more 
prone  to  set  up  an  x-ray  dermatitis  than  hard  tubes.  Very 
soft  tubes  give  off  a  yellow  light,  which  must  be  employed  with 
care,  as  this  quality  of  x-rays  readily  produces  burns. 

The  dosage  of  the  x-rays  depends  upon — (1)  The  amount 
of  current  run  into  the  tube ;  (2)  the  quality  of  the  tube ;  (3)  the 
distance  of  the  tube  from  the  patient;  (4)  the  duration  of  the 
stance;  and  (5)  the  frequency  of  the  treatments. 


THE   ROENTGEN  OR   X-RAYS  405 

For  most  cutaneous  diseases,  as,  for  instance,  acne,  a  medium 
soft  tube  should  be  used,  with  no  more  current  than  is  neces- 
sary to  produce  a  quiet  green  light;  treatment  may  be  given 
twice  a  week  at  first,  the  frequency  to  be  diminished  later. 
The  distance  from  the  anticathode  should  be  in  the  neighbor- 
hood of  eight  inches,  and  the  duration  of  the  treatment  five  to  six 
minutes.  Upon  the  first  sign  of  an  erythema  treatment  should 
be  suspended,  and  not  resumed  until  the  redness  has  disappeared. 
Other  approved  methods  of  treatment  for  acne  should  be  em- 
ployed, for  the  fewer  the  number  of  *-ray  treatments  employed  in 
the  treatment  of  acne,  the  greater  is  the  assurance  of  preservation 
of  the  integrity  of  the  normal  texture  of  the  skin.     The  fact 


5.    Patient  was  treated  tor  a  cancer  of  the 
r  larger  area  shows  an  x-ray  erythema  with 

;  the  smaller  central  patch  shows  a  more  pronounced  burn  where  treat- 

inlinued,  the  larger  area  (hen  being  pror  — 

should  be  emphasized  that  excessive  x-ray  irradiation  may  lead 
to  atrophy  of  various  elements  of  the  skin,  producing  punctiform 
or  stellate  scarring  or  unnatural  dryness  and  wrinkling.  In 
addition  disfiguring  telangiectasis  may  be  produced. 

ACTION    OF    THE    J-RAYS    IN    CUTANEOUS    DISEASES 

The  mode  of  action  of  the  Roentgen  rays  appears  to  be  quite 
complex.  They  stimulate  and  alter  the  function  and  structure 
of  living  cells;  doubtless,  as  a  result  of  this,  the  vitality  and 
resisting  power  of  tissues  are  increased,  and  the  noxious  influence 
of  bacteria  prevented  or  the  bacteria  destroyed.  The  bac- 
tericidal properties  of  the  x-rays  are  not  due  to  a  direct  influence 


406 


DISEASES  OF  THE  SKIN 


upon  the  microorganisms  themselves,  but  result  from  a  stimu- 
lation of  the  bactericidal  power  of  thfe  body-cells.  The  anti- 
pyogenic  influence  of  the  *-rays  is  well  established.  When 
carried  beyond  the  point  of  stimulation,  the  z-rays  produce 
degeneration,  atrophy,  and  necrosis.  Cells  of  low  vitality, 
such  as  tumor-cells,  suffer  first,  and.  later  highly  specialized 
tissues,  such  as  blood-vessels,  hair-follicles,  and  the  sweat- 
and  sebaceous  glands.  The  x-rays  are  also  analgesic,  and  cap- 
able of  lessening  pain  and  itching. 

The  cutaneous  diseases  in  which  the  x-rays  have  been  found 
to  be  most  useful  are: 

i.  New-growths: 

Epithelioma,    particularly    of    the 

superficial  types. 
Lupus  vulgaris  and  verrucose  tuber- 

culids. 
Sarcoma. 

Mycosis  fungoides. 
Blastomycosis  cutis. 
Keloid  and  hypertrophic  scars. 


Action  chiefly  due  to  break- 
ing down  of  tumor-cells. 


2.  Follicular  and  glandular  affections: 


Acne. 
Sycosis. 
Hyperidrosis. 
Hypertrichosis. 


Action  due,  at  least  in  part,  to  atrophy  of 
the  glands  and  follicles. 


3.  Inflammatory  diseases: 


Chronic  eczema. 
Recurrent  vesicular 

eczema. 
Psoriasis. 
Lichen  planus,  etc. 

4.  Parasitic  affections : 


Action  due  to  physical  and  chemical  stimula- 
tion of  cells,  and  promotion  of  absorption  of 
inflammatory  infiltrate. 


Favus. 

Tinea  tonsurans 


\  Action  largely  due  to  depilation  and  extrusion 
,  etc.  /  of  parasitic  fungi. 


5.  Cutaneous  neuroses: 

Pruritus  ani.  1 

Pruritus  vulvae,  etc.   J-  Action  due  to  analgesic  influence  of  rays. 

Dermatalgia.  ) 


THE    ROENTGEN   OR   X-RAYS 


DISEASES  OF  THE  SKIN 


Fig.    iQi. — Same  paiicnt;  growth 


RADIUM  409 

The  various  new-growths  may  be  treated  vigorously,  pro- 
vided the  surrounding  healthy  integument  is  thoroughly  pro- 
tected by  lead  masks  or  similar  devices. 

Acne,  sycosis,  eczema,  psoriasis,  etc.,  should  be  treated  with 
great  care,  particularly  when  irradiation  of  the  face  is  carried 
out. 

Hypertrichosis  is  one  of  the  most  difficult  of  all  conditions 
to  treat,  and  requires  the  greatest  degree  of  skill.  It  is  obvious 
that,  to  produce  an  atrophy  of  the  hair-papillae  without  causing 
an  atrophy  of  other  elements  of  the  dermic  architecture,  requires 
the  nicest  adjustment  of  the  rays.  Freund,  of  Vienna,  effects 
a  falling  of  the  hair  in  twenty  treatments,  and  then  prevents 
a  return  of  the  hair  by  supplementary  courses  of  treatment 
every  four  to  six  weeks,  until  a  year  and  a  half  has  elapsed. 
At  the  end  of  this  tirne,  he  states,  a  permanent  cure  is  effected. 
Most  operators,  however,  acknowledge  a  percentage  of  failures, 
and  the  successes  are  often  in  patients  in  whom  considerable 
skin  atrophy  has  been  produced.  No  cases  of  this  character 
should  be  treated  with  x-rays  unless  the  hirsutic  growth  con- 
stitutes an  actual  deformity. 

Favus  and  ring-worm  of  the  scalp  have  been  successfully 
treated  with  x-rays.  Sabouraud,  of  Paris,  claims  that  tinea 
tonsurans  may  be  cured  in  a  much  shorter  period  by  Roentgen- 
ray  treatment  than  by  any  other  means.  He  effects  a  loss  of 
hair  over  the  disease  area  by  a  single  exposure,  the  dosage 
being  carefully  determined  by  the  use  of  a  sensitized  paper 
simultaneously  exposed  to  the  rays. 


RADIUM 

It  has  long  been  known  that  salts  of  uranium  luminesce 
under  the  influence  of  sunlight.  In  1896  Becquerel  demon- 
strated that  uranium  compounds  emitted  rays  which  penetrated 
ordinarily  opaque  media  and  affected  photographic  plates. 
The  'uranium  rays,"  or  "Becquerel  rays,"  have  been  studied 
by  many  physicists. 

Uranium  is  largely  derived  from  pitchblende,  a  complex 
mineral  substance  found  in  Bohemia  and  elsewhere.  Madame 
Curie,  working  with  uranium  ores,  obtained  a  radioactive  sub- 
stance resembling  bismuth,  which  she  designated  "  polonium, " 
after  the  land  of  her  nativity.     Subsequently  M.  and  Mme, 


4IO  DISEASES   OF   THE    SKIN 

Curie  discovered  a  stronger  radioactive  substance  in  pitch- 
blende, which  was  named  radium. 

Radium  has  not  yet  been  isolated  in  its  pure  state.  It  is 
used  chiefly  in  the  form  of  radium  brotnid  or  chlorid,  and  is 
commonly  sold  for  therapeutic  use  in  combination  with  barium 
salts. 

Radium  salts  gradually  assume  color  and  also  induce  color 
in  glass,  porcelain,  and  other  containers. 


The  energy  of  radium  is  expressed  in  relation  to  that  of 
uranium  taken  as  a  unit.  Therapeutic  specimens  of  radium 
vary  in  radioactivity  from  iooo  to  1,000,000. 

Rutherford  and  others  have  shown  that  the  energy  given 
off  by  radium  consists  of  three  kinds  of  rays:  a  (alpha)  rays; 
ji  (beta)  rays,  and  j-  (gamma)  rays. 

1.  The  a  (alpha)  rays  correspond  to  the  canal  rays  of  Gold- 
stein, and  represent,  according  to  Wicn,  positivelv  charged 
particles  at  great  velocity.  The  alpha  rays  are  easily  absorbed, 
and  have  the  power  of  ionizing  gases,  but  are  not  deviable. 

2.  The  /9  (beta)  rays  are  practically  cathode  rays.  They  are 
penetrating,  and  can  be  deviated  by  a  magnetic  field. 


412  DISEASES  OF  THE  SKIN 

3.  The  T  {gamma)  rays  correspond  closely  to  x-rays  given 
off  by  a  hard  tube.  They  are  very  penetrating,  but  are  non- 
deviable  in  a  magnetic  field. 

For  therapeutic  purposes  the  radium  bromid,  which  is  in 
the  form  of  a  brownish  powder,  is  inclosed  in  various  sized  and 
shaped  aluminum  or  mica-covered  capsules  or  in  glass  tubes. 
The  weaker  mixtures  of  radium  and  barium  are  whitish  in 
color. 

The  radium  capsule  or  tube  is  retained  by  an  appropriate 
holder  in  contact  with  or  a  short  distance  from  the  skin,  for  a 
period  varying  from  twenty  minutes  to  an  hour  or  more.  The 
activity  of  the  radium  and  the  distance  greatly  influence  the 
intensity  of  effect.  As  light  energy  acts  inversely  as  the  square 
of  the  distance,  slight  differences  in  the  distance  of  the  radium 
from  the   skin  enormously  influence   the   grade   of   reaction 

induced. 

* 

Radium  has  been  used  in  epithelioma,  naevus  vasculosus, 
lupus  vulgaris,  lupus  erythematosus,  kukokeratosis  buccalis, 
verruca,  etc.  It  has  not  been  definitely  proved  that  radium 
accomplishes  more  in  these  diseases  than  other  approved 
remedies.  Its  action  is  much  like  that  of  the  x-rays,  and  the 
same  degrees  of  inflammatory  and  necrotic  change  may  be 
induced.  The  reaction  develops,  as  a  rule,  in  from  four  days 
to  two  weeks  after  the  treatment. 

I  have  used  radium  in  epithelioma  with  gratifying  results, 
but  only  in  that  form  of  the  disease  curable  by  other  means. 
In  ordinary  warts  I  have  frequently  been  enabled  to  effect  a 
disappearance  of  the  growth  by  a  single  exposure  of  one  and 
one-half  hours  with  radium  of  1 ,000,000  activity. 

A  great  advantage  of  radium  is  the  simplicity  of  application 
and  its  painlessness.  Small  epithelial  cancers  in  the  aged  may 
be  cured  at  home  without  discomfort  or  the  use  of  surgical 
measures  or  of  cumbersome  apparatus.  Another  great  advan- 
tage is  the  possibility  of  using  radium  in  otherwise  inaccessible 
cavities,  such  as  the  nose,  mouth,  or  vagina.  New  therapeutic 
uses  may  be  found  for  radium,  but  at  the  present  time  there 
is  no  adequate  evidence  to  show  that  radium  will  accomplish 
more  than  will  the  x-rays. 


/ 


OPSONOTHERAPY  413 

THE  USE  OF  BACTERIAL  mjTECTIONS  OR  VACCINE  (SO 

CALLED):  OPSONOTHERAPY 

Metchnikoff  some  years  ago  advanced  the  theory  that  leuko- 
cytes played  an  important  r61e  in  the  defense  of  the  body 
against  bacterial  invasion. 

In  1902  Leishman  developed  a  method  of  measuring  the 
phagocytic  activity  of  leukocytes;  the  following  year  Wright 
and  Douglass  proved  that  the  leukocytes  ingested  and  destroyed 
bacteria  only  under  the  influence  of  activating  substances  in  the 
blood,  to  which  the  term  "  opsonins  "  was  applied.  The  opso- 
nins are  presumed  to  act  by  sensitizing  the  bacteria  and  thus 
rendering  them  easy  prey  for  the  phagocytes. 

The  bactericidal  power  of  the  blood  against  certain  organ- 
isms can  be  raised  by  the  injection  of  a  proper  quantity  of  a 
sterilized  culture  of  these  bacteria.  Many  patients  exhibit  a 
vulnerability  to  staphylococcic  invasion;  it  will  usually  be 
found  that  they  suffer  from  a  weakness  of  their  staphylo- 
opsonins;  this  can  be  determined  by  mixing  measured  quanti- 
ties of  the  serum  of  fresh  blood  with  suspensions  of  the  incrimi- 
nated organism,  developed  in  culture,  and  ascertaining  the 
number  of  bacteria  ingested  by  the  phagocytes.  By  proper 
computation  the  opsonic  index  is  obtained. 

Bacterial  injections  may  be  prepared  from  organisms  re- 
covered from  the  patient  (autogenous  vaccines),  or  stock  sus- 
pensions may  be  employed.  It  is  important  not  to  employ  too 
large  an  initial  dose:  the  dose  may  be  gradually  increased. 
Injections  may  be  given  about  once  a  week. 

The  treatment  is  of  value  in  furunculosis  and  carbunculosis, 
and  at  times  in  sycosis  vulgaris,  acne,  pustular  dermatitis, 
septic  ulcers,  lupus  vulgaris,  etc.  Except  in  the  first  two  con- 
ditions named  the  results  may  be  characterized  as  uncertain; 
in  some  cases  they  are  brilliant,  and  in  others  entirely  disap- 
pointing. 

Boils. — The  treatment  of  boils  with  bacterial  injections  is 
the  most  scientific,  rational,  and,  on  the  whole,  successful  of 
any  method.  One  may  begin  with  the  injection  of  100,000,000 
staphylococcus  aureus  or  mixed  staphylococcus  emulsion. 
Weekly  injections  should  be  given,  the  dose  being  increased 
until  500,000,000  or  1 ,000,000,000  organisms  is  reached.  One 
to  ten  injections  will  usually  effect  a  cure. 

Sycosis  vulgaris  is  occasionally  cured  by  injections  of  staphy- 
lococci emulsions.     In  most  instances,  however,  the  treatment 


4^4  DISEASES  OP  THE  SKIN 

produces  merely  an  improvement,  and  other  therapeutic 
methods  must  be  conjoined. 

In  acne  the  best  results  are  obtained  by  injecting  the 
staphylococcus  and  the  so-called  acne  bacillus.  Many  cases 
have  been  reported  in  which  improvement  or  cure  has  been 
achieved,  but  in  most  cases  the  treatment  is  disappointing.  It 
is,  however,  well  worth  a  trial  in  obstinate  cases. 

Staphylococcic  injections  are  a  valuable  aid  in  the  treatment 
of  septic  ulcers  and  pustular  dermatitis. 

In  lupus  vulgaris  tuberculin  is  a  useful  auxiliary  to  other 
methods  of  treatment,  but  results  are  too  slow  and  uncertain  to 
rely  upon  its  use  alone. 

Time  and  future  study  will  increase  our  knowledge  of  this 
relatively  new  therapy,  and  will  enable  us  more  accurately  to 
estimate  its  value  and  determine  its  limitations. 

TREATMENT  BY  REFRIGERATION 

LIQUID  AIR 

Liquid  air,  which  has  a  freezing-point  of  about  1850  C.  below 
zero,  has  been  used  in  the  treatment  of  certain  diseases  of  the 
skin.  The  difficulty  of  obtaining  and,  more  particularly,  of 
preserving  it  has  greatly  restricted  its  use. 

CARBON  DIOXID 

Solid  carbon  dioxid  was  introduced  by  Pusey,  of  Chicago,  as 
a  substitute  for  liquid  air  in  the  treatment  of  diseases  of  the 
skin.     The  freezing-point  of  carbon  dioxid  is  8o°  C.  below  zero. 

Refrigeration  of  the  skin  with  carbon  dioxid  produces  an 
inflammatory  action  varying  in  intensity  according  to  the  dura- 
tion of  contact  of  the  freezing  agent  and  the  degree  of  pressure 
employed.  The  resulting  traumatism  may  vary  from  an 
evanescent  inflammatory  reaction  to  necrosis  of  the  tissue 
treated.  The  degree  of  pressure  exerted  determines  the  depth 
of  the  freezing.  The  most  important  factor  in  inducing  the 
tissue  changes  is  the  duration  of  the  refrigeration.  Momentary 
freezing  produces  a  mild  inflammatory  reaction.  Five  to  ten 
seconds'  freezing  causes  an  acute  but  dry  dermatitis;  if  the 
freezing  is  prolonged  to  twenty  or*  thirty  seconds,  a  severe 
dermatitis  is  occasioned,  usually  with  the  formation  of  a  bleb, 
but  without  any  visible  resultant  scarring. 


TREATMENT  BY  REFRIGERATION  415 

If  the  refrigeration  is  continued  for  a  minute,  a  bleb  is 
formed  and  likewise  a  dry  eschar,  which  upon  its  disappearance 
leaves  a  thin,  whitish  scar.  The  skin  of  infants  is  three  or  four 
times  more  sensitive  than  that  of  adults.  Tissues  previously 
treated  with  the  #-rays  or  radium  are  also  much  more  sensitive. 

Technic. — Carbon  dioxid  in  gaseous  form  is  available  in  iron 
cylinders,  such  as  are  supplied  to  druggists  for  the  carbonation 
of  soda-water.  The  cylinder  is  best  placed  upon  a  suitably 
constructed  stand,  in  a  slightly  oblique  position,  with  the  out- 
let downward.  After  the  nozzle  is  screwed  on,  a  small  chamois 
bag  is  tied  about  it  and  the  gas  allowed  slowly  to  enter  the 
bag.  The  carbon  dioxid  is  recovered  from  the  bag  in  the  form 
of  a  snow,  which  can  then  be  packed  by  pressure  in  cylindric  or 
square  tubes  to  obtain  a  cohesive  stick.  A  simple  method  is  to 
empty  a  suede-leather  glove-finger  and  retain  it  in  position 
until  a  firm,  solid  mass  is  obtained,  which  may  then  be  ex- 
pressed. The  chalk-like  mass  is  then  pared  with  a  knife  to  the 
desired  shape.  In  treating  areas  larger  than  the  diameter  of 
the  carbon  dioxid  stick  it  is  well  to  make  the  contact  end  rec- 
tangular so  that  the  adjacent  areas  can  be  treated  without 
overlapping.  The  pain  accompanying  and  following  the  appli- 
cation is  of  a  burning  character,  but,  as  a  rule,  it  is  not  severe. 
Applications  with  C02  can  be  repeated  after  all  evidence  of 
the  inflammation  produced  has  subsided. 

THERAPEUTIC   INDICATIONS 

Lupus  erythematosus,  a  disease  notoriously  obstinate,  is  com- 
monly much  improved,  and  occasionally  a  disappearance  of  the 
patches  is  effected.  Under  moderate  pressure  the  application 
should  vary,  according  to  the  thickness  of  the  patch,  between 
five  and  thirty  seconds.  In  acute  cases  less  vigorous  methods 
of  treatment  should  be  employed.  The  vascular  patches  are 
less  favorable  for  this  procedure  than  the  circumscribed, 
thickened  plaques. 

In  vascular  nevi,  particularly  those  of  small  size,  refrigeration 
with  carbon  dioxid  constitutes  one  of  the  best  methods  of  treat- 
ment. The  duration  of  the  application  varies  between  fifteen 
and  thirty  seconds;  in  infants,  between  ten  and  twenty  seconds. 
Hypertrophic  and  cavernous  angiomata  give  much  better  results 
than  flat  nevi.  Several  applications  are  often  necessary.  The 
results  and  not  disfiguring. 

•  say  of  the  size  of  the  palm  of  the 


416  DISEASES  OF  THE   SKIN 

hand,  a  flattening  of  the  growth  and  a  lessening  of  the  colora- 
tion are  often  achieved,  but  complete  cure  is  rare. 

Port-wine  stains  are  at  times  benefited  by  this  treatment. 
In  a  man  under  my  care  there  was  a  reduction  of  about  50 
per  cent,  in  the  intensity  of  the  discoloration. 

In  pigmented  nevi  carbon  dioxid  constitutes  the  best  method 
of  treatment  at  our  command.  Even  when  the  nevus  is  cov- 
ered with  hair,  successful  results  are  often  obtained.  The  ap- 
plication in  children  is  from  ten  to  thirty  seconds,  and  in 
adults,  twenty  to  forty  seconds.  As  a  rule,  little  or  no  scarring 
is  left. 

Moles  and  warts  may  be  removed  in  a  similar  manner. 

In  senile  and  x-ray  keratoses  excellent  results  are  frequently 
achieved. 

Refrigeration  has  also  been  employed  in  the  treatment  of 
lupus  vulgaris,  epithelioma,  circumscribed  eczema,  lichen 
planus,  etc.,  but  for  these  conditions  there  are  more  eligible 
methods  of  treatment. 


ACUTE  ERUPTIVE  FEVERS 


In  this  chapter  are  included  those  acute  febrile  diseases  asso- 
ciated with  a  constant  eruption,  which  are  commonly  called 
the  " exanthemata.'*  These  disorders  are  characterized  by 
their  great  transmissibility,  and  by  the  fact  that  nearly  all 
persons  are  susceptible  to  them.  The  eruption  is  the  most 
conspicuous  feature  of  the  disease,  and  the  consideration  of  these 
affections  in  a  work  on  diseases  of  the  skin  would  seem  eminently 
proper.  In  this  chapter  there  are  also  described  the  cutaneous 
complications  of  vaccination. 

SMALL-POX 

Synonyms. — L.,  variola;  French,  La  petite  verole;  Ger.,  Blattern  or  Pocken; 
Ital.,  Vajuola. — Derivation. — Some  writers  allege  that  the  term  variola  had 
its  origin  in  the  Latin  varus,  a  papule,  pimple,  or  tubercle,  a  word  found 
in  Pliny.  Other  writers,  however,  believe  it  to  be  derived  from  the  word 
varius,  which  means  spotted  or  variegated. 

The  Saxon  equivalent  pocca,  meaning  a  bag  or  pouch,  has  given  rise  to 
the  English  pock  and  the  German  Pocken.  Syphilis  appeared  in  Europe 
about  1498,  and  caused  some  confusion  of  nomenclature,  so  that  it  became 
necessary  to  prefix  the  adjective  small  to  the  term  pock  or  pox,  in  order  to 
distinguish  it  from  the  great  pox  or  syphilis.  The  same  change  was  made 
in  French  phraseology,  so  that  at  the  present  day  variola  is  designated 
small-pox,  or  la  petite  verole,  and  syphilis  the  pox,  or  la  verole. 

Definition. — Small-pox  is  an  acute,  highly  contagious  dis- 
order, characterized  by  a  prodromal  febrile  period  lasting  about 
three  days,  followed  by  an  exanthem  passing  through  the 
stages  of  maculopapule,  vesicle,  pustule,  and  crust,  with  a 
marked  tendency  to  produce  pits  or  scars.  The  fever  declines 
in  the  early  eruptive  period  and  increases  in  the  suppurative 
stage.  One  attack  protects  against  subsequent  infection  in 
the   vast  majority  of  cases. 

Symptoms. — The  period  of  incubation  of  small-pox  will 
usually  be  found  to  be  between  ten  and  twelve  days.  It  may, 
in  rare  instances,  be  shorter  or  more  prolonged.  The  period, 
however,  is  seldom  less  than  eight  days,  nor  longer  than  fourteen. 

The  stage  of  invasion,  or  initial  stage,  is  usually  ushered  in 
with  suddenness  and  with  considerable  violence.     The  earliest 

27  4*7 


41 8  DISEASES  OF  THE   SKIN 

symptom  is  commonly  a  more  or  less  pronounced  chill,  followed 
by  rapid  rise  of  temperature.  The  fever  is,  ordinarily,  103  °  or 
104  °  F.,  but  may  be  several  degrees  higher.  The  pulse  is  full, 
tense,  and  accelerated,  although  not  always  proportionate  to 
the  pyrexia.  Nausea  and  vomiting  occur  with  great  frequency, 
the  emesis  in  severe  small-pox  continuing  for  several  days. 

Headache  is  the  most  prominent  and  constant  among  the 
early  nervous  symptoms,  and  is,  at  times,  excruciating.  Rest- 
lessness and  insomnia  are  common  in  adults,  while  children 
are  more  prone  to  be  drowsy.  Convulsions  occur  in  children 
with  greater  frequency  than  in  any  other  exanthematic  disease. 
When  the  temperature  is  very  high,  delirium,  often  violent, 
manifests  itself.  Pain  in  the  back  occurs  in  more  than  one- 
half  of  the  cases,  and  is  always  diagnostically  suggestive.  The 
lumbar  and  sacral  regions  are  the  parts  chiefly  affected;  the 
intensity  of  the  pain  is  often  proportionate  to  the  severity  of 
the  small-pox,  being  particularly  severe  in  hemorrhagic  small- 
pox. General  aches  and  pains  are  often  complained  of.  Ver- 
tigo is  a  symptom  of  common  occurrence,  even  in  extremely 
mild  attacks.  It  is  particularly  manifest  when  the  patient 
assumes  the  vertical  posture.  Prostration  and  muscular 
relaxation  are  pronounced,  particularly  in  severe  cases.  A 
mild  initial  stage  is  usually  followed  by  a  scant  eruption;  a 
well-marked  initial  stage  may  precede  either  a  mild  or  severe 
cutaneous   outbreak. 

Peculiar  prodromal  rashes  often  make  their  appearance  during 
the  initial  illness.  When  they  develop,  it  is  usually  upon  the 
second  day  of  the  invasive  fever.  They  disappear  ordinarily 
in  from  twenty-four  to  forty-eight  hours.  They  may,  however, 
continue  several  days  after  the  appearance  of  the  true  eruption. 
The  frequency  of  these  rashes  appears  to  vary  in  different 
epidemics.  During  the  wide-spread  and  malignant  epidemics 
of  1 87 1  and  1872  they  were  very  common.  Osier  observed 
prodromal  rashes  during  this  period  in  13  per  cent,  of  his 
cases.  The  most  common  type  is  that  resenibling  measles,  with 
which  disease,  indeed,  it  is  liable  to  be  confounded.  The 
eruption  has  an  irregular  distribution,  being  at  times  generalized 
and  at  other  times  limited  to  certain  regions  of  the  body.  It, 
moreover,  differs  from  the  eruption  of  measles  in  that  the  rash 
is  not  elevated  above  the  level  of  the  skin,  and,  therefore, 
scarcely  appreciable  to  the  finger  passed  over  it.  Its  ephemeral 
character  is  also  a  differentiating  feature.     This  roseola  vario- 


SMALL- POX  419 

hsn,  as  it  has  been  designated,  has  a  close  analogue  in  the 
roseola  vaccinosa,  which  occasionally  appears  about  the  ninth 
to  the   eleventh  day  of  vaccination. 

The  scarlatinijorm  rash  is  less  common  than  the  measles- 
like  eruption.  It  may  involve  a  large  part  of  the  cutaneous 
surface,  but  is  more  apt  to  affect  certain  areas,  as  the  thighs, 
inguinal  regions,  extensor  surfaces  of  the  extremities,  and  the 
trunk.  Some  authors  refer  to  the  appearance  of  an  urticarial 
eruption  in  rare  cases. 

The  petechial  or  hemorrhagic  initial  rash  has  a  special  pre- 
dilection for  certain  regions  of  the  body,  which  were  carefully 
studied  by  Simon,  of  Hamburg. 
This  writer  pointed  out  the  fre- 
quent occurrence  of  the  erup- 
tion in  the  lower  abdominal, 
inguinal,  and  genital  regions 
and  inner  aspects  of  the  thighs, 
constituting  a  triangle  whose 
base  traverses  the  neighborhood 
of  the  umbilicus  (the  so-called 
crural  triangle  of  Simon).  The 
"axillary  triangle,"  including 
the  inner  aspect  of  the  arm, 
axilla,  and  pectoral  region,  is 
also  a  commonly  affected  area. 
The  petechial  rash  is  also  fre- 
quently seen  along  the  lateral 
surface  of  the  thorax  and  ab- 
domen. The  eruption  consists 
of  closely  aggregated  pin-point- 
to  pin -he  ad -sized  purplish  or 
clarety  spots,  which  are  in  such 

intimate  juxtaposition  as  to  convey  the  impression  of  a  diffuse 
redness.  Being  the  result  of  a  hemorrhagic  extravasation  into 
the  skin,  the  discoloration  does  not  disappear  upon  pressure. 

Occasionally  an  erythematopetechial  rash  is  seen,  the  erup- 
tion partaking  of  the  character  of  both  the  erythematous  and 
hemorrhagic  rashes. 

The  petechial  eruptions  may,  during  mild  epidemics,  occur  in 
cases  which  later  prove  to  be  quite  mild.  More  often,  however, 
they  are  the  harbingers  of  severe  small-pox  of  the  hemorrhagic 
type.     Toe  morbilliform  eninHoos  are  much  more  common  in 


420  DISEASES  OF  THE   SKIN 

cases  of  varioloid,  and  their  occurrence,  therefore,  may  be  re- 
garded as  an  auspicious  sign.  At  times,  the  roseolous  eruption 
is  practically  the  only  cutaneous  manifestation.  These  cases  be- 
long to  the  class  commonly  designated  variola  sine  exanthemate, 
which  is  the  most  benignant  form  that  small-pox  may  assume. 
That  such  cases  are  occasionally  encountered  is  evident  from  the 
writings  of  both  ancient  and  modern  authors.  In  every  epi- 
demic patients  are  seen  who  give  a  history  of  exposure  to  small- 
pox and  who,  in  due  course  of  time,  are  suddenly  seized  with 
chills,  followed  by  headache,  vomiting,  fever,  prostration,  and 
pain  in  the  back.  These  symptoms  continue  for  three  or  four 
days,  and  then  subside  without  the  development  of  any  erup- 
tion except,  perhaps,  one  of  the  prodromal  rashes  to  which 
reference  has  been  made.  It  is  impossible  to  explain  such 
cases  on  any  other  supposition  than  that  the  disease  was  variola 
without  the  eruption.  Trousseau  refers  to  cases  observed  by 
him  in  which  the  only  symptoms  characteristic  of  the  disease 
were  a  "few  pustules  in  the  pharynx  and  on  the  pendulous 
veil  of  the  palate." 

Stage  of  Eruption. — The  true  eruption  of  small-pox  makes 
its  appearance  with  remarkable  regularity  on  the  third  day  of 
the  illness,  calculating  from  the  day  on  which  the  initial  chill 
or  rigor  occurred.  In  modified  small-pox  deviations  from  this 
rule  may  be  noted.  The  eruption  almost  always  appears 
first  on  the  forehead  and  temples,  near  the  edge  of  the  hair, 
and  on  the  wrists.  Not  infrequently  it  is  seen  first  on  the  upper 
lip  and  around  the  mouth.  It  rapidly  spreads  to  the  scalp, 
face,  neck,  ears,  forearms,  and  hands,  always  showing  a  decided 
preference  for  the  cutaneous  surfaces  habitually  exposed  to  the 
atmosphere.  In  the  course  of  twenty-four  hours,  sometimes 
somewhat  earlier,  it  extends  to  the  body  and  lower  extremities. 
It  does  not  simultaneously  affect  these  regions,  but  attacks 
in  succession  the  back,  arms,  breast,  and  finally  the  legs  and 
feet.  In  rare  cases  the  exanthem  may  be  first  noted  on  the 
trunk  and  extremities. 

The  full  complement  of  lesions  does  not  make  its  appearance 
at  once  in  any  given  part;  the  eruption  continues  rather  to 
multiply  for  two  or  three  days  before  its  definite  limit  is  reached. 
In  modified  small-pox  new  lesions  may  continue  to  appear 
for  a  longer  period  of  time.  Upon  carefully  examining  the 
eruption  it  is  seen  that  many  lesions  develop  at  the  sites  of 
hair-follicles  or  orifices  of  the  sebaceous  and  sudorific  glands. 


422  DISEASES  OF  THE  SKIN 

The  eruption  begins  as  small  red  spots  or  macules,  some  oi 
which  may  be  so  small  and  faint  as  to  be  scarcely  visible,  while 
others  reach  the  size  of  a  lentil-seed.  The  color  is  at  first  pink- 
ish-red, later  assuming  a  deeper  tint.  In  many  cases  the  lesions 
on  the  trunk  and  extremities  present  the  appearance  of  flea- 
bites.  The  lesions  gradually  increase  in  size  and  number, 
becoming  more  and  more  prominent,  so  that  in  twenty-four 
hours  they  assume  the  form  of  elevated  papules  with  a  char- 
acteristic feel.  The  early  papules,  particularly  about  the  fore- 
head and  cheeks,  may  be  more  demonstrable  to  the  sense  of 
touch  than  to  the  eye.  They  possess  a  peculiar  induration, 
and  convey  to  the  finger  a  sensation  similar  to  that  which  would 
be  produced  by  grains  of  shot  imbedded  in  the  skin.  The 
"  shotty  "  feel  varies  in  degree  in  different  cases.  Some  papules 
are  extremely  hard,  while  others  possess  comparatively  little 
induration.  They  are  at  first  always  discrete,  but  they  may 
rapidly  increase  in  number  and  become  confluent,  even  before 
the  vesicular  stage  is  reached. 

On  the  third  day  of  the  eruption  or  the  fifth  day  of  the  disease 
very  many  of  the  lesions  which  made  their  appearance  first 
will  be  found  to  contain  a  little  clear  serum.  Indeed,  in  many 
patients  one  will  be  able  to  note,  on  the  second  day,  a  lesion  here 
and  there  which  has  become  vesicular  in  advance  of  the  general 
eruption.  These  precocious  vesicles  are  frequently  of  diag- 
nostic import,  enabling  one  in  doubtful  cases  to  assert  the 
variolous  nature  of  the  disease.  By  the  fourth  or  fifth  day  all 
the  lesions  are  converted  into  vesicles.  At  this  stage  they 
commonly  have  the  size  and  shape  of  a  split-pea.  Small 
vesicles  are  apt  to  be  conical  or  acuminate,  while  the  larger 
lesions  have  a  convexly  flat  or  hemispheric  appearance.  The 
vesicle  of  small-pox  is  extremely  firm ;  not  infrequently  it  feels 
harder  to  the  finger  than  the  papule  from  which  it  developed. 
In  no  other  disease  do  the  vesicles  acquire  such  a  degree  of  indu- 
ration and  hardness.  The  color  of  the  vesicle  is  at  first  pinkish, 
the  tint  extending  to  the  areola  surrounding  it.  Later,  as  the 
fluid  exudation  into  it  increases,  it  assumes  a  peculiar  opaline 
or  pearly  hue.  This,  with  the  shining  and  glistening  surface, 
imparts  to  the  vesicle  a  most  distinctive  appearance.  One  of 
the  most  characteristic  features  of  the  small-pox  vesicle  is  the 
so-called  umbilication.  In  the  smaller  acuminate  vesicles  this 
is  seen  as  a  minute  central  depression  or  invagination,  repre- 
senting, in  all  probability,  the  mouth  of  a  hair-folliele  or  sweat 


SMALL-POX  423 

duct.  This  form  of  umbilication  may  occasionally  be  met  with 
in  other  cutaneous  diseases,  when  the  lesions  are  situated  at  the 
mouths  of  the  sebaceous  or  sudoriparous  orifices.  In  the  larger, 
pea-sized  vesicles  the  umbilication  is  seen  as  a  round,  oval. 


Rirl — sixlh  day 


or  slightly  irregular  indentation.  In  this  case  the  depression 
is  flatter  and  is  probably  due  to  the  bulging  of  the  periphery  of 
the  pock.  This  latter  form  of  umbilication  is  of  important 
diagnostic  value,  as  but  few  other  vesicular  diseases  produce 
quite  the  same  appearance.     The  forearms  and  the  backs  of 


424  DISEASES   OF    THE   SKIN 

the  hands  are,  perhaps,  the  regions  upon  which  umbilication 
is  most  characteristically  seen.  Umbilication  is  only  observed 
in  a  certain  proportion  of  vesicles.  It  is  by  no  means  a  con- 
stant feature  of  small-pox  eruption,  and,  indeed,  is  not  infre- 
quently absent  altogether.  This  is  particularly  true  of  cases 
of  varioloid.     A  form  of  secondary  umbilication  is  commonly 


...ruvi. 


seen  during  the  stage  of  decline  or  desiccation,  when  the  pus- 
tules, as  a  result  of  rupture  and  collapse-,  show  a  depression 
in  the  center. 

If  one  observes  closelv  the  large  clear  vesicle 
fifth  or  sixth  day,  particularly  those'  situated 
surfaces  of  the  hands,  one  can  frequently  discei 
epidermal  roof,  something  of  the  interior  cons 


■f  about  the 
1  the  dorsal 
through  the 
etion  of  the 


SMALL-POX  425 

lesions.  They  will  be  seen  to  be  made  up  of  compartments 
which  are  divided  by  vertical  septa,  very  much  like  the  divisions 
of  an  orange.  The  vertical  partitions  are  formed  by  the  spin- 
ning out  and  reticulation  of  the  epithelial  cells  of  the  rete 
mucosum.  This  accounts  for  the  multilocular  character  of 
the  small-pox  vesicle,  and  explains  the  inability  to  completely 
evacuate  its  contents  by  a  single  puncture.  Large,  fully 
developed  vesicles  frequently  show  at  their  central  summit  a 
disk  of  the  color  of  yellowish  serum,  and  around  the  periphery 
a  whitish,  puriform  ring,  looking  not  unlike  an  arcus  senilis. 

The  predominance  of  the  eruption  of  small-pox  on  the  face 
and  terminal  extremities  is  to  be  accounted  for  by  the  greater 
vascularity  of  the  skin  in  these  regions.  That  lesions  are 
attracted  by  an  overfilling  of  the  cutaneous  vessels  is  seen  in 
the  excessive  development  of  the  eruption  whenever  the  skin 
has  been  irritated  or  congested.  It  is  a  common  experience 
to  see  in  a  discrete  case  of  small-pox  a  profusion  of  lesions  over 
a  rectangular  area  in  the  lumbar  or  epigastric  region,  where  a 
mustard-plaster  had  been  applied  during  the  initial  stage  for 
the  relief  of  pain. 

It  is  only  when  mechanical  or  chemical  irritation  is  applied 
to  the  skin  before  the  appearance  of  the  eruption  that  an  increase 
in  the  number  of  lesions  is  produced.  I  have  frequently  applied 
tincture  of  iodin  after  the  appearance  of  the  eruption  without 
augmenting  the  variolous  crop  in  the  region  thus  treated. 

Stage  of  Suppuration. — The  contents  of  the  vesicles  gradually 
become  more  and  more  turbid  as  the  result  of  the  increased 
exudation  of  leukocytes  until  the  lesions  become  frankly  puru- 
lent. This  condition  is  usually  reached  in  unmodified  small- 
pox about  the  sixth  day  of  the  eruption,  and  marks  the  begin- 
ning of  the  stage  of  suppuration.  The  pustules  now  in  good 
part  become  large  and  globular,  and  stand  out  prominently 
from  the  skin.  Their  color  varies  somewhat  in  different  cases. 
At  times  the  pustules  acquire  a  distinctly  yellowish  tint,  not 
unlike  the  color  of  ordinary  pus.  Frequently,  however,  they 
retain,  until  rupture,  a  peculiar  chalky  or  grayish- white  hue. 
The  reddish  areola  which  is  observed  about  the  vesicles  develops 
in  this  stage  into  a  broader,  deeper-hued,  violaceous  halo. 
Where  the  lesions  are  closely  aggregated,  the  entire  interpus- 
tular  integument  becomes  reddened  and  tumefied. 

On  the  face  and  scalp,  where  the  eruption  is  apt  to  be  profuse, 
the  redness  and  intumescence  are  so  extreme  as  to  render  the 


426 


DISEASES  OP  THE   SKIN 


features  of  the  patients  completely  unrecognizable.  The  eye- 
lids, as  the  result  of  edema  of  the  loose  areola  tissue,  become 
enormously  puffed  and  completely  close  the  palpebral  cleft, 
which  is  bathed  in  a  puriform  secretion.  The  patient  for  a 
time  is  unable  to  see,  owing  to  a  complete  closure  of  the  eyelids. 
The  lips,  nose,  and  ears  are  distorted,  the  normal  contour  of 
the  face  is  lost,  and  the  entire  head  swollen  beyond  human 
proportions.  The  patient  presents  a  most  revolting  and  loath- 
some appearance.  Seeing  the  disease  for  the  first  time  one  is 
apt  to  be  appalled  by  the  horrible  spectacle.  The  patient  is 
sorely  distressed  by  the  inflammation  and  swelling  of  the  scalp, 
inasmuch  as  contact  with  the  pillow  is  a  source  of  unendurable 
pain. 

As  the  eruption  on  the  body  and  lower  extremities  is  later 
in  making  its  appearance  than  that  on  the  face,  so  also  is  it 
later  in  reaching  maturation.  When  the  lesions  upon  the  face 
have  become  vesicular,  it  will  be  found  that  the  efflorescence 
upon  the  trunk  and  extremities  is  still  in  the  papular  stage. 
In  like  manner  the  facial  lesions  will  have  advanced  to  pustu- 
lation  by  the  time  that  the  eruption  on  the  body  has  become 
vesicular.  There  is  noticeable,  therefore,  this  regular  multi- 
formity in  the  character  of  the  lesions  upon  the  different  portions 
of  the  body.  About  the  eighth  day  the  pustules  on  the  face  have 
reached  their  greatest  development,  and  the  process  of  retro- 
gression then  begins.  They  become  yellowish,  present  a 
shrunken  or  shriveled  appearance,  and  rupture  or  collapse.  On 
rupturing  the  pustules  give  exit  to  a  viscid,  glairy,  dirty-yellow 
pus  which  dries  in  the  form  of  yellowish  or  brownish  crusts. 
A  gradual  subsidence  in  the  inflammation  and  swelling  takes 
place,  and  the  normal  outlines  of  the  face  are  once  more  restored. 

During  the  stage  of  pustulation  the  lesions  which  exhibited 
umbilication  become  distended  and  globular,  thus  effacing  the 
central  depression.  The  epithelial  bands  holding  down  the 
center  of  the  lesion  in  all  probability  become  dissolved,  per- 
mitting the  roof  of  the  pustule  to  assume  a  hemispheric  form. 

The  eruption  on  the  trunk  is  almost  always  much  less  abun- 
dant than  on  other  parts  of  the  body.  Not  infrequently  the 
hypogastrium  is  quite  free  from  pustules,  even  when  the  face 
and  hands  show  a  marked  degree  of  confluence.  Exceptions 
to  this  rule  are,  however,  met  with.  I  have  seen  patients  the 
skin  of  whose  body  was  so  profusely  covered  that  it  would  have 
been  almost  impossible  to  place  the  tip  of  the  finger  upon  a 


SMALL-POX  427 

healthy  area  of  skin.  Of  course,  in  such  cases  the  danger  to 
the  patient  is  correspondingly  increased,  inasmuch  as  the 
gravity  of  the  disease  is,  as  a  rule,  directly  proportionate  to 
the  extent  of  the  eruption. 

In  a  well-pronounced  case  of  semiconfluent  small-pox  an 
approximate  count  of  the  number  of  lesions  was  made.  This 
was  accomplished  by  dividing  the  cutaneous  surface  into 
certain  areas  by  means  of  a  colored  crayon,  and  counting  the 
pustules  within  these  boundaries.  Upon  the  face  and  scalp 
the  confluence  of  the  pustules  precluded  the  possibility  of  their 
being  counted.  A  conservative  estimate  of  the  number  present 
was,  therefore,  made. 

The  number  of  lesions  computed  upon  the  different  portions 
of  the  body  is  herewith  appended: 


Thumb 61 

Index-finger 97 

Middle  finger 95 

Ring-finger 81 

Little  finger 58 

Total 392 


Total  on  fingers  of  one  hand : 


Dorsal  surface  of  one  hand 382 

Palmar  surface  of  one  hand 1 29 

Total  lesions  on  both  hands 1,806 

Forearms 4,400 

Arms 2,840 

Chest 1,000 

Abdomen 175 

Thighs 4, 1 80 

Legs 2,850 

Feet 750 

Back 5,700 

Estimated  number  on  face  and  scalp 3,000 

Total 26,701 

By  evacuating  some  of  the  pustules  with  a  pipet  it  was  esti- 
mated that  the  lesions,  at  the  height  of  their  development, 
each  contained  about  three  drops  of  pus.  Such  a  computation 
developed  the  surprising  fact  that  the  patient  referred  to 
carried  in  his  skin  about  five  quarts  of  pus. 

I  have  seen  larger  men,  with  more  profuse  eruptions,  who 
must  have  had  in  the  neighborhood  of  40,000  pustules.  With 
this  prodigious  amount  of  purulent  material  in  the  skin,  the 
wonder  is  that  any  patient  thus  afflicted  should  recover. 

The  pustules  on  the  trunk  appear  to  have  a  more  superficial 


428  DISEASES   OF   THE    SKIN 

seat  in  the  skin  than  on  cutaneous  surfaces  constantly  exposed 
to  the  air;  hence  they  are  not  accompanied  by  the  same  amount 
of  inflammatory  swelling  or  ulcerative  destruction  of  the  cutis. 
There  is,  moreover,  very  little  tendency  on  the  trunk  and  lower 
extremities  to  confluence  of  the  lesions.  One  frequently  notes 
a  coalescence  of  two  or  three  pustules  as  a  result  of  their  con- 
tiguity, but  the  vast  majority  of  lesions  remain  discrete. 

This  statement,  however,  does  not  apply  to  the  efflorescence 
on  the  hands  and  feet.  In  these  regions  the  degree  of  confluence 
may  be  intense  and  cause  the  patient  great  suffering.  As  a 
result  of  the  thickness  of  the  overlying  epidermis  on  the  palms 
and  soles,  the  pustules  do  not  acquire  as  great  a  prominence  as 
elsewhere.  Being  bound  down  by  the  tense  and  unyielding 
horny  layer  of  skin,  pressure  is  made  upon  the  delicate  under- 
lying cutaneous  nerves,  producing  distressing  pain.  In  a 
severe  attack  of  small-pox  the  palms  and  soles,  the  fingers  and 
toes,  and  the  dorsal  surfaces  of  the  hands  and  feet  are  pro- 
fusely covered.  When  the  pustular  stage  is  reached,  the  patient 
becomes  perfectly  helpless;  he  is  unable  to  feed  himself  or  in 
any  way  utilize  his  hands.  It  is  pitiful  to  behold  him  in  bed, 
with  his  hands  and  fingers  semiflexed  and  his  arms  outstretched 
for  fear  of  the  dreaded  contact  with  the  bed-clothing.  At 
times  the  pustules  on  the  backs  of  the  hands  fuse  and  produce 
large  bulla?,  or  even  an  extensive  undermining  of  the  epidermis, 
similar  to  that  seen  in  a  severe  scald. 

During  the  suppurative  stage  a  most  penetrating  and  offen- 
sive odor  emanates  from  the  body  of  the  patient  and  from  the 
pus-stained  bed-  and  body-linen.  This  stench  results  from 
the  decomposition  of  the  effete  and  purulent  discharge,  and  is 
not  peculiar  to  small-pox.  In  neglected  cases  the  odor  is 
most  sickening,  and  may  pervade  the  atmosphere  of  a  room 
or,  indeed,  of  an  entire  house. 

Eruption  upon  the  Mucous  Membranes. — Simultaneous 
with  the  appearance  of  the  small-pox  efflorescence  upon  the 
cutaneous  surface,  or  a  little  earlier,  the  eruption  develops 
upon  the  adjacent  mucous  membranes.  The  involvement  is 
almost  exclusively  confined  to  those  mucous  surfaces  which  are 
near  the  external  orifices  or  to  which  the  air  has  access.  The 
eruption  early  attacks  the  lining  of  the  mouth,  nose,  and 
pharynx,  and  in  severe  cases  the  larynx,  bronchi,  and  eso- 
phagus. The  extent  of  the  exanthem  bears  a  direct  relation 
to  the  severity  of  the  eruption  of  the  skin.     The  lesions,  how- 


SMALL-POX  429 

ever,  are  seldom  as  profuse  upon  the  mucous  surfaces  as  upon 
the  integument.  If  an  examination  of  the  mouth  and  fauces 
be  made  at  the  very  beginning  of  the  eruptive  stage,  small  yet 
distinct  red  spots  may  be  seen  upon  the  roof  of  the  mouth, 
buccal  surface,  and  anterior  arches  of  the  palate. 

These  macules  are  pin-head-sized  and  larger,  and  of  an  intense 
red  color,  which  contrasts  with  the  violaceous  or  bluish-red 
tint  of  the  surrounding  mucous  membrane.  In  a  short  time 
the  spots  become  slightly  elevated  or  papular,  frequently 
exhibiting  a  whitish,  glistening  center.  The  parallelism  with 
the  evolution  of  the  cutaneous  pock  ceases  at  this  stage  of 
development.  There  is  an  effort  on  the  part  of  nature  toward 
the  formation  of  vesicles,  but  the  thin  and  delicate  epithelium 
which  serves  as  a  covering  is  destroyed  by  the  macerating 
influence  of  the  moist  secretion  in  which  they  are  constantly 
bathed.  As  the  eruption  upon  the  skin  becomes  vesicular 
and  pustular,  the  lesions  in  the  mouth  assume  a  whitish  or 
grayish  appearance,  with  but  little  if  any  elevation  above  the 
surface.  The  denudation  of  the  epithelial  covering  of  the  pocks 
leads  to  the  production  of  circumscribed  erosions  or  super- 
ficial ulcerations. 

The  tongue  is  often  the  seat  of  lesions  which  seriously  embar- 
rass its  movement  in  speaking  and  eating.  Occasionally  an 
intense  form  of  glossitis  is  set  up,  causing  the  organ  to  swell  so 
enormously  as  to  prevent  its  retention  wholly  within  the  mouth. 
This  condition,  which  was  designated  by  the  older  writers  as 
glossitis  variolosa,  is  apt  to  greatly  interfere  with  swallowing, 
and  is  under  all  circumstances  to  be  regarded  as  an  unfavorable 
sign. 

Much  annoyance  is  occasioned  by  the  presence  of  the  erup- 
tion in  the  nasal  cavities.  The  mucous  membrane  is  at  first 
swollen  and  inflamed,  and  later  covered  with  crusts  which 
obstruct  the  nares  and  render  nasal  breathing  difficult  and 
often  impossible. 

The  eruptive  process  may  involve  the  larynx  and  cause  so 
much  inflammation  and  swelling  as  to  make  deglutition  difficult 
or  impossible,  or  it  may  lead  to  the  production  of  hoarseness 
and  complete  aphonia.  In  severe  cases  an  acute  edema  of 
the  glottis  may  develop,  which  may  seriously  or  even  fatally 
impede  respiration. 

The  mucous  membranes  of  the  lower  portion  of  the  body 
may  also  be  involved.     The  eruption  may  attack  the  vulva 


430  DISEASES  OF  THB  SKIN 

and  the  mucous  surface  of  the  vagina,  but  the  lesions  in  these 
parts  are  not  apt  to  be  abundant.  The  lower  part  of  the 
rectal  mucosa  may  also  be  the  seat  of  the  variolous  eruption. 
The  meatus  urinarius  is  occasionally  involved  in  both  males 
and  females,  but  the  urethral  channel  nearly  always  escapes. 
•  Delirium. — During  the  early  days  of  the  eruption  violent 
disturbances  of  cerebration  in  the  form  of  delirium  and  acute 
mania  may  take  place.  Patients  are  frequently  the  subject 
of  hallucinations  and  of  delusion  of  persecution.  I  have  seen 
patients  at  this  time  attempt  escape  through  the  windows  of 
the  hospital.  Suicidal  and  homicidal  attempts  may  be  made. 
These  mental  derangements  are  more  common  among  alcoholics. 

General  Symptoms  of  the  Eruptive  Stage. — In  unmodified 
small-pox  the  initial  fever  continues  high  until  the  third  or 
fourth  day  of  the  eruption,  when  there  occurs  a  remission 
in  the  temperature  or  a  complete  drop  to  normal.  The  pulse 
and  respiration  are  lessened  in  frequency.  The  pains  in  the 
head  and  back  abate,  the  vomiting  ceases,  and  the  patient 
experiences  a  feeling  of  well-being.  In  modified  small-pox 
this  is  often  the  termination  of  disturbing  general  symptoms. 
In  variola  vera  the  subsidence  of  the  symptoms  is  never  so 
complete  as  in  varioloid,  and  the  respite  is  of  but  short  dura- 
tion. On  the  fifth  or  sixth  day  of  the  eruption,  when  suppura- 
tion is  established,  the  secondary  or  suppurative  fever,  begins, 
continuing  throughout  the  eruptive  period  and  longer  if  com- 
plications arise.  The  febrile  curve  is  lower  than  that  of  the 
initial  stage,  seldom  exceeding  104  °  F.,  and  usually  running 
between  102  °  and  103  °  F.,  with  morning  falls  and  evening 
exacerbations.  The  duration  of  the  fever  is  indefinite,  vary- 
ing between  three  or  four  days  and  several  weeks.  In  severe 
cases  there  are  great  nervous  apprehension,  restlessness,  insom- 
nia, and  prostration.  At  the  end  of  the  eighth  or  ninth  day, 
in  favorable  cases,  a  sudden  improvement  sets  in,  coincident 
with  the  involution  and  drying  of  the  pustules. 

Period  of  Involution  and  Retrogression  of  the  Eruption. — 
The  exanthem  of  small-pox  reaches  the  acme  of  its  develop- 
ment with  the  completion  of  the  pustular  stage.  This  con- 
stitutes the  turning-point  not  only  of  the  eruption,  but  fre- 
quently of  the  disease.  The  first  evidence  of  retrogression  of 
the  exanthem  is  noted  in  the  subsidence  of  the  inflammatory 
swelling  of  the  skin,  more  particularly  in  the  immediate  neigh- 
borhood of  the  pustules.     The  abatement  is  first  seen  upon  the 


SMALL-POX  431 

face,  where  the  redness  and  edema  have  been  most  conspic- 
uous. The  eyelids  become  less  swollen,  permitting  the  patient 
to  again  perceive  the  grateful  light  of  day.  The  tumefied 
features  gradually  assume  their  normal  contour,  and  the  patient 
begins  to  acquire  some  semblance  of  his  former  self.  Syn- 
chronous with  the  disappearance  of  the  intumescence  the 
pustules  begin  to  dry;  this  period  is  called,  therefore,  the  stage 
of  desiccation.  The  drying  of  the  contents  of  the  pustules  is 
soon  followed  by  a  casting-off  of  crusts,  when  the  stage  of 
decrustation  is  entered  upon.  Nature  in  this  manner  attempts 
to  rid  the  surface  of  the  skin  of  the  effete  products  which  have 
there  collected,  and  finally  restore  it  to  its  normal  condition. 

The  involution  of  the  small-pox  exanthem  does  not  occur 
simultaneously  upon  all  portions  of  the  body  surface,  but  follows 
the  same  sequence  observed  during  the  development  of  the 
eruption.  It  is  but  natural,  therefore,  that  the  first  evidence 
of  desiccation  should  be  found  in  the  facial  lesions.  The  pus- 
tules in  this  region  may  dry  without  rupture,  although  more 
commonly  the  purulent  contents  of  the  lesions  exude  upon 
the  surface  and  dry  in  the  form  of  yellowish  crusts.  The  color 
gradually  becomes  darker,  until  it  assumes  a  brownish  tint. 
In  neglected  cases  the  crusts  may  become  almost  black,  envelop- 
ing the  face  in  an  unsightly,  immovable  mask.  The  adhesion 
of  the  crusts  to  the  subjacent  tissues  varies  in  degree  according 
to  the  depth  and  intensity  of  the  involvement  of  the  cutis. 
Where  the  pustule  is  superficially  seated  and  there  is  no  ulcera- 
tion of  the  skin,  the  crust  is  readily  detached,  exposing  to 
view  merely  a  reddened  area  of  the  skin. 

At  the  same  time  that  desiccation  is  well  established  on  the 
face,  the  trunk  and  extremities  will  exhibit  lesions  distended 
with  fluid  pus. 

After  the  rupture  of  large  pustules,  the  centers  frequently 
dry  and  sink  in,  producing  a  cup-shaped  depression  or  umbilica- 
tion.  This  secondary  umbilication  differs  from  the  primary 
variety  in  being  distinctly  larger  and  more  conspicuous,  and 
occurring  at  a  much  later  stage  of  the  eruption.  This  form  of 
umbilication  is  most  typically  seen  on  the  dorsal  surfaces  of 
the  hands. 

When  the  variolous  pocks  desiccate  without  rupture _s 
undergo  a  gradual  condensation  of  structure  and  a  ^ed  with 
of  their  colon    Wfr*  r  *re  completely  dried,  tv   papillary 

vexly  flat,  ss,  and  of  a 


434  DISEASES  OP  THE  SKIN 

layer  of  the  skin  has  been  affected.  On  the  spontaneous 
shedding  of  the  crusts  these  areas  will  be  seen  as  reddish,  cica- 
trized excavations.  The  extent  of  scarring  depends  entirely 
upon  the  depth  to  which  the  destructive  inflammation  has 
extended.  Pocks  which  remain  encapsuled  within  the  epider- 
mis will  leave  no  permanent  evidence  of  their  presence.  They 
will  be  followed  by  reddish  stains,  which  are  quite  disfiguring 
in  themselves,  but  disappear  in  the  course  of  a  few  months. 
On  exposure  to  cold  the  reddish  discolorations  acquire  a  bluish 
or  purplish  appearance.  As  time  goes  on  the  reddish  color 
becomes  darker  and  eventuates  in  a  brownish  pigmentation. 
This  pigmentation  is  fortunately  less  conspicuous  and  less  per- 
sistent on  the  face  than  on  the  covered  surfaces.  Even  after 
several  months  the  trunk  and  limbs  frequently  exhibit  stains 
of  a  cafe  au  lait  hue.  In  persons  of  swarthy  complexion  and 
in  negroes  the  pigmentation  is  greater  than  in  fairer-skinned 
individuals. 

After  the  lapse  of  three  or  four  months  the  scars  of  small- 
pox assume  a  whitish  color — paler,  indeed,  than  the  surrounding 
integument.  Thev  may  be  round,  oval,  linear,  stellate,  radiate, 
or  irregular,  according  to  the  configuration  or  grouping  of  the 
lesions  which  caused  thenl.  They  may  be  large  or  small,  deep 
or  shallow;  not  infrequently  they  present  sharp,  overhanging 
edges.  Indeed,  there  is  nothing  specially  characteristic  about 
the  pits  left  after  variola  save  their  extent  and  distribution. 
Affecting  most  profusely  and  conspicuously  the  face,  they  give 
rise  to  the  well-known  "pock-mark "  countenance.  It  is  well 
to  remember,  however,  that  similar  pits  sometimes  follow  a 
severe  acne,  particularly  of  the  necrotic  type.  I  have  seen 
scarred  acne  patients  who  might  have  passed  for  variola  sub- 
jects. The  older  writers  gave  to  acne  the  significant  title  of 
"stone  pock." 

By  a  curious  irony  of  fate  nature  obliterates  the  remains  of 
the  vast  majority  of  variolous  lesions  upon  the  covered  surfaces 
of  the  body,  whereas  indelible  evidence  is  left  upon  the  face, 
and  frequently  the  hands,  to  bear  witness  to  the  cruel  disease 
through  which  the  patient  has  passed.  Time,  however,  accom- 
plishes much  toward  the  effacement  of  the  more  superficial 
scars  and  the  mitigation  of  the  disfigurement  produced  by 
the  deeper  cicatrices. 

The  hair  of  the  head,  beard,  and  eyebrows,  etc.,  may  be  lost 
after  the  termination  of  a  severe  small-pox,  especially  in  cases 


SMALL-POX  435 

in  which  the  eruption  has  been  profuse  in  these  areas.  This 
alopecia  is  probably  in  part  of  febrile  origin,  and  partly  the 
result  of  the  local  influence  of  the  exanthem.  Restoration  of 
the  hair  usually  occurs,  and  this  is  complete,  except  in  areas 
in  which  the  hair-papillae  have  been  destroyed  by  the  variolous 
lesions. 

The  nails  of  the  fingers  and  the  toes  may  be  shed  in  severe 
cases.  This  is  usually  accomplished  slowly  through  the  push- 
ing off  of  the  old  nail  by  the  new  one  growing  from  behind. 
After  six  or  eight  weeks  a  sharp,  elevated  ridge  is  seen  near 
the  nail-fold ;  this  represents  the  free  border  of  the  new  nail, 
which  in  the  course  of  time  extends  forward.  Not  infrequently 
variolous  lesions  are  located  beneath  the  nail.  These  sub- 
ungual pocks  are  of  a  purplish  or  reddish-brown  color,  looking 
not  unlike  traumatic  ecchymoses. 

Impetigo  Variolosa. — During  the  period  of  desiccation  and 
incrustation  in  small-pox  certain  secondary  changes  commonly 
occur  upon  the  skin.  One  of  these  is  the  development  of 
sparsely  distributed  blebs  containing  a  thin,  dirty-yellow  fluid. 
These  may  originate  in  several  distinct  ways.  They  may  spring 
up  upon  previously  healthy  interpustular  areas  of  skin,  or  they 
may  result  from  a  distinct  conversion  of  the  pustules  into  blebs. 
At  times  a  pustule  is  seen  one-half  of  which  is  still  yellowish, 
while  the  other  half  is  spreading  out  into  a  muddy-colored  bleb. 
The  blebs  are  commonly  flat,  although  at  times  they  rise  promi- 
nently from  the  surface;  they  vary  in  size  from  a  bean  to  a 
walnut.  The  epidermal  roof  is  flaccid,  wrinkled,  thin,  and 
easily  disposed  to  rupture,  when  a  thin,  yellowish  fluid  exudes 
which  dries  in  the  form  of  irregular  crusts.  This  form  of  bleb 
formation  is  most  frequently  seen  on  the  hands  and  feet,  where 
the  bhbs  may  reach  the  diameter  of  an  inch  or  more. 

A  more  common  change  in  the  pustules,  however,  is  the 
development,  around  the  partially  desiccated  crust,  of  a  reddish, 
vesicular  ring,  containing  a  turbid,  puriform  secretion;  just 
beyond  the  border  of  the  raised  epidermis  is  a  narrow,  pinkish 
band  which  indicates  the  spreading  edge.  These  flat  bullous 
patches  spread  peripherally,  lifting  up  the  epidermis  as  exten- 
sion takes  place,  until  perhaps  an  area  the  size  of  a  silver  half- 
dolhr  is  reached.  Central  crusting  proceeds  concurrently 
with  centrifugal  extension.  In  this  manner  large,  dirty-yellow, 
irregular,  friable  crusts  are  formed.  It  is  not  uncommon  f™ 
most  of  the  pustules  on  the  trunk  and  extremi* 


436  DISEASES  OP  THE  SKIN 

surrounded  by  a  spreading,  vesicopustular  ring,  producing  an 
extensive  secondary  eruption.  Nearly  all  patients  with  unmodi- 
fied small-pox  present  these  "sores"  upon  the  skin.  Where 
the  eruption  is  profuse,  there  may  be  considerable  elevation  of 
temperature  and  other  evidences  of  septicemia.  Indeed,  this 
extensive  secondary  skin  involvement  may  even  cause  death. 

The  various  forms  of  pustulobleb  formation  just  described 
are  so  common  in  small-pox  that  this  complicating  condition 
might  appropriately  be  designated  impetigo  variolosa.  Indeed, 
this  term  was  employed  by  Hebra  for  one  of  the  forms  of  bleb 
formation  above  referred  to.  In  1867  he  wrote:  "In  other 
instances  a  consecutive  suppuration  appears,  not  round  crusts 
formed  from  variolous  pustules,  but  in  the  intervening  spaces 
which  were  free  from  the  efflorescence.  Thus  there  appears  a 
second  pustular  eruption,  which  might  also  be  regarded  as  a 
second  small-pox  eruption,  were  it  not  that  the  pustules  have 
a  different  form  and  take  a  different  course.  In  fact,  they 
resemble  rather  those  of  the  common  pustular  affections,  and, 
therefore,  this  affection  may  be  called  impetigo  variolosa." 
Hebra  preceded  this  description  by  a  reference  to  "central  crusts 
with  small  vesicular  rings  containing  a  puriform  fluid/'  to 
which  he  applied  the  name  rupia  variolosa. 

Microscopic  and  cultural  examination  of  the  contents  of 
variolous  vesicles  and  pustules  demonstrates  that  the  ordinary 
pyogenic  organisms  are  absent  in  the  early  stages  of  the  lesions, 
but  commonly  appear  during  the  late  pustular  period. 

In  a  bacteriologic  study  of  the  vesicles  and  pustules  of  small- 
pox I  found  the  lesions  to  be  sterile  until  a  late  stage  of  the 
eruption.  Of  34  cultures  of  fluid  from  variolous  lesions  before 
the  seventh  day  of  the  eruption,  33  remained  sterile.  And  even 
on  the  eighth,  ninth,  and  tenth  days  bacteria  cultiva table  on 
ordinary  tnedia  are  not  infrequently  absent.  Of  a  total  of  82 
cultures  made,  64,  or  77  per  cent.,  failed  to  show  any  growth 
whatsoever.  Frequently  thick,  creamy  pus  was  deposited  upon 
the  nutrient  media  without  giving  rise  to  any  colonies  what- 
soever. The  results,  which  are  in  accord  with  most  similar 
investigations,  suggest  that  the  causa  causans  of  small-pox, 
which  is,  of  course,  resident  in  the  lesions,  is  itself  pyogenic, 
and  that  it  is  responsible  for  the  suppuration  of  the  variolous 
pock.  Suppuration  is,  therefore,  to  be  regarded  as  a  part  of 
the  normal  evolution  of  the  eruption  of  small-pox.  After  the 
eighth  or  ninth  day  of  the  eruption,  however,  it  would  appear 


SMALL-POX  437 

that  a  secondary  infection,  with  germs  commonly  present  on 
the  skin,  takes  place.  At  this  time  variolous  impetigo  develops. 
The  thin,  seropurulent  fluid  in  the  impetigo  blebs,  when 
examined  in  smear,  is  seen  to  contain  myriads  of  microorgan- 
isms, chiefly  streptococci,  although  staphylococci  and  pseudo- 
diphtheria  bacilli  are  also  found.  When  death  occurs  in 
small-pox,  streptococci  may,  in  the  vast  majority  of  instances, 
be  recovered  from  the  heart  and  other  internal  organisms. 
Most  of  the  deaths  from  small-pox  occur  from  a  streptococcus 
septicemia  from  the  ninth  to  the  eleventh  day  of  the  eruption. 

Secondary  Toxic  or  Septic  Rashes. — Another  secondary 
eruption  in  small-pox,  to  which  but  little  reference  has  been 
made  in  literature,  is  the  toxic  or  septic  rash,  which  appears  in 
a  certain  percentage  of  cases  during  the  stage  of  decrustation. 
Between  the  eighth  and  eighteenth  days,  and  most  commonly 
on  the  thirteenth  or  fourteenth  days,  there  develops  upon  the 
trunk,  extremities,  and  at  times  the  face,  a  peculiar  erythe- 
matous efflorescence.  In  most  instances  the  rash  consists  of 
a  diffuse,  dusky  redness,  bearing  a  strong  resemblance  to  the 
exanthem  of  scarlet  fever  (scarlatiniform  erythema).  At  times 
it  is  mottled  and  inclined  to  become  somewhat  morbilliform 
in  appearance.  The  scarlatiniform  eruption  is  peculiar  in  that 
the  skin  immediately  surrounding  the  drying  pocks  is  often 
exempt,  producing  a  sort  of  anemic  halo.  The  rash  lasts  for 
two  or  three  days  and  then  fades.  If  the  erythema  has  been 
well  marked,  it  is  prone  to  be  followed  by  desquamation,  which 
may  be  most  profuse  in  character.  The  exfoliation  of  the  epi- 
dermis is  usually  rapid,  and  may  be  out  of  proportion  to  the 
intensity  of  the  rash.  Such  cases  merit  the  designation  of 
dermatitis  exfoliativa  variolosa. 

In  rare  instances  these  secondary  rashes  may  become  hemor- 
rhagic. Hemic  extravasation  into  the  skin  is  most  apt  to  occur 
upon  the  lower  extremities,  where  the  stasis  in  the  vessels  is 
greater,  owing  to  gravity. 

The  secondary  rashes  are  not  infrequently  accompanied  by 
rise  of  temperature.  The  temperature  may  suddenly  mount  to 
1040  F.,  decline  rapidly,  and  then  remain  for  some  days  in  the 
neighborhood  of  101  °  or  102  °  F.  In  some  patients,  with  rashes 
of  moderate  severity,  no  pyrexial  elevation  occurs.  While  the 
eruption  lasts  the  patients  are,  as  a  rule,  somnolent,  extremely 
irritable,  and  considerably  prostrated.    The  rashes  are  more 


438  DISEASES  OP  THE  SKIN 

commonly  observed  in  patients  who  have  had  severe  small-pox 
eruptions.  During  the  epidemic  of  1901-03  in  Philadelphia 
these  eruptions  occurred  in  perhaps  5  to  8  per  cent,  of  all  patients 
admitted.  The  incidence  among  children  seemed  to  be  greater 
than  among  adults.  In  the  severe  epidemic  of  small-pox  of 
1871-72  Wm.  M.  Welch  informs  me  that  such  rashes  were 
much  less  frequently  observed.  In  the  year  1904  they  were 
distinctly  less  frequent  than  in  the  two  preceding  years. 

The  scarlatiniform  eruption  is  the  type  far  more  commonly 
seen.  The  resemblance  to  the  rash  of  scarlet  fever  is  so  strong 
that,  in  the  beginning,  the  existence  of  the  latter  disease  was 
suspected. 

The  postvariolous  rashes  are,  in  all  probability,  septic  or  toxic 
in  character,  due  doubtless  to  the  absorption  of  some  poison 
into  the  blood.  It  would  seem  that  these  are  more  common  in 
patients  who  have  been  subjects  of  an  abundant  impetigo. 

THE    VARIETIES    OF    SMALL-POX 

Variations  in  the  extent  of  the  eruption  of  small-pox  may 
reach  extreme  limits,  from  a  few  small  pustules,  scarcely  char- 
acteristic enough  to  enable  one  definitely  to  proclaim  the  vario- 
lous nature  of  the  disease,  to  the  most  extensive  eruption,  cover- 
ing the  entire  cutaneous  surface.  Between  these  two  extremes 
there  may  occur  numerous  grades  of  intermediate  severity. 

Confluent  Small-pox  (Variola  Confluens). — Most  promi- 
nent among  the  early  symptoms  of  confluent  small-pox  are 
severe  headache,  persistent  retching  and  vomiting,  delirium,  or 
in  children  stupor,  violent  pain  in  the  back,  and  high  fever. 
The  temperature  always  rises  rapidly  and  attains  frequently  an 
extraordinary  height.  It  is  not  at  all  uncommon  for  the  fever 
to  reach  105  °  or  1060  F.,  and  cases  have  been  recorded  in  which 
a  temperature  of  no°  F.  was  registered.  On  the  third,  fourth, 
or  fifth  day  of  the  eruption  the  temperature  declines,  but  this 
remission  is  never  so  complete  as  in  milder  cases,  nor  does  it 
continue  so  long. 

Ordinarily,  in  forty-eight  hours,  the  efflorescence  covers  the 
entire  body  surface.  Owing  to  the  extensive  involvement  of 
the  skin,  redness  and  swelling  begin  early.  The  face  is  intensely 
hyperemic,  and  the  seat  of  distressing  burning  and  itching.  The 
marked  suffussion  of  the  countenance  frequently  enables  one 
to  prophesy  that  the  disease  will  take  the  confluent  form.     As 


small-pox  439 

the  eruption  progresses  it  passes  through  the  usual  stages, 
though  somewhat  more  slowly  than  in  the  milder  cases.  The 
papules  are  thickly  set,  and  even  at  this  stage  a  coalescence 
of  the  lesions  may  be  noted.  The  skin  is  thickened  and  indu- 
rated, and  feels  like  embossed  leather.  Soon  the  grayish  out- 
lines of  the  vesicles  make  their  appearance,  and  the  confluent 
aspect  of  the  exanthem  becomes  accentuated.  With  conver- 
sion of  the  vesicular  contents  into  pus,  great  swelling  and 


.e.u.  » — „....„^...  ™  ,»,.    Eighlh  day 
md  Schambcrg). 

edema  develop,  particularly  about  the  face  and  scalp.  The 
eyelids  are  enormously  puffed,  and  the  margin  of  the  upper 
■  lid  so  greatly  thickened  that  it  completely  overlaps  the  lower. 
The  nose,  lips,  and  ears  are  swollen  and  distorted,  imparting 
to  the  countenance  a  most  hideous  expression.  The  hands 
and  feet  are  swollen  to  double  their  natural  size,  and  are  most 
exquisitely  tender  and  painful.  When  full  pustulation  is 
established,  the  neighboring  lesions  coalesce  and  form  large, 
flat  blebs.  In  severe  cases  the  walls  of  the  pustules  are  com- 
pletely swept  away,  producing  fiat,  purulent,  pasty-looking 
infiltrations  of  enormous  proportions.  When  the  pus  exudes 
upon  the  surface  and  dries,  a  most  disgusting  stench  arises  from 
the  body. 

In  favorable  cases,  with  the  beginning  of  desiccation,  a  sub- 
sidence in  the  edema  takes  place,  and  the  crusts  are  cast  off 
from  the  skin.  The  decrustation  is,  however,  slower  than  in 
the  discrete  and  semiconfluent  forms  of  the  disease.  The 
suppurative  process  is  deeper  and  more  persistent,  and  may 
lead  to  the  consecutive  production,  in  the  same  areas,  of  large 
crusts  which  are  successively  thrown  off  as  they  form.     Owing 


440  DISEASES   OF  THE   SKIN 

to  the  greater  depth  of  the  purulent  inflammation  in  the  integu- 
ment, more  extensive  destruction  of  the  true  skin  occurs,  and 
consequently  the  scarring  is  deeper  and  more  conspicuous. 
Instead  of  discrete  pits,  the  face  may  be  seamed  with  scars  in 
a  most  frightful  manner. 

In  severe  cases  which  are  going  to  terminate  fatally  the  course 
pursued  is  rather  different  from  that  above  described.  The 
evolution  of  the  eruption  is  exceedingly  slow,  the  lesions  appear- 
ing to  be  suppressed  and  accompanied  by  but  little  swelling. 
The  face  has  a  peculiar  blurred  appearance.  An  ominous 
sign  in  these  cases  is  the  early  development  of  flat,  brownish, 
depressed  scabs  on  a  few  of  the  vesicles  on  the  forehead  and 
cheeks.  In  these  suppressed  eruptions  the  vesicles  are  only 
partially  filled  with  fluid,  and  the  features  are  only  slightly 
swollen ;  the  skin  is  roughened  and  presents  a  somewhat  parch- 
menty  appearance.  There  is  most  profound  prostration,  and 
death  results  in  almost  every  case. 

The  constitutional  symptoms  during  the  suppurative  stage 
of  confluent  variola  are  most  pronounced.  There  are  marked 
pyrexia  (1040  to  1050  F.),  rapid  pulse,  frequent  cough  and 
expectoration,  great  restlessness,  inability  to  sleep,  and  pro- 
found prostration.  Delirium  is  very  common,  but  the  patient 
does  not  become  maniacal,  as  he  often  docs  earlier  in  the  dis- 
ease. At  this  stage,  also,  complications  are  liable  to  occur, 
such  as  corneal  ulcer,  keratitis,  pleurisy,  empyema,  suppuration 
of  the  joints,  cellulitis,  phlegmonous  inflammation,  and  gan- 
grene of  the  skin.  Vomiting  and  diarrhea  may  supervene, 
and  still  further  exhaust  the  patient's  ebbing  vitality.  In 
fatal  cases  the  patient  sinks  into  a  comatose  condition,  the  pulse 
becomes  excessively  rapid,  and  the  temperature  not  infrequently 
rises  to   105  °,  1060,  or  107  °  P. 

The  mortality  in  confluent  small-pox  varies  in  different 
epidemics,  but  it  is  always  extremely  high.  In  general  terms 
it  may  be  stated  that  at  least  one-half  of  such  cases  perish. 
When  this  form  of  the  disease  terminates  in  recovery,  it  is  onlv 
after  a  long  and  tedious  convalescence,  interrupted  by  the 
development  of  boils,  abscesses,  and  other  complications. 

Hemorrhagic  Small-pox. — Of  all  the  forms  of  variola,  the 
hemorrhagic  is  the  most  formidable  and  malignant.  For  those 
who  contract  a  well-marked  attack  of  this  type  of  the  disease 
there  is  absolutely  no  hope. 


SMALL- POX  441 

According  as  the  hemorrhage  precedes  or  follows  the  appear- 
ance of  the  variolous  lesions  two  varieties  are  distinguished: 
first,  the  so-called  purpura  variolosa,  in  which  the  hemorrhage 
is  the  primary  exanthero,  and,  secondly,  variola  puslulosa 
hemorrhagica,  in  which  it  comes  on  secondarily. 

In  certain  epidemics  a  petechial  eruption  is  frequently  seen 
at  the  close  of  the  initial  stage  of  the  disease,  at  or  about  the 


face  covered   with   petechia  and  ef 
!*nt  (Welch  and  Schambcrg). 


time  when  the  eruption  should  appear.  This  symptom  often 
precedes  the  purpuric  or  hemorrhagic  form  of  the  disease,  and 
is,  therefore,  as  a  rule,  an  early  sign  of  malignancy.  At  other 
times  petechia  and  ecchymoses  appear  between  the  papules 
and  vesicles,  or  develop  actually  in  the  bases  of  these  lesions. 
The  vesicles  and  pustules  may  contain  purulent  material,  or 
may  fill  up  with  sanguinopurulent  fluid.  Considerable  diversity 
of  appearance  is  sometimes  manifest  in  the  eruption  of  a  single 
case. 

There  is  no  satisfactory  explanation  at  hand  to  elucidate  the 
causation  of  hemorrhagic  small-pox.  It  would  appear  that  the 
determining  factor  is  largely  resident  in  the  individual,  inas- 
much as  such  cases  may  be  derived  from  ordinary  small-pox 
and,  on  the  other  1  •*•»  to  the  usual  forms  in 


442  DISEASES  OP  THE  SKIN 

other  people.  The  frequency  of  this  form  of  the  disease  varies 
in  different  epidemics,  being  commonest  when  a  more  malignant 
type  of  the  disease  prevails. 

Variola  purpurica,  or  purpura  variolosa,  is  the  gravest 
and  most  malignant  form  of  small-pox.  The  initial  stage  does 
not  differ  essentially  from  that  of  ordinary  variola.  The  patient 
suffers  from  chill,  fever,  and  headache,  although  the  temperature 
is  not  so  likely  to  reach  so  extraordinary  a  height  as  in  con- 
fluent small-pox.  The  pain  in  the  back  is  usually  violent,  and 
prostration  excessive.  Furthermore,  the  patient  often  suffers 
from  precordial  distress  and  from  severe  retching  and  vomiting. 
The  vomiting  in  this  form  of  the  disease  is  a  most  distressing 
symptom,  and  commonly  proves  more  persistent  than  in  ordi- 
nary small-pox.  It  not  infrequently  continues  for  several  days 
after  the  appearance  of  the  exanthem.  Toward  the  end  of  the 
initial  stage  a  diffuse  efflorescence  appears  on  various  parts  of 
the  trunk  and  extremities,  while  the  face  remains  for  a  time 
exempt.  The  rash  is  at  first  scarlatinoid  in  appearance,  and 
disappears  partially  under  digital  pressure;  later  it  becomes 
more  intense  and  of  a  deeper  hue,  and  hemorrhagic  extrava- 
sation into  the  skin  occurs.  Petechia,  vibices,  and  ecchy- 
moses  develop  upon  the  chest,  axilla?,  lower  portion  of  the 
abdomen,  groins,  and  legs;  the  dark-red  or  purplish  discolor- 
ation now  present  no  longer  fades  under  pressure  of  the  finger. 
The  discoloration  rapidly  extends  to  the  face,  which  becomes 
dusky  red  or  livid  and  swollen.  The  conjunctiva?  are  injected, 
the  eyes  blood-shot,  and  the  lids  bluish,  owing  to  hemorrhage 
into  the  cellular  tissue.  Frequently  the  extravasation  of  blood 
under  the  conjunctiva  covering  the  sclerotica  is  so  great  as  to 
cause  this  membrane  to  project  beyond  the  lids  like  a  sac  filled 
with  blood.  Under  such  conditions  the  patient  is  unable  com- 
pletely to  close  the  eyes.  The  cornea  retains  its  normal  trans- 
parent appearance,  but,  owing  to  the  elevated  conjunctiva 
about  its  periphery,  appears  to  be  sunken  deeply  into  the  eye- 
ball. This  condition,  together  with  a  dark  discoloration  of 
face  and  the  tumefied  features,  gives  to  the  patient  a  peculiarly 
unnatural  expression.  A  close  scrutiny  of  the  skin  usually 
reveals  the  presence  of  small,  abortive  vesicles,  which  may  be 
almost  obscured  by  the  purplish  ecchymoses  upon  which  they 
may  be  situated.  These  are  most  apt  to  be  found  upon  the 
forehead,  axillae,  groins,  or  wrists.     The  vesicles,  which  are  of 


SMALL-POX  443 

a  plum-colored  or  leaden-gray  tint,  never  develop  to  any  extent, 
but  remain  perfectly  flat.  As  the  disease  progresses  the  dis- 
coloration of  the  skin  deepens  on  all  parts  of  the  body,  giving 
to  the  integument  a  deep  indigo  hue  which  at  times  almost 
approaches  black.  In  such  cases  it  is  difficult  to  say,  judging 
from  the  skin  alone,  that  the  patient  is  not  of  African  origin. 
Hence  this  form  of  the  disease  has  been  known  as  black  small- 
pox, or  variola  nigra. 

In  this,  as  in  other  types  of  variola,  the  pharynx  and  upper 
part  of  the  respiratory  passages  participate  in  the  eruption. 
Purplish  spots  may  be  seen  upon  the  gums,  palate,  tongue, 
and  buccal  surfaces,  but  the  general  mucous  membrane  is 
usually  pale.  Hemorrhages  are  quite  certain  to  occur  from 
the  nose,  bronchial  mucous  membrane,  kidneys,  rectum,  and 
uterus.  Vomiting  of  blood  occurs  in  quite  a  large  percentage 
of  cases,  and  bloody  stools  are  by  no  means  infrequent.  Indeed, 
blood  may  issue  from  any  or  all  of  the  mucous  surfaces  of  the 
body. 

The  course  of  this  type  of  small-pox  is  extremely  rapid. 
Death  usually  takes  place  from  the  third  to  the  sixth  day 
of  the  eruption,  commonly  as  a  result  of  sudden  heart 
failure. 

Variola  Pustulosa  Hemorrhagica. — Hemorrhagic  extra- 
vasation into  th?  skin  may  develop  at  any  time  during  the 
course  of  the  variolous  exanthem.  Various  types  of  hemor- 
rhagic small- pox  may  exist,  intermediate  between  variolous 
purpura  and  the  pustular  hemorrhagic  form.  Hemic  effusion 
may  take  place  during  the  papular  stage  of  the  disease,  and 
may  occur  in  the  papules  themselves  or  in  the  intervening  areas 
of  skin.  Or  the  cutaneous  hemorrhage  may  first  appear  during 
the  period  of  vesiculation.  In  this  case  the  vesicles,  instead 
of  containing  clear  serum,  fill  with  a  sanguinolent  fluid.  In 
other  cases  the  extravasation  of  blood  may  be  delayed  until 
the  pustular  stage  is  reached.  The  later  the  hemorrhage  is 
postponed,  the  more  conspicuous  are  the  variolous  lesions. 
The  earlier  it  develops,  the  more  will  the  true  small-pox  erup- 
tion be  suppressed.  The  amount  of  swelling  and  edema  is 
proportionate  to  the  extent  and  development  of  the  small-pox 
exanthem.  When  petechia  and  ecchymoses  develop  early, 
the  skin  has  a  peculiar  livid  appearance  and  there  is  not  much 
swelling.     Scattered    here  and  there  between  the  flat,  poorly 


444  DISEASES  OF  THE  SKIN 

formed   vesicles  are   seen   non-elevated,   pea-sized  or  larger, 
bluish,  ecchymotic  spots. 

The  hemorrhagic  condition  of  the  pustules  may  be  limited 
to  certain  localities,  or  it  may  extend  over  the  entire  body. 
Inspection  of  the  legs  will  often  afford  the  first  evidence  of  this 
malignant  tendency.  During  the  papular  or  vesicular  stage 
it  will  be  noted  that  some  of  the  lesions  upon  the  lower  extremi- 
ties are  surrounded  by  a  halo  of  the  tint  of  dilute  claret  wine. 
At  a  later  period  scattered  pustules  in  this  region  will  be  seen 
to  have  centers  of  the  color  of  indigo  blue.  By  degrees  others 
will  take  the  same  appearance,  and  the  color  gradually  deepens 
until  at  last,  in  severe  cases, 
the  pustules  on  all  parts  of 
the  body  become  distinctly 
hemorrhagic. 

Pustular  hemorrhagic 
small-pox  is  more  apt  to 
develop  in  aged  and  debili- 
tated subjects,  in  pregnant 
women,  and  in  those  ad- 
dicted to  the  free  use  of  al- 
cohol. 

The  prognosis  in  less 
marked  hemorrhagic  cases 
depends  somewhat  upon  the 
character  of  the  prevailing 
type  of  the  disease.  Modi- 
fied eruptions  associated 
with  hemorrhage  might  with 
propriety  be  termed  hemor- 
rhagic varioloid. 
Exceptionally  Mild  Small-pox. — An  extremely  mild  form 
of  small-pox  has  been  prevalent  In  different  sections  of  the 
United  States  during  various  periods  since  1898.  The  initial 
illness  and  the  succeeding  eruption  are  both  much  milder  and 
less  protracted  than  in  ordinary  smallpox.  Even  in  unvae- 
cinated  subjects,  the  eruption  is  often  scant,  and  when  it  is 
more  copious,  the  period  of  evolution  and  involution  is  abridged. 
Owing  to  the  remarkable  mild  character  of  the  disease,  con- 
troversies as  to  the  diagnosis  have  arisen :  the  affection  lias  been 
confounded  with  chicken-pox,  and  bv  others  has  been  regarded 


berg). 


SMALL-POX 


445 


as  a  form  of  impetigo  contagiosa,  or  as  a  hitherto  undescribed 
cutaneous  disease. 

Varioloid  (Variola  Benigna;  Variola  Modiflcata;  Modi- 
fied or  Mitigated  Small-pox). — The  term  varioloid,  from  an 


V 


FiE.   10;.— Small -po* — extremely  mild;  lesioi 


etymologic  point  of  view,  would  indicate  a  disease  merely  bear- 
ing a  resemblance  to  variola.  The  impression  thus  conveyed  is, 
Of  course,  a  false  one,  for  varioloid  is  true  small-pox  in  a  modi- 


446  DISEASES  OP  THE  SKIN 

fied  form.  Phis  is  evident  from  the  fact  that  the  infection 
arising  from  this  milder  form  of  the  disease  gives  rise  to  variola 
vera  in  unprotected  persons.  Since  the  introduction  of  vac- 
cination, varioloid  has  become  much  more  frequent  than  in 
former  times. 

The  term  varioloid  may  be  reserved  for  vaccinated  cases  in 
which  the  eruption  is  markedly  abridged  in  its  course,  and  in 
which  there  is  but  little,  if  any,  secondary  rise  of  temperature. 
In  many  cases  the  invasive  manifestations  in  varioloid  are 
extremely  mild,  and  will  warrant  a  prediction  of  a  sparse 
exanthem.  The  average  case  of  varioloid  is  attended  with 
fever  only  during  the  initial  stage. 

The  extent  of  the  eruption  varies  greatly  in  different  cases  of 
varioloid.  I  have  seen  several  undoubted  cases  with  but  a 
single  lesion  upon  the  skin.  The  protection  may  be  almost, 
but  not  quite,  complete,  and  the  patient  may  pass  through  the 
initial  stage,  but  remain  free  of  eruption.  To  this  most  benig- 
nant form  of  small-pox  the  term  variola  sine  exanthemate,  or 
variola  sine  variolis,  has  been  given. 

There  is  nothing  peculiar  about  the  eruption  of  varioloid 
except  that  it  is  milder  in  its  course,  of  shorter  duration  than 
that  of  variola,  and  exhibits  various  irregularities.  In  the 
milder  forms  the  lesions  do  not  pass  through  all  the  stages, 
but  become  abortive  and  dry  up  at  an  early  period.  In  the 
severer  forms  the  eruption,  although  confluent  or  scmiconfluent, 
pursues  a  distinctly  modified  course.  In  such  cases  the  lesions 
do  not  penetrate  into  the  deeper  layers  of  the  skin,  but  remain 
limited  to  the  epidermis.  Hence  the  course  of  eruption  is 
shorter,  the  process  of  suppuration  is  abridged,  and  the  lesions 
desiccate  early;  in  addition,  the  crusts  are  rapidly  thrown  off, 
and  there  is  little  or  no  scarring. 

When  the  modification  of  the  eruption  is  still  greater,  it  is 
not  unusual  to  find  that  the  lesions  develop  into  large,  solid, 
conical  papules,  having  at  their  apices  small  vesicles  which 
rapidly  desiccate  and  form  thin  crusts.  After  the  crusts  have 
fallen  off,  the  lesions  remain  tuberculated  for  some  time.  Some- 
times these  tubercles  present  the  appearance  of  warty  excres- 
censes;  to  this  form  of  the  eruption  the  name  variola  verrucosa, 
or  wart- pox,  has  been  given.  This  modification  of  the  small- 
pox eruption  is  seen  usually  upon  the  face.  In  the  course  of 
time  the  elevations  flatten  down  and  disappear,  as  a  rule, 
without  leaving  scars.     Another  somewhat  common  form  of 


SMALL- POX  447 

the  eruption  is  that  known  as  variola  miliaris;  in  this  variety 
the  majority  of  the  vesicles  are  very  small— not  larger  than 
a  millet-seed;  without  progressing  further  they  turn  yellow, 
desiccate,  and  disappear.  Not  rarely  a  few  tolerably  well- 
developed  pustules  are  found  mixed  with  these  smaller  lesions. 
Variola  corymbosa  is  a  designation  applied  to  those  erup- 
tions which  exhibit  grouping  of  rather  flat  pustules  in  the  form 
of  corymbs  or  clusters.     It  is  alleged  by  some  writers  that  the 


Fig.  K>8.— So-called      _. 

has  been  shed  from  Ihe  apex;  favorable  form}  delations  ultimately  disappear  (Welcb 
and  Schamberg). 


mortality -rate  is  particularly  high  in  cases  showing  this  char- 
acter of  eruption. 

The  contents  of  abortive  vesicles  and  pustules  frequently 
desiccate  without  rupturing,  producing  hard,  horny,  convex, 
shining,  reddish-brown  crusts.  This  form  is  designated  variola 
cornea,  or  horn-pox.  The  reddish -brown,  homy  crusts  are 
quite  characteristic  of  small-pox.  They  are  particularly 
common  in  varioloid,  and  often  materially  aid  one  in  the  diag- 
nosis of  doubtful  cases.     The  horny  crusts  are  seen  most  fre- 


448  DISEASES  OF  THE   SKIN 

quently  on  the  hands  and  forearms,  but  may  also  be  noticed 
at  times  on  the  face. 

In  the  form  of  the  eruption  termed  variola  sUiquosa  there  is 
a  retrogression  of  the  pustules,  with  absorption  of  the  contents 
and  the  production  of  epidermal  cavities  filled  with  air.  In 
addition  to  the  above  irregular  form  of  the  small-pox  eruption 
writers  have  described  other  varieties,  such  as  variola  conica, 
crystallina,  emphysematica,  fimbrwta,  lymphatica,  pemphigosa, 
pustular is ',  rosea,  morbillosa,  carbunculosa,  globulosa,  etc. 
These  various  designations  do  not  indicate  separate  varieties 
of  the  disease,  but  merely  different  appearances,  produced  by 
more  or  less  trifling  changes  in  the  lesions. 

Cutaneous  Complications  and  Sequelae. — Boils  constitute 
the  most  frequent  complicating  disorder  met  with  in  small-pox. 
But  few  patients  pass  through  an  attack  of  variola  vera  with- 
out suffering  from  numerous  furuncles.  The  subjects  of  con- 
fluent small-pox  suffer  more  severely  than  those  who  have  a 
lighter  form  of  the  disease.  Even  patients  with  varioloid  are 
not  always  exempt  from  this  troublesome  complication.  The 
furuncles  develop  most  commonly  after  the  stage  of  decrusta- 
tion,  about  the  twentieth  or  twenty-fifth  day  of  the  disease. 

Subcutaneous  Abscesses. — Subcutaneous  abscesses  are 
commonly  associated  with  the  more  superficial  furuncular 
inflammations.  These  may  occur  upon  any  part  of  the  body 
surface,  but  involve  with  predilection  the  scalp,  face,  arms, 
and  legs.  They  are  often  preceded  by  a  cellulitis  or  a  phlegmo- 
nous inflammation  of  the  skin  and  subcutaneous  tissue. 

Carbuncles  occasionally  occur  during  convalescence  from 
small-pox. 

Erysipelas. — This  complication,  when  it  develops,  usually 
appears  at  the  end  of  the  second  or  third  week  of  the  disease. 
The  face  is  the  region  most  often  affected,  although  the  process 
mav  attack  the  extremities  or  trunk.  At  times  a  diffuse 
erysipelatoid  inflammation  of  the  skin  occurs,  without  the  actual 
development  of  a  true  erysipelas. 

Bed-sores. — Bed-sores  occasionally  occur  in  the  course  of 
small-pox,  as  they  do  in  other  protracted  diseases.  They  are 
far  less  frequent  at  the  present  time  than  in  earlier  days.  They 
result  from  pressure,  malnutrition,  and  uncleanliness,  and  may 
usually  be  avoided  by  careful  nursing. 

Gangrene. — At  times,  during  the  pustular  stage  of  small-pox, 
the  swelling  and  inflammation  of  the  skin  may  be  so  great  as 


SMALL-POX  449 

to  produce  multiple  areas  of  necrosis.  Sloughing  of  the  skin 
may  also  result  from  undermining  of  the  integument  by  sub- 
cutaneous abscesses. 

Apart  from  these  losses  of  cutaneous  tissue,  spontaneous 
gangrene  of  the  skin  occasionally  occurs  during  the  course  of 
variola.  The  genitalia  are  the  parts  most  commonly  involved. 
Gangrene  of  the  scrotum  is  a  complication  of  great  gravity,  for 
most  patients  thus  attacked  succumb  to  the  disease. 

Gangrene  of  the  skin  is  not  limited  to  the  regions  above 
mentioned.  It  may  attack  almost  any  portion  of  the  cutaneous 
surface.  During  a  recent  epidemic  I  observed  three  cases  of 
gangrene  of  the  scrotum  and  five  cases  in  which  gangrene 
occurred  upon  various  portions  of  the  thigh.  In  some  of  the 
latter  cases  extensive  destruction  of  the  cutaneous,  subcuta- 
neous, and  muscular  tissues  occurred,  the  sphacelated  areas 
attaining  at  times  the  size  of  the  palm  of  the  hand.  In  four 
of  the  five  cases  recovery  took  place  after  a  tedious  convales- 
cence. It  may  be  of  interest  to  note  that  most,  if  not  all,  of 
these  patients  suffered  from  more  or  less  impetigo  variolosa. 

Etiology. — Small-pox  is  one  of  the  most  contagious  of  all 
disorders,  and  there  is  an  almost  universal  susceptibility  to  the 
infection.  Age,  sex,  and  condition  of  life  do  not  materially 
influence  liability  to  attack.  The  prevalence  of  the  disease  is 
considerably  influenced  by  season,  small-pox  being  in  the 
temperate  zones  much  more  common  in  the  cold  months  of 
the  year. 

Small-pox  is  infectious  in  all  stages  characterized  by  symp- 
toms; the  infectivity  is  least  during  the  initial  stage,  and  great- 
est during  the  suppurative  and  early  desiccative  periods.  The 
disease  is  usually  contracted  by  more  or  less  close  contact  with 
a  person  suffering  from  the  disease,  but  it  may  be  transmitted 
through  infected  garments  or  other  articles.  The  contagion 
may  be  carried  a  considerable  distance  through  the  air  from 
large  small -pox  hospitals. 

Bacteriology. — There  can  be  no  doubt  that  small-pox  is 
the  result  of  the  introduction  into  the  body  of  a  specific  micro- 
parasite.  The  causative  organism  must  be  present  in  the  cuta- 
neous lesions,  for  the  disease  may  be  readily  inoculated.  The 
fluid  of  early  variolous  1*«ions  is  sterile  on  ordinary  media. 
After  the  se™»«**fc ■■"■  "*"  ^unds  in  microorganisms, 

chiefly  stu  ns  have  been  described 

in  conn*  te  can  be  excluded 


45°  DISEASES  OP  THE  SKIN 

as  bearing  any  etiologic  relationship.  Great  interest  attaches 
to  the  researches  of  Guarnieri,  and  more  recently  to  those  of 
Councilman  and  his  associates,  upon  the  presence  of  an  alleged 
protozoon,  the  cytoryctes  variolae,  in  the  lesions  of  small-pox 
and  vaccinia.  This  is  regarded  by  these  and  other  workers  as 
the  parasite  causing  the  disease.  Certain  other  investigators 
believe  the  bodies  to  be  degeneration  products.  In  view  of 
our  imperfect  knowledge  of  protozoology  the  parasitic  nature 
of  these  bodies  can,  at  the  present  time,  neither  be  positively 
proved  nor  refuted.  • 

Pathology. — The  Histopathology  of  the  Pock. — The  micro- 
scopic structure  of  variolous  lesions  has  been  studied  by  Baren- 
sprung,  Auspitz  and  Basch,  Ebstein,  Rindfleisch,  Unna,  Weigert» 
Touton,  Renaut,  Leloir,  Buri,  and  others. 

Unna  has  carefully  studied  the  structural  changes  in  the 
skin,  employing  the  most  modern  histologic  technic 

According  to  Unna,  the  development  of  the  variolous  vesicle 
is  the  result  of  certain  peculiar  degenerations  of  the  protoplasm 
of  the  epithelial  cells.  The  main  features  which  differentiate 
the  vesicle  formation  in  small-pox  from  that  in  chicken-pox 
are  the  slowness  of  growth  and  the  prompt  addition  of  sup- 
puration to  the  epithelial  degeneration. 

The  changes  in  the  protoplasm  of  the  cells  of  the  mucous 
layers  of  the  epidermis  are  of  two  chief  varieties.  These  have 
been  designated  by  Unna  reticulating  and  ballooning  colliqua- 
tion  (softening).  Both  are  special  forms  of  fibrinoid  degener- 
ation. 

Reticulating  colliquation  occurs  as  follows:  As  a  result  of 
the  poison  of  the  disease,  the  protoplasm  of  the  cells  becomes 
edematous  and  undergoes  partial  or  complete  liquefaction, 
thus  converting  the  cell-body  into  a  large  cavity.  When  the 
liquefaction  of  the  cells  is  partial,  protoplasmic  trabeculae  form, 
which  coagulate  into  a  network  often  radially  arranged,  and 
hold  the  nucleus  and  cell-mantle  together. 

The  name  "reticulating"  colliquation  is  given  to  this  degen- 
eration because  of  the  net-like  character  of  the  structure. 

In  the  second  form  of  fibrinoid  metamorphosis— that  desig- 
nated ballooning  colliquation — the  whole  protoplasm  of  the 
cell  swells  up  and  becomes  cloudy  and  opaque.  Most  of  the 
cells  have  the  form  of  hollow  spheres  or  balloons,  the  predomi- 
nance of  which  gives  rise  to  the  name  "ballooning  colliquation." 

The  reticulating  degeneration  mainly  attacks  the  older  cells,. 


SMALL-POX  45" 

or  those  in  the  upper  strata  of  the  Malpighian  layer,  and  the 
ballooning  degeneration  the  younger  cells,  or  those  in  the  lower 
strata. 

Exceptionally  a  sort  of  umbilication  may  result  from  the 
accidental  piercing  of  the  center  of  the  pock  by  a  hair-follicle, 
the  ramified  neck  of  which  limits  the  swelling  of  the  prickle- 
cells.  The  characteristic  depression  in  the  center  of  the  vesicle 
is  due,  however,  to  another  cause.  It  is  the  result  of  the  retic- 
ulating degeneration  and  edematous  swelling  of  the  cells. 
These  occur  chiefly  at  the  periphery,  whereas  the  ballooning 
degeneration,  which  occurs  slowly  and  gives  rise  to  less  swelling, 
takes  place  in  the  center.  The  umbilication  is,  therefore,  due 
rather  to  a  bulging  of  the  periphery  of  the  vesicle  than  to  a 
retraction  of  the  center. 

The  primary  pustulation  is  due  to  the  variolous  poison,  but 
prolonged  suppuration  must  be  ascribed  to  secondary  pyo- 
genic infection. 

Healing.— Even  before  the  contents  of  the  pustule  are  com- 
pletely dry,  a  thin  layer  of  epithelial  cells  lying  close  on  the 
connective  tissue  extends  from  all  sides  under  the  pustule. 

When  the  scab  is  thrown  off,  there  is  displayed  a  persistent, 
trough-like  depression.  Where  the  scab  does  not  to  any  great 
extent  depress  the  base  of  the  pock,  the  papillary  layer  is  not 
completely  flattened  out,  and  the  scar  is  not  so  deeply  exca- 
vated. 

The  pocks  upon  the  palms  of  the  hands  and  soles  of  the  feet 
develop  in  a  somewhat  different  manner  from  those  elsewhere. 
The  reticulating  and  ballooning  degenerations  are  only  imper- 
fectly seen  here. 

Stokes  believes  that  "the  primary  exudation  of  plasma- 
cells  has  not  been  sufficiently  emphasized  by  Unna.  These 
plasma-cells  are  probably  derived  in  part  from  proliferation 
of  the  endothelial  lining  of  the  lymph-spaces  and  blood-vessels. 
Very  early  there  is  increased  number  of  plasma-cells  in  the 
lymph-spaces  and  around  the  small  blood-vessels.  The  con- 
dition resembles  the  response  to  some  injury,  and  seems  to 
be  the  first  change  in  the  skin,  since  the  various  changes  in  the 
epithelial  cells  are  not  yet  present." 

Councilman  and  his  associates  have  carefully  studied  the 
pathology  of  variolous  lesions. 

In  tin.'  main.  Unna's  findings  are  confirmed,  but  some  new 
fact-  concerning  the  histology  of  tl 


45^  DISEASES  OP  THE   SKIN 


The  earliest  form  of  degeneration  is  said  to  take  place  in 
the  nuclei  of  the  cells  of  the  rete  mucosum.  They  become 
swollen,  more  vesicular,  and  exhibit  increased  central  dumping 
of  the  chromatin.  In  the  lesions  leading  to  vesicular  formation 
there  is  a  reticular  degeneration  of  the  cytoplasm,  with  a  more 
advanced  degeneration  of  the  nucleus.  The  nuclei  may  lose 
their  form  and  become  irregular  and  shriveled,  assuming 
peculiar  shapes.  Advanced  forms. of  cytoplasmic  inclusions 
are  common  in  the  nuclear  spaces  and  in  vacuoles  in  the  pro- 
toplasm. 

A  later  form  of  degeneration,  the  ballooning  degeneration 
of  Unna,  is  regarded  as  a  hyaline  fibrinoid  degeneration. 

The  early  exudate  is  clear,  and  contains  no  admixture  of 
cells.  Indeed,  a  conspicuous  feature  of  the  small-pox  process 
everywhere  is  the  paucity  of  cells  in  the  exudate.  The  cells 
appear  only  at  a  late  stage  of  the  process,  and  are  much  less 
than  in  other  degenerations  and  exudations  due  to  bacterial 
infection. 

Councilman,  Magrath,  and  Brinckerhoff  believe  that  Weigert's 
explanation  of  the  cause  of  the  umbilication  is  correct  in  many 
instances.  Weigert  regarded  the  umbilication  to  be  due  to 
the  diphtheroid  degeneration  of  the  epithelium  of  the  center 
of  the  vesicle,  thus  preventing  the  distention  of  the  center  by 
the  exudate;  he  believed,  however,  that  the  hair-follicles  and 
sweat-ducts  also  played  a  part  in  its  formation. 

The  Diagnosis  of  Small-pox. — The  detection  of  small-pox 
in  the  pustular  stage,  particularly  in  well-marked  eruptions, 
is  a  facile  matter,  even  for  the  merest  tyro  in  medicine.  The 
picture  of  a  profuse  pustular  variola  can  scarcely  be  mistaken 
for  anything  else. 

It  is  especially  the  mild  and  modified  forms  of  small-pox 
that  present  difficulties  in  diagnosis.  The  degree  of  protection 
in  varioloid,  i.  e.,  in  small-pox  modified  by  vaccination,  may  be 
so  great  that  the  eruption  may  consist  of  but  a  few  papules 
or,  indeed,  the  eruption  may  be  absent  altogether,  constitut- 
ing a  variola  sine  exanthemate.  The  diagnosis  in  such  cases 
would,  of  course,  present  perplexities.  It  is  a  matter  of  con- 
siderable importance  to  ascertain  whether  variola  is  prevailing 
in  a  community,  and  whether  the  patient  has  been  exposed  to 
the  infection. 

The  degree  to  which  the  patient  is  protected  by  vaccination 
or  previous  attack  of  small-pox  should  always  be  investigated. 


SMALL-POX  453 

The  presence  of  a  comparatively  recent  vaccine  scar  or  pits  of 
a  former  attack  would  constitute  strong  presumptive  evidence 
against  the  existence  of  small-pox  in  the  individual. 

The  occurrence  of  a  characteristic  initial  illness  preceding, 
by  several  days,  the  outbreak  of  an  eruption,  is  of  important 
diagnostic  value.  The  diagnosis  cannot  be  positively  made 
before  the  appearance  of  the  eruption,  unless  there  has  been 
undoubted  exposure  to  the  disease. 

The  initial  illness  may  be  confounded  with  influenza,  typhus 
or  typhoid  fever,  meningitis,  acute  gastritis,  etc.  After  the 
appearance  of  the  eruption,  the  diseases  which  may  be  brought 
into  diagnostic  conflict  are  measles,  scarlet  fever,  chicken-pox, 
roseola  vaccinosa,  syphilis,  acne,  iodid  and  bromid  eruptions, 
glanders,  eczema,  etc. 

Measles. — Measles  may  be  confounded  both  with  the  mor- 
billiform prodromal  rash  and  with  the  beginning  true  eruption 
of  variola. 

That  measles  may  bear  a  strong  resemblance  to  small-pox 
is  evidenced  by  the  fact  that  in  epidemics  of  variola  cases  of 
measles  are  not  infrequently  sent  to  the  small-pox  hospitals 
under  erroneous  diagnoses.  It  is  the  confluent  forms  of  variola 
which,  in  the  early  eruptive  stage,  resemble  measles  most,  for 
in  this  type  of  the  disease  the  face  is  often  considerably  suffused. 

The  diagnosis  can,  in  the  vast  majority  of  cases,  be  deter- 
mined by  attention  to  the  following  points: 

The  constitutional  symptoms  preceding  the  eruption  in 
small-pox  are  usually  more  severe  (temperature,  104 °  to  105  ° 
F.),  and  are  commonly,  though  not  always,  accompanied  by 
pronounced  backache.  The  temperature,  moreover,  falls  a 
few  days  after  the  appearance  of  the  eruption,  while  the  fever 
in  measles  at  this  time  continues  high.  The  catarrhal  symp- 
toms affecting  the  eyes  and  the  respiratory  passages  and  the 
buccal  eruption,  which  are  so  constant  in  measles,  are  absent 
in  small-pox,  at  least  during  the  prodromal  stage.  The  erup- 
tion in  measles  consists  of  large  maculopapules  which  are  soft 
and  velvety  to  the  touch,  while  the  papules  in  small-pox  are 
smaller  and  have  a  firm  and  shotty  feel.  The  sweep  of  an 
experienced  hand  over  the  skin  will  often  suffice  to  differentiate 
the  two  diseases.  Where  there  is  doubt,  twenty-four  hours' 
delay  will  dispel  all  uncertainty,  for  by  this  time  the  eruption 
of  measles  will  have  become  flatter  and  more  diffuse  and  the 
papules  of  small-pox  firmer  and  more  distinctly  elevated. 


454  niSKASRS  OP  THE  SKIN 

Scarlet  Fever. — The  peculiar  distribution  and  fleeting  char- 
acter of  the  scarlatiniform  prodromal  rash  will  enable  one  to 
distinguish  it  from  scarlet  fever. 

Scarlet  fever  may,  however,  be  closely  simulated  by  that 
form  of  hemorrhagic  small-pox  in  which  the  entire  cutaneous 
surface  becomes  the  seat  of  a  diffuse,  dusky-red  rash,  especially 
well  marked  in  the  crural  triangle.  This  form  of  purpura 
variolosa  is,  however,  usually  preceded  by  excruciating  back- 
ache. If  the  patient  be  watched  for  a  short  time,  a  few  ill- 
defined  vesicles  will  usually  make  their  appearance.  The 
development  of  hemorrhages  would  not  in  itself  be  conclusive, 
as  these  might  occur  in  hemorrhagic  scarlet  fever,  except  that 
hemorrhage  beneath  the  conjunctiva  would  indicate  the  exist- 
ence of  small-pox.  The  early  occurrence  of  sore  throat  would 
point  toward  the  scarlatinal  nature  of  the  disease. 

Chicken-pox. — The  differential  diagnosis  between  small-pox 
and  chicken-pox  will  be  considered  under  the  latter  disease. 

Syphilis. — It  may  at  first  seem  strange  that  syphilis  and  small- 
pox should  ever  be  confounded.  Upon  reflection,  however, 
it  will  be  seen  that  the  two  diseases  have  many  phenomena  in 
common.  Thev  are  both  infectious  diseases,  due,  we  mav 
assume,  to  the  invasion  of  the  blood  by  a  microorganism.  Each 
has  a  period  of  incubation,  at  the  end  of  which  there  develop 
certain  general  manifestations  accompanied  by  an  exanthem 
and  an  enanthem.  The  resemblance  may  be  still  further  accen- 
tuated by  the  fact  that  the  varioliform  syphilid  is  not  rarely 
associated  with,  and  even  preceded  by,  fever  and  general  aches 
and  pains.  It  is  particularly  the  pustular  syphiloderm  which  is 
apt  to  be  confounded  with  small-pox.  The  eruption  may  at 
times  appear  rather  suddenly  and  pass  through  the  stages  of 
papule,  vesicle,  and  pustule  in  a  surprisingly  brief  period  of 
time.  The  lesions  may  be  quite  firm  to  the  touch,  and  in  other 
respects  closely  simulate  those  seen  in  small-pox. 

In  syphilis  one  can  frequently  obtain  — (i)  A  history  of  infec- 
tion and  a  description  of  the  initial  lesion.  Indeed,  the  chancre 
or  the  remains  mav  still  be  detected.  Not  uncommonlv  there 
are  present  associated  evidences  of  syphilis,  such  as  mucous 
patches,  flat  condylomata,  ulceration  of  the  tonsils,  alopecia, 
etc.  The  varioliform  syphilid  may  develop  after  the  disap- 
pearance of  one  of  the  earlier  syphilitic  eruptions. 

(2)  The  onset  of  the  two  diseases  is,  as  a  rule,  quite  different. 
The  syphilitic  subject  will  usually  give  a  history  of  having  felt 


SMALL-POX  455 

weak  and  debilitated  for  some  weeks.  If  fever  precedes  the 
eruption,  it  is  ordinarily  not  very  high,  and  is  not  accompanied 
by  severe  prostration.  When  the  eruption  appears,  the  patient 
usually  calls  upon  the  physician  at  his  office  or  at  the  hospital. 
We  do  not  note  that  sudden  illness  and  prostration  which  pre- 
cede unmodified  small-pox.  In  the  latter  disease  the  patient, 
instead  of  calling  upon  the  physician,  sends  for  him. 

It  must  be  remembered,  however,  that  in  varioloid  the  initial 
symptoms  may  be  mild  or,  in  rare  instances,  absent.  On  the 
other  hand,  in  rare  cases  syphilis  may  present  an  initial  illness 
which  strongly  counterfeits  that  of  small-pox. 

(3)  The  development  of  the  eruption  in  small-pox  is  rather 
sudden.  Ordinarily,  in  twenty-four  to  forty-eight  hours,  the 
full  complement  of  lesions  has  appeared.  In  syphilis  the  erup- 
tion may  continue  to  come  out  for  quite  a  number  of  days  in 
successive  crops.  It  must  be  admitted,  however,  that  in 
modified  small-pox  three  or  four  days  may  sometimes  elapse 
before  the  complete  appearance  of  the  exanthem. 

(4)  The  distribution  of  the  varioliform  syphilid  may  be  iden-. 
tical  with  that  observed  in  small-pox.  Frequently,  however, 
variations  are  noted.  The  pustular  syphilid  may  involve  the 
trunk  more  copiously  than  the  face ;  this  would  be  exceedingly 
rare  in  well-marked  small-pox.  The  dorsal  surfaces  of  the  wrists 
and  hands  are  nearly  always  involved  in  small-pox,  but  may 
escape  entirely  in  syphilis.  The  palms  of  the  hands  and  soles 
of  the  feet  are  always  involved  in  severe  small-pox ;  in  moderate 
eruptions  they  nearly  always  present  some  lesions,  and  in 
modified  small-pox  they  may  or  may  not  escape  completely. 
The  pustular  syphilid,  on  the  contrary,  attacks  the  palmar 
and  plantar  surfaces  with  the  greatest  rarity. 

(5)  The  character  of  tlie  eruption  in  syphilis  and  small-pox 
may,  in  the  beginning,  be  so  nearly  identical  as  to  make  the 
diagnosis  from  the  eruption  alone  quite  impossible.  It  will 
be  noted,  however,  that  the  efflorescence  of  small-pox  presents 
a  much  greater  uniformity  in  the  character  and  development 
of  the  lesions  over  the  body  than  does  syphilis.  Syphilis  is 
characterized  by  an  essentially  multiform  eruption;  it  is  not 
uncommon  to  find  small  pustules,  large  pustules,  and  papules 
interspersed,  and  these  in  varying  stages  of  evolution  and 
involution. 

The  vesicles  and  pustules  of  syphilis  are  usually  conical, 
and  involve  merely  the  summits  of  the  elevations;  they  never 


456  DISBASBS  O*  THE  SEN  ' 

become  full  and  globular,  and  fill  the  entire  lesion,  as  do  those 
of  small-pox.  Beneath  the  syphilitic  crusts  considerable  ulcer- 
ation not  uncommonly  occurs.  According  as  this  is  slight  or 
severe  there  will  be  seen,  upon  detachment  of  the  crusts,  a  small, 
reddish-brown,  pigmented  stain  or  an  excavated  ulcer.  The 
latter  heals  with  the  production  of  a  depressed  scar. 

(6)  The  course  of  the  syphilitic  eruption  is  relatively  chronic, 
compared  with  that  of  small-pox.  The  lesions  of  variola 
undergo  a  striking  change  in  a  few  days.  The  syphilitic 
efflorescence  is  indolent,  and  presents,  as  a  rule,  no  decided 
alteration  of  appearance  within  this  period  or  time.  By  the 
sixth  or  seventh  day  in  small-pox  the  lesions  develop  into 
those  large,  full,  round,  .hemispheric  pustules  which  are  so 
characteristic  of  the  disease. 

Finally,  to  the  physician  who  has  seen  much  small-pox,  there 
is  a  something  in  the  picture — an  impression  given  by  the 
ensemble — which,  while  not  definable  in  language,  is,  neverthe- 
less, of  subtle  aid  in  the  diagnosis. 

Roseola  Vaccinosa. — Vaccination  with  animal  virus  sometimes 
causes  an  erythematous  or  rubeoloid  rash,  known  as  roseola 
vaccinosa,  to  appear  from  the  eighth  to  the  twelfth  day  of  the 
vaccine  disease.  I  have  on  several  occasions  seen  this  rash 
confounded  with  the  eruption  of  variola,  especially  during 
epidemic  visitations  of  the  disease.  The  distinguishing  features 
are  that  it  accompanies  vaccinia,  that  it  is  not  preceded  by  a 
very  high  temperature,  and  that  it  consists  of  macules  rather 
than  papules. 

Acne.— Mild  cases  of  modified  small-pox.  exhibiting  but  a 
few  papulopustules  about  tlie  face,  may  bear  a  close  resemblance 
to  acne.  The  history  of  exposure,  the  existence  of  an  initial 
Stage,  and  the  progressive  evolution  of  the  lesions  will  speak 
for  the  variolous  nature  of  the  eruption,  while  the  presence  of 
blackheads,  a  history  of  previous  outbreaks  in  the  individual, 
and  the  absence  of  preceding  illness  will  decide  in  favor  of  acne. 

f>r«i;  Em(>tiens. — Drug  eruptions,  particularly  those  result- 
ing from  the  ingestion  of  the  iodids  and  bromids.  may  simulate 
the  exanthem  of  smallpox.  The  history  and  absence  of  an 
invasive  stage  will  usually  suffice  to  make  the  diagnosis  clear. 
I  have  seen  some  bromid  eruptions  which  closely  resembled  the 
eruption  of  small  pox. 

(■V.iM.i.T*. — Glanders  in  an  early  sta^e  may  be  mistaken  for 
small-pox.     The   febrile   symptoms  are   not    unlike    those   of 


SMAL.L-POX 


457 


variola,  and  the  su  be  pi  dermic  abscesses,  when  small,  feel  like 
hard  infiltrations  in  the  skin.  In  this  disease,  however,  there 
are,  in  addition,  deep-seated  abscesses,  infiltration  of  the  areolar 
tissue,  rapid  ulceration,  and  at  times  gangrene.  The  disease 
is  rare,  and  the  patients  are  usually  stablemen. 

Eczema. — Severe  crusted  eczemas  of  the  face  may  bear  a 
rough  resemblance  to  confluent  small-pox  during  the  desic- 
cativc  stage.     I  have  known  physicians  experienced  in  small- 


Palteison). 


pox  to  make  this  error  through  a  hasty  and  superficial  examina- 
tion of  the  patient.  Inspection  of  the  trunk  and  extremities 
will  make  the  diagnosis  clear. 

During  epidemics  the  anticipatory  attitude  of  the  physician's 
mind  will  often  lead  him  to  suspect  and  diagnose  as  variola  dis- 
eases which  bear  only  a  superficial  or  remote  resemblance  to  it. 
Thus,  patients  with  febrile  herpes,  herpes  zoster,  erythema 
multiforme,  and  other  skin  diseases  have  at  such  times  been 
sent  to  a  small-pox  hospital  as  cases  of  variola.     Contrariwise, 


458  DISEASES  Of  THE  SKIN 

in  the  absence  of  an  epidemic,  mild  cases  of  small-pox  are  very 
likely  to  be  overlooked. 

Whenever  the  diagnosis  between  small-pox  and  a  disease 
simulating  it  is  in  doubt,  observation  of  the  progress  of  the 
eruption  for  a  period  of  twenty-four  to  thirty-six  hours  will 
usually  make  clear  the  nature  of  the  disease. 

Prognosis. — The  prognosis  of  small-pox  is  influenced  by  the 
vaccinal  condition  of  the  patient,  the  severity  of  the  prevailing 
form  of  smallpox,  the  age  of  the  patient,  and  the  extent  and 
depth  of  the  cutaneous  lesions.  Of  all  the  factors  bearing  upon 
the  outcome  of  the  disease,  the  vaccinal  condition  is  the  most 
important. 

Treatment. — The  preventive  treatment  of  small-pox  out- 
weighs all  other  considerations  in  the  therapeutics  of  this  dis- 
ease. Proper  vaccination  and  revaccination  are  all-sufficient 
safeguards  against  this  dread  malady.  After  the  symptoms 
have  once  developed,  the  purpose  of  treatment  is  to  keep  the 
patient  alive  until  the  disease  has  run  its  course.  The  general 
treatment  is  not  unlike  that  applicable  to  any  other  acute 
infectious  process — consisting  of  a  nutritious  and  easily  assimil- 
able diet,  stimulants,  and  symptomatic  remedies. 

Local  Treatment. — The  topical  use  of  antiseptics  in  small- 
pox has  been  advised  and  employed  for  many  years.  Mercury, 
in  the  form  of  corrosive  sublimate  solution  or  an  ointment  of 
some  salt  of  mercury,  boric-acid  solution,  permanganate  of 
potash  solution,  iodoform,  carbolic  acid,  eucalyptus,  thymol, 
salicylates,  and  a  host  of  other  remedies  have  been  used  with- 
out striking  results. 

The  object  of  local  treatment  is  to  assuage  the  pain,  burning, 
and  itching,  to  correct  the  offensive  odor,  to  guard  against 
septicemia,  and  to  lessen  or  prevent  scarring. 

Lint  masks  soaked  in  ice-water  and  glycerin  greatly  relieve 
tlie  itching  and  burning.  Dusting- powders  containing  5  per 
cent,  of  iodoform  or  15  per  cent,  of  aristol  are  useful  in  abating 
the  offensive  stench. 

To  guard  against  septicemia  prolonged  warm  baths  may  be 
given  during  the  stage  of  suppuration  and  desiccation ;  the  pus- 
tules become  macerated  and  may  be  evacuated  by  rubbing 
the  skin  with  gauze.  These  baths  serve  also  to  lower  the 
temperature  and  improve  the  nervous  symptoms.  Some- 
times it  is  advantageous  to  give  antiseptic  baths,  the  water 
containing  bichlorid  of  mercury  (1  :  10,000  to   1  :  20,000)  or 


SMALL-POX  459 

creolin  in  the  strength  of  i  :  50a.  When  it  is  inconvenient  or 
impossible  to  employ  baths,  much  good  will  often  be  derived 
from  opening  and  evacuating  the  pustules  on  the  trunk  and 
extremities  and  sponging  the  bases  with  absorbent  cotton  wet 
in  a  1  :  5000  bichlorid  of  mercury  solution. 

For  extensive  impetigo  variolosa  a  bichlorid  bath  is  given, 
followed  by  dusting  of  the  body  with: 

Iodoform 3j ; 

Talci 51V.— M 

Or— 

Aristol xiij ; 

Talci §iv.— M. 

Prevention  0}  .Scarring.— Various  methods  have  been  employed 
to  prevent  pitting  in  small-pox,  but  none  has  stood  the  test  of 
experience.     It  muet  be  remembered  that  many  patients  will 


hambcrg). 


escape  scarring  no  matter  what  treatment  is  employed.  In 
children  the  lesions  are  more  superficially  located,  as  a  rule, 
than  in  adults.  In  a  patient  once  vaccinated  the  chances  of 
recoverv  without  pitting  are  also  good. 

In  order  that  so-called  ectrotic  remedies  should  be  regarded 
as  meriting  the  claims  made  for  them,  they  should  prevent 


ere  smali-pox   in  un  vaccina  ted  individuals.      In 
lall-pox,  pitting  is  as  great  and  as  much  to  be 
former  times.     Gregory,  the  great  English  small- 
-  •  rote:   "There  is  no  peculiar  method  which  can 

the  prevention  of  pits  and  scars.  .  .  .  The  appli- 
tle  cold-eream  to  the  hardened  scabs  is  all  that 
e      .        icnded." 

i...  &        pretty  much  all  the  vaunted  remedies  tried,  but 

ut  **,■      raging  results.     The  application  that  seemed  to 

,-iplish  trn,.  e  of  u><Jin.     The  pure  or  diluted 

ture  is  paitiu  iace  once  or  twice  a  day  according 

■  the  sensitiveness  ol  tne  skin.     About  the  eighth  or  tenth 

'  a  hard,  parchmenty  mask  is  formed,  which  begins  to  crack 

.1  peel  off,  at  which  time  a  weak  carbolized  vaselin  is  to  be 

jlied.     The  iodin  treatment  tends  to  shrink  the  pustules, 

hasten  decrustation,  to  destroy  the  offensive  odor,  and  to 

ae  extent  to  lessen  pitting,  although  in  severe  cases  it  will 

<  prevent  it.     The  liability  to  secondary  pyogenic  infection  of 

skin  is  obviated,  as  is  demonstrated  in  the  accompanying 

itograph. 

The  red-light  treatment  oj  small- pox,  based  upon  the  exclusion 
of  chemical  rays  of  light,  was  strongly  championed  by  the  late 
Niels  Pinsen,  of  Copenhagen.  I  concur  in  the  verdict  of 
Ricketts  and  Byles,  of  London,  who  say:  "We  cannot  agree 
that  the  treatment  has  any  of  the  merits  which  have  been 
claimed  for  it." 

VACCINATION  AND   CUTANEOUS  DISEASES 

The  following  classification  of  skin  diseases  associated  with 
vaccination  is  a  modification  of  that  formulated  by  Malcolm 
Morris  and  later  revised  by  Frank: 


I.  Eruptions  attributable 
to  the  vaccine  virus  pure 
and  simple. 


(areola). 

f  Generalized  vaccinia. 

Diffuse  vaccine  erythem 

Vaccinal  roseola. 

Vaccinal  lichen. 
I   Vaccinal  miliaria. 

Erythema  multiforme. 
I  Urticaria. 


VACCINATION   AND   CUTANEOUS   DISEASES 


46  J 


II.  Eruptions  attribut- 
able to  mixed  infection 
at  time  of  vaccination  or 
later. 


Local 


Constitutional 


Erysipelas. 
Impetigo  contagiosa. 
Furunculosis. 
Vaccinal  ulcer. 
Localized  gangrene. 
Cellulitis. 

Disseminated  gangrene. 
Syphilis. 
Leprosy  (?). 
Tuberculosis  (?). 


III.  Eruptions    sometimes 
following  vaccination. 


Eczema. 

Pemphigus  (dermatitis  bullosa) 

Psoriasis. 

Furunculosis. 

Urticaria. 


The  above  classification  is  doubtless  faulty  in  many  respects 
and  open  to  criticism,  but  will,  perhaps,  serve  the  purpose  of 
indicating,  in  a  general  way,  the  etiologic  factors  in  the  pro- 
duction of  the  various  dermatoses  that  may  complicate  vac- 
cinia. 

Generalized  Vaccinia. — This  is,  perhaps,  the  only  eruption 
among  those  enumerated  (with  the  exception,  of  course,  of  the 
normal  vaccine  disease)  which  may  with  positiveness  be  attrib- 
uted to  the  pure  vaccina  virus.  There  are  two  varieties  of 
generalized  vaccinia:  (1)  Spontaneous  generalized  vaccinia 
(vaccinal  eruptive  fever,  vaccinola).  (2)  Generalized  vac- 
cinia from  autoinoculation. 

Spontaneous  generalized  vaccinia  is  an  extremely  rare  con- 
dition; many  cases  formerly  regarded  as  instances  of  spon- 
taneous diffusion  of  the  eruption  are,  in  all  likelihood,  cases  of 
autoinoculated  vaccinia.  The  eruption  appears  usually  from 
the  fourth  to  the  tenth  day  after  vaccination,  and  most  often 
from  the  sixth  to  the  ninth  dav. 

The  lesions  appear  in  successive  crops,  and  pass  through  the 
stages  of  papule,  vesicle,  and  pustule.  The  eruptive  lesions, 
being  of  different  age,  may  be  seen  in  varying  stages  of  develop- 
ment. Complete  subsidence  of  the  efflorescence  usually  occurs 
befpre  the  twenty-first  day.  The  lesions  may  be  few  or  numer- 
ous, and  may  appear  upon  any  portion  of  the  body  surface. 
Fever  is  absent  in  some  cases  and  present  in  others,  being  usually 
proportionate  to  the  extent  of  the  eruption  and  the  associated 
complications,  particularly  glandular  enlargement. 

Generalized  vaccinia  may  present  a  considerable  resemblance 
to  variola.     It  may  usually  be  distinguished  by  the  absence  of 


+62  DISEASES  OP  THE   SKIN 

an  initial  stage,  its  occurrence  after  vaccination,  the  appearance 
*  of  the  eruption  in  crops,  and  the  irregular  distribution  of  the 
lesions.     Its  differentiation  from  inoculated  variola  is  rather 
more  difficult. 

Generalized  Vaccinia  from  Autoinoculation. — This  form 
of  generalization  of  the  vaccine  lesions  is  by  no  means  rare. 
Many  writers  at  the  present  day  are  inclined  to  regard  the  vast 
majority  of  cases  of  generalized  vaccinia  as  due  to  external 
inoculation.     French    writers    have    reported    a    number    of 


Fig.  in.— Accidental  multiple 

instances  of  diffusion  of  the  vaccinal  eruption  over  an  exten- 
sive cutaneous  area  the  seat  of  a  moist  eczema.  Unless  there 
is  danger  of  exposure  to  small-pox,  it  is.  indeed,  advisable  to 
postpone  vaccination  if  the  subject  is  suffering  from  a  dermato- 
sis in  which  there  is  denudation  of  the  skin.  The  number  of 
lesions  may  be  but  two  or  three,  or  there  may  be  a  profuse 
eruption.  The  development  of  a  few  supernumerary  lesions 
in  the  neighborhood  of  the  original  vaccine  insertion  is  by  no 
means  uncommon;  this  may  occur  even  when  there  is  no 
demonstrable  abrasion  of  the  skin.     The  virus  may  be  trans- 


VACCINATION    AND  CUTANEOUS    DISEASES  463 

ferred  by  the  patient  himself  through  scratching,  or  it  may  be 
conveyed  by  a  second  person. 

The  lesions  in  vaccinia  generalized  by  autoinoculation  appear 
at  intervals  after  the  original  vesicle  is  well  advanced;  they 
seldom  continue  to  make  their  appearance  after  the  third  week. 

Sore  Arm. — Under  this  caption  may  be  discussed  a  condi- 
tion which,  only  in  its  severer  phases,  is  to  be  regarded  as  a  com- 
plication. A  certain  amount  of  inflammatory  reaction  (areola) 
about  the  fully  developed  vesicle  is  to  be  viewed  as  a  not  unde- 
sirable and  probably  an  essential  part  of  the  normal  evolution 
of  the  vaccine  lesion.  It  not  infrequently  happens  that  instead 
of  a  moderate  erythema  and  edema  of  the  skin,  these  phenomena 
are  present  to  an  excessive  degree.  Now  and  then  the  inflam- 
mation about  the  vaccination  reaches  a  violent  degree  of  inten- 
sity and  spreads  over  a  considerable  portion  or  the  whole  of  the 
affected  arm.  In  such  cases  the  cellular  tissue  may  become 
implicated,  giving  rise  to  a  diffuse  cellulitis.  The  arm  under 
such  conditions  is  red,  swollen,  hot,  and  painful,  and  there  is 
apt  to  be  some  associated  systemic  disturbance. 

In  other  cases  the  inflammation  is  more  circumscribed,  and 
its  force  is  spent  upon  the  vaccine  lesion  and  the  skin  in  its 
immediate  neighborhood.  In  such  cases  b.  necrosis  of  the 
cutaneous  and  subcutaneous  tissues  mav  occur,  with  the  for- 
mation  of  a  slough.  When  this  is  thrown  off,  an  ulcer  is  left 
at  the  site  of  the  vaccination.  In  other  cases  the  vaccinia  may 
pursue  a  normal  course  to  the  development  and  decline  of  the 
areola,  but  instead  of  the  formation  of  a  typical  scab,  an  exca- 
vated ulcer  appears,  covered  by  a  soft,  thin  crust  which  fre- 
quently falls  off  and  is  renewed,  the  ulcer  persisting  in  this 
manner  for  a  long  time.  Martin,  of  Boston,  repeatedly  observed 
this  irregular  course  upon  arms  which  had  been  vaccinated 
with  long  humanized  virus.  Upon  the  opposite  arm,  on  which 
bovine  virus  had  been  simultaneously  employed,  a  perfect 
result  was  obtained. 

This  observation,  as  well  as  the  scientific  investigations,  of 
latter-day  observers,  suggests  that  the  excessively  "sore  arm" 
is  due  to  the  introduction  of  something  in  addition  to  the  pure 
vaccine  virus,  and,  furthermore,  that  this  additional  something 
is  of  the  nature  of  extraneous  microorganisms. 

It  is  not  uncommon  for  the  arm  to  become  very  "sore"  as 
the  result  of  thoughtless  or  accidental  traumatism  on  the  part 
of  the  vaccinee.     The  vesicle  is  frequently  ruptured  by  a  blow, 


464  DISEASES  OP  THE  SKIN 

friction  of  clothing,  scratching,  and  other  like  causes.  Where 
the  vesicle  is  unprotected,  the  shirt-sleeve  often  becomes  glued 
to  the  vaccination  lesion;  the  attempts  at  separation  cause 
a*  detachment  of  the  crust.  All  these  forms  of  traumatism 
doubtless  act  in  the  same  manner:  they  prevent  the  formation 
of  a  firm,  compact  crust,  which  is  nature's  protective  covering 
of  the  vaccine  wound.  By  opening  up  the  wound  they  permit 
of  infection  with  extraneous  germs,  which  may  produce  merely 
excessive  inflammation  or  may  lead  to  ulceration  or  other  more 
severe  vaccinal  complications. 

Inasmuch  as  we  can  obtain  a  lymph  which  is  rendered  free 
of  extraneous  germs  by  the  process  of  glycerinization,  by 
proper  care  of  the  arm  before,  during,  and  after  vaccination, 
we  should  be  able,  in  the  vast  majority  of  instances,  to  prevent 
the  development  of  "sore  arms.,, 

Vaccinia  Hemorrhagica. — From  time  to  time  cases  of 
vaccinia  are  seen  in  which  the  areola  about  the  vesicle  at  ths 
acme  of  its  development  becomes  hemorrhagic,  assuming  the 
appearance  of  a  diffuse  ecchymosis.  In  some  instances  the 
skin  beyond  the  areola  may  present  a  bluish  appearance.  In 
rare  cases  there  may  occur  scattered  petechia  and  ecchymoses, 
and  hemorrhages  from  some  of  the  mucous  membranes.  The 
cause  of  this  complication  is  obscure;  it  is  doubtless  not  so 
much  due  to  any  peculiarity  of  the  lymph,  as  to  some  under- 
lying systemic  condition  favoring  hemorrhagic  extravasation, 
such  as  scorbutus. 

Vaccinal  Ulceration. — Ulceration  at  the  site  of  insertion 
of  the  lymph  is  by  no  means  an  uncommon  complication  of 
vaccinia.  Acland  says  that  nearly  4  per  cent,  of  the  vaccinal 
injuries  inquired  into  by  the  English  Local  Government  Board 
(1888-91 )  were  due  either  to  ulceration  or  to  glandular  abscess. 
There  is,  in  all  probability,  one  of  two  factors  which  may  give 
rise  to  vaccinal  ulceration — either  the  introduction  into  the  skin 
of  extraneous  microorganisms  (at  the  time  of  vaccination  or  later) 
capable  of  producing  a  tissue  necrosis,  or  an  abnormal  or  vitiated 
state  of  health  wrhich  permits  of  an  excessive  and  unusual  local 
reaction.  Both  of  these  factors  appeared  to  play  an  important 
role  in  the  production  of  "bad  arms"  among  the  soldiers  during 
the  United  States  Civil  War.  In  the  admirable  report  of  the 
Board  of  Health  of  Louisiana  of  1884,  compiled  by  Dr.  Joseph 
Jones,  we  read  the  following:  "In  scorbutic  patients  all 
injuries  tend  to  form  ulcers  of  an  unhealthy  character,  and  the 


VACCINATION   AND   CUTANEOUS   DISEASES  465 

vaccine  vesicles,  even  when  they  appeared  at  the  proper  time 
and  manifested  many  of  the  usual  symptoms  of  the  vaccine 
disease,  were,  nevertheless,  larger  and  more  slow  in  healing, 
and  the  scabs  presented  an  enlarged,  scaly,  dark,  unhealthy 
appearance.  In  many  cases  a  large  ulcer,  covered  with  a  thick, 
laminated  crust,  from  one-quarter  to  one  inch  in  diameter, 
followed  the  introduction  of  the  vaccine  matter  into  scorbutic 
patients.' '  Either  a  weakened  resistance,  on  the  one  hand,  or 
an  extraneous  infection. on  the  other,  may  be  responsible  for 
vaccinal  ulcerations. 

Localized  Vaccinal  Gangrene. — In  extremely  rare  instances 
death  of  the  tissues  en  masse  at  the  site  of  vaccination  may  occur, 
producing  a  localized  gangrene.  It  would  seem  that  in  these  cases 
the  gangrene  is  due  to  low  vitality  of  the  tissues,  rather  than 
to  any  impurity  of  the  lymph.  In  cases  observed  by  Balzer, 
Wheaton,  and  Acland,  the  children  were  of  syphilitic  parentage. 
Hutchinson,  however,  saw  three  cases  of  vaccinal  gangrene  in 
children  in  whom  no  such  cause  could  be  invoked.  The  view  that 
the  condition  of  the  tissues  is  the  most  important  etiologic  factor 
in  the  production  of  this  complication  is  corroborated  by  the 
experience  of  surgeons  in  the  Confederate  Army  during  the 
United  States  Civil  War.  Dr.  Joseph  Jones  writes:  "After 
careful  inquiry  we  were  led  to  the  conclusions  that  these  acci- 
dents were,  in  the  case  of  Federal  prisoners,  referable  wholly 
to  the  scorbutic  condition  of  their  blood  and  the  crowded  con- 
dition of  the  stockade  and  hospital.  The  smallest  accidental 
injuries  and  abrasions  of  the  surface,  as  from  splinters  or  bites 
of  insects,  were  in  a  number  of  instances  followed  by  such 
extensive  gangrene  as  to  necessitate  amputation.  The  gangrene 
following  vaccination  appeared  to  be  due  essentially  to  the  same 
cause,  and  in  the  condition  of  blood  of  these  patients  would 
most  probably  have  attacked  any  puncture  made  by  a  lancet 
without  anv  vaccine  matter  or  anv  other  extraneous  material." 

Vaccinia  Gangrenosa. — As  has  been  pointed  out  by  Crocker 
and  others,  the  term  vaccinia  gangrenosa  is  a  misnomer,  inas- 
much as  the  affection  recorded  under  this  title  occurs  after 
varicella  (varicella  gangrenosa)  and  other  discrete  pustular 
eruptions.  Disseminated  necrosis  of  the  skin,  which  in  rare 
instances  follows  vaccinia,  varicella,  and  pustular  dermatoses, 
may  occur  independently  of  these  diseases  in  apparently  healthy 
infants;  a  better  designation,  therefore,  for  this  condition  is 
dermatitis  gangrcenosa  infantum.  The  gangrenous  changes  in  the 
30 


466  -        DISEASES   OP   THE  SKIN 

skin  may  occur  early  or  late.  Stokes,  of  Dublin,  reports  a 
case  of  so-called  vaccinia  gangrenosa  developing  forty-eight 
hours  after  vaccination.  The  vaccinal  or  varicellous  pustules 
may  be  directly  converted  into  blackish  sloughs,  which  are 
thrown  off  and  leave  deep,  excavated  ulcers;  or  the  gangrene 
may  not  set  in  until  a  week  or  two  has  elapsed,  beginning  as 
papulopustules  which  crust  over,  become  surrounded  by  an 
areola,  and  then  break  down  and  ulcerate.  High  fever  is  often 
present.     The  cause  of  this  rare  condition  is  obscure ;  it  usually 


supervenes  in  the  course  of  some  pustular  febrile  disease,  par- 
ticularly in  tuberculous,  syphilitic,  or  rachitic  children.  It  is 
quite  possible  that  the  gangrene  is  due  to  infection  with  some 
virulent  microorganism. 

Vaccinal  Roseola  (Roseola  Vaccinosa;  Vaccinal  Rash 
or  Erythema). — Under  the  above  designations  has  been 
described  a  rosy,  macular  rash  which  occasionally  appears  in 
vaccinated  persons  about  the  time  of  maturation  of  the  vesicle. 
While  this  eruption  is  ordinarily  seen  about  the  tenth  day  aftei 
vaccination,  it  has  been  observed  as  early  as  the  third  clay,  and 


VACCINATION    AND    CUTANEOUS    DISEASES  467 

as  late  as  the  eighteenth.  It  usually  appears  first  upon  the 
vaccinated  arm,  rapidly  spreading  to  the  trunk  and  other 
portions  of  the  body.  The  macules  are  large,  irregular,  blotchy 
in  appearance,  of  a  rose  tint,  and  not  elevated  above  the  level 
of  the  skin.  In  rare  instances  the  macules  may  coalesce, 
giving  rise  to  a  diffuse  erythema. 

The  eruption  is  of  brief  duration,  lasting  from  a  few  hours 
to  a  day  or  two.  It  may  be  accompanied  by  moderate  eleva- 
tion of  temperature. 


The  rash  is  not  unlike  that  of  measles,  with  which,  indeed, 
it  has  not  infrequently  been  confounded.  During  epidemics 
of  small-pox  vaccinal  roseola  has  been  mistaken  for  the  begin- 
ning of  confluent  small-pox.  Roseola  vaccinosa  has  a  complete 
analogue  in  the  roseola  variolosa,  and  exanthem  presenting 
almost  identical  features,  which  is  not  infrequently  observed 
just  before  the  appearance  of  the  eruption  of  modified  small-pox. 

Vaccinal  Lichen. — Crocker  states  that,  in  his  experience, 
vaccine  lichen  has  been  the  most  common  of  the  true  vaccinal 
exanthema.  He  has  made  notes  of  twenty  cases  of  this  erup- 
tion.    He  states  that  it  may  be  either  papular,  papulovesicular, 


.  appears  from  the  fourth  to  the  eighteenth  day — 

j  on  the  eighth;  in  about  one-half  the  cases  it 

the  arms,  appearing  in  the  remainder  on  the 

face;  the  eruption  then  extends  in  successive 

ov  •  portions  or  the  entire  cutaneous  surface. 

■  i  HI  reddish,  conical,  pin-head-sized,  surrounded 

rei  ilo,  and  often  surmounted  by  minute  vesicles  or 

les.     in  the  experience  of  the  writer,  vaccine  lichen  has 

.  i-xcessivcly  rare. 

ccinal    Miliaria.—  '~    —ire  cases,    instead   of  a   papular 

ion,  a  vesicular  c  i  may  take  place,  usually  from 

-  eighth  to  the  ekveum  day.     Danchez  writes:     "We  give 

■  name  vaccinal  miliaria  to  a  satellite  eruption  of  the  vaccinal 

er,  appearing  from  the  eighth  to  the  twelfth  day  (very  rarely 

r)   after  vaccination.      It  is  constituted  by  small  vesicles 

the  size  of  a  grain  of  milLt,  accumulated  in  great  numbers 

over  large  surfaces,  containing  a  transparent  liquid  at  first, 

then  opaque,  followed  by  slight  furfuralion  and  never  leaving 

:u  trices  after  it." 

A  miliary  vesicular  eruption  is  occasionally  seen  in  or  around 
the  vaccination  areola.  These  vesicles  are  not  true  vaccine 
lesions,  for  Martin  has  shown  that  the  contents  inoculated  upon 
another  individual  fail  to  produce  the  vaccine  disease. 

Erythema  Multiforme  and  Urticaria  after  Vaccination. — 
The  eruption  of  multiform  erythema  is  occasionally  seen  in 
vaccinated  individuals  between  the  first  and  t^nth  days  after 
the  insertion  of  the  virus.  In  some  cases  the  eruption  is  delayed 
considerably  beyond  this  period.  The  lesions  may  be  erythe- 
matous, papular,  tubercular,  vesiculobullous,  or  mixed. 

At  times  the  eruption  is  annular.  Crocker  saw  a  well-marked 
case  which  b-.-gan  on  the  ninth  day  after  vaccination  and  was 
characterized  by  shilling-sized  annulopapular  patches.  Napier 
observed  a  case  on  the  eleventh  day  which  began  as  rings. 

Not  infrequently  urticarial  lesions  are  present,  the  eruption 
being  a  type  of  combined  erythema  multiforme  and  urticaria. 
Allen  and  Sobel  regard  urticaria  as  one  of  the  most  common  of 
the  generalized  vaccinal  eruptions. 

Norman  Walker  has  observed  five  cases  of  erythema  multi- 
fotme  after  vaccination  with  glycerinated  lymph.  In  all,  the 
early  course  of  the  vaccination  was  uneventful.  The  eruption 
was  invariably  seen  on  the  face  and  hands,  but  on  other  parts 
as  well. 


VACCINATION    AND    CUTANEOUS   DISEASES  469 

In  a  review  of  the  vaccinal  complications  in  1160  vaccina- 
tions, Sinigar  states  that  there  were  23  cases  of  erythema, 
including  simple  erythematous  blushes,  finely  punctate  erythe- 
mata,  erythema  of  papular  or  urticarial  type,  and  erythema 
multiforme.  Concerning  the  date  of  appearance,  1  rash 
appeared  on  the  third  day,  5  on  the  eighth,  2  on  the  ninth, 
5  on  the  tenth,  4  on  the  eleventh,  1  on  the  twelfth,  4  on  the 
thirteenth,  and  1  on  the  sixteenth.  No  age  was  exempt;  in 
4  cases  the  patient  was  over  seventy  years  of  age.  The  average 
duration  of  the  rash  was  forty-eight  hours,  but  in  1  severe  case 
it  lasted  six  days. 

Impetigo  Contagiosa. — The  disease  is  extremely  common, 
independent  of  vaccination,  among  dirty  and  poorly  nourished 
children.  Any  abrasion  of  the  skin  increases  the  liability  of 
its  development.  Its  occasional  occurrence  after  vaccination, 
particularly  among  children  in  poor  hygienic  circumstances, 
is,  therefore,  scarcely  to  be  marvelled  at.  The  introduction 
of  the  infection  of  impetigo  with  the  insertion  of  the  vaccine 
virus  must  be  an  occurrence  of  the  greatest  rarity;  inasmuch 
as  impetigo  sores  develop  rapidly  (from  one  to  two  days)  after 
the  skin  is  infected,  we  would  expect,  if  the  disease  were  invac- 
cinated,  to  discover  the  impetigo  lesions  twenty-four  to  forty- 
eight  hours  after  the  vaccination. 

As  a  matter  of  experience,  however,  impetigo  usually  develops 
at  a  considerably  later  period.  It  may  make  its  appearance 
at  any  period  up  to  the  complete  healing  of  the  vaccinal  wound. 
The  first  lesions  are  usually  seen  about  the  site  of  insertion  of 
the  vaccine  lymph.  This  area  may  become  quite  inflamed, 
the  surrounding  epidermis  raised  up  by  a  seropurulent  fluid, 
and  the  process  extend  upon  the  periphery,  with  the  production 
of  voluminous,  ocher-colored  crusts.  From  this  as  a  focus 
other  portions  of  the  skin  become  infected  by  autoinoculation 
through  scratching  and  other  means.  At  times  impetigo  may 
assume  a  bullous  form,  simulating  pemphigus;  most  of  the 
pemphigoid  eruptions  after  vaccination  would  appear,  how- 
ever, to  belong  to  the  group  of  bullous  dermatitis  presently 
to  be  described. 

In  1885  an  outbreak  of  a  cutaneous  disease  said  to  have 
presented  the  clini  1  features  of  impetigo  occurred  in  villages 
on  the  island  of  Rugcn,  in  the  Baltic  Sea,  after  the  vaccination 
of  seventv-nine  children. 

Impetigo  contagiosa  is  caused  by  invasion  of  the  skin  by 


DISEASES  uF   THE   SKIN 

germs  of  contagious  pus,  independently  of  its  source.  There 
probably  two  chief  varieties,  due  respectively  to  the  strepto- 

_cus  and  to  the  staphylococcus  pyogenes. 

Vaccinal  Erysipelas. — Erysipelas  is  an  acute  infectious 
iase  resulting  from  invasion  of  the  bodv  with  the  strepto- 

iccus  of   Fehleisen.      In  the   vast   majoritv  of  cases  of   this 

ilady  the  infection  gains  its  entrance  to  the  system  through 
a  wound  of  the  cutaneous  or  mucous  surfaces;  the  disease, 
refore,  is  essentially  a  wound  infection. 

inasmuch  as  vaccinia  is  attended  with  the  production  of  a 
wound  of  the  skin,  it  is  not  surprising,  particularly  in  view  of 
the  frequent  negk'ct  of  vaccination  wounds,  that  erysipelas 
should  occasionally  occur  after  this  procedure.  The  erysipela- 
tous infection  is  usually  conveyed  to  the  vaccination  wound 
at  some  period  subsequent  to  the  insertion  of  the  vaccine  virus; 
in  rare  cases,  however,  the  specific  germs  of  erysipelas  may  be 
present  in  the  lymph,  in  which  event  this  complication  develops 
on  the  second  or  third  day  after  vaccination. 

Erysipelas  may  develop  in  an  infant  after  vaccination  and 
still  be  independent  thereof.  Erysipelas  is  a  common  disease 
among  infants;  according  to  Dr.  Ogle's  testimony  before  the 
British  Royal  Vaccination  Commission,  2000  per  1,000,000 
infants  under  three  months  of  age  perish  from  it.  It  has  been 
known  to  develop  after  very  trivial  injuries,  such  as  the  scratch 
of  a  pin,  abrasion  from  the  friction  of  clothing,  etc, 

Both  vaccinal  erysipelas  and  erysipelas  from  other  causes  are 
attended  with  a  rather  high  mortality- rate  in  infants.  Of  the 
deaths  attributed  to  vaccination  in  England  between  1886  and 
1891,  almost  one-half  resulted  from  erysipelas. 

As  a  vaccinal  complication,  erysipelas  appears  to  be  dis- 
tinctly on  the  decrease.  In  1877  Lotz  was  able  to  collect  in 
Germany  but  two  cases  of  death  from  this  cause  in  1,252,554 
vaccinations. 

The  increased  attention  to  asepsis  in  vaccination,  the  careful 
protection  to  the  vesicle  when  formed,  and  the  employment  of 
bovine  lymph  will  doubtless  continue  to  lessen  the  frequency 
of  this  complication. 

It  is  claimed  that  animal  virus,  on  account  of  the  comparative 
insusceptibility  of  the  bovine  species  to  erysipelas,  gives  greater 
security  against  the  disease  than  humanized  virus. 

Vaccine  erysipelas  should  be  trenchantly  distinguished  from 
the  derma tocellulit is,  which  is  not  infrequently  observed  about 


VACCINATION    AND   CUTANEOUS    DISEASES  471 

the  vaccine  lesion,  and  which  occasionally  involves  the  entire 
upper  arm  and  even  the  forearm ;  this  is  nothing  more  than  an 
exaggeration  of  the  inflammatory  areola.  The  arm  is  swollen 
and  intensely  reddened,  but  there  is  no  tendency  for  the  proc- 
ess to  spread  to  other  parts  of  the  body,  the  inflammatory 
phenomena  subsiding  after  the  height  of  the  vaccinia  has  been 
reached. 

Vaccinal  Syphilis. — The  study  of  vaccinal  syphilis  has  been 
bereft  of  much  of  its  importance  since  the  general  adoption  of 
calf-lymph  for  vaccination.  Inasmuch  as  the  bovine  species  is 
totally  insusceptible  to  the  syphilitic  infection,  it  is  obviously 
impossible  to  convey  this  poison  by  vaccination  with  lymph 
from  this  source.  It  has  been  suggested  that  syphilis  might  be 
conveyed  in  the  vaccine  virus  as  a  result  of  a  syphilitic  vaccinator 
expelling  the  lymph  through  the  capillary  tube  with  his  breath, 
but  this  is  a  purely  gratuitous  assumption,  entirely  without  any 
clinical  evidence. 

The  Relation  of  Vaccination  to  Tuberculosis. — Whether 
or  not  it  is  possible  to  transmit  tuberculosis  in  vaccine  lymph  is 
an  undetermined  question. 

The  danger  of  conveying  tuberculosis  in  bovine  lymph  is 
almost  inappreciable.  The  virus  is  obtained  from  calves,  and 
it  is  pretty  well  established  that  calves  are  but  rarely  the  sub- 
jects of  tuberculosis.  It  is  stated  by  Furst,  on  the  authority 
of  Pfeiffer,  that  but  one  case  of  tuberculosis  was  found  among 
34,400  calves  under  four  months  of  age.  The  statistics  of  the 
abattoirs  of  Augsburg  and  Munich  corroborate  the  above  figures; 
only  one  tuberculous  calf  was  discovered  at  Augsburg  among 
22,230  slaughtered,  and  a  smaller  percentage  at  Munich. 

Furthermore,  in  well-regulated  vaccine  establishments  calves 
are  subjected  to  the  tuberculin  test  before  vaccination,  and  are 
autopsied  before  the  lymph  is  distributed  for  use.  Even  though 
it  were  possible,  despite  these  precautions,  for  tubercle  bacilli 
to  get  into  the  lymph,  they  would  perish  if  the  lymph  were 
glycerinated.  Copeman,  speaking  of  glycerinated  lymph,  says: 
"The  tubercle  bacillus  is  effectually  destroyed  even  when  large 
quantities  of  virulent  cultures  have  been  purposely  added  to 
the  lymph/' 

Bollinger,  Heron,  and  Acland  all  seriously  doubt  whether 
tuberculosis  has  ever  been  transmitted  by  vaccination. 

Postvaccinal  Lupus  Vulgaris. — Cases  of  lupus  occurring  in 
and    around   vaccination  have   been  reported   by   Lennander, 


Little,  Colcott  Fox,  Stelwagon,  Acland,  and  others, 
observers  saw  the  lupus  years  after  the  vaccination 
>rmed.     Fox  saw  a  case  of  lupus  begin  in  a  vac- 
ate hortly  after  the  sore  had  healed.     The  child  sub- 
uentiv  atv  'loped  a  disseminated  lupus,  subperiosteal  tuber- 
rs  nodul'    ,  and  pulmonary  phthisis.      It  is  highly  prolwible 
this  ch1      was  already  tuberculous,  as  another  child  in  the 
me  family     id  died  previously  of  this  disease.     Stelwagon  saw 
.xihu-sized  patch  of  lupus  on  the  arm  in  a  girl  ten  or  twelve 
irs  after  a  vaccination,  which  was  said  to  have  been  imme- 
:ely  followed  I  •.         opment  of  the  lupus,  the  history 
»'ig  give"  by  a  prr,         n,  trie  brother  of  the  patient.     All  that 
n  be  stated  as  regards  the  relationship  of  vaccination  to  lupus 
:hat  vaccination  in  rare  cases  in  tuberculous  individuals  may 
■■—x  rise  to  st  lupus  at  the  site  of  the  vaccination.     Thai  lupus 
mid  occasionally  choose  a  vaccination  scar  for  its  seat  is  no 
proof  that  it  was  caused  by  vaccination. 

Vaccination  and  Leprosy. — Since  the  general  adoption  of 
bovine  lymph  for  vaccination,  the  question  of  the  invaednadon 
leprosy  has  resolved  itself  into  one  of  academic  and  retrospec- 
e  interest.  It  is  well,  however,  for  physicians  in  leprous 
toim  tries,  if  required  by  unusual  circumstances  to  employ  human- 
ized lymph,  to  remember  that  leprosy  has  probably  in  isolated 
instances  been  conveyed  by  vaccination.  Gairdner,  Daubler, 
and  Hillis  have  each  recorded  instances  of  vaccinal  leprosy, 
although  some  doubt  attaches  to  all  these  cases. 

Beavan  Rake  and  Buckmaster,  who  have  given  this  matter 
much  study,  believe  that  "the  alleged  cases  of  transmission  of 
leprosy  by  vaccination  are  open  to  serious  doubt."  Hansen,  of 
Bergen,  in  1890,  made  extensive  inquiry  by  circular  to  all  the 
physicians  of  Norway  as  to  the  occurrence  of  vaccination  leprosy. 
In  not  a  single  case  was  there  any  ground  to  suspect  such  an 
origin.  This  statement  is  of  especial  importance,  inasmuch  as 
there  is  much  leprosy  in  Norway  and  vaccination  is  practised 
extensively  in  that  country. 

From  experimental  evidence  we  would  scarcely  expect  leprosy 
to  be  transmissible  by  vaccination.  Inoculation  of  man  and 
lower  animals  has  been  repeatedly  attempted  by  Daniellson, 
Profeta,  Hansen,  and  others,  who  inserted  fragments  of  leprous 
tissue  and  injected  blood  from  lepers  beneath  the  skin,  but  with 
entirely  negative  results.  There  is,  indeed,  no  conclusive  case 
on  record  of  the  successful  experimental  transmission  of  leprosy. 


VACCINATION    AND    CUTANEOUS    DISEASES  473 

It  is  true  that  lepra  bacilli  have  occasionally  been  found  in 
vaccine  lymph  in  vesicles  raised  upon  leprous  skin,  but,  as 
Beavan  Rake  properly  states,  nd  responsible  person  would  think 
of  vaccinating  a  leper  in  an  affected  part  and  using  such  lymph 
for  further  vaccinations. 

Eczema  Following  Vaccination. — Vaccination  may  now 
and  then  induce  the  appearance  of  an  eczema  in  a  child  predis- 
posed to  the  disease,  just  as  an  attack  of  measles,  scarlet  fever, 
or  simple  teething  may  act  as  an  exciting  cause.  Eczema  is  an 
extremely  common  disease  among  infants  and  young  children, 
and  is  particularly  referable  to  faulty  feeding  and  digestive  dis- 
orders. Of  600  cases  of  eczema  under  the  care  of  Dr.  T.  Colcott 
Fox,  249,  or  41.5  per  cent.,  were  seen  before  the  end  of  the  first 
year;  in  40  of  these  eczema  was  known  to  have  appeared  before 
vaccination.  Doubtless  if  these  had  appeared  after  vaccination, 
the  latter  would  have  been  viewed  as  a  probable  etiologic  factor. 

Crocker  says :  "  In  no  case  can  vaccination  be  held  responsible 
where  the  vaccinia  pustule  has  completely  healed  before  eczema 
appears." 

Eczematous  children,  if  in  good  health  otherwise,  may  usually 
be  vaccinated  without  any  aggravation  of  the  existing  cutaneous 
disease.  Van  Harlingen  has  carefully  studied  the  influence  of 
vaccination  on  previously  existing  skin-diseases.  He  writes: 
"During  the  small-pox  epidemic  of  1872  I  observed  all  cases  of 
skin-diseases  coming  under  my  notice  in  which  vaccination  had 
been  practised.  In  a  few  some  aggravation  of  the  symptoms 
followed ;  in  others,  an  apparent  improvement  took  place.  But  in 
the  great  majority  of  cases  vaccination  did  not  appear  to  exercise 
any  influence  whatever  on  the  course  of  the  more  common  dis- 
eases of  the  skin  coming  under  my  observation."  I  have,  from 
time  to  time,  vaccinated  persons  with  eczema  and  other  cutaneous 
diseases  without  any  injury  whatsoever.  On  the  other  hand, 
vaccination  has,  on  a  number  of  occasions,  been  followed  by 
improvement  and  even  cure  of  eczemas.  Stelwagon  says:  "I 
have  noted  in  several  instances  that  amelioration  followed  vac- 
cination, and  in  one  instance,  in  a  chronic  case,  a  disappearance 
of  the  eczema."  Duhring,  Tait,  and  others  have  testified  to 
the  occasional  curative  influence  of  vaccination  on  eczema. 

While  I  would  not  elect  to  perform  vaccination  upon  a  child 
suffering  from  eczema,  I  should  not  consider  the  latter  condition 
a  sufficient  contraindication  if  small-pox  were  prevalent. 

Bullous  Eruptions  (Dermatitis  Bullosa ;  Dermatitis  Her- 


DISEASES  (IF  THE  SKIN 

cute  Pemphigus). — In  relatively  rare  instances 
eruptions,    variously    designated    as    pemphigus, 
js    ne rma litis,    and    dermatitis    herpetiformis    (Duhring's 
.se),  have  followed  vaccination.     While  we  have  found  no 
■of  positive  of  a  causative  relationship  between  vaccinia  and 
e  eruptions,  they  have  now  been  reported  by  careful  observers 
i  sufficient  number  of  instances  to  warrant  the  assumption 
t   the  antecedent  vaccination  has  been  of  some  etiologic 
■nent. 
>ey  reported  a  case  of  this  character  under  the  title  of  der- 
tis  herpetiformis,  in  which  the  lesions  were  vesicobullous 
L  erythematous,  followed  by  pigmentation. 
Dyer  reported  2  similar  cases  under  the  same  title  after  vac- 
ition.     One    case    occurred    three    weeks   after    vaccination, 
1  several  (?)  weeks  thereafter.     Bowen  has  placed  on  record 
series  of  6  cases  of  bullous  dermatitis  resembling  dermatitis 
-petiformis  following  vaccination.     In  3  of  the  cases  the  erup- 
uon  is  stated  to  have  made  its  appearance  within  two  weeks 
er  vaccination,  in  1  within  a  week,  while  in  2  it  did  not  show 
If  until  after  the  lapse  of  a  month.     Corlett  exhibits  two 
jotographs  of  postvaccinal  bullous  dermatitis  in  his  work  on 
trie  Acute  Infectious  Exanthemata.     Stelwagon  saw  within  one 
year  3  cases  of  bullous  eruption  after  vaccination,  2  of  which  he 
regarded  as  acute  pemphigus,  and  the  third  as  a  persistent  bul- 
lous   erythema    multiforme    or    dermatitis    herpetiformis.     In 
these  cases  the  vaccination  was  what  is  usually  described  as  a 
"good  take,"  but  was  somewhat  slow  in  healing,  the  crust  remain- 
ing adherent  for  a  long  time.     The  eruption  appeared  from  two 
to  four  weeks  after  vaccination,  and  had  persisted,  at  the  time 
they  were  reported — three,  four,  and  eight  months,  respectively. 
Sequeira  showed  to  the  Dermatological  Society,  of  London,  in 
1902,  a  case  of  pemphigus  in  a  man  of  thirty-nine  years,  the  erup- 
tion appearing  three  weeks  after  revaccination.     Three  vaccine 
insertions  were  made,  and  the  first  bleb  is  alleged  to  have 
developed  at  the  site  of  one  of  these.     This  was  followed  in 
several  weeks  by  bulla?  on  the  arms,  and  later  on  the  thighs. 
Cultures  from  the  early  blebs  were  sterile,  and  inoculations  of 
this  fluid  into  animals  were  negative. 

In  all  the  above  cases  save  the  last  the  patients  were  children 
under  twelve  years  of  age.  The  eruption  usually  appeared  from 
two  to  three  weeks  after  vaccination,  and  in  no  case  after  six 
weeks.     In  most  cases  the  eruption  was  extensive  and  of  long 


VACCINATION    AND   CUTANEOUS    DISEASES  475 

duration,  with  marked  tendency  to  relapse.  Some  of  the  cases 
were  cured  at  the  end  of  three  or  six  months,  but  some  persisted 
much  longer.  Pusey's  case  continued  to  have  relapses  for  four 
and  a  half  years. 

Bowen  says:  "The  chief  features  that  these  cases  present  in 
common,  and  that  lead  to  a  conviction  that  they  have  a  common 
etiology,  are  their  occurrence  in  children  after  vaccination ;  their 
course,  varying  from  several  months  to  several  years,  or  perhaps 
longer;  their  uniformly  vesicular  and  bullous  character,  with 
only  occasional  evidences  of  multiformity;  the  almost  complete 
exemption  of  the  trunk;  the  characteristic  grouping  about  the 
mouth,  nose,  ears,  wrists,  ankles,  and  feet,  and  the  very  slight 
prominence  of  itching  or  other  subjective  symptoms."  While 
most  of  these  cases  run  a  relatively  benign  course,  I  saw  a  fatal 
termination  in  a  case  of  bullous  eruption  of  the  acute  pemphigus 
type.  This  occurred  in  a  girl  of  five  years,  the  eruption  begin- 
ning two  weeks  after  vaccination.  I  have  also  seen  four  other 
cases  of  generalized  bullous  eruption  of  the  type  described  above, 
occurring  shortly  after  vaccination. 

A  remarkable  series  of  bullous  eruptions  occurring  after  vac- 
cination is  reported  by  Howe,  of  Boston.  Ten  cases  are  referred 
to,  all  but  one  occurring  in  persons  who  had  been  recently  vac- 
cinated. The  skin  lesions  began  on  an  average  of  five  weeks 
after  vaccination,  the  longest  time  elapsing  between  vaccination 
and  the  appearance  of  the  eruption  was  sixteen  weeks,  and  the 
shortest  period,  three  weeks. 

All  the  patients  were  adults,  the  ages  varying  from  twenty-one 
to  fifty-two.  Six  of  the  ten  cases  proved  fatal;  the  average 
duration  until  recoverv  or  death  occurred  was  six  weeks. 

It  will  be  seen  that  these  cases  present  points  of  variation 
from  the  cases  described  by  Bowen.  The  interval  between  vac- 
cination and  the  appearance  of  the  eruption  in  Bowen 's  cases 
was  about  two  and  one-half  weeks;  in  Howe's  cases  it  was  double 
this  period.  Bowen 's  cases  occurred  in  children;  none  of  them 
was  fatal,  and  the  trunk  was,  as  a  rule,  free  of  eruption,  which 
was  not  true  in  the  cases  described  bv  Howe. 

Howe  was  inclined  to  attribute  the  eruptions  to  infectious 
material  introduced  at  the  time  of  or  after  vaccination.  The 
cases  occurred  at  a  time  when  small-pox  was  prevalent  in  epi- 
demic form,  and  when  thousands  of  vaccinations  were  being 
performed. 

While  these  eruptions,  when  compared  with  the  number  of 


476  DISEASES  OF  THE  SKIN 

vaccinations  performed,  are  extremely  rare,  no  effort  should  be 
spared  to  determine  their  cause  with  a  view  to  their  future 
avoidance.  It  is  possible  that  they  are  manifestations  of  an 
extraneous  infection  through  the  vaccine  wound.  In  this  con- 
nection the  investigations  of  Pernet  and  Bulloch  into  the  causa- 
tion of  acute  pemphigus  are  of  interest.  These  writers  report 
and  analyze  8  cases  of  acute  pemphigus  in  butchers;  6  of  the  cases 
proved  fatal  in  from  twenty-four  hours  to  eighteen  days.  Three 
patients  gave  histories  of  wounds,  which  continued  to  suppurate 
up  to  the  time  of  the  pemphigus  outbreak.  The  period  of  incu- 
bation would  appear  to  be  very  long  if  the  disease  arose  from 
an  infection,  as  is  suggested.  In  the  three  cases  referred  to,  the 
wound  antedated  the  eruption  three  months,  two  months,  and 
five  weeks,  respectively.  Special  interest  attaches  to  one  case, 
in  which  the  patient  is  alleged  to  have  inoculated  himself  by 
contact  with  a  bullous  eruption  on  the  udders  of  a  cow. 

Psoriasis. — Psoriasis  is  known  to  have  made  its  first  appear- 
ance at  the  site  of  vaccination,  and  also  as  a  generalized  outbreak 
after  vaccinia.  No  one,  however,  who  is  at  all  familiar  with  the 
disease  would  look  upon  vaccination  as  a  cause  of  psoriasis.  It 
may  simply  determine  the  time  of  outbreak  in  an  individual 
predisposed  to  this  common  skin  affection ;  it  is  quite  possible 
that  those  persons  who  developed  psoriasis  after  vaccination 
would  not  have  been  attacked  with  this  disease  until  a  later 
period.  The  occurrence  of  postvaccinal  outbreaks  of  psoriasis 
has  been  noted  by — Klamann,  i  case;  Campbell,  i  case;  Roh6, 
2  acute  general  cases  of  psoriasis  after  vaccination ;  Piffard,  i  case ; 
Wood,  2  cases;  Hyde,  i  case;  Gaskoin,  5  cases;  Chambard,  1 
case;  and  Rioblanc,  1  case. 

Furunculosis. — Crops  of  boils  have  occasionally  been  ob- 
served during  the  course  of  and  following  vaccination.  The 
complication  is  usually  a  trivial  one,  the  furuncles  disappearing 
in  a  short  time.  Sinigar  met  with  2 1  cases  of  furuncles  among 
1 160  vaccinations  in  a  large  institution.  The  boils  develop,  as 
a  rule,  late  in  the  course  of  vaccinia.  One  case  appeared  on  the 
tenth  day,  1  on  the  sixteenth,  4  on  the  twenty-second,  1  on  the 
twenty  fifth,  2  on  the  twenty-seventh,  2  on  the  twenty -eighth, 
4  on  the  twenty-ninth,  3  on  the  thirtieth,  and  3  on  the  thirty- 
fifth  day  after  vaccination.  As  bearing  on  the  cause  of  this 
complication,  it  is  interesting  to  note  that  13  of  these  cases 
developed  among  epileptics,  who,  as  Sinigar  remarks,  include 
some  of  the  dirtiest  and  most  troublesome  patients  in  the  asylum. 


CHICKEN-POX  477 

CHICKEN-POX 

Synonyms. — Varicella;  formerly,  Variola  cry  stall  in  a ;  Variola  notha;  Var- 
iola spuria.  Em*.,  formerly,  Water-pock;  Glass-pock;  Ger.,  Varicellen; 
Wasserpocken;  \\  ind-blattern;  Schajpocken;  Fr.,  La  varicelle;  La  vhroletie; 
Ital.,  Moruiglione;  Ravaglione. 

Definition. — Chicken-pox  is  an  acute,  highly  contagious  dis- 
ease, occurring  chiefly  in  children,  characterized  by  an  eruption 
of  vesicular  type,  appearing  in  crops  and  accompanied  by  mild 
febrile  disturbance,  which  usually  begins  with  the  appearance 
of  the  cutaneous  outbreak.  The  lesions  dry  in  a  few  days  into 
crusts.     One  attack  protects  for  life  in  the  vast  majority  of  cases. 

Symptomatology. — Period  of  Incubation. — The  period  of 
incubation  is  ordinarily  between  fourteen  and  seventeen  days, 
although  it  may  occasionally  be  a  little  shorter  or  longer. 

Preemptive  Stage. — In  the  vast  majority  of  cases  chicken-pox 
is  not  preceded  by  prodromal  illness.  The  onset  of  the  con- 
stitutional manifestations  is  usually  coincident  with  the  appear- 
ance of  the  eruption.  The  ordinary  history  elicited  from  mothers 
is  that  the  eruption  is  the  first  symptom  to  attract  their  atten- 
tion, and  that  the  children  are  not  ill  prior  to  this  time. 

In  a  small  percentage  of  cases  some  little  constitutional  dis- 
turbance may  be  observed  a  day  or  two  before  the  appearance 
of  the  exanthem.  This  consists  of  slight  rise  of  temperature, 
anorexia,  vague  pains,  and  chilliness.  More  common  is  it  to 
discover  these  symptoms  a  half-day  or  so  before  the  eruption 
breaks  out.  During  the  night  preceding  the  appearance  of  the 
exanthem  the  child  may  be  slightly  feverish  and  restless.  But 
these  mild  precursory  symptoms  should  not  be  regarded  as 
representing  a  prodromal  illness,  for  by  this  term,  as  applied  to 
small-pox,  is  meant  a  distinct  stage,  preceding  by  two  or  three 
days,  the  onset  of  the  eruptive  phenomena. 

It  is  important,  however,  to  call  attention  to  the  fact  that 
varicella  in  adults  may  occasionally  be  preceded  by  a  prodromal 
stage.  I  have  seen  perhaps  a  half-dozen  of  adults  suffering 
from  varicella  who  had  distinct  prodromata.  These  symptoms 
consist  chiefly  of  chilliness,  lassitude,  anorexie,  nausea,  slight 
headache,  backache,  and  some  elevation  of  temperature  (ioi° 
to  io2°  F.).  These  manifestations  may  precede  the  appearance 
of  the  eruption  by  two  or  three  days,  though  more  often  not 
longer  than  twenty-four  hours.  It  is  rare  to  observe  high  fever, 
vomiting,  severe  lumbar  pain,  and  prostration — symptoms  which 
usher  in  a  well-pronounced  small-pox. 


478  DISEASES  OF  THE  SKIN 

A  prodromal  erythema  is,  in  rare  cases,  seen  before  the  appear- 
ance of  the  varicellous  eruption,  as  it  is  at  times  before  the  erup- 
tion of  small-pox  and  measles. 

1  have  seen  a  well-pronounced  scarlatinoid  rash  preceding 
the  appearance  of  the  varicella  eruption  in  a  child  who  some 
days  later  contracted  scarlet  fever  in  an  infectious  disease  hospital 
where  she  had  been  taken  through  an  error  of  diagnosis.  Other 
writers  likewise  refer  to  this  prodromal  rash. 

The  Eruptive  Stage. — As  has  been  stated,  the  eruption  is 
commonly  the  first  symptom  to  attract  attention  to  the  disease. 
Synchronously  with  the  appearance  of  the  cutaneous  outbreak, 
or  a  few  hours  before  or  afterward,  a  varying  degree  of  fever  sets 
in.  In  some  cases  this  does  not  reach  higher  than  99  °  F.;  in 
others,  however,  the  pyrexial  elevation  is  most  marked,  even 
reaching  1040  or  105  °  F. 

The  temperature  commonly  falls  to  normal  in  the  course  of 
one  to  three  days.  Where  the  eruption  is  copious,  however, 
moderate  fever  may  persist  for  four  or  five  days.  In  cases  in 
which  the  varicellous  lesions  become  secondarily  infected,  the 
temperature  may  continue  above  normal  for  a  fortnight  or  even 
longer. 

The  Eruption. — The  eruption  of  chicken-pox  usually  appears 
first  on  the  back  or  the  face,  although  other  regions  may  be  the 
seat  of  the  initial  lesions.  Irregular  extension  then  occurs,  new 
lesions  developing  on  different  portions  of  the  cutaneous  surface. 
The  hairy  scalp  is  nearly  always  beset  with  some  vesicles. 

The  distribution  of  the  eruption  is  subject  to  some  variation, 
but  is  tolerably  uniform  in  the  majority  of  cases.  The  trunk, 
particularly  the  back,  is  relatively  more  profusely  attacked  than 
the  distal  portions  of  the  extremities—  the  wrists,  ankles,  hands, 
and  feet.  The  face  usually  presents  a  moderate  number  of  dis- 
crete vesicles.  It  is  rare  for  the  face  to  escape  completely, 
although  at  times  but  two  or  three  lesions  may  be  present.  At 
other  times,  in  copious  eruptions,  quite  an  abundance  of  lesions 
may  be  seen  on  the  face.  The  arms  and  legs  are  seldom  pro- 
fusely attacked,  except  in  unusually  extensive  cases. 

It  has  been  claimed  by  some  writers  that  varicellous  lesions 
do  not  occur  upon  the  palms  and  soles.  It  is  true  that  in  most 
cases  the  palmar  and  plantar  surfaces  are  free  of  eruption;  but 
it  is  by  no  means  rare  to  find  a  few  vesicles  in  these  regions,  and 
in  severe  cases  the  lesions  may  be  fairly  numerous. 

The  palms  and  soles  are  much  less  frequently  and  less  abun- 


CHICKEN-POX 


479 


dantly  involved  than  in  small-pox,  in  which  disease  some  lesions 
are  nearly  always  present  in  these  regions.  The  dorsal  surfaces 
of  the  hands  and  feet  are  likewise  relatively  lightly  affected, 
compared  with  the  general  extent  of  the  eruption.  In  fact,  it 
may  be  stated  that  the  distal  portions  of  the  extremities  usually 
suffer  but  little  in  chicken-pox — the  eruption  prefers  the  covered 
surfaces. 


^lopmcnt  (Welch 


The  distribution  of  the  eruption  may,  to  some  extent,  be 
influenced  by  irritation  of  the  skin  prior  to  the  appearance  of 
the  lesions.  I  have  seen  a  profuse  crop  of  lesions  develop  over 
a  rectangular  area  on  the  sternum  over  which  a  mustard -plaster 
had  been  applied  during  the  preemptive  stage.  Any  irritant, 
by  increasing  the  vascularity  of  the  skin,  may  attract  lesions  to 


i  irritated.     It  is  not  so  common,  however,  to 

ease  of  the  eruption  from  this  cause  as  it  is  in 

the  latter  disease  the   influence  of  cutaneous 

«w*-- ■'  '        .'termining  an  increase  of  the  eruption  in  a  given 

5  «ed  by  frequent  experience. 

y  the  time  that  the  physician  is  called  to  see  a 
ccn-pox,  vesicles  are  observable  upon  the  body. 
SKin      "HlflfuUy  examined  early,  it  will  be  noted  that  the 
jti  arc       tally  preceded  by  erythematous  spots.     These  are 
to  lx'un»si3C£  id  in  appearance  not  unlike 

rosc-spots  oi  flea-bites.     Very  soon  the 

Hits  of   | he   mac  rxec         iaiscd,  and  small  vesicles  are 

med  which  rapid.,  ...-Tease  in  size.  In  some  cases  the  rosy 
maTI it'll  are  elevated,  somewhat  acuminated,  and  in  reality  rep- 
resent papules. 

Tile  duration  of  the  transitional  bsions  before  vesiculation 
takes  place  is  extremely  variable.  At  times  some  of  the  lesions 
of  varicella  aboil  in  [he  macular  or  papular  stage,  and  never 
go  to  the  development  of  vesicles.  Indeed,  Thomas  mentions 
3.  case  the  nature  of  which  was  verified  by  the  previous  occurrence 
of  varicella  in  a  sister,  in  which  erythematous  spots  (roseola;) 
persisted  for  thirty-six  hours  and  then  disappeared  without  the 
formation  of  any  vesicles  whatever.  Varicella  without  the 
development  of  vesicles  must,  however,  be  extremely  rare. 

Varicella  vesicles  may  spring  up  so  rapidly  that  they  appear 
to  arise  directly  from  the  normal  skin.  The  lesions  often  look 
as  if  they  had  been  produced  by  drops  of  scalding  water  sprinkled 
upon  the  skin.  They  are  superficially  situated,  differing  in  this 
respect  from  the  deeper- sea  ted  vesicles  of  small- pox.  The 
epidermal  roof  of  the  vesicle  is  thin  and  readily  ruptured. 

The  vesicles  of  chicken-pox  vary  greatly  in  size;  they  may 
be  no  larger  than  a  pin-head,  or  they  may  reach  the  dimensions 
of  a  large  pea.  They  are  commonly  tense,  although  rarely  as 
hard  as  the  variolous  vesicle.  Slight  traumatism,  such  as  is 
produced  by  scratching  or  the  friction  of  clothing,  suffices  to 
rupture  the  vesicle.  The  fluid  from  an  early  vesicle  is  clear  and 
watery  in  appearance;  later  it  becomes  turbid  and  lactescent. 
The  vesicles  are  round  or  oval,  the  shape  being  somewhat  deter- 
mined by  the  lines  of  cleavage  of  the  skin.  In  the  axillary  and 
lateral  costal  regions  they  are  commonly  oval,  the  long  axis 
corresponding  with  the  direction  of  the  ribs. 
Chicken-pox  vesicles  are  commonly  surrounded  by  a  reddish 


CHICKEN-POX  481 

areola.  This  may  be  narrow,  measuring  but  an  eighth  of  an 
inch ;  in  other  cases,  however,  it  may  have  a  breadth  of  a  half- 
inch  or  more. 

The  eruption  of  chicken-pox  appears  in  crops.  The  first  out- 
break commonly  consists  of  a  dozen  or  fifteen  lesions.  After 
an  interval  of  some  hours — usually  a  day  or  two — a  second  crop 
appears,  which  often  numerically  exceeds  the  first.  Twenty-four 
hours  later  a  third  outbreak  may  occur,  and  new  lesions  may 
thus  continue  to  appear  for  four  or  five  days  or  even  a  week. 
Owing  to  the  fact  that  the  lesions  are  of  different  age,  they  are 
seen  in  varying  stages  of  evolution  and  involution.  There  may 
be  present  at  the  same  time  small,  new,  tense  vesicles,  older, 
drying  vesicopustules,  and,  in  addition,  dark-colored  crusts  which 
represent  the  remains  of  the  first  vesicles.  This  multiformity  is 
one  of  the  most  distinguishing  features  of  the  eruption  of  chicken- 
pox. 

The  duration  of  the  individual  lesions  of  chicken-pox  is  brief. 
The  vesicles,  after  reaching  the  acme  of  their  development, 
become  flaccid,  and  in  from  one  to  three  days  dry  into  crusts. 
The  unruptured  vesicle  desiccates  first  at  its  central  summit. 
Lesions  which  are  ruptured  by  mechanical  force  give  exit  to  a 
fluid  which  forms  an  irregularly  shaped  crust. 

The  fluid  contained  in  the  vesicle  is  at  first  as  clear  as  water ; 
it  later  becomes  turbid,  and,  finally,  if  unruptured,  quite  puru- 
lent. During  these  changes  the  vesicle,  which  has  in  the 
beginning  a  "dew-drop-like"  appearance,  acquires  a  grayish 
or  vellowish  color. 

True  umbilication,  such  as  is  seen  in  the  early  small-pox 
vesicle,  does  not  occur  in  chicken-pox.  There  is  sometimes 
seen  a  pin-point-sized  invagination  of  the  surface  of  a  vesicle, 
due  to  the  presence  of  a  hair-follicle.  Commonly  there  is 
observed  a  central  sinking  in  of  some  of  the  vesicles  or  vesico- 
pustules, due  to  partial  evacuation  and  central  collapse.  This 
is  also  seen  in  the  late  pustular  stage  of  small-pox,  and  might 
be  called  a  secondary  umbilication. 

As  the  vesicles  of  chicken-pox  begin  to  dry,  there  not  infre- 
quently develops  a  flat,  vesicular,  spreading  ring  upon  the 
border  of  the  crust;  beneath  the  raised -up  horny  layer  is  a  little 
puriform  fluid.  The  lesions  may,  as  a  result  of  this  process, 
spread  to  the  size  of  a  silver  quarter  or  half-dollar.  This  con- 
dition is  extremely  common  in  small-pox,  and  has  been  called 
"impetigo  variolosa.11  The  process  being  the  same  in  chicken- 
3l 


4.82  DISEASES  OP  THE  SKIN 

pox,  the  condition  might  be  appropriately  designated  "impetigo 
varicellosa."  The  cause  of  these  spreading  sores  is  an  infection 
of  the  varicellous  sites,  with  streptococci  and  staphylococci 
present  upon  the  surface  of  the  skin.  In  extensive  eruptions, 
where  there  is  much  of  this  impetigo,  moderate  elevation  of 
temperature  may  develop,  giving  rise  to  a  secondary  fever. 

The  extent  of  the  varicellous  eruption  is  extremely  variable. 
The  total  number  of  lesions  in  some  cases  may  amount  to  but 
a  half-dozen ;  on  the  other  hand,  they  may  cover  almost  com- 
pletely the  entire  cutaneous  surface,  and  number  hundreds, 
or  even  thousands.  Thomas  says:  "As  many  as  eight  hundred 
have  been  counted  or  estimated."     In  a  copious  eruption  in 


a  young  boy  I  counted  1400  lesions;  shortly  afterward,  in  an 
older  lad  convalescent  from  scarlatina.  I  observed  a  much  more 
extensive  eruption,  in  which  3000  lesions  were  estimated  to 
be  present. 

While  neighboring  and  closely  set  vesicles  may  occasionally 
coalesce,  one  never  sees  a  confluence  of  the  lesions  such  as  is 
observed  in  small-pox, 

Scarring  after  Varicella. — It  is  not  uncommon  for  some 
varicella  lesions  to  be  followed  by  sears.  Indeed,  it  is  rather 
the  rule  for  patients  to  have  one  or  several  cicatrices  which 
persist  after  the  disappea ranee  of  the  eruption.  These  are 
from  piu-head-  to  pea-sized,  round  or  oval,  and  excavated  to 


CHICKEN-POX  483 

a  variable  degree.  In  severe  cases  the  number  may  reach  a 
half-dozen  or  a  dozen  or  more.  They  are  never,  however,  as 
numerous  as  is  seen  in  small-pox.  The  scars  result  from  a 
destruction  of  the  papillary  layer  of  the  true  skin;  this  may 
be  due  to  a  secondary  infection  as  a  result  of  scratching,  but 
it  may  occur  entirely  apart  from  this  cause.  Chicken-pox 
vesicles  at  times  break  down  early  and  produce  a  necrosis  of 
the  underlying  corium;  the  ulcer  left  heals  with  the  formation 
of  a  depressed  scar.  Occasionally  a  hypertrophic  scar  or  sort 
of  keloid  forms  at  the  site  of  these  losses  of  tissue. 

The  mucous  membranes  are  not  infrequently  the  seat  of  vari- 
cellous  lesions.  It  is  quite  common  to  find  a  few  vesicles  upon 
the  soft  and  hard  palate,  and  these,  in  doubtful  cases,  are  of 
diagnostic  importance.  Lesions  are  also  occasionally  noted 
upon  the  buccal  mucous  membrane,  tongue,  and  posterior 
pharyngeal  wall.  Situated  in  these  regions  the  flaccid  roof 
of  the  vesicle  soon  ruptures,  leaving  at  first  a  grayish  pellicle 
of  epithelial  d6bris,  and  later  a  circumscribed  superficial  abra- 
sion, surrounded  by  a  reddish  areola,  and  resembling  to  some 
extent  the  sore  of  aphthous  stomatitis.  The  eruption  in  the 
mouth  is  usually  scant,  even  in  cases  characterized  by  an  abun- 
dant cutaneous  outbreak. 

Varicella  in  Adults. — Varicella  is  certainly  not  so  rare  in 
adults  as  has  been  generally  maintained.  The  assertions  of 
many  writers  of  prominence  have  caused  varicella  in  adults 
to  be  regarded  as  a  rata  avis.  Thomas,  whose  teachings  are 
based  upon  a  large  and  well-digested  experience,  states:  "Vari- 
cella is  a  disease  of  childhood,  and  attacks  by  preference  young 
children  and  even  sucklings.  In  children  over  ten  years  of 
age  attacks  are  infrequent,  and  /  never  saw  an  adult  suffering 
from  varicella."  And,  again,  "the  predisposition  (to  varicella) 
is  wont  to  vanish  of  itself  spontaneously  about  the  eleventh 
year."  Von  Jiirgensen  remarks:  "With  regard  to  the  differ- 
ences between  variola  and  varicella,  it  is  important  to  state 
that  the  latter  is,  if  not  wholly,  yet  practically,  limited  to  the 
age  of  childhood — the  first  ten  years  of  life";  and,  further  on, 
"varicella  is  a  disease  which  is  quite  peculiar  to  the  age  of  child- 
hood." Jonathan  Hutchinson,  in  a  wide-spread  experience, 
saw  one  or  two  cases  about  the  age  of  twenty,  and  states  that 
"a  point  of  great  interest  in  varicella  is  the  almost  complete 
immunity  of  adults." 

Within  the  past  seven  or  eight  years  I  have  seen  about  25 


484  DISEASES  OP  THE   SKIN 

cases  of  varicella  in  adults,  the  oldest  patient  being  forty-eight 
years  old.  My  friend  and  colleague,  Dr.  William  M.  Welch, 
has  likewise  seen  a  considerable  number  of  cases. 

The  underestimated  frequency  of  chicken-pox  in  adults  is 
further  attested  by  the  figures  which  Wanklyn  presents  of  the 
cases  of  varicella  sent  to  the  diagnosing  station  of  the  Asylums 
Board  of  London  during  the  small-pox  epidemic  of  1901-02. 
Of  200  cases  of  chicken-pox  which  were  seen,  16.7  per  cent., 
or  33  cases,  were  over  eighteen  years  of  age. 


Wrll-markcd  chiclwn-poi   in   an   adult   man  (courtesy  of   Dr.  E.  \V. 


It  is  not  rare  for  adults  to  feel  ill  a  couple  of  days  before  the 
appearance  of  the  varicellous  eruption.  There  may  be  malaise, 
chilliness,  headache,  and  some  backache,  nausea,  and  moderate 
rise  of  temperature  to  101°  or  102 °  I".  These  symptoms  are 
similar  to  those  observed  in  small-pox,  but  are'  less  severe. 
High  fever,  intense  backache,  repeated  vomiting,  and  prostra- 
tion are  absent  in  chicken-pox.  Every  now  and  then  one  will 
see  cases  of  varicella  in  adults  in  which  quite  indurated  papules 
will  be  observed  on  certain  parts  of  the  body.      It  is  particularly 


CHICKEN-POX  485 

on  the  thick  skin  of  the  forehead  that  these  are  seen.  Typical 
varicellous  vesicles,  however,  will  be  found  elsewhere  upon 
the  cutaneous  surface.  A  significant  sign  in  many  of  these 
cases  is  the  presence  of  vesicles  here  and  there  which  have 
undergone  rapid  rupture  and  crusting,  with  the  production  of 
a  blackish  or  bluish-black  scab  depressed  in  the  center;  the 
borders  of  these  lesions  will  be  vesicular.  They  present  the 
appearance  of  having  been  excoriated  by  scratching. 

Complications  and  Sequelae  of  Chicken-pox. — Varicella  is 
attended  by  comparatively  few  complications.  It  is  extremely 
common  for  the  partially  dried  vesicle  to  spread  upon  the  border 
in  the  form  of  flat  pustules,  or  blebs  of  considerable  size  may 
be  formed,  which  dry  into  yellowish,  friable  crusts.  These 
spreading  pustules  may  attain  the  diameter  of  a  silver  half- 
dollar.  This  peripheral  extension  is  due  to  infection  of  the 
lesion  with  the  pyogenic  organisms  commonly  found  upon  the 
skin,  and  might  appropriately  be  designated  impetigo  varicel- 
losa.  Most  well-marked  cases  of  chicken-pox  show  some 
lesions  which  become  the  seat  of  impetigo. 

Trousseau  states  that  in  an  epidemic  of  chicken-pox  which 
prevailed  in  the  Necker  Hospital  the  fever  ceased  when  the 
malady  began,  and  during  from  fifteen  to  forty  days  pemphigoid 
blebs  appeared  on  different  parts  of  the  body,  leaving,  on  the 
surfaces  which  they  had  occupied,  ulcerations  exactly  like 
those  of  pemphigus,  which  ulcerations  continued  for  six  weeks 
or  two  months. 

As  a  result  of  pyogenic  skin  infection  the  neighboring  glands 
may  become  enlarged,  and  in  rare  cases  undergo  suppuration. 
Boils  and  subcutaneous  abscesses  may  occur  as  a  result  of  pyo- 
genic infection.  These  are  not  infrequently  seen  upon  the 
scalp,  although  any  portion  of  the  cutaneous  surface  may  be 
attacked. 

Erysipelas  and  pyemia  have  been  recorded  in  a  few  instances. 

Disseminated  Gangrene. — Literature  contains  numerous  refer- 
ences to  a  serious  complication  of  chicken-pox  which  was  called 
by  Hutchinson  varicella  gangrenosa.  This  gangrenous  con- 
dition is  not  to  be  regarded  as  a  variety  of  varicella,  or  even 
as  a  complication  peculiar  to  this  disease.  It  may  occur  also 
in  vaccinia,  variola,  scarlatina,  typhoid  fever,  and  in  various 
pustular  dermatoses;  it  is  true,  however,  that  it  most  com- 
monly complicates  varicella. 

In  mild  cases  but  one  or  several  varicellous  lesions  may 


DISEASES  OF    THE   5KIN 

i,         r,,.™,  ,s;  jn  more  extensive  cases  many  of  the  vesicles 

Tie  d.     The  vesicle  may  either  become  converted 

a  Diei/,      le  gangrenous  process  beginning  beneath   this 

lermal  ek-v  ition,  or  the  vesicle  may  dry  into  a  hard  crust 

enlarge  uj  >n  the  periphery.     Upon  removal  of  the  crust  a 

y  marriti.ated,   punched-out,   freely  discharging  ulcer  is 

A  du:      -red  areola  surrounds  the  ulcer  or  eschar.     In 

nsive  ca^j  the  temperature  rises  to  104  °  or  105  °  F.,  and 

patient   rapidly   sinks.     Lung  complications,    particularly 

lonary  infarction,  are  common.     Mild  cases  of  gangrene 

«lj   recover.     The  affection  is  most  common  in  debilitated 

infants,  more  especially  those  in  whom  the  varicella  is  preceded 

'  some  other  illness.      In  Griffith's  case  the  chicken-pox  was 

edcd  by  measles,  diphtheria,  and  pneumonia. 

ises  of  gangrenous  varicella  have  been  reported  by  Hutchin- 

,,  Demme,  Abercrombie,  Andrew,  Crocker,  Buchter,  Jamieson, 

weuhardt,    Payne,    Stanifooth,    Haward,    Vierordt,    Griffith, 

u„ckwood,  Silver,  Woodward,  and  others. 

Synovitis,  arthritis,    pleurisy,    nephritis,    laryngeal   stenosis, 
onchitis,  and  pneumonia  are  rare  complications. 
Etiology. — Chicken-pox    is    essentially    a    disease    of    early 
childhood,  although  it  occasionally  occurs  in  adult  life.     Sus- 
ceptibility is  not  influenced  by  race,  climate,  or  season.     Second 
attacks  of  the  disease  are  of  great  rarity. 

There  is  a  difference  of  opinion  as  to  the  inoculability  of 
varicellous  fluid,  although  Steiner's  attempts  are  alleged  to 
have  been  successful. 

Pathology. — Unna  excised  a  characteristic  "'chicken-pox" 
lesion  from  an  eight- year-old  boy  on  the  second  day  of  its 
existence.  The  following  description  is  condensed  from  Unna's 
detailed  findings. 

In  contrast  with  the  central  depression  in  the  variolous 
vesicle  the  vesicle  of  varicella  is  tent-shaped,  with  the  central 
point  at  the  summit.  The  lateral  walls  rise  obliquely  from  a 
broad  base  toward  the  roof,  which  is  formed  by  a  few  stretched 
horny  scales.  From  these,  cellular  partitions  radiate  down- 
ward as  in  small-pox.  The  chicken-pox  lesion  is  consequently 
divided  like  the  small-pox  lesion,  but  the  point  where  the  septa 
join  lies  not  in  the  center  of  the  base,  but  in  the  covering  or 
roof.  The  cavity  proper  occupies  only  the  upper  part  of  the 
much  widened  prickle -layer.  It  is  limited  beneath  by  the 
deeper   strata   of   the    prickle-layer,   which   show    pathologic 


CHICKEN-POX  487 

changes.  In  the  center  the  cavity  extends  downward  to  the 
papillae  of  the  corium,  which  are  swollen  and  enlarged  and 
which  project  into  the  cavity.  The  roof  of  the  vesicle  is  formed 
by  the  original  horny  layer,  with  the  addition  of  a  few  layers 
of  flattened  transitional  epithelium. 

The  degenerative  changes  in  the  cells  of  the  rete  mucosum 
are  typically  represented  in  varicella,  and  can  be  better  studied 
in  this  disease  than  in  variola,  for  in  the  latter  affection  the 
onset  of  suppuration  obscures  the  process.  The  early  pus- 
formation  and  the  slowness  of  the  process  are  the  chief  features 
which  distinguish  the  cavity  formation  in  small-pox  from  that 
in  chicken-pox. 

Extensive  fibrinoid  metamorplwsis  of  the  epithelium  takes 
place,  as  in  variola.  The  varicellous  process  commences  with 
reticulating  liquefaction  of  a  few  prickle-cells  of  the  central  and 
upper  prickle-cell  layer,  in  the  middle  of  the  first  appearing 
congestive  spot.  The  completely  liquefied,  confluent  cavities 
rapidly  dilate  to  form  the  vesicles;  the  persistent  unliquefied 
epithelium  is  compressed  to  form  the  septa,  as  are  the  cells  above 
to  form  the  cover.  While  this  separate  cavity  chiefly  enlarges  by 
swelling  upward,  the  ballooning  colliquation  proceeds  in  all  the 
epithelial  cells  of  the  base,  especially  at  the  center  of  the  pock, 
then  at  the  lateral  margin,  and  in  all  the  healthy  epithelial 
cells  of  the  center. 

Many  of  the  colliquated  cells  assume  the  form  of  peculiar 
giant-cells.  Even  the  septa  which  run  through  the  vesicle 
are  frequently  surrounded  by  ballooned  giant-cells.  At  the 
base  of  the  chicken-pox  lesion  the  balloons  form  a  loosely 
connected  covering  which  runs  over  the  central  papillary 
apices,  often  only  in  a  single  layer.  The  contents  of  the  vesicle 
at  the  height  of  its  development  consist  of  finely  granular  or 
coagulated  fibrin,  inclosing  a  few  fibrinously  degenerated, 
compressed  or  ballooned  epithelia,  and  almost  no  wandering 
cells.  The  cutis  shows  a  marked  dilatation  of  the  blood-vessels, 
a  moderate  serous  saturation,  and  a  considerable  enlargement 
and  multiplication  of  the  cells  about  the  vessels;  the  emigra- 
tion of  white  corpuscles  is  reduced  to  a  minimum. 

Notwithstanding  its  appearance,  the  vesicle  of  chicken-pox 
is  not  unilocular.  The  absence  of  resultant  scarring  is  due  to 
the  superficial  position  of  the  pock,  the  non-occurrence  of  sup- 
puration, and  the  early  repair  by  young  epithelial  cells. 

The  Diagnosis  of  Chicken-pox. — Small-pox. — Chicken-pox 


488  DISEASES  OF  THE  SKIN 

may  usually  be  distinguished  from  small-pox  without  much 
difficulty.  In  exceptional  instances,  however,  the  diagnosis 
may  present  perplexities  which  may  cause  even  a  physician 
experienced  in  these  diseases  to  delay  in  pronouncing  definitely 
as  to  the  nature  of  the  disease.  Errors  may  occur  through 
regarding  a  mild  small-pox  as  chicken-pox,  or  looking  upon  a 
severe  varicella  as  variola.  The  •  points  of  differential  impor- 
tance are  as  follows: 

The  Vaccinal  Condition  of  the  Patient. — If  a  child  under 
five  or  six  years  of  age  presents  an  eruption  which  exhibits 
features  both  of  chicken-pox  and  of  small-pox,  the  presence 
of  a  typical  vaccinal  cicatrix  would  constitute  strong  presump- 
tive evidence  against  the  variolous  nature  of  the  exanthem;  for 
successfully  vaccinated  children  of  this  age  do  not  acquire  small- 
pox save  under  rare  and  extraordinary  circumstances.  The 
same  evidence  would  obtain  in  an  adult  successfully  vaccinated 
within  a  similar  period  of  time. 

Initial  Symptoms. — The  appearance  of  the  small-pox  erup- 
tion is  preceded  two  or  three  days  by  an  illness  characterized 
in  its  most  complete  form  by  chills,  fever,  headache,  back- 
ache, vertigo,  nausea  and  vomiting,  prostration,  and  general 
pains.  The  more  severe  the  oncoming  eruption,  the  more 
pronounced  are  these  symptoms  apt  to  be.  The  syndrome  is 
often  incomplete,  the  invasive  illness  presenting  but  a  few  of 
the  above-mentioned  symptoms.  In  exceptionally  mild  cases 
one  may  not  be  able  at  all  to  elicit  a  history  of  a  prodromal 
stage.  It  is  extremely  uncommon,  however,  for  this  to  occur, 
and  the  existence  of  premonitory  symptoms  should  always  be 
regarded  as  of  great  differential  importance. 

Except  for  occasional  malaise,  a  half-day  or  so  before  the 
appearance  of  the  chicken-pox  eruption,  there  is,  in  the  vast 
majority  of  cases,  no  prodromal  stage. 

Constitutional  Symptoms. — The  fever  and  prostration  in  the 
eruptive  stage  are  usually  more  severe  in  small-pox  than  in 
chicken-pox.  This  is  not  an  invariable  guide,  however,  as 
severe  cases  of  varicella  may  be  accompanied  by  higher  tem- 
perature than  very  mild  cases  of  small-pox. 

Distribution  of  the  Eruption. — It  is  a  well-known  and  impor- 
tant fact  that  the  small-pox  eruption  attacks  with  predilection 
the  fact*  and  distal  portions  of  the  extremities.  Upon  the 
trunk,  and  especially  the  abdomen,  the  lesions  are  nearly 
always  more  sparse.  In  chicken-pox  the  eruption  is  usually 
most  profuse   on  the  trunk,  particularly  the  back,  and  rela- 


CHICKEN-POX  489 

tively  sparse  on  the  wrists,  hands,  feet,  and  face.  In  general 
it  may  be  stated  that  small-pox  prefers  the  exposed  surfaces 
and  chicken-pox  the  covered. 

It  has  been  stated  that  chicken-pox  does  not  attack  the 
palmar  and  plantar  surfaces.  This  statement  is  erroneous, 
inasmuch  as  the  palms  of  the  hands  and  soles  of  the  feet  are 
every  now  and  then  attacked  in  pronounced  cases.  Of  course, 
one  never  sees  such  a  profusion  of  lesions  in  these  regions  as  is 
observed  in  small-pox. 

Extent  of  the  Eruption. — The  number  of  lesions  upon  the  skin 
should  not  be  regarded  as  important  evidence.  I  have  seen 
an  unvaccinated  child  with  but  five  variolous  lesions  upon  the 
entire  cutaneous  surface.  On  the  other  hand,  I  have  noted 
the  presence  of  1400  lesions  in  one  case  of  chicken-pox,  and 
3000  in  another. 

Character  of  the  Lesions. — In  small-pox  the  eruption  begins 
as  firm  papules,  which  slowly  increase  in  size  and  develop  into 
vesicles  and  pustules.  Not  all  variolous  papules  are  shotty, 
but  they  are  more  deeply  seated  and  have  a  more  infiltrated 
base  than  the  chicken-pox  lesions.  The  variolous  vesicles  are 
often  harder  than  the  papules.  They  are  moderately  uniform 
in  size,  and  are  often,  although  by  no  means  always,  umbilicated. 
The  vesicles  are  multilocular,  and  difficult  to  rupture  with  the 
finger-nail. 

Chicken-pox  lesions  may  begin  as  maculopapules,  but  within 
a  few  hours  become  frankly  vesicular.  The  epidermal  roof  is 
thin  and  easily  broken,  permitting  the  exit  of  a  clear,  watery 
serum.  With  the  collapse  of  the  vesicle  the  infiltration  seems 
to  disappear  and  a  superficial  excoriation  is  often  left.  Chicken- 
pox  lesions  vary  greatly  in  size,  some  being  as  small  as  a  millet- 
seed  and  others  as  large  as  a  finger-nail.  They  do  not  become 
umbilicated,  save  by  central  caving  in  or  desiccation.  The 
early  drying,  with  the  production  of  a  depressed,  blackish  crust 
in  the  center  and  irregular  puckering  of  the  vesicle  or  pustule 
on  the  periphery,  is  highly  characteristic  of  chicken-pox. 

It  is  not  rare,  in  an  extensive  eruption  of  varicella,  to  find 
one  or  several  vesicles  which  resemble  variolous' vesicles,  and, 
on  the  other  hand,  in  small-pox  occasionally  to  see  a  few  super- 
ficial vesicles  which  resemble  those  of  small-pox. 

Manner  of  Eruption. — The  eruption  of  small-pox  comes  out 
without  interruption  in  the  course  of  twenty-four  to  forty- 
eight  hours.  The  lesions  show,  therefore,  a  quite  uniform 
development.     (It   should   be    remarked,    however,    that   the 


dl       ■  face  is  always  a  little  in  advance  of  the  develop- 
....   — ewnere.)     The   chicken-pox   eruption   comes   out   in 
3S  on  successive  or  alternate  days,  and  the  lesions  may  be 
.1  in  varying  stages  of  development.     The  coexistence  of 
ent  tense  vesicles,  older  puckered  vesicopustules,  and  dried 
lists  is  highly  characteristic  of  the  disease. 
Course  oj  the  Eruption. — Small-pox  lesions  undergo  a  gradual 
>lution  from  papule  to  crust  in  the  course  of  ten  to  twelve 
's— in  modified  cases,  five  to  six  days.     Chicken-pox  lesions 
from  two  to  four  days  and  then  crust.     The  crusts  of  small- 
are  dense  and  compact,  while  those  of  chicken-pox  are  thin 
friable.     The    presence    of   numerous    hard,    mahogany- 
red  crusts  embedded  in  the  horny  layer  of  the  palms  and 
5  bespeaks  small-pox. 
there  is  no  one  characteristic  svniptom  on  which  a  differ- 
ential diagnosis  between   small-pox   and  chicken-pox   can   be 
based.     The  case  is  to  be  viewed  in  all  its  aspects,  and  a  diagno- 
sis made  from  the  history  and  the  associated  local  and  consti- 
tutional manifestations.     A  due  sense  of  proportion  should  be 
'ifrciscd    in  attributing   proper    weight    to  the  presence  and 
lence  of  the  various  symptoms.      Even  when  this  is  done, 
tnere  are  occasional  cases  in  which  twenty-four  hours'  delay 
and  observation  are  desirable  in  order  definitely  to  establish 
the  diagnosis. 

Impetigo  Contagiosa. — If  chicken-pox  is  seen  after  the  desic- 
cation of  the  vesicles,  the  disease  may  be  confounded  with 
impetigo.  Indeed,  impetigo  is  commonly  ingrafted  upon  a 
varicella,  in  which  event  the  lesions  spread  upon  the  borders 
in  the  form  of  a  vesicular  ring,  fmpetigo  contagiosa  is  char- 
acterized by  the  formation  of  vesicles  or  blebs  which  rapidly 
become  pustular,  rupture,  and  form  superficial  crusts.  The 
face  is  the  seat  of  predilection,  and  is  usually  exclusively  affected, 
although  the  hands,  and  in  rare  cases  the  trunk,  may  present 
lesions.  The  vesicles  are  thin  roofed  and  flaccid,  seldom 
exhibiting  the  tenseness  of  varicella  vesicles.  The  patient, 
as  a  rule,  suffers  no  constitutional  disturbance.  The  mucous 
membrane  of  the  mouth  is  exempt.  The  lesions  do  not  appear, 
as  in  varicella,  in  several  crops,  but  increase  irregularly  as  a 
result  of  finger  inoculation.  The  disease  is  caused  by  inocula- 
tion of  the  skin  with  certain  pyogenic  organisms. 

Varicella  runs  a  briefer  course,  and  the  lesions  disappear  in 
a  short  time  without  local  treatment;  the  existence  of  ante- 
cedent cases  of  chicken-pox,  or  the  development  of  later  ones 


CHICKEN-POX  491 

after  an  interval  of  two  weeks,  constitutes  strong  corroborative 
evidence. 

Prognosis. — Chicken-pox  is,  with  the  possible  exception 
of  rubella,  the  mildest  of  the  acute  exanthematous  diseases. 
As  Trousseau  remarks,  patients  never  die  of  varicella  per  set 
although  deaths  in  rare  instances  have  occurred  from  compli- 
cations. 

Treatment. — The  constitutional  symptoms  of  varicella 
are  ordinarily  so  mild  as  to  require  no  internal  treatment. 
Where  there  is  febrile  disturbance,  children  should  be  kept 
in  bed  and  upon  a  bland  diet. 

The  local  treatment  is  of  considerable  importance.  To  pre- 
vent scars,  the  best  local  application  for  facial  lesions  is  tincture 
of  iodin  diluted  one-half  with  alcohol.  This  should  be  painted 
upon  the  lesions  daily.  When  the  vesicles  become  distended 
with  pus,  particularly  those  upon  the  face,  they  should  be 
evacuated  and  cleaned  with  a  weak  antiseptic  solution.  The 
following  ointment  will  be  found  useful  in  preventing  secondary 
infection  of  the  lesions: 

H.     Acidi  carbolici gr.  x; 

Hydrargyri  chlorid.  mit gr.  xv; 

Pulv.amyli         \ u     .. 

Pulv.  zinci  oxidi  J  °  «" 

Petrolati 3ss. — M. 

As  has  already  been  stated,  some  chicken-pox  lesions  are 
followed  by  indelible  scars;  these  may  be  due  to  an  early 
necrosis  involving  the  papillary  layer  of  the  skin,  in  which  event 
they  cannot  be  prevented.  In  other  cases  the  scars  are  due  to 
a  slow  ulceration,  the  result  of  pyogenic  infection  of  the  lesions. 
Scratching  is  liable  to  produce  scars  by  infecting  the  skin.  In 
young  children  the  finger-nails  should  be  closely  trimmed  to 
prevent  traumatism  from  scratching;  when  scratching  cannot 
be  otherwise  controlled,  the  hands  should  be  inclosed  in  muslin 
bags  attached  firmly  about  the  wrists,  or  the  elbows  should  be 
immobilized  by  splints.  Doubtless  the  rare  cases  of  varicella 
gangrenosa  are  due  to  infection  of  the  skin.  It  is  important 
to  keep  the  hands  and  the  entire  body  scrupulously  clean. 

To  relieve  the  itching,  which  is  not  infrequently  present, 
the  following  lotion  will  be  found  efficacious: 

R.     Acidi  carbolici gr.  xxx-^j ; 

Glycerini 2 J I 

Spirit,  vini  rect ^Q^'* 

Aquae q.  s.  ad  fgvj. — M. 

Sig. — Use  locally. 


Deflnitio"  -Scarlatina  is  an  acute,  specific,  infectious 
se,  chsi  terized  by  a  sudden  onset  with  high  fever,  head- 
„,  vora  g,  and  sore  throat,  followed  on  the  second  day  by 
eneralizea  punctiform  rash  which  later  gives  rise  to  destina- 
tion. 

here  is  a  tendency  to  the  development  of  cervical  abscess, 
uutis  media,  and  nephritis.  One  attack  usually  confers 
mmunity   for  a   life-time. 

Etiology. — Although   the  identity  of  the  causative  agent 
of  scarlet  fever  has  not  been  definitely  established,  there  can 
no  doubt  that  the  disease  is  due  to  a  microparasite.     The 
ise  is.  as  a  rule,  directlv  contracted  from  a  patient  suffering 
.11  the  disease,  but  may  be  conveyed  by  a  third  person  or  by 
?cted    objects.     The    scarlet    fever    contagiuni    may    cling 
■iciously,  and  for  a  long  period  of  time,  to  the  sick-room 
to  the  articles  contained  therein.     The  susceptibility  to 
scarlet  fever  is  by  no  means  as  universal  as  that  which  exists 
toward  small-pox  and  measles.     Many  children  escape  scarlet 
fever,  although  intimately  exposed  to  it;  at  some  subsequent 
exposure  the  disease  may  be  contracted.     Infants  under  one 
year  of  age,  and  more  especially  those  under  six  months,  exhibit 
a  lessened  disposition  to  acquire  the  disease.     Adult  life  confers 
a  relative  immunitv,  the  vast  majority  of  persons  of  this  age- 
period  failing  to  take  the  disease.     Children  from  two  to  five 
years  appear  to  offer  the  greatest  susceptibility.     In  this  country 
scarlet  fever  is  most  prevalent  during  the  late  winter  and  early 
spring  months.     Negroes  are  less  susceptible  to  scarlet  fever 
than  whites,  and  the  mortality -rate  among  them  is  lower  than 
in  the  Caucasian  race. 

Scarlet  fever  has  been  inoculated  with  mucus  from  the  mouth 
and  throat  of  scarlatinal  patients;  it  seems  thus  proved  that 
these  cavities  harbor  the  causa  causans  of  the  disease.  The 
presence  of  the  infectious  principle  in  the  skin  has  not  been 
proved. 

The  scarlatinal  poison  is  ordinarily  received  into  the  system 
through  the  upper  air-passages;  it  is  believed  by  many  that  the 
throat,  especially  the  tonsils,  constitutes  the  chief  channel  of 


SCARLET   FEVER  493 

infection.  It  would  seem  .that  the  genital  tract  in  puerperal 
women  and  cutaneous  wounds  may  also  offer  avenues  of  ingress. 
Surgical  operations  about  the  mouth,  nose,  and  throat  are  not 
infrequently  followed  by  scarlet  fever.  Cutaneous  burns 
apparently  increase  susceptibility  to  this  disease. 

Symptomatology. — The  period  of  incubation  is  ordinarily 
between  three  and  seven  days,  although  in  rare  cases  it  may 
be  only  twenty-four  hours,  or,  on  the  other  hand,  longer  than 
a  week. 

The  onset  of  the  disease  is  sudden.  The  earliest  symptoms 
are  indisposition,  fever,  headache,  vomiting,  and  sore  throat. 
In  children  vomiting  is  the  earliest  as  well  as  the  commonest 
of  the  invasive  symptoms.  Older  persons  often  complain 
first  of  sore  throat.     Convulsions  may  occur  in  infants. 

The  temperature  rises  rapidly,  often  reaching  1020  to  io4°F. 
or  more,  in  the  course  of  a  few  hours.  The  fever  remains  high 
(1040  F.  or  thereabouts)  until  the  eruption  has  fully  developed. 
With  the  fading  of  the  rash  there  is  a  gradual  decline  in  the 
temperature.  Severe  cases  may  be  accompanied  by  hyper- 
pyrexia, the  thermometer  registering  105  °  or  106  °  F.  On  the 
other  hand,  in  mild  cases  there  may  be  but  slight  elevation  of 
temperature.  The  pulse  increases  in  frequency  and,  compared 
with  the  temperature,  is  often  disproportionately  rapid.  The 
radial  pulsations  may  number  in  children  140  to  160  a  minute, 
and  in  adults,  120  to  140. 

Headache  and  vertigo  are  common,  and  the  patient  may  be 
alternately  somnolent  and  restless.  Thirst  is  often  intense. 
The  patient  is  greatly  prostrated,  and  presents  the  facies  of  a 
very  sick  person.  The  skin  is  hot  and  dry,  the  eyes  dull  and 
listless,  and  the  face  flushed. 

Sore  throat  is  an  early  and  prominent  symptom.  On  inspec- 
tion, general  faucial  redness  is  observed,  involving  particularly 
the  uvula,  tonsils,  and  soft  palate.  When  the  cutaneous 
eruption  begins  to  manifest  itself,  the  redness  increases  and 
there  develop  edema  and  swelling  of  the  mucous  tissues.  At 
times  a  thin,  grayish  or  yellowish  film  of  exudate  may  be  seen 
on  the  swollen  tonsils.  Often  the  soft  palate,  uvula,  and  buccal 
mucous  membrane  show  a  punctated  redness  similar  to  that 
later  observed  upon  the  skin.  In  mild  cases  nothing  may  be 
seen  save  a  general  redness. 

The  tongue  is,  as  a  rule,  heavily  covered  with  a  grayish- white 
fur  at  the  onset  of  an  attack  of  scarlatina.     Soon  the  tip  and 


494  DISEASES  OF  THE  SKIN 

edges  assume  an  angry,  reddish  coloration,  and  a  roughened 
or  granular  appearance. 

At  this  time  also  the  fungiform  papillae  on  the  dorsal  surface 
of  the  tongue  become  swollen  and  prominent,  and  peep  through 
the  surface  coating.  Usually  on  the  fourth  day  or  thereabouts 
lingual  desquamation  takes  place,  and  the  coating  is  cast  off, 
disclosing  to  view  a  red,  raw  looking,  often  glazed  surface, 
studded  with  enlarged  papilhe. 

At  times  the  papillary  elevations  are  numerous  and  small, 
looking  like  the  granulations  in  a  wound.  At  other  times  they 
are  scattered  and  more  prominent.     This  condition  of  the  tongue 


is  of  considerable  diagnostic  importance,  and  has  been  variously 
described  as  the  "raspberry,"  "strawberry, "  or  "cat's  tongue-" 
It  should  be  remembered,  however,  that  mild  cases  of  scarlatina 
occasionally  exhibit  no  abnormalitv  of  the  tongue  whatsoever. 
If  the  gums  are  inspected  from  the  second  lo  the  fifth  day, 
there  will  oftentimes  be  seen  milk-white  (Hitches  which  look 
much  as  if  they  had  been  produced  by  the  application  of  pure 
carbolic  acid.  These  represent  a  desquamation  of  the  epithelial 
covering  of  the  gingival  mucous  membrane,  and  can  readily 
be  peeled  off  by  slight  friction.  This  process  occurs  at  times 
in  measles,  and  perhaps  also  in  other  infections  in  which  there 
is  congestion  of  the  oral  mucous  membrane. 


SCARLET   FEVER  495 

The  Stage  of  Eruption. — The  rash  usually  appears  within 
twenty  hours  of  the  onset  of  the  illness.  The  exanthem  of 
scarlet  fever  ordinarily  begins  upon  the  neck  and  subclavicular 
regions,  and  then  spreads  rapidly  to  the  chest,  face,  abdomen, 
arms,  and  legs.  A  variable  time  elapses  in  different  cases 
before  the  acme  of  the  eruption  is  reached.  The  milder  efflores- 
cences reach  their  height  earlier  than  those  of  greater  intensity. 
In  severe  cases  the  rash  may  take  until  the  third  or  fourth  day 
before  its  greatest  intensity  is  attained. 

The  color  of  the  scarlatina  exanthem  varies  in  different 
individuals,  and  is  extremely  difficult  to  depict  in  words.  It 
has  been  variously  designated  by  writers  as  scarlet,  bright-red, 
boiled-lobster  tint,  raspberry- juice  color,  rose-colored,  wine- 
colored,  etc.  It  is  a  matter  of  daily  observation  that  the  rash 
in  fair-skinned  persons  is  brighter  than  in  those  of  swarthy 
complexion,  whose  skin  contains  a  greater  amount  of  epidermal 
pigment.  In  general,  the  scarlatinal  rash  is  reddish,  sometimes 
bright,  but  more  often  dull  or  dusky  red.  Sometimes  the 
eruption  is  so  brownish-red,  particularly  in  dark-complexioned 
individuals,  as  to  almost  approach  a  bright  terra-cotta  tint. 
More  rarely  the  element  of  blue  is  so  well  marked,  particularly 
in  dependent  areas  of  skin,  as  to  be  quite  purplish,  owing.tb  the 
venous  congestion.  The  color  varies  not  only  in  different 
persons,  but  at  different  periods  in  the  same  individual.  A 
bright  eruption  commonly  becomes  dusky  before  it  fades— 

When  the  scarlatinal  exanthem  is  viewed  at  a  little  distance, 
it  gives  the  impression  of  a  uniform  reddish  blush.  When, 
however,  the  skin  is  closely  scrutinized,  it  is  seen  that  it  is  made 
up  of  innumerable  reddish  points  or  puncta.  They  are  of  a 
deeper  tint  than  the  skin  intervening  between  them. 

At  times  eruptions  are  seen  in  which  the  skin  between  the 
puncta  is  of  normal  coloration.  This  appearance  may  occa- 
sionally be  noted  during  the  evolution  of  the  exanthem.  Ordi- 
narily the  points  of  greatest  color  intensity  are  surrounded  by 
areolae  of  somewhat  brighter  hue.  When  these  coalesce,  as  is 
usually  the  case,  a  diffuse  eruption  is  presented,  the  puncta 
being  scarcely  distinguishable  through  the  obliteration  of 
contrast.  At  times  the  areolae  are  narrower,  exhibiting  a 
little  intervening  normal  skin  and  giving  the  eruption  a  more 
or  less  speckled  appearance.  In  other  cases,  with  larger  pale 
areas,  a  mottled  appearance  is  noted.  Finally,  there  may 
exist  large,  irregular  patches  of  healthy  skin,  particularly  on 


496 


DISEASES  OF  THE  SKIN 


the  arms,  legs,  and  buttocks,  producing  so  marked  a  blotchiness 
of  the  exanthem  as  to  suggest  a  stronger  semblance  to  measles. 

The  scarlatinal  eruption  frequently  exhibits  small  pin-point- 
to  pin -he  ad- sized,  reddish  elevations,  which  occur  most  com- 
monly at  the  sites  of  hair- follicles.  These  are  frequently  seen 
upon  the  extremities,  particularly  the  lower,  but  may  also 
appear  upon  the  trunk.  This  condition  was  called  by  the 
older  writers  scarlatina  papulosa. 

In  addition  to  these  elevations  a  general  goose-flesh  condition 
of  the  skin  is  not  infrequently  observed.  This  is  best  marked 
upon  the  abdomen  and  chest,  and  is  characterized  by  numerous 
pin -head -sized    papules    bearing   a    close    resemblance    to    the 


skin  by  exposure  to 
papules  may  lx-  faintly 


either  extreme  of  temperature.  Those  papules  may  lx-  faintly 
red  or  of  the  normal  skin  hue.  They  differ  from  ordinary 
goose-flesh  in  that  they  persist  usually  for  some  (lavs.  At 
times  this  condition  is  so  pronounced  as  to  imparl  to  the  skin 
a    "nulmejj-jrrater"   feel   and   appearance. 

In   the  older  descriptions  of  scarlel    lever  one  reads  of  the 


l-developed 


iima  at  the  heigh)  01  uie  i-nioi 
.his  stage  the  skin  is  hot  and  dry, 
.  one  would  not  expeol  1m  find  sud 
extremely  common,  however,  t. 


ads  of  the 

ith  no 


find   in 

To  (his 


SCARLET  FEVER  497 

condition  the  term  scarlatina  miliaris,  or  scarlatina  vesicularis. 
has  been  given.  The  vesicles  are  conical,  epidermal  elevations 
pin-point-  to  pin -head -sized  (size  of  mil  let- seed) ,  with  turbid  01 
lactescent  contents  and  usually  disseminated,  although  occasion- 
ally occurring  in  groups.  They  are  commonly  situated  on  the 
abdomen  and  chest,  and  to  a  lesser  extent  on  the  extremities. 
The  region  in  which  they  are  frequently  most  copiously  present 


is  the  mons  veneris,  for  here  the  erythema  is  often  intense. 
In  this  region  they  are  prone  to  develop  into  minute  but  well- 
marked  yellowish  pustules. 

Rarely,  contiguous  vesicles  may  coalesce,  forming  blebs  of 
the  size  of  a  pea  or  larger,  constituting  the  scarlatina  pern- 
phigoidea  of  the  older  writers. 

Miliary  vesicles  may  be  seen  in  nearly  all  we  11 -pronounced 
scarlet-fever  eruptions.     They  are  much  more  frequent  than 


DISEASES  OP  THE  SKIN 

pposed,  being  often  overlooked  on  account  of 

proportions.     A     magnify  in  g-glass     will    often 

tnem  into  view  when  they  are  not  clearlv  perceived  by 

unaided  eye.     The  vesicles  are  more  conspicuous  in  severe 

ions   +i,an    in    mild    rashes.     In    decidedly    exceptional 

es        "  may  be  so  pronounced  as  to  overshadow  the 

~..li  scan    inal  exanthcm  and  puzzle  the  physician  in  the 

sis. 

..ing  the  period  of  fading  and  decline  of  the  eruption, 

-•-sized  or  larger  Hat  ep'^ermal  elevations  are  often  noted. 

"="  are  whitish,  and  suggest  sudamina,  the  contents  of  which 

v     seen  absorbed,  for  one  seldom,  if  ever,  discovers  fluid  in 

m.     They  may  be  readily  opened  with  a  needle  and  resemble 

y  pea-pods.     The  exfoliation   of  the   summits  of  these 

us  and  of  the  miliary  vesicles  constitutes  the  beginning 

ucn^uamation  on  the  trunk. 

The  character  of  the  eruptwn  on  the  face  varies  somewhat. 
In  some  cases  this  region  remains  entirely  free.     More  commonly 
e  temples  and  cheeks  are  the  seat  of  a  deep-red  flush;  it  is 
bable  that  this  flushing  is  often  associated  with  the  true 
.i,  for  it  is  not  rare  to  see  the  face  desquamate  profusely, 
i  ne  forehead  often  shows  redness,  but  this  is  usually  less  intense 
than  on  the  lateral  aspects  of  the  face.     The  tip  and  alas  of  the 
nose,  the  upper  and  lower  lips  and  the  chin  commonly  appear 
preternaturally  pale.     This  circumotal  pallor;  defined  by  the 
marked  flushing  of  the  cheeks,  gives  the  patient  a  most  curious 
appearance,  which,  if  not  peculiar  to,  is  always  strongly  sugges- 
tive of,  scarlet  fever. 

On  the  arms  and  legs  the  rash  exhibits  no  peculiarities  save 
its  likelihood  early  to  involve  the  flexures  of  the  joints  (groins, 
popliteal  space,  and  elbow  flexures)  and  its  greater  tendency 
to  be  blotchy.  Upon  the  palms  and  soles  the  eruption  is  usually 
diffusely  red,  without  any  puncta. 

When  pressure  is  made  upon  the  scarlatinal  rash,  a  momentary 
pallor  is  produced,  then  a  return  of  redness,  and  finally  a 
gradual  paling  again,  which  persists  for  some  minutes.  I  have 
seen,  on  the  legs,  pale  bands  persist  where  garters  had  pre- 
viously been  worn.  Indeed,  one  may  inscribe  a  name  upon 
the  efflorescence  with  a  blunt  instrument,  and  in  a  few  moments 
note  the  white  letters  stand  out  upon  a  red  background. 
This  is  the  reverse  of  the  ordinary  dermographism,  and  might 
be  termed  anemic  dermographism.     This  is  a  vasomotor  pecu- 


SCARLET   PEVBR 


499 


liarity,  but  it  is  doubtful  whether  it  possesses  any  reliable 
diagnostic  value. 

Itching  is  not  infrequently  experienced  by  scarlet  fever 
patients.  While  in  most  cases  it  is  insignificant  or  entirely 
absent,  it  is  occasionally  quite  severe.  It  may  be  noted  during 
the  early  evolution  of  the  eruption,  at  its  height,  or  during  the 
decline,  just  before  desquamation  sets  in. 

In  intense  eruptions  there  is  often  some  edema  and  swelling 
of  the  skin,  accompanied  by  an  exaggeration  of  the  lines  of 


&  ri 


Fie.  uo. — Scarlet  fever — desquamation  upon  face.     This  developed  on  the  fourth 
day  (Welch  and  Schamberg). 

cleavage.  The  skin,  under  such  circumstances,  is  thickened 
and  shows  wrinkling  of  the  epidermis. 

On  the  other  hand,  the  eruption  may  be  so  mild  as  to  make 
the  diagnosis  difficult  and  even  impossible.  Indeed,  in  rare 
cases  the  eruption  may  be  absent  altogether. 

The  eruption  persists  at  its  maximum  intensity  but  for  a  brief 
period — from  a  few  hours  to  a  day  or  two — and  then  gradually 
fades.  Much  variation  is  shown  as  to  the  entire  duration  of 
the  exanthem ;  ordinarily  the  eruption  lasts  from  three  to  seven 


5«> 


DISEASES  OF  THB  SKIN 


days,  but  its  duration  may  be  shorter  or  longer  than  this  period. 
Cases  doubtless  occur  in  which  the  eruption  is  of  such  brief 
duration  as  to  escape  notice  entirely ;  instances  of  scarlet  fever 
without  eruption,  but  followed  by  desquamation,  are  probably 
to  be  accounted  for  by  evanescent  undiscovered  eruptions. 


ll 


Fig.   mi. — Scarlet  fever — desquamation  upon  neck  ( 

In  some  cases  a  temporary  jading  or 
occurs.  It  is  not  rare  for  the  exanlhem  to  be  more  vivid  in 
color  at  certain  times.  The  rash  is  not  infrequently  brighter 
in  the  evening  than  during  the  day.  It  is  more  rare  for  the 
eruption  to  recede  completely  and  later  reappear. 


SCARLET    FEVBR 


50I 


Desquamation. — Desquamation  begins  upon  those  parts  Ot 
the  cutaneous  surface  which  were  first  the  seat  of  the  exanthem. 
Where  the  face  has  presented  much  eruption,  or  even  intense 
flushing,  a  branny  desquamation  will  often  be  noted  as  early 
as  the  fourth  day.  Almost  simultaneously  a  similar  epidermal 
exfoliation  occurs  upon  the  neck  and  upper  portions  of  the  chest. 
This  process  is  commonly  inaugurated  about  the  sixth  or  seventh 
day  of  the  disease. 


If  one  watches  for  the  first  evidence  of  desquamation  on  the 
trunk,  it  will  be  noticed  as  a  number  of  discrete,  pin-point- 
sized,  powdery  scales.  These  represent  the  desiccated  summits 
of  the  miliary  vesicles.  In  a  day  or  two  these  small  scales  are 
cast  off,  leaving  minute,  jagged  rings  of  desquamation.  The 
horny  layer  is  now  lifted  off  by  centrifugal  extension  of  these 
rings,  which  grow  progressively  larger.  On  meeting  enlarging 
rings  of  neighboring  lesions  they  produce  gyrate  and  geographic 


S02 


DISEASBS  OF  THE  SKIN 


configurations  resembling  the  contours  of  maps.  In  this  man- 
ner the  upper  layer  of  the  corneous  stratum  is  removed. 

Upon  the  hands  and  feet  the  desquamation  is  of  quite  a 
different  character.  Here  the  horny  layer  is  shed,  either  in 
large  flakes  or  more  rarely  en  masse,  with  the  result  that  a 
partial  or  complete  epidermal  cast  is  thrown  off,  resembling 
a  glove  or  a  slipper.  It  is  seldom  that  these  epidermal  gloves 
remain  intact  until  complete  exfoliation  unless  the  hands  are 
kept  bandaged. 

The  most  typical  and  characteristic  scarlatinal  peeling, 
however,  is  that  which  begins  about  the  free  border  of  the  nail. 


Fig-   2*3- — Scarlel  fever — profi 


Just  beneath  the  edge  of  the  nail  a  Assuring  or  cleavage  of  the 
horny  layer  takes  place,  the  latter  being  stripped  back  toward 
the  finger-tip  and  thence  up  the  finger.  The  peeled  portion  of 
the  finger  exhibits  to  view  the  new,  soft,  pinkish  skin,  whereas 
beyond  is  seen  the  harsh,  horny  cuticle.  This  desquamation. 
originating  in  subungual  cleavage  of  the  epidermis,  is  of  con- 
siderable diagnostic  import;  it  is  seen  also  upon  the  toes,  but 
not  so  well  pronounced. 

Before  desquamation  begins  upon  the  hands  the  skin  becomes 
harsh,  dry,  and  wrinkled.  The  occurrence  of  peeling  may,  by 
attention  to  this  condition,  be  determined  in  advance. 


SCARLET   FEVER 


503 


In  some  cases,  particularly  when  the  rash  is  extremely  mild, 
desquamation  may  be  so  slight  as  scarcely  to  be  perceptible. 
Indeed,  in  rare  cases  it  may  be  entirely  lacking. 

On  the  other  hand,  it  may  be  so  intense  as  to  resemble  the 
affection  known  as  exfoliative*  dermatitis.  This  is  the  form 
which  is  apt  to  be  attended  with  exfoliation  of  large  strips  of 
epidermis  and  casts  of  the  feet  and  hands.  Other  epidermal 
structures,  such  as  the  hair  and  nails,  occasionally  become 
affected,  in  which  event  the  hair  and  nails  are  shed.     Where 


the  nails  are  not  actually  thrown  off,  they  may  show  a  trans- 
verse furrow,  which  in  the  course  of  time  grows  out  of  the  free 
edge. 

The  duration  of  desquamation  cannot  be  stated  in  definite 
terms,  as  it  is  subject  to  the  greatest  variation.  There  are 
mild  cases  in  which  no  desquamation  can  be  detected  after 
two  weeks.  On  the  other  hand,  severe  cases,  and  even  mild 
cases,  may  continue  to  desquamate  for  seven,  eight,  or  nine 
weeks.     Indeed,  where  the  rash  has  been  intense,  a  second 


504  DISEASES   OF   THE    SKIN 

and  third  scaling  may,  in  rare  cases,  occur  after  the  first  desqua- 
mation has  been  completed.  The  average  duration  of  desqua- 
mation is  about  six  weeks. 

If  the  skin  is  closely  inspected  during  the  height  of  the 
eruption,  distended  cutaneous  capillaries  will  often  be  found 
to  be  visible  to  the  naked  eve.  It  is  not  uncommon  in  intense 
rashes  to  note  the  presence  of  scanty,  claret-colored,  petechial 
extravasations  into  the  skin.  These  are  noted  particularly 
in  regions  where  the  skin  is  thin  and  tender,  such  as  on  the 
neck,  axillary  folds,  inner  sides  of  the  arms,  flexors  of  joints, 


etc.  These  hemorrhages  betoken  intensity  of  the  eruption 
rather  than  malignity  of  the  infection. 

Lymphatic  Glands. — Intumescence  of  the  lymph-glands  may 
be  regarded  as  an  almost  constant  accompaniment  of  scarlet 
fever.  The  subcutaneous  lymph-nodes  in  the  maxillary,  sub- 
maxillary, cervical,  axillary,  inguinal,  and  epitrochlear  regions 
are  all  enlarged.  The  lymphoid  tissues  of  the  liver,  spleen, 
and  intestines  are  likewise  hvperplastic. 

In  anginose  scarlet  fever  there  is  an  excessive  development 
of  all  the  symptoms,  the  throat  changes  being  characterized 
by  particular  severity.  High  temperature,  prostration,  and 
marked  nervous  symptoms  are  observed.     The  throat  is  in- 


SCARLET   FEVER  505 

tensely  inflamed  and  covered  with  a  dark,  membranous  deposit. 
A  mucopurulent  discharge  commonly  issues  from  the  nose. 
Otitis  media  with  suppuration  occurs  early;  the  glands  of  the 
neck  are  tremendously  swollen.  Ulceration  and  necrosis  of 
the  mucous  membrane  of  the  mouth  and  throat  may  take  pla.ce. 
The  rash  in  these  cases  is  apt  to  be  intense. 

In  malignant  scarlet  fever,  fortunately,  a  rare  disease,  the 
onset  is  sudden,  with  extremely  high  temperature  and  pro- 
found nervous  symptoms.  The  patient  is  often  overwhelmed 
by  the  poison  at  the  onset.  The  throat  symptoms  are  severe. 
The  rash  is  irregular  in  distribution;  it  is  sometimes  livid  and 
beset  with  petechiae  and  yibices.  In  rare  cases  death  may  occur 
before  the  appearance  of  an  eruption. 

Hemorrliagic  scarlet  fever  is  ushered  in  by  high  fever,  severe 
prostration,  and  marked  brain  symptoms.  A  dusky  red  ery- 
thema, usually  imperfectly  developed,  is  seen  upon  the  skin, 
and  is  soon  followed  by  the  appearance  of  scattered,  wine- 
colored  or  purplish,  pin-head-  and  larger  sized  petechiae  and, 
later,  ecchymoses.  Bleeding  occurs  from  the  various  mucous 
membranes. 

Partial  Eruptions. — In  some  very  mild  cases  the  exanthem 
may  be  poorly  developed  and  limited  to  certain  regions  of  the 
body.  The  associated  fever  and  angina  are  often  correspond- 
ingly slight.  Gregory  saw  cases  in  which  the  exanthem  appeared 
only  on  the  thighs.  Thomas  speaks  of  cases  in  which  it  is 
limited  to  one  side  of  the  body,  or  the  upper  or  lower  half  of  the 
body  or  the  lower  extremities.  Glaser  described  a  form  in 
which  the  exanthem  appears  as  a  broad  band  around  the  neck 
or  around  the  joints.  Wildberg  also  noted  it  in  the  latter 
situation.  Zehnder  observed  it  in  the  form  of  red  spots 
scattered  over  the  body. 

Poorly  developed  eruptions  are  not  always  indicative  of 
benign  attacks,  for  the  exanthem  is  sometimes  partial  in  severe 
and  even  malignant  cases  of  scarlatina. 

Secondary  Septic  Erythema. — Occasionally  in  severe  cases  of 
scarlatina  of  the  anginose  variety  a  dusky-red,  maculopapular 
erythema  is  observed  to  occur  in  the  second  or  third  week  of 
the  disease.  The  eruption  is  most  commonly  seen  about  the 
extensor  surfaces  of  the  knees  and  elbows,  although  it  is  at 
times  more  extensive  and  may  involve  the  face  and  a  con- 
siderable portion  of  the  surface  of  the  trunk  and  extremities. 
This  erythema   usually   persists  for   two   or   three   days.     It 


506  DISEASES  OF  THE  SKIN 

occurs  in  bad  septic  cases  with  purulent  rhinitis,  sloughing 
throat,  and  discharging  ears,  and  is  of  evil  prognostic  import. 

Recurrent  Eruptions  and  Relapses. — It  is  well  known  that 
the  exanthem  of  scarlet  fever  may,  in  rare  instances,  disappear 
and  recur  in  a  few  days;  it  is  manifestly  improper  to  regard 
the  reappearance  of  the  eruption  under  such  circumstances 
as  a  true  relapse.  Again,  after  complete  convalescence  from 
scarlatina,  the  eruption  of  scarlatina  and  other  symptoms  may 
appear  for  a  second  time,  constituting  a  true  relapse. 

Before  accepting  a  secondary  eruption  as  a  true  relapse  the 
possibility  of  its  being  a  septic  rash  must  be  eliminated.  These 
septic  eruptions  are  often  spotted  in  character,  but  may  at 
times  closely  resemble  the  true  eruption  of  scarlet  fever. 

Complications. — Otitis  media  is  one  of  the  commonest  com- 
plications of  scarlet  fever;  it  usually  develops  during  the  second 
week,  but  may  occur  quite  early  in  the  anginose  variety. 
Middle-ear  trouble  may  lead  to  complete  deafness,  mastoid 
disease,  purulent  meningitis,  or  cerebral  abscess.  The  glands 
of  the  neck  may  undergo  suppuration,  producing  abscesses. 
Articular  tenderness  is  common  during  scarlet  fever,  and 
actual  arthritis  is  by  no  means  rare.  Whether  or  not  the 
condition  is  a  true  articular  rheumatism  is  not  determined; 
endocarditis  may  be  associated  with  this  condition.  Peri- 
carditis and  myocarditis  may  likewise  occur.  Lud  wig's 
angina,  gangrene  of  the  pharynx,  pyemia,  purpura,  etc., 
are  among  the  rarer  complications.  No  exanthematous  dis- 
ease is  so  frequently  accompanied  and  followed  by  nephritis. 
Transient  febrile  albuminuria  often  occurs  early.  True  scar- 
latinal nephritis  usually  develops  during  the  third  week  of  the 
disease.  The  symptoms  come  on,  as  a  rule,  insidiously;  they 
consist  of  fever,  marked  pallor,  puffiness  of  eyelids,  edema, 
and,  in  severe  cases,  anasarca.  The  urine  is  diminished  in 
quantity,  contains  albumin,  casts,  and  frequently  blood. 

Skin  Complications. — Febrile  herpes  occurs  occasionally 
during  the  invasive  stage  of  the  disease.  The  patches  develop 
usually  about  the  mouth,  although  they  may  be  situated  upon 
the  cheeks  or  ears. 

Urticaria  is  not  an  infrequent  accompaniment  of  scarlet 
fever,  although  it  cannot  be  considered  as  bearing  any  special 
relation  to  the  disease.  It  may  be  seen  early  or  late  in  the 
course  of  the  illness,  and  is  usually  neither  extensive  nor 
protracted. 


SCARLET  FEVER  507 

Blebs  may  occasionally  develop  upon  the  skin  as  a  result  of 
a  coalescence  of  neighboring  miliary  vesicles  in  intense  rashes. 
Thomas  says  they  may  reach  the  size  of  hazel-nuts.  Bullae 
may  also  occur  upon  patches  which  are  destined  to  terminate 
in  gangrene  of  the  skin.  Some  authors  speak  of  the  occurrence 
of  pemphigus,  particularly  in  certain  epidemics.  These  are, 
in  all  probability,  not  true  instances  of  pemphigus,  but  of 
bullous  dermatitis  of  septic  origin. 

I  have  occasionally  seen  cases  of  localized  necrosis  of  the 
skin  in  small  areas,  a  condition  analogous  to  the  so-called 
varicella  gangrenosa,  but  better  designated  dermatitis  gan- 
grcetwsa. 

Eczema  may  occur  as  a  complication  of  scarlatina,  but  is 
more  apt  to  develop  as  a  sequel.  Intense  desquamation  may 
leave  the  skin  dry,  harsh,  fissured,  and  the  seat  of  eczematous 
patches;  these  may  persist  for  some  time  after  convalescence. 
In  other  cases  a  purulent  discharge  from  the  ears  or  nose  may 
give  rise  to  an  impetiginous  eczema  in  the  region  of  these 
orifices;  the  skin  becomes  moist  and  covered  with  crusts,  as 
the  result  of  the  irritating  and  infective  discharges. 

Cutaneous  abscesses  may  occur  upon  any  portion  of  the 
integument.  This  complication  is  uncommon,  usually  occur- 
ring in  septic  cases.  I  recall  an  adult  patient  in  whom  a  large 
number  of  small  abscesses  occurred  in  the  skin. 

Furuncles  may  develop  during  an  attack  of  scarlet  fever, 
although  they  are  more  apt  to  appear  after  the  termination  of 
the  disease. 

Bacteriology  and  Pathology. — That  scarlet  fever  is  caused 
by  a  contagium  vivum  is  a  proposition  which  commands  general 
acquiescence.  The  identity  of  the  causal  parasite  is,  however, 
still  shrouded  in  obscurity,  despite  much  laborious  research. 
Space  will  not  permit  of  mention  of  the  organisms  found  in  the 
disease.  Fiessinger,  Dowson,  Berge*,  Lemoine,  and  others 
assert  their  belief  that  the  streptococcus  is  the  cause  of  the 
disease.  While  there  is  considerable  evidence  in  favor  of  this 
view,  the  assumption  is  far  from  proved.  No  one  has  isolated 
a  streptococcus  in  scarlet  fever  which  can  be  trenchantly 
distinguished  from  other  streptococci.  Moreover,  streptococci 
are  found  in  normal  throats  and  in  the  blood  and  tissues  in 
various  diseases,  notably  in  small-pox. 

The  blood  in  scarlet  fever  shows  a  pronounced  leukocytosis 
and  an  early  increase  in  the  eosinophiles. 


DISEASES   OF    THE   S'KIJJ 


:>nguc,    lymphatic   glands,    spleen,   liver,    gastro- 
~."t,    bone-marrow,    heart,    and    kidneys    exhibit 
.nu  i     nges  after  death,  but  these  alterations  are  not 

ractt       i._  of,  nor  peculiar  to  scarlet  fever. 

,g         3. —When  scarlet  fever  exhibits  itself  in  a  frank 

1  'yp.-ai  manner,  the  diagnosis  is  simple.     The  presence  of 

le  more  important  symptoms  of  the  disease  constitutes 

mistakable   syndrome.     Aberrant   and   extremely   mild 

.  may,  however,  present  great  difficulties  in  diagnosis. 

ere  is  no  one  symptom  which  is  pathognomonic  of  the 

;ase.     The  rash — the  most  conspicuous  manifestation  and 

oite  which  has  given  the  affection   its  name — is  not  in  itself 

sufficient,    inasmuch    as   an    almost    identical   exanthem    may 

occur  in  other  conditions.     It  is  thus  seen  that  a  diagnosis 

must  be  based  upon  an  association  of  symptoms,  and  from  a 

consideration  of  the  disease  in  all  its  aspects. 

The  presence  of  early  whitish  furring  of  the  tongue,  with  pro- 
jecting papilla?  and  subsequent  exfoliation  of  the  coating, 
with  the  persistence  of  a  reddened  surface  studded  with  enlarged 
papilla-,  is  important  contributory  evidence  of  the  scarlatinal 
nature  of  the  disease. 
,  The  occurrence  of  well-marked  desquamation  after  an  illness 
suspected  of  being  scarlet  fever  is  of  confirmatory  value.  Too 
much  importance,  however,  must  not  be  attached  to  the  mere 
occurrence  of  peeling,  for  there  are  many  rashes  which  desqua- 
mate— some,  indeed,  much  more  profusely  than  scarlet  fever. 
It  would  seem  that  the  amount  of  scaling  in  a  rash  of  given 
intensity  is  more  pronounced  after  scarlet  fever  than  after  most 
rashes  which  simulate  it.  The  time  of  onset  of  the  desqua- 
mation, its  orderly  progression,  and  its  long  persistence  are  of 
diagnostic  import. 

Among  affections  to  be  differentiated  from  scarlet  fever  the 
most  important  are  those  grouped  under  the  designation  of 
erythema  scarlatiniforme,  or  erythema  scarlatinoides  (see  Ery- 
thema Scarlatinoides). 

The  eruption  has  about  the  same  duration  as  that  of  scarlet 
fever,  although  it  is  often  briefer.  It  is  followed  by  a  desqua- 
mation which  is  ordinarily  branny,  but  which  may  take  place 
in  large  flakes. 

Desquamative  scarlatiniform  erythema,  termed  by  some 
writers  acute  exfoliative  dermatitis,  differs  from  the  above  type 
in  degree  rather  than  in  kind.     Epidermal  casts  of  the  palms 


SCARLET   FEVER 


509 


and  soles,  looking  not  unlike  gloves  or  slippers,  may  be 
exfoliated  (see  page  152).  The  nails  may  be  lost  and,  in 
severe  cases,  the  hair  also.  This  type  of  the  disease  is  pecu- 
liarly prone  to  recurrences,  which  may  appear  every  six  months 
or  a  year.  Sometimes  marked  periodicity  is  exhibited,  the 
recurring  attacks  developing  with  almost  calendar  precision. 


Fie.: 


These  eruptions  are  due  to  toxic  or  septic  states  or  to  the 
action  of  drugs  or  sera.  Simple  scar  latin  i  form  erythema  may 
occur  during  the  course  of  various  infectious  processes,  such  as 
rheumatism,  septicemia  (puerperal  or  other  forms),  pyemia, 
malaria,  typhoid  fever,  etc.  An  evanescent  scarlatiniform 
rash  may  appear  before  the  true  exanthem  of  measles,  vari- 
cella, small-pox,  and  vaccinia. 

All  grades  of  scarlatiniform  erythema  may  develop  during 
the  stage  of  decrustation  of  small-pox. 


DISEASES  Of   TUB   SKIN 

feting  from  severe  burns  may  develop  scarlatini- 

Some  of  these  prove  to  be  the  exanthem  of  true 

h  i   antitoxin   and  other  sera  may  produce  scarla- 

mrm  er       ions.     Antitoxin  rashes  developing  in  the  course 

ithent    nay,  in  some  cases,  so  closely  simulate  the  erup- 

scarit.  fever  as  to  defy  all  efforts  at  satisfactory  differ- 

n. 

estinal  autointoxication  may  give  rise  to  a  sear  la  Uniform 

iiion.     Crocker  ■•*"  •*™1  "lay  follow  the  use  of  enemata, 

:h  sometimes  fat  lution  and  absorption  of  toxins. 

.he  drugs  which  must  tum...july  give  rise  to  scarlatiniform 

■"'ptions  are  quinin,  antipyrin,  mercury,  belladonna,  veronal, 

I  salicylic    acid.     Many    other    medicaments    occasionally 
iduce  scarlatinoid  rashes  in  susceptible  subjects.     The  erup- 

II  resulting  from  the  administration  of  quinin  is  the  most 
•"■quent  and  the  most  likely  to  be  confounded  with  scarlet 

er.     If  may  be  followed  by  well-marked  desquamation. 

It  is  often  a  matter  of  great  difficulty  to  differentiate  scar- 

tinifonn  erythema  from  true  scarlet  fever.     In  the  former, 

ie  invasive  symptoms  are  often  extremely  mild;  the  patient 

commonly  does  not  complain  of  feeling  ill;  the  temperature 

elevation  is  slight- — perhaps,  101  °  or  102  °  F.     The  throat  may 

be  reddened,  but  the  tonsils  and  uvula  are  not  swollen,  and 

exudate  is  not  present  upon  the  tonsils.     The  reddened,  papil- 

lated  tongue  is,  as  a  rule,  absent.     The  eruption  may  begin 

upon  any  portion  of  the  body;  it  may  be  patchy  and  irregular, 

or  it  may  be  diffuse,  with  or  without  punctation.     The  glands 

at  the  angles  of  the  jaws  are  not  apt  to  exhibit  any  pronounced 

enlargement;  albuminuria  is  rare,  and  otitis  media  does  not 

It  is  thus  seen  that  scarlatiniform  erythema  may  be  readily 
distinguished  from  a  we  11 -pronounced  attack  of  scarlet  fever, 
but  the  fact  must  not  be  overlooked  that  there  are  many  mild 
cases  of  scarlet  fever  in  which  the  fever  is  slight,  the  eruption 
poorly  marked,  and  the  other  symptoms  correspondingly 
uncharacteristic. 

The  significant  feature  in  scarlatiniform  erythema,  particularly 
when  the  rash  is  well  pronounced,  is  that  the  intensity  of  the  erup- 
tion is  out  of  all  proportion  to  the  amount  of  constitutional 
disturbance.  There  are  not  present  the  prostration  and  high 
fever  which  would  accompany  a  rash  of  similar  severity  in 


SCARLET   FEVER  51 1 

scarlet  fever.  Furthermore,  there  is  never  seen  in  scarlatini- 
form  erythema  a  severe  sore  throat.  Another  point  of  great 
diagnostic  importance  is  the  history  as  to  previous  attacks; 
the  tendency  to  recurrence  is  a  well-recognized  feature  of 
scarlatiniform  erythema. 

Measles,  rubella,  and  the  prodromal  rash  of  small-pox  may 
occasionally  be  confounded  with  scarlet  fever.  The  differential 
diagnosis  is  considered  under  these  diseases. 

Cases  of  scarlet  fever  with  considerable  exudate  in  the  throat 
are  not  infrequently  diagnosed  as  diphtheria,  the  physician 
failing  to  make  an  examination  of  the  trunk. 

Prognosis. — The  prognosis  is  influenced  by  the  character 
of  the  prevailing  epidemic,  the  age  of  the  patient,  the  severity 
of  the  attack,  and  the  presence  or  absence  of  complications. 
In  mild  epidemics  the  mortality  ranges  from  4  to  8  per  cent. 
Outbreaks  are  on  record  in  which  deaths  reached  the  appaling 
figure  of  30  per  cent,  or  more. 

Treatment. — Prophylaxis. — Isolation  of  the  patient  and  his 
attendants,  sterilization  of  all  articles  coming  from  the  sick- 
room, and  thorough  disinfection  of  the  apartment  and  all  it 
contains,  after  the  termination  of  the  illness,  are  necessary  to 
prevent  transmission  of  the  disease. 

The  general  treatment  is  that  ordinarily  applied  to  infectious 
diseases,  bearing  in  mind  the  special  liability  to  subsequent 
nephritis.  The  patient  should  be  confined  to  bed  in  a  well- 
ventilated  room,  kept  at  an  equable  temperature.  During  the 
early  days  of  scarlatina,  when  the  fever  is  high,  milk  con- 
stitutes the  best  and  usually  the  most  acceptable  diet.  When 
the  fever  has  subsided,  patients  will  request  more  substantial 
food,  and  I  have  never  seen  any  harm  result  from  permitting 
the  use  of  a  bland,  soft  diet  at  this  time.  When  the  temperature 
reaches  io3°F.,  tepid  or  cool  sponge-baths  should  be  given. 
Hyperpyrexia  may  demand  the  use  of  cold  packs. 

To  lessen  the  tension  of  the  skin  and  to  allay  itching,  the 
inunction  of  some  unguentous  substance  is  desirable.  For  this 
purpose  cacao-butter  is  both  pleasant  and  useful ;  if  the  itching 
is  pronounced,  a  1  per  cent,  mentholated  or  a  2  per  cent,  carbo- 
lated  ointment  may  be  used. 

When  the  throat  symptoms  are  mild,  no  special  topical 
applications  are  necessary.  When  exudate  is  present,  the 
throat  should  be  sprayed  with  hydrogen  dioxid,  pure  or  diluted. 
In  purulent  rhinitis  the  nose  should  be  gently  irrigated  with 


512  DISEASES  OF  THE  SKIN 

warm  normal  salt  solutions.  When  the  glands  of  the  neck  are 
greatly  enlarged,  the  application  of  an  ice-bag  is  grateful  to 
the  patient.  Cleanliness  of  the  nasopharynx  lessens  the 
liability  to  otitis  media.  Earache  is  most  relieved  by  heat; 
the  external  auditory  canal  may  be  gently  syringed  with  hot 
water.  Abscess  of  the  middle  ear  should  be  evacuated  by 
paracentesis,  and  this  followed  by  irrigation  with  a  warm  boric- 
acid  solution.  Nephritis  is  one  of  the  most  common  and  most 
serious  of  the  complications  of  scarlet  fever.  It  is  best  guarded 
against  by  a  sufficiently  prolonged  detention  in  bed  and  avoid- 
ance of  exposure.  The  urine  should  be  frequently  examined. 
If  albumin  or  casts  be  found,  the  patient's  diet  should  be 
restricted  to  milk  and  the  patient  kept  in  bed.  Uremic  symp- 
toms indicate  the  use  of  hot  packs  or  hot-air  baths;  free  catharsis 
should  be  produced  by  calomel  or  salines.  Pilocarpin,  hypo- 
dermically,  -£%  to  ^  grain,  according  to  the  age,  may  be  given. 
Convulsions  should  be  combated  by  chloral,  morphin,  or 
chloroform.  For  the  anemia  following  nephritis  iron,  in  the 
form  of  Basham's  mixture,  will  be  found  to  serve  a  useful 
purpose. 

MEASLES 

Synonyms. — Rubeola;  Morbilli;  Vr.,  La  rougeolc;  Ger.,  Masern;  Flecken; 
Ital.,  Morbilli;  Rosalia;  Sp..  Serampion. — Derivation. — Probably  derived 
from  old  English  maselcs.  Hirsch  calls  attention  to  the  resemblance  to  the 
German  masern  and  the  Sanskrit  masura,  meaning  sjK)ts.  The  term 
"morbilli"  is  derived  from  the  Italian  morbillo,  which  signifies  the  little 
disease.  This  diminutive  was  doubtless  employed  to  distinguish  measles 
from  small -pox,  the  plague,  il  morbo,  probably  referring  to  the  latter  dis- 
ease. 

Definition. — Measles  is  an  acute  epidemic,  highly  contagious 
disease,  characterized  by  fever,  a  catarrhal  inflammation  of  the 
upper  respiratory  mucous  membranes,  and  a  blotchy,  macular 
eruption. 

Etiology.— Measles  may  be  regarded  as  the  most  contagious 
of  the  various  exanthematous  diseases.  The  inoculability  of 
measles  is  still  a  disputed  question  despite  much  experimenta- 
tion. The  usual  mode  of  contagion  is  by  direct  exposure,  and 
it  is  not  proved  that  the  disease  can  be  transmitted  by  infected 
objects  or  third  persons.  Susceptibility  to  measles  is  practi- 
cally universal,  although  there  is  commonly  an  immunity 
exhibited  by  infants  under  the  age  of  six  months  and  often 
during  the  entire  first  year  of  life.     The  contagious  period  of 


MEASLES  513 

the  disease  lasts  from  the  beginning  of  prodromal  symptoms 
to  the  complete  disappearance  of  the  eruption.  Second  attacks 
of  measles  are  extremely  rare. 

The  extreme  contagiousness  of  measles  is  proof  of  its  parasitic 
origin.  Canon  and  Pielicke,  in  1892,  found  in  14  cases  of 
measles  a  bacillus  which  they  considered  to  be  the  specific 
causative  agent.  Czajkowski  isolated  a  bacillus,  Lesage,  a 
micrococcus,  and  Doehle  and  Weber,  protozoa-like  bodies. 
Further  research  is  necessary  before  the  identity  of  the  causal 
microparasite  is  established. 

Symptomatology. — The  incubation  period  of  measles  is 
usually  in  the  neighborhood  of  ten  or  eleven  days,  the  eruption 
appearing  on  or  about  the  fourteenth  day. 

The  prodromal  or  invasive  period  is  ushered  in  by  catarrhal 
symptoms.  The  eyes  are  reddened,  watery,  and  sensitive  to 
light;  there  are  sneezing  and  nasal  discharge;  hoarseness  and 
cough  indicate  involvement  of  the  larynx  in  the  catarrhal 
process.  The  constitutional  symptoms  consist  of  fever,  head- 
ache, anorexia,  drowsiness,  and  irritability.  The  fever  is 
variable  (1010  to  103  °  F.),  and  gradually  increases  up  to  the 
appearance  of  the  eruption.  In  the  average  case  of  measles 
the  invasive  stage  lasts  about  four  days. 

The  enanthem  upon  the  mucous  membrane  of  the  mouth  may 
be  seen  in  advance  of  the  cutaneous  exanthem.  This  eruption, 
which  has  been  especially  studied  by  Filatow,  Canby,  and 
Koplik,  consists  of  small,  irregular,  bright-red  spots,  in  the 
center  of  which  there  is  a  minute  bluish- white  speck.  These 
are  particularly  well  seen  in  good  light  upon  the  inside  of  the 
lower  lip  and  the  buccal  mucous  membrane.  Koplik  has 
insisted  that  the  spots  are  pathognomonic  of  measles. 

Prodromal  rashes  of  a  scarlatiniform,  morbilliform,  or  urti- 
carial type  occasionally  appear  during  the  prodromal  stage  of 
measles.  They  last  but  a  day  or  two,  and  are  later  followed 
by  the  characteristic  eruption  of  the  disease.  J.  D.  Rolhston 
noted  a  prodromal  eruption  in  30  cases,  almost  one-half  of 
the  cases  observed  in  a  certain  series. 

The  Eruptive  Period. — The  measles  exanthem  usually  appears 
upon  the  fourth  day  of  the  febrile  disorder.  The  most  common 
initial  sites  are  the  side  of  the  neck,  the  mastoid  region  of  the 
temples  and  frontal  border  of  the  hair,  the  cheeks,  and  the 
chin — in  other  words,  about  the  face  and  neck.  The  eruption 
of  measles  has  a  special  predilection  for  the  face,  which  is  earlier 

33 


$■4  DISEASES  Of  THE    SKIN 

and  more  copiously  covered  than  other  areas.  It  is  not 
uncommon  for  the  eruption  in  this  region  to  become  confluent 
and  to  give  rise  to  a  dusky  turgescence  of  the  skin.  From  the 
face  and  neck  the  rash  rapidly  extends  over  the  trunk  and  upper 
extremities.  The  lower  extremities  are  the  last  and  least 
intensely  attacked;  commonly  but  a  few  scattered  lesions  are 
seen  upon  the  legs. 

Character  of  the  Eruption. — The  essential  lesion  of  measles 
is  a  slightly  elevated  macule;  it  is  sufficiently  elevated  to  be 
recognized  both  by  the  sense  of  sight  and  touch.  The  more 
circumscribed  the  lesion  is,  the  more  it  is  distinctly  papular, 
and  the  more  diffuse  and  confluent  the  eruption  is.  the  more 


does  it  approach  an  erythematous  and  unelcvated  efflorescence. 
The  macules  vary  greatly  in  size  from  a  pin-head  to  a  bean  or 
finger-nail.  They  are  irregular  in  outline,  being  at  times 
rounded  or  oval,  but  at  other  times  angular,  indented,  and 
spun  out.  They  are  usually  sharply  marginated.  and  stand 
out  sharply  against  the  pale,  integumentary  background. 

To  the  fingers  passed  over  the  lesions  a  soft  or  velvety  feci 
is  imparted,  quite  unlike  the  indurated  feel  of  the  early  small- 
pox eruption.  The  color  of  the  measles  exanthem  varies  in 
different  patients  and  at  different  stages  in  the  same  individual. 
It  is  seldom  as  vivid  a  red  as  is  seen  in  the  exanthem  of  scarla- 
tina.    The   macules  in  the  beginning  commonly  present  the 


MEASLES 


5'5 


appearance  of  flea-bites;  they  are  of  a  dull  red  color,  not 
infrequently  becoming  dusky.  In  some  patients  the  eruption, 
particularly  when  it  becomes  confluent,  has  a  distinct  bluish 
tinge.  The  bluish  coloration  is  not  at  all  uncommon  upon 
dependent  areas,  such  as  the  back.  In  pronounced  cases, 
particularly  in  adults,  the  face  may  exhibit  an  extremely 
dusky-red  appearance  which,  with  a  slight  swelling  of  the 
skin,  produces  a  strange  and  disfiguring  turgescence. 

On  the  first  day  of  the  eruption  the  lesions  are  small  and 
discrete,  in  many  cases  bearing  a  resemblance  to  the  eruption  of 
rubella.  The  macules  subsequently  enlarge  in  size  and  in 
number,  coalesce  in  areas,  and  produce  a  rash  which  is  essen- 
tially blotchy.  The  arrangement  of  the  measles  lesions  lacks 
symmetry  and  uniformity.  At  times  distinct  crescents  and 
segments  of  circles  can  be  distinguished;  at  other  times  such 


Fig.  118.— Measles  in  a  child  (Welch  and  Schamberg). 

configurations  are  absent.  The  rash  of  measles  does  not 
invariably  consist  of  slightly  elevated,  velvety  macules.  There 
are  at  times  distinct  papules  present,  and  miliary  vesicles  are 
not  infrequently  seen. 

Mayr,  in  his  article  on  "Measles"  in  Hebra's  "Diseases  of 
the  Skin"  (1866),  distinguishes  a  number  of  varieties  of  measles 
based  upon  the  character  of  the  eruption.  The  term  morbilli 
Iceves  is  applied  to  the  common  form,  in  which  the  eruption  is 
smooth  and  flat,  the  individual  macules  being  separated  by 
areas  of  healthy  skin. 

In  morbilli  papitlosi  there  appear  dark-red  or  reddish-brown 
points  or  papules,  the  size  of  a  millet-  or  a  hemp-seed,  situated 
at  the  mouths  of  the  hair -follicles.  This  form  of  measles  is 
said  to  occur  in  certain  epidemics,  taking  the  place  of  the  more 
usual  variety. 


5i6  -  DIS8ASBS  OF  THB  SKIN 

I  have  known  the  papular  form  to  be  confounded  with  small- 
pox on  more  than  one  occasion. 

In  morbiUi  vesiculosa  or  miliares  small  pin-point-   to    pin- 
head  sized  vesicles  are  seen  upon  the  summits  of  the  lesions. 


Irs  of  the  papular 
demir.  for  srrfal 


This  gives  the  skin  an  appearance  resembling  prickly  heat, 
and,  indeed,  the  presence  of  the  miliary  vesicles  has  been 
ascribed  to  the  sweating  process.  This  is  probablv  not  the 
case,  as  the  vesicles  are  identical  with  those  common! v  seen  in 


MEASLES  517 

scarlet  fever,  in  which  disease  the  sweating  process  is  in  abey- 
ance. 

Morbilli  confluenies  describes  the  form  in  which  the  macules 
run  together  and  become  confluent.  It  will  be  remembered 
that  this  was  the  term  applied  to  scarlatina  before  the  days  of 
Sydenham. 

I  have  seen  numerous  cases  which  justify  the  use  of  the  term 
confluent  measles.  I  recall  a  severe  epidemic  of  measles  which 
prevailed  in  the  scarlet-fever  wards  of  the  Municipal  Hospital 
of  Philadelphia  a  few  winters  ago.  The  eruption  in  these  cases 
was  normal  in  the  beginning,  but  in  a  few  days  became  intensely 
confluent  and  vivid  over  the  greater  part  of  the  cutaneous 
surface.     The  mortality  among  these  patients  was  very  high. 

Morbilli  hcemorrhagici  is  that  variety  in  which  the  macules 
are  purplish  or  bluish,  and  from  which  the  color  cannot  be  made 
to  disappear  by  the  pressure  of  the  fingers.  This  condition  is 
usually  observed  in  malignant  cases. 

The  lesions  here  described  may  be  seen  to  a  certain  extent 
in  ordinary  cases,  but  the  form  characterized  by  papules,  by 
miliary  vesicles,  or  confluence  may  each  be  particularly  well 
pronounced  in  certain  epidemics. 

At  the  beginning  of  the  measles  eruption  the  temperature 
does  not  register  its  maximum ;  it  is  only  after  the  full  develop- 
ment of  the  exanthem  that  the  pyrexial  fastigium  is  reached. 
The  temperature  at  this  time  is  commonly  104  °  F.,  and  not 
infrequently  105  °  F. 

When  the  maximum  fever  is  attained,  the  eruption  is  copious 
and  intense ;  the  face  is  often  of  a  uniform,  dusky-red  color  and 
edematous,  particularly  about  the  eyelids.  The  entire  body 
is,  as  a  rule,  covered,  not  even  the  palms  and  soles  being  exempt. 
Not  infrequently  the  rash  gives  rise  to  a  considerable  degree 
of  itching. 

During  the  development  of  the  eruption  the  local  as  well 
as  the  constitutional  symptoms  increase  in  intensity.  There  is 
an  aggravation  of  the  catarrhal  symptoms.  Children  are  much 
prostrated,  manifest  great  thirst,  refuse  food,  and  are  either 
extremely  restless  and  peevish,  or  somnolent.  The  eruptive 
stage  lasts  ordinarily  four  or  five  days.  With  the  fading  of 
the  rash  there  is  a  gradual  subsidence  of  the  fever  and  the 
catarrhal  symptoms.  The  decline  of  the  fever  is  by  steps, 
but  is,  nevertheless,  moderately  rapid. 

As  the  rash  fades  the  appetite  improves,  somnolence  and 


irritability  disappear,  and  the  child  begins  to  acquire  its  normal 
brightness  and  desires  to  leave  the  bed. 

Stains  (Pigmentation). — As  the  rash  disappears  there  are 
left  on  the  skin  faint  reddish-brown  stains  which  may  be 
detected  for  a  number  of  days.  The  stains  correspond  with  the 
size  and  shape  of  the  original  lesions  and  are  highly  character- 
istic; these  are  of  considerable  diagnostic  value,  and  will  often 
enable  one  to  diagnosticate  an  attack  of  measles  after  it  has 
subsided. 

Hemorrhagic  Eruption  in  Measles  of  Moderate  Severity. — It 
is  not  rare  for  the  eruption  in  cases  of  measles  of  average  severity 
to  exhibit  hemorrhagic  extravasation  into  the  skin.  The 
macules  in  such  cases  are  of  a  deeper  hue,  varying  from  a  claret- 
red  to  a  reddish-blue  tint.  It  is  observed  that  the  spots  do  not 
disappear  upon  pressure  of  the  fingers.  The  hemorrhage  into 
the  skin  may  be  noticed  at  the  height  of  the  eruption,  or  it  may 
become  evident  only  during  the  decline,  when  the  redness 
begins  to  fade.  Claret -colored  or  bluish  disco  lo  rat  ions  are 
left,  which  pass  through  the  color  variations  observed  in  an 
ordinary  bruise.  The  discolorations  coincide  in  size  and  shape 
with  the  original  measles  spots. 

It  is  important  to  distinguish  this  benign  form  of  hemorrhagic 
eruption  from  the  malignant  variety.  Holt  observed  hemor- 
rhagic eruptions  in  about  5  per  cent,  of  his  cases. 

Desquamation  begins  as  the  rash  fades,  and  is  first  noted 
upon  the  initial  sites  of  the  eruption,  namely,  the  face  and 
neck.  The  scaling  is  branny  and  furfuraceous,  and  is  often  so 
fine  as  to  require  careful  scrutiny  to  observe  it.  The  skin 
seldom  comes  off  in  large  flakes,  as  it  does  in  scarlet  fever. 
The  amount  of  desquamation  varies  in  different  cases,  and  is 
usually  proportionate  to  the  intensity  of  the  antecedent  erup- 
tion. In  many  patients  no  desquamation  will  be  seen  at  all. 
On  the  trunk  the  perspiration,  which  is  common  in  measles, 
obscures  the  fine  scales  or  enables  them  to  cling  to  the  body 
linen.  The  desquamation  is  usually  most  observable  on  the 
face.  Scaling  continues  ordinarily  from  a  few  days  to  a  week, 
but  rarely  is  protracted  for  ten  days  or  two  weeks. 

Measles  without  Eruption  (HorbilH  sine  exanthemata ; 
Horbilli  sine  morbillis). — As  is  the  case  in  small-pox  and 
scarlet  fever,  it  is  possible  for  measles  to  occur  without  the 
development  of  the  exanthem.  Such  cases  are,  of  course, 
excessively  rare,  but  are  recognized  by  careful  and  conserva- 


<\j 


MEASLES  519 

tive  writers.  Cases  may  occur  in  which  the  attack  of  measles 
is  typical  up  to  the  eruptive  stage,  but  at  this  point  the  antici- 
pated exanthem  fails  to  appear,  and  convalescence  is  established. 

Malignant  Hemorrhagic  Measles. — Black  measles  was, 
according  to  the  descriptions  of  the  older  writers,  much  more 
common  years  ago  than  at  the  present  day.  It  is  also  much 
rarer  than  hemorrhagic  small-pox,  with  which  it  has  certain 
features  in  common.  Hemorrhagic  measles  is  more  apt  to 
develop  in  previously  ill  and  debilitated  subjects. 

The  onset  of  the  disease  is  usually  violent,  the  fever  being 
high  and  nervous  symptoms  prominent.  The  eruption  is 
bluish  or  purplish  in  color,  and  fails  to  disappear  upon  pres- 
sure. In  other  cases  the  exanthem  may  appear,  recede  rapidly, 
and  be  followed  by  hemorrhagic  extravasation  into  the  skin 
in  the  form  of  petechia  or  ecchymoses.  At  the  same  time 
bloody  discharges  occur  from  the  various  mucous  membranes. 
There  is  commonly  severe  epistaxis,  and  blood  may  be  observed 
in  the  urine,  stools,  and  vomited  matter.  The  patient  becomes 
rapidly  exhausted,  the  pulse  is  frequent  and  thready,  the  skin 
pale  and  cold,  and  death  closes  the  scene. 

Recession  of  the  Rash. — It  occasionally  happens  that  the 
measles  exanthem  suddenly  and  prematurely  fades  after  reach- 
ing its  maximum,  or  even  before  the  height  of  the  eruption  is 
attained.  The  recession  of  the  rash  may  be  temporary,  the 
eruption  later  reappearing,  or  it  may  be  permanent.  The  lay 
community  has  a  traditional  dread  of  this  "striking  in"  of 
the  eruption,  fearing  the  involvement  of  one  of  the  internal 
organs.  As  a  matter  of  fact,  the  sudden  fading  of  the  exanthem 
is  not  the  cause,  but  the  result,  of  such  a  condition.  The 
phenomenon  is  usually  due  to  severe  pulmonary  involvement, 
leading  to  cardiac  failure  and  consequent  crippling  of  the  cir- 
culatory apparatus. 

Complications  and  Sequels. — The  chief  complications  of 
measles  are  referable  to  the  respiratory  tract,  bronchopneumonia 
being  the  most  common  and  most  fatal.  Membranous  laryn- 
gitis, lobar  pneumonia,  and  pleurisy  are  occasionally  encoun- 
tered. Other  complications  are  observed  in  connection  with 
the  alimentary  canal,  nervous  system,  lymphatic  glands, 
special  senses,  heart,  and  kidneys. 

Cutaneous  Complications. — Accidental  erythematous  rashes 
may,  in  rare  cases,  precede  or  follow  the  true  exanthem  of 
measles. 


520  DISEASES  OP  THE  SKIN 

During  the  invasive  period  it  is  not  rare  for  herpes  facialis 
to  appear,  a  phenomenon  which  develops  in  many  infectious 
processes.  Urticaria  may  also  occur  either  in  the  course  of 
the  disease  or  at  a  later  period.  The  urticarial  eruption  is 
usually  moderate  and  of  short  duration.  Claus  reports  urti- 
caria occurring  in  two  cases  of  measles  during  the  period  of 
incubation. 

Several  authors  have  called  attention  to  the  development 
of  a  bullous  eruption  resembling  pemphigus.  Cases  have  been 
reported  by  Krieg,  Loschner,  Henoch,  Steiner,  Du  Castel,  and 
recently  by  Baginsky.  Steiner  saw  4  cases,  all  in  the  same 
family.  The  blebs  varied  in  size  from  a  pea  to  a  pigeon's  egg, 
came  out  in  crops,  attacked  both  the  skin  and  mucous  mem- 
branes, were  accompanied  by  fever,  and  occurred  at  any  time 
during  the  course  of  the  disease,  before,  during,  or  after  the 
measles  exanthem. 

In  Henoch's  patient  the  bullae  were  so  large  that  a  single 
one  covered  each  cheek;  2  out  of  these  5  cases  terminated 
fatally.  Masarei  saw  upon  the  palms  and  soles  during  desqua- 
mation large  blebs  which  burst  and  left  obstinate  and  painful 
ulcers. 

Gangrene  may  attack  other  parts  of  the  skin  than  the  cheeks 
and  genitalia,  which  are  the  most  common  sites  of  the  process. 
Thomas,  of  Paris,  has  reported  an  extensive  gangrene  of  the 
buttocks  in  a  child  two  years  of  age.  Mayr,  Kaye,  Battersey, 
and  Carroll  report  instances  of  gangrene  attacking  various 
portions  of  the  cutaneous  surface. 

Impetigo,  boils,  and  abscesses  are  occasionally  observed  during 
convalescence  from  measles.  They  represent  varying  grades 
of  infection  with  the  common  pyogenic  organisms.  Eczema 
occasionally  makes  its  initial  appearance  after  an  attack  of 
measles,  and  may  persist  for  an  indefinite  period.  On  the 
other  hand,  chronic  eczemas  have  been  known  to  disappear 
after  an  attack,  as  in  cases  reported  by  Behrend  and  others. 
Psoriasis  has  been  observed  to  appear  for  the  first  time  after 
measles.  Measles,  of  course,  does  not  cause  the  psoriasis, 
but  merely  determines  the  date  of  its  outbreak. 

Disseminated  tuberculosis  of  the  skin  may  follow  in  the  wake 
of  measles,  as  in  the  cases  reported  by  Du  Castel,  Haushalter, 
and  Adamson. 

Roger  observed,  in  the  spring  of  1900,  four  cases  of  erythema 
nodosum  after  attacks  of  measles.     A   girl,   aged   seventeen 


MEASLES  521 

years,  eleven  days  after  the  termination  of  an  attack  of  measles 
of  moderate  severity,  developed  fever,  and  twenty-four  hours 
later  a  typical  erythema  nodosum  of  the  legs,  and  subsequently 
of  the  arms,  accompanied  by  painful  joints;  the  condition 
lasted  fifteen  days. 

Purpura. — Hemorrhages  developing  late  in  the  course  of 
the  disease  or  during  convalescence  should  not  be  interpreted 
as  evidence  of  malignant  hemorrhagic  measles,  but  as  a  secon- 
dary and  superadded  condition. 

Masarei  saw  eight  patients  convalescing  from  measles 
attacked  with  fever,  dropsy  without  albuminuria,  and  "scurvy, 
mostly  in  the  form  of  purpura ";  all  the  cases  ended  fatally. 
Gley  saw  intense  purpura  hemorrhagica,  together  with  scorbutic 
appearances  in  the  mouth,  some  days  after  the  disappearance 
of  the  measles  rash. 

Gangrene. — Although  gangrene  is  not  a  common  complication 
of  measles,  it  appears  to  occur  more  often  after  this  infection 
than  any  other,  excepting,  of  course,  cutaneous  gangrene  in 
small-pox. 

The  necrosis  is  apt  to  take  the  form  variously  designated  as 
cancrum  oris,  gangrenous  stomatitis,  or  noma.  This  formidable 
complication  commonly  develops  during  the  decline  of  the 
eruption.  It  is  often  associated  with,  or  preceded  by,  an 
ulcerative  stomatitis.  The  condition  begins  upon  the  mucous 
surface  of  the  cheek,  the  exterior  being  subsequently  involved. 
A  bluish-red  spot  appears  upon  the  skin,  which  becomes 
gangrenous  and  breaks  through.  A  progressive  necrosis  with 
a  dusky-red  zone  showing  a  vesicular  ring  upon  the  spreading 
border  takes  place.  The  entire  half  of  the  face  may  become 
involved  in  the  process.     In  severe  cases  most  patients  succumb. 

Pathology  of  the  Skin. — At  autopsy  the  eruption  of 
measles  is  not  visible  unless  there  has  been  hemic  extravasa- 
tion into  the  skin. 

The  skin  has  been  studied  histologically  by  Neumann, 
Catrin,  and  Unna.  Neumann  found,  as  the  chief  changes, 
a  round-cell  infiltration  about  the  blood-vessels,  hair-follicles, 
and  sweat-glands.  Catrin  likewise  observed  pronounced 
infiltration  of  leukocytes,  but,  in  addition,  in  the  nodular  form 
of  measles,  a  series  of  changes  in  the  deep  epithelial  cells. 
These  consisted  of  a  colloid  degeneration  of  the  perinuclear  zone 
of  some  of  the  deep  lying  epithelial  cells.  Around  the  areas 
of  colloid  change  were  dilated  interepithelial  spaces  containing 


522  DISEASES  OF  THE  SKIN 

coagulated  fibrin  and  leukocytes.  In  the  center  of  the  papule 
the  colloid  masses  run  together  and  undergo  coagulation 
necrosis,  this  taking  place  in  the  prickle-layer. 

Catrin  found  migration  of  leukocytes  from  the  papillary 
blood-vessels  only  at  those  places  where  the  surface  epithelium 
contained  colloid  cells.  Unna  regards  the  colloid  change  and 
necrosis  of  the  epithelium  as  the  result  of  the  direct  influence 
of  the  poison  of  the  disease  upon  the  epidermal  structures. 

Unna  states  that  in  measles  a  spastic  resistance  in  the 
cutaneous  vessels  is  added  to  the  primary  congestive  hyperemia 
which  develops  around  the  infection  in  the  capillaries,  and  this 
explains  the  cyanotic  color,  the  papular  swelling,  and  the 
urticarial  edema  of  the  center,  as  well  as  the  frequent  escape  of 
coloring-matter  in  the  blood.  The  rapidly  developing  and 
spastic  edema  always  collects  at  the  place  of  least  resistance, 
which,  in  children,  is  in  the  fatty  tissue  around  the  coil-glands 
and  in  the  sheaths  of  the  larger  vessels,  the  cutaneous  muscles, 
and  follicles.  The  individual  coils,  the  hair-follicles,  and  the 
muscles  seem  to  swim  free  in  widely  dilated  spaces. 

Dilated  lymph-vessels  and  enormously  distended  lymph- 
spaces  are  seen  in  the  lower  and  central  parts  of  the  cutis. 
Another  characteristic  is  the  almost  complete  absence  of  a 
cellular  exudate.  Leukocytic  migration  is  not  more  than  in 
all  simple  stagnatory  hyperemias — less,  indeed,  than  in  most. 
But  a  few  leukocytes  are  found  in  the  epithelium.  During 
the  stage  of  scaling,  the  subbasal  horny  layer  separates  from 
the  basal,  and  with  the  central  and  upper  horny  layers  forms 
the  scale.  The  lost  epithelium  is  replaced  as  usual  by  mitotic 
proliferation.  The  above  description,  Unna  remarks,  refers 
merely  to  the  ordinary  flat  or  slightly  papular  eruption. 

Diagnosis. — The  diagnosis  of  measles  can  be  made  before 
the  appearance  of  the  eruption,  when  the  various  catarrhal 
symptoms  referred  to  are  associated  with  Koplik's  spots  in 
the  mouth.  The  development  of  the  eruption,  which  is  usually 
characteristic,  renders  the  diagnosis  clear.  Rashes  almost  or 
quite  indistinguishable  from  that  of  measles  may  appear  at 
times  in  other  diseases.  Attention,  therefore,  must  be  given 
to  the  entire  syndrome,  and  the  diagnosis  not  based  exclusively 
upon  the  cutaneous  efflorescence. 

The  differential  diagnosis  from  conditions  that  may  be  con- 
founded with  measles  is  appended. 

Rubella  (Rotheln). — This  affection  is  more   apt  to  be  con- 


MEASLES  523 

founded  with  measles  than  anv  other.  Confusion  mav  arise 
when  measles  presents  itself  in  very  mild  form  or  when  rubella 
appears,  as  it  sometimes  does,  with  severe  manifestations. 
The  history  as  to  the  previous  occurrence  in  the  patient  of  the 
one  or  the  other  disease  is  evidence  of  considerable  importance. 
It  is  uncommon  for  measles  to  attack  an  individual  twice, 
and  still  rarer  for  rubella  to  act  in  this  manner. 

The  prodromal  stage  in  rubella  is  very  brief,  rarely  lasting 
more  than  twenty-four  hours;  the  catarrhal  symptoms  are 
slight  or  absent.  It  will  be  helpful  to  remember  that  catarrhal 
manifestations  are  more  pronounced  in  mild  cases  of  measles 
than  in  severe  cases  of  rubella.  The  fever  is  slight — commonly 
990  or  100 °  F.,  and  rarely  exceeding  ioi°F.  ;  it  is  of  short 
duration.  The  eruption  in  rubella  spreads  more  rapidly  than 
measles,  and  is  of  briefer  duration.  The  lesions  are  slightly 
elevated  macules,  of  a  pale  rose-red  color,  and  pin-head-  to  pea- 
sized.  The  eruptive  elements  are  smaller,  paler,  and  more 
discrete  than  in  measles.  The  patient  with  rubella  often  feels 
well  enough  to  remain  out  of  bed. 

Scarlet  Fever. — It  is  only  in  anomalous  cases  that  scarlatina 
is  apt  to  be  confounded  with  measles;  ordinarily  the  differenti- 
ation of  the  affection  is  a  simple  matter. 

In  scarlatina  the  onset  is  more  stormy,  with  high  fever  and 
a  much  greater  tendency  to  vomiting.  The  eruption  usually 
comes  out  on  the  second  day,  earlier,  therefore,  than  that  of 
measles.  Photophobia,  coryza,  hoarseness,  and  cough  are 
lacking  in  scarlatina,  but  instead  we  find  sore  throat,  marked 
glandular  enlargement  about  the  jaws,  and  a  characteristic 
tongue.  The  peculiar  buccal  spots  of  measles  are  absent,  the 
oral  and  pharyngeal  mucous  membrane  showing  merely  con- 
gestion. The  face  is  less  intensely  involved  by  the  rash  than 
in  measles,  and,  moreover,  shows  circumoral  pallor. 

The  rash  of  scarlet  fever  is  diffused  and  punctiform ;  it  should 
be  remembered,  however,  that  on  the  arms  and  legs  it  is  not 
infrequently  blotchy  and  suggestive  of  measles.  The  sub- 
sequent desquamation  is  more  profuse  and  lamellar  in  char- 
acter. Otitis  media  and  albuminuria  are  common  complica- 
tions. In  septic  cases  purulent  nasal  discharge  is  not 
uncommon,  even  in  the  early  stages  of  the  disease ;  laryngeal 
symptoms  are,  however,  rare. 

Confusion  may  result  in  those  cases  of  measles  in  which  there 
is  a  tendency  to  general  confluence  of  the  rash;  usually  some 


524  DISEASES  OF  THE   SKIN 

portions  of  the  cutaneous  surface  will  exhibit  the  measly  char- 
acter of  the  rash.  In  patients  seen  late  brownish  stains  on 
the  body  speak  for  measles,  and  pronounced  desquamation  of 
the  hands  and  feet  and  albuminuria  point  toward  an  antecedent 
scarlet  fever. 

Influenza. —  "La  grippe,"  particularly  that  form  accom- 
panied by  catarrhal  inflammation  of  the  upper  air-passages, 
may  present  a  considerable  resemblance  to  measles  during  the 
invasive  stage.  It  is  manifest  that  a  disease  beginning  with 
fever,  coryza,  and  cough  might  readily  be  either  measles  or 
influenza.  Photophobia,  which  is  justly  regarded  as  a  sig- 
nificant symptom  by  the  laity,  is  usually  well  marked  in  measles 
and  absent  in  influenza.  If  the  characteristic  bluish-red  spots 
with  whitish  specks  on  their  summits  be  visible  upon  the  buccal 
mucous  membrane,  the  diagnosis  is  at  once  made  clear.  Influ- 
enza is  occasionally  accompanied  by  an  eruption. 

Small-pox. — The  differential  diagnosis  between  small-pox 
and  measles  is  referred  to  under  the  former  disease. 

Typhus  Fever. — During  epidemics  of  typhus  a  confounding 
of  this  disease  with  measles  might  take  place  when  the  eruption 
is  profuse.  Pastau  is  quoted  by  Thomas  as  saying  that  the 
exanthem  of  typhus  is  by  no  means  rarely  papular,  or  even 
hemorrhagic,  like  that  of  measles,  and  a  catarrhal  affection  of 
the  air-passages,  especially  of  the  trachea,  is  usually  one  of  the 
concomitant  symptoms.  The  fever  and  nervous  symptoms 
are  more  pronounced  in  typhus,  and  there  is  great  enlarge- 
ment of  the  spleen;  the  eruption  is  usually  absent  on  the  face, 
and  oculonasal  catarrh  is  lacking. 

Roseola  Syphilitica.  -The  macular  eruption  of  syphilis  has 
on  more  than  one  occasion  been  confounded  with  measles.  The 
error  of  mistaking  syphilis  for  measles  may  be  made  when  the 
patient  is  an  adult  and  when  the  febrile  symptoms  are  mild. 
On  the  other  hand,  syphilis  with  pyrexial  elevation  might  be 
regarded  as  measles. 

The  eruption  of  syphilis  is  slower  in  development  and  the 
lesions  are  much  more  uniform  in  size  and  distribution.  The 
face  is  but  slightly,  if  at  all,  involved.  Usually  the  initial 
lesion  or  the  hardened  remains  thereof  can  still  be  discovered. 
In  addition,  other  evidence  of  syphilitic  disease  may  be  present, 
such  as  mucous  patches,  pronounced  inguinal  adenopathy,  etc. 

Morbilliform  Erythemata. — There  are  a  number  of  conditions 
in  which  rashes  bearing  a  more  or  less  close  resemblance  to  that 


MEASLES  525 

of  measles  may  occur.  They  may  be  divided  into — (a)  acci- 
dental rashes  accompanying  the  exanthematous  fevers;  (6) 
drug  eruptions;  (c)  serum  eruptions. 

Mention  has  already  been  made  of  the  resemblance  of  the 
roseola  variolosa  to  measles.  An  analogous  eruption,  roseola 
vaccinosa,  develops  occasionally  about  the  tenth  day  of  vac- 
cination. Morbilliform  rashes  may  in  rare  instances  be  observed 
also  in  the  course  of  varicella,  scarlet  fever,  and  other  infectious 
diseases. 

Drug  Eruptions. — The  drugs  which  most  frequently  give 
rise  to  eruptions  simulating  measles  are  antipyrin,  quinhr 
chloral,  copaiba,  cubebs,  and  veronal. 

The  most  common  eruption  resulting  from  the  administration 
of  antipyrin  is  a  morbilliform  erythema.  Of  52  instances  of 
eruption  from  the  use  of  antipyrin  collected  by  Spitz,  41  were 
of  the  measles  type.  The  eruption  may  be  generally  distributed 
over  the  trunk  and  extremities,  or  it  may  be  limited  to  certain 
regions  thereof;  an  important  distinguishing  feature  is  that  the 
face  is  usually  exempt.  Crocker  states  that  these  eruptions 
may  be  accompanied  by  oronasal  catarrh.  The  difficulty  in 
diagnosis  may  be  increased  by  the  appearance  of  the  antipyrin 
eruption  following  catarrhal  symptoms,  such,  for  instance,  as 
afe  encountered  in  influenza,  for  which  the  drug  is  administered. 
The  conjunctivitis,  photophobia,  hoarseness,  cough,  and  buccal 
eruption  are  all  absent.  Fever,  when  present,  is  slight  and 
not  characteristic  of  measles.  Furthermore,  the- normal  pro- 
gression of  the  measles  exanthem  from  the  face  and  neck 
gradually  downward  will  be  found  lacking.  The  eruption, 
moreover,  is  apt  to  be  non-elevated  and  exhibit  irregularities 
as  to  distribution.  If  a  large  dose  of  antipyrin  has  been  taken, 
it  can  be  found  in  the  urine  by  testing  the  same  with  the  per- 
chlorid  of  iron. 

Quinin. — Quinin  gives  rise  not  infrequently  to  erythematous 
eruptions.  Of  60  quinin  eruptions  analyzed  by  Morrow,  38 
were  of  the  erythematous  type.  Most  of  these  are  of  the 
scarlatiniform  type,  but  some  resemble  measles.  The  rash 
may  develop  after  the  administration  of  as  small  a  quantity 
as  one  grain,  or  even  a  fraction  of  a  grain,  of  the  drug.  The 
idiosyncrasy  appears  to  be  most  frequently  observed  in  women. 
Catarrhal  symptoms  are  absent. 

The  eruptions  from  the  administration  of  chloral  are  less 
com******  *i«a«  those  after  antipyrin  or  quinin.     Gee  saw  2  cases 


526  DISEASES  OP  THE  SKIN 

in  which  there  was  a  dusky-red,  papular  eruption  surrounded 
by  a  more  diffuse  redness  of  the  face  and  neck,  and  patchy  or 
mottled-red  spots  on  the  extremities,  especially  about  the 
articulations.  The  absence  of  the  catarrhal  and  constitutional 
manifestations  of  measles  would  enable  one  to  exclude  this 
infection. 

Copaiba  and  Cubebs. — Copaiba  and  cubebs  may  give  rise  to 
scarlatiniform  or  morbilliform  rashes;  the  latter  often  strongly 
suggest  measles.  Copaiba  usually  produces  an  eruption  con- 
sisting of  rose-red  colored,  slightly  raised  patches,  which  may  be 
discrete  or  blotchy,  and  generalized  or  limited.  (See  Fig.  73.) 
Above  the  elbows  and  knees  there  is  a  tendency  toward  con- 
fluence of  the  patches.  Itching  is  apt  to  be  a  distressing 
symptom.  The  eruption  may  develop  rapidly  after  the  admin- 
istration of  the  drugs  or  only  after  some  days  have  elapsed. 
Most  of  the  eruptions  have  occurred  in  persons  who  were  receiv- 
ing treatment  for  urethritis.  A  peculiar  and  disagreeable  bal- 
samic odor  is  often  imparted  to  the  skin  when  copaiba  is  taken. 

All  the  drug  eruptions  are  apt  to  exhibit  irregularities  in  the 
manner,  rapidity,  distribution,  or  duration  of  the  eruption, 
which  will  arouse  suspicion  as  to  its  nature;  furthermore,  the 
prodromal  stage  of  measles,  with  its  characteristic  catarrhal 
symptoms,  is  wanting. 

Antitoxic  Seta. — Antitoxic  sera  occasionally  call  forth 
eruptions  which  are  measle-like  in  character.  Diphtheria 
antitoxin  may  now  and  then  give  rise  to  a  morbilliform  ery- 
thema, although  much  more  commonly  the  eruption  comes 
under  the  head  of  urticaria  or  exudative  erythema.  Antitoxin 
rashes  may  develop  at  any  time  from  three  days  to  three  weeks 
after  its  administration;  most  rashes,  however,  appear  from 
eight  to  fourteen  days  thereafter.  There  may  be  elevation  of 
temperature,  with  joint  pains  and  occasionally  joint  swellings, 
accompanying  the  eruption.  The  temperature  may  rise 
suddenly  to  102  °  F.  or  thereabouts,  but  it  soon  falls.  Catarrhal 
symptoms  are  invariably  absent. 

The  antistreptococcus  serum  and  antitetanic  serum  may, 
on  rare  occasions,  also  give  rise  to  morbilliform  eruptions. 

Prognosis. — The  prognosis  of  measles  in  vigorous  and 
well-nourished  children  beyond  the  age  of  two  or  three  years 
is  extremely  favorable.  In  the  very  young  and  debilitated 
fatalities  through  pulmonary  complications  are  not  rare. 

Treatment. — Measles,  like  other  self-limited  diseases,  runs 


RUBELLA  527 

its  course  in  a  definite  period  of  time,  and  tends,  in  uncom- 
plicated cases,  to  recovery.  No  known  drug  is  capable  of 
abridging  or  modifying  the  course  of  the  disease.  The  chief 
indications  are  to  mitigate  or  control  excessively  developed 
symptoms  and  to  treat,  or  preferably  to  prevent,  complications. 
Confinement  to  bed,  guarding  against  exposure,  and  proper 
diet  are  the  most  important  measures.  To  be  sure,  for  the 
safety  of  others,  adequate  isolation  of  the  patient  should  be 
carried  out. 

RUBELLA 

Synonyms. — German  measles;  Rotheln.  There  is  an  embarrassment  of 
riches  in  the  various  designations  applied  to  this  disease.  The  Germans 
use  the  terms  Rotheln  and  rubeola;  the  French  call  it  rubeole.  The  latter 
term  being  used  at  times  to  denote  true  measles,  it  is  confusing  to  apply  it 
to  another  disease.  Among  other  appellations  are:  Rubeola  sine  catarrho 
seu  incocta,  rubeola  notha,  rubeola  epidemica,  rubeola  morbillosat  rubeola  scar- 
latinosa, rosania,  roseola  epidemica,  rosalia,  exantheme  fugace,  essera  Vogelii; 
hybrid,  bastard,  spurious,  or  imperfect  measles;  hybrid  or  bastard  scarlatina; 
rougeole  fausse;  Feuer-masern;  German  measles;  French  measles,  etc. 

Definition. — Rubella  is  an  acute,  contagious,  epidemic 
disease,  characterized  by  an  eruption  of  barely  elevated,  rose- 
colored  macules,  slight  catarrhal  symptoms,  and  mild  febrile 
disturbance,  running  a  course  lasting  usually  three  or  four 
days.  Rubella  is  a  specific  entity,  unrelated  to  either  measles 
or  scarlet  fever,  and  protecting  only  against  future  attacks  of 
the  same  affection. 

Etiology. — Rubella,  like  other  exanthematous  diseases, 
is  derived  from  and  begets  a  like  disorder.  Although  the 
parasitic  cause  of  the  disease  has  not  been  discovered,  there 
can  be  little  doubt  that  it  is  produced  by  the  reception  into 
the  body  of  an  animal  or  vegetable  microorganism.  The 
disease  prevails  largely  in  epidemic  form,  and  is  almost  as 
common  as  measles,  with  which  it  has  doubtless  often  been 
confused.  The  infection  of  rubella  appears  to  be  more  tenacious 
and  persistent  than  that  of  measles,  and  is  more  often  carried 
by  infected  articles.  The  disease  is  contagious  at  a  very  early 
date  in  its  course.  It  is  chiefly  an  affection  of  children,  but 
adults  are  not  infrequently  attacked.  One  attack  protects 
for  life,  no  authentic  report  of  a  true  second  attack  being  on 
record. 

Symptoms. — The  period  of  incubation  is  more  variable  than 
that  of  measles.  It  may  vary  between  five  and  twenty-one 
days,  but  is  «  ^orhood  of  two  weeks.    The 


528  DISEASES  OF  THE  SKIN 

* 

period  of  invasion  is  often  devoid  of  symptoms,  although  mild 
prodromes,  such  as  malaise,  headache,  nausea  or  vomiting,  and 
catarrhal  symptoms,  affecting  the  eyes,  nose,  throat,  and 
bronchial  tubes,  may  be  present.  This  stage  is  usually  brief , 
lasting  about  twelve  hours,  but  it  may  vary  between  a  few 
hours  and  five  days. 

General  Symptoms  During  the  Eruptive  Stage. — Fever  is,  as  a 
rule,  proportionate  to  the  extent  and  the  severity  of  the  eruptive 
and  catarrhal  symptoms*  In  some  epidemics  the  fever  is 
extremely  slight,  and  in  some  instances  absent.  In  other 
epidemics,  in  severe  cases,  the  temperature  may  register  103  ° 
or  104  °  F.  or  higher.  It  is  common  for  the  temperature  to 
range  between  99  °  and  ioi°F.  The  catarrhal  symptoms 
affect  the  eyes,  nose,  throat,  and  bronchial  tubes.  The  eyes 
are  usually  "watery"  and  slightly  injected.  Sneezing  is  apt 
to  be  present,  and  in  some  cases  distinct  coryza.  Cough  is 
usually  slight,  but  varies  in  different  epidemics.  Sore  throat 
of  a  mild  character  is  an  extremely  common  symptom.  It  is 
seldom  as  severe  as  that  seen  in  scarlet  fever,  the  redness  often 
being  limited  to  the  anterior  pillars.  Koplik  spots  are  absent, 
but  I  have  seen  pin-head-sized,  deep-reddish  spots  upon  the 
buccal  mucous  membrane.  Hoarseness,  usually  mild,  but 
occasionally  pronounced,  has  been  noted  by  a  number  of 
writers.  The  tongue  is  commonly  coated  with  a  thin,  grayish 
coating,  with,  at  times,  slight  enlargement  of  the  papillae  upon 
the  tip.     The  "strawberry  tongue"  of  scarlet  fever  is  absent. 

Enlargement  of  the  lymphatic  glands  has  long  been  regarded 
as  a  symptom  of  considerable  diagnostic  import.  A  general 
glandular  intumescence  is  present,  but  this  is  also  true  of 
scarlet  fever  and,  to  a  lesser  extent,  of  measles.  Nausea  and 
vomiting  are  rare  symptoms  except  in  severe  cases.  Itching 
varies  in  intensity,  but  is  usually  mild  or  absent. 

Period  of  Eruption. — A  half -day  or  so  after  the  onset  of  mild 
invasive  symptoms,  or  in  many  cases  without  any  prodromes 
at  all,  the  eruption  of  rubella  makes  its  appearance.  The 
rash  is  commonly  the  first  symptom  to  attract  attention, 
the  other  mild  initiatory  disturbances  then  being  recalled. 
Not  infrequently  a  child  awakens  in  the  morning  with  the 
eruption  visible  upon  the  face.  Patterson  and  Copland  assert 
that  it  comes  out  simultaneously  on  different  parts  of  the 
body.  The  eruption,  as  a  rule,  appears  first  on  the  face.  In 
noting  the  eruption  a  short  time  after  its  appearance  upon  the 


RUBELLA  529 

face,  however,  I  have  seldom  failed  to  find  it  to  some  extent 
on  the  trunk  and  arms. 

The  exanthem  spreads  quite  rapidly  over  the  body  in  the 
course  of  twenty-four  to  forty-eight  hours.  It  is  interesting 
to  note,  however,  that  the  maximum  intensity  of  the  rash  is 
not  simultaneously  observed  on  the  entire  cutaneous  surface. 
It  is  not  unusual  for  the  face,  chest,  and  arms  to  show  the 
eruption  at  its  height,  while  the  legs  are  yet  unaffected.  When 
the  lower  extremities  exhibit  the  exanthem  in  its  greatest 
intensity,  it  is  fading  upon  the  face  and  upper  part  of  the  body. 
In  other  words,  the  rash  often  seems  to  pass  over  the  cutaneous 
surface  in  a  sort  of  wave-like  progression.  The  duration  of  the 
eruption  at  its  height  in  any  given  region  is  from  a  few  hours 
to  a  half -day.  The  more  severe  the  attack,  the  longer  is  the 
period  of  maximum  intensity  and  the  longer  the  duration  of 
the  eruption. 

Character  of  the  Eruption. — The  eruption,  in  its  most  typical 
form,  consists  of  pin-head-  to  lentil-seed-sized,  pale  rose-tinted, 
slightly  elevated,  moderately  defined  macules.  The  lesions 
are  usually  rounded  or  oval,  but  may  be  irregular.  The 
elevation  is  scarcely  sufficient  to  warrant  the  use  of  the  term 
papule,  but  is  appreciable  to  the  finger  passed  over  the  surface 
of  the  skin.  The  macules  are  ordinarily  discrete,  with  con- 
siderable intervening  skin,  particularly  at  the  onset  of  the 
eruption  and  on  the  trunk.  Later,  they  are  apt  to  become 
more  closely  set  and  may  coalesce,  with  the  production  of 
irregular  patches  resembling  measles  or  sheets  of  eruption  of  a 
scarlatiniform  character. 

Ordinarily  macular  grouping,  such  as  is  seen  in  measles, 
is  absent,  but  I  have  now  and  then  seen  distinct  linear  and 
crescentic  configuration,  indistinguishable  from  that  observed 
in  measles.  Rubella  in  its  purest  form,  however,  shows  smaller, 
more  regular,  and  more  discrete  lesions  than  those  of  measles, 
which  are  inclined  to  present  an  irregular,  blotchy  appearance. 
The  color  of  the  macules  of  rubella  has  been  described  as  a  pale 
rose  tint  or  rosy-red  by  most  writers.  The  color  doubtless 
varies  to  some  extent  in  different  individuals,  as  does  the  tint 
in  all  eruptive  diseases,  but  it  may  be  said,  in  general,  that 
it  is  ordinarily  not  so  vivid  as  the  eruption  of  scarlet  fever,  nor 
so  dusky  or  bluish  as  the  measles  exanthem. 

The  discreteness  of  the  slightl"  "   *  <nves  the 

eruption  its  distinctive,  apr  *mg 

34 


out  in  striking  contrast  with  the  pale  integument.     Confluence 
is,  however,  frequently  noted  in  certain  areas,  particularly  on 


the   face.     On  the  second  or  third  day  of  the  eruption  it  is  not 
uncommon  for  the  rash  to  Income  paler  in  lint  and  to  assume 


RUBELLA  53! 

Pressure  or  irritation  of  the  skin  seems  to  increase  the  inten- 
sity of  the  eruption  and  to  encourage  confluence. 

Distribution  of  the  Eruption. — The  face  almost  invariably 
exhibits  an  abundance  of  eruption,  especially  upon  the  fore- 
head, cheeks,  and  chin.  The  lesions  may  be  so  copious  as  to 
produce  the  appearance  of  slight  edema.  The  eruption  does 
not  respect  the  circumoral  region,  as  does  the  exanthem  of 
scarlet  fever.  The  scalp  is  profusely  covered,  as  is  also  the 
neck.  The  chest,  abdomen,  back,  and  arms  show  rather  less 
eruption ;  the  buttocks  and  posterior  aspect  of  the  thighs,  owing, 
perhaps,  to  pressure,  commonly  exhibit  the  eruption  in  such 
profusion  as  to  present  confluent  patches.  The  legs,  as  a  rule, 
are  the  seat  of  the  least  eruption,  the  lesions  often  being  widely 
scattered.  It  has  been  asserted  by  some  writers  that  the 
palmar  and  plantar  surfaces  are  exempt,  but  this  is  not  true, 
as  lesions  are  not  infrequently  found  in  these  regions  in  well- 
pronounced  attacks.  The  above  outline  presents  the  distri- 
bution of  the  eruption  in  normal  cases;  it  is  not  rare  for  depar- 
tures from  this  to  take  place. 

Barthez  and  Rilliet  have  noted  the  fading  of  the  eruption, 
followed  by  the  reappearance  of  the  same  upon  the  same  day 
or  later.  Griffith  also  mentions  a  case  in  which  it  was  invisible 
during  one  day  and  returned. 

Duration  of  the  Rash. — The  eruption  ordinarily  persists 
from  one  to  five  days :  the  average  duration  is  two  or  three  days. 
In  mild  cases  it  is  shorter  and  in  severe  cases  longer. 

Anomalous  Features  of  the  Eruption. — In  rare  instances 
miliary  vesicles  have  been  noted  upon  the  reddish  macules. 
This  has  been  observed  by  Curtman,  Cuomo,  Thomas,  Hard- 
away,  and  Copland. 

Petechial  spots  have  been  recorded  by  Dunlop,  and  likewise 
by  Cheadle;  Erskine  reports  similar  lesions  of  the  uvula  and 
soft  palate.     A  purpuric  rash  was  also  observed  by  Glaister. 

Claussen  makes  mention  of  lesions  which  gave  the  impression 
of  small  shot  being  buried  in  the  skin.  Griffith  saw  an  unusual 
eruption  which  also  imparted  a  shotty  feel  to  the  finger. 

Scarlatiniform  Variety  of  Rubella. — Thus  far  reference 
has  been  made  only  to  normal  rubella,  and  to  the  form  which 
bears  more  or  less  resemblance  to  measles.  There  are  other 
cases  in  which  the  exanthem  bears  a  strong  resemblance  to  that 
of  scarlet  fever.     Some  writers  of  ™«*  -take  no  mention 

of  this  variety,  and  exn  tion  of 


532  DISEASES  OF  THE  SKIN 

similarity  between  the  rashes  of  rubella  and  scarlatina.  Thomas 
says:  "According  to  my  observations,  the  exanthem  of  rubeola, 
(rubella)  possesses  a  similarity  to  that  of  measles  only,  not  the 
slightest  to  that  of  a  normal  scarlet  fever."  Cristowe  and 
Bourneville  and  Bricon  entertain  similar  views.  These  opinions 
may  be  attributed  to  the  fact  that  the  scarlatiniform  variety 


of  rubella  has  not  come  within  the  range  of  the  personal  exper- 
ience of  these  physicians. 

Mention  could  be  made  of  a  large  number  of  writers  who 
have  observed  this  variety.  Hatfield  speaks  of  an  epidemic 
in  which  the  rash  in  many  cases  was  indistinguishable  from 
measles,  and  in  other  cases  strongly  resembled  scarlet  fever. 
J.  L.  Smith  refers  to  a  case  which,  had  he  been  guided  alone 


RUBELLA  533 

by  the  eruption,  he  would  have  regarded  it  as  a  mild  scarlet 
fever.  Griffith  describes  a  case  in  which  the  eruption  was  at 
first  macular,  yet  on  the  second  day  it  so  closely  resembled 
scarlet  fever  that  he  was  unable  for  several  days  to  make  a 
diagnosis.  The  whole  body  was  covered  by  a  general  scarla- 
tinal blush,  and  nowhere  could  a  single  macule  or  papule  be 
found.     A  short  time  afterward  the  brother  took  rubella. 

1  have  seen  one  or  two  cases  of  rubella  with  scarlatiniform 
eruptions  in  children  convalescent  from  scarlet  fever. 

Griffith,  from  a  careful  study  of  a  large  number  of  cases, 
comes  to  the  conclusion  that  there  are  two  easily  recognized 


Rubella — morbilliform  type  (Welch  and  Schamberg). 


types  of  variation  from  the  character  of  the  eruption  in  a 
normal  case : 

"An  eruption  in  which  the  spots  are,  for  the  most  part, 
nearly  or  fully  the  size  of  a  split-pea,  more  or  less  grouped, 
and,  in  fact,  having  the  greatest  resemblance  to  measles. 

"A  rash  which  is  confluent  in  patches  or  universally,  not 
elevated,  and  which  produces  a  uniform  redness  closely  simu- 
lating that  of  scarlatina.  Very  careful  examination  will  often 
reveal  a  few  papules  amid  the  general  diffuse  redness." 

Desquamation. — Upon  the  subsidence  of  the  eruption  a  deli- 
cate brownish  or  yellowish  staining  may  be  noticed  for  a  short 
time. 

A  slight  branny  or  furfuraceous  desquamation  occasionally 
follows  the  disappearance  of  the  rash.  The  development  of 
this  scaling  is  proportionate  to  the  severity  of  the  attack  and 
the  intensity  of  the  rash. 


nions  and  sequela?  of  rubella  are   compara- 
limportant.     Pneumonia,  stomatitis,  erysipelas, 
mphigus,  urticaria,  otitis,  endocarditis,  albumi- 
.  etc..  been  encountered  in  rare  instances. 

j\  The  diagnosis  of  an  atypical  case  of  rubella, 

■*■-,  en   occurring   sporadically,    may   be     attended 

it  difficulty.     In  its  classic  form,  and  espcciallv 
g  tr  ic   prevalence,    the   diagnosis   is  a   very  simple 

■uiem.  re  is  no  one  symptom  which  in  itself  is  char- 

eristic;  the  d"  "    must  be  made  from  a  consideration  of 

composite  s;  ...atology- 

Meastes  is  the  disease  most  apt  to  be  confounded  with 
■>e11a.  The  differentiation  is  given  in  the  chapter  on  Measles. 
bcarlet  Fcvct.— It  is  quite  possible  to  confound  one  form  of 
e  eruption  of  rubella  with  that  of  scarlatina.  Many  writers 
ve  acknowledged  their  inability  to  distinguish  at  times 
iween  the  confluent  scarlati  inform  type  of  rubella  and  the 
*rlet  fever  exanthem.  In  these  cases  other  symptoms  than 
!  skin  appearance  must  be  relied  upon  for  the  differential 
.gnosis. 

The  incubation  period  of  scarlet  fever  is  distinctly  shorter 
than  that  of  rubella,  lasting  ordinarily  from  three  to  seven 
days.  The  invasive  symptoms  are  sudden  and  quite  severe; 
vomiting  occurs  in  the  majority  of  cases,  followed  by  rapid 
rise  of  temperature — usually  to  io3°orio4°F.  There  is 
marked  sore  throat,  the  tonsils,  soft  palate,  and  uvula  being 
particularly  affected.  The  glands  generally  are  enlarged,  but 
more  especially  about  the  angles  of  the  jaw.  The  tongue  is  at 
first  coated,  later  exhibiting  the  characteristic  red,  papillated 
appearance. 

The  eruption  appears  first  on  the  neck  and  upper  chest;  the 
face  usually  shows  the  circumoral  pallor.  The  eruption  lasts 
ordinarily  five  or  six  days.  Desquamation  occurs  in  flakes 
and  is  most  marked  on  the  hands  and  feet.  Middle-ear  disease 
and  albuminuria  are  extremely  common  complications. 

Influenza.- — Forchheimer  states  that  in  the  epidemic  of 
influenza  in  1892  many  cases  were  observed  in  which  the  differ- 
ential diagnosis  between  scarlatina,  rubella,  and  influenza  pre- 
sented difficulties,  at  least  in  the  beginning. 

There  may  be  present  in  influenza  an  erythematous  eruption 
which  may  be  localized,  or  which  may  rapidly  spread  over 
the  body.     The  fever,  prostration,  severe  gastro- intestinal  or 


RUBELLA  535 

respiratory  symptoms  and  the  known  prevalence  of  the  disease 
will  serve  to  distinguish  it  from  rubella. 

Prognosis. — The  prognosis  is  absolutely  favorable  in  the 
vast  majority  of  cases.  Deaths  have  been  so  uncommon  as 
to  attract  attention  by  their  rarity;  they  have  invariably  been 
due  to  complications,  usually  affecting  the  respiratory  tract. 

Treatment. — The  only  treatment  that  is  necessary  in  the 
majority  of  cases  is  the  guarding  of  the  patient  against  undue 
exposure.  When  fever  is  absent  and  catarrhal  symptoms  are 
slight,  one  need  not  insist  on  rest  in  bed,  although  the  child 
should  be  kept  in  a  properly  heated  and  ventilated  room.  The 
diet  should  be  regulated  according  to  individual  requirements. 
No  special  medication  is  required  unless  the  attack  be  severe 
or  some  complications  develop. 


riOUS  DISEASES  ACCOMPANIED  AT 
'IMES  BY  ERUPTIONS 


h  chapter  is       voted  to  a  consideration  of  the  cutaneous 

stations    of    those    infectious   disorders    which    are    fre- 

luy,  although  not  uniformly,  accompanied  by  au  exantheni. 

bus  fever  might,  owing  to  the  constancy  of  its  eruption,  be 

Gilded  among  the  exanthemata,   but  it  has  been  thought 

:st  to  consider  it  with  typhoid  fever. 

'n  addition  to  the  ordinary  cutaneous  expressions  of  these 

?ascs,  an  effort  has  been  made  to  describe  the  more  unusual 

1  accidental  eruptions  which  are  from  time  to  time  encoun- 

ed.     These  include  various  toxic  erythemas — scarlatiniform, 

-orbilliform,  urticarial,  etc.     It  is  interesting  and  important 

to  note  that  a  variety  of  toxins  developed  in  different  infectious 

processes  may  evoke  the  appearance  of  rashes  closely  simulating 

those  of  the  common  exanthemata. 

TYPHOID  FEVER 

The  characteristic  eruption  of  typhoid  fever  makes  its  appear- 
ance toward  the  end  of  the  first  week  or  early  in  the  second 
week  of  the  disease.  Most  commonly  it  is  observed  upon  the 
seventh  or  eighth  day.  In  children  the  spots  have  been  known 
to  appear  as  early  as  the  second  or  fourth  day;  on  the  other 
hand,  Murchison  has  seen  them  develop  thrice  on  the  fourteenth 
day  and  in  one  case  on  the  twentieth  day. 

The  eruption  appears  in  the  form  of  discrete,  rounded,  more 
or  less  circumscribed,  rose-colored  spots,  which  are  always 
slightly  elevated  above  the  level  of  the  skin.  They  vary  in 
size  from  a  pin-head  to  a  lentil-seed,  but  may  increase  some- 
what in  diameter.  They  are  at  first  pale  red,  the  color  disap- 
pearing upon  pressure;  later  the  tint  becomes  darker.  The 
roseola;  are  rarely  petechial  save  in  the  uncommon  cases  of 
hemorrhagic  typhoid  fever. 
536 


TYPHOID   FEVER  537 

The  spots  appear  in  crops,  usually  at  intervals  of  three  or 
four  days.  According  to  Curschmann,  they  persist  from  three 
to  five  days — in  rare  cases,  seven  to  ten  days — and  then  fade. 
New  spots  appear  while  the  old  ones  are  disappearing.  The 
entire  eruption  lasts  from  ten  days  to  two  weeks. 

The  roseolous  eruption  is  most  commonly  observed  upon 
the  abdomen,  thorax,  and  back ;  on  the  back,  the  spots  are  some- 
times seen  before  they  appear  elsewhere.  The  roseolae  are 
usually  confined  to  the  trunk,  but  in  profuse  eruptions  they 
may  extend  to  the  extremities;  they  become  sparser  as  the 
distance  from  the  trunk  increases.  In  rare  cases  the  neck 
and  border  of  the  lower  jaw  may  exhibit  some  eruptive  elements. 

The  number  of  spots  is  ordinarily  small,  varying  from  five 
to  twenty-five  or  thereabouts.  Exceptionally,  an  enormous 
profusion  of  spots  may  exist.  Murchison  counted  at  one  time 
iooo  lesions  upon  a  patjent.  The  rose-spots  are  said  to  be 
fewer,  as  a  rule,  in  children  than  in  adults. 

In  some  cases  of  typhoid  fever  the  eruption  is  absent  through- 
out the  entire  course  of  the  disease.  Curschmann  remarks  that 
in  the  Leipzig  clinic  persistent  absence  of  spots  was  noted  in  260 
out  of  1 261  cases.  Pepper  has  stated  that  the  extent  of  the 
eruption  varies  in  different  epidemics  and  in  different  seasons. 

Although  some  writers  believe  that  a  copious  eruption  is  of 
favorable  prognostic  significance,  others  deny  any  relationship 
between  the  severitv  of  the  disease  and  the  extent  of  the  roseo- 
lous  outbreak. 

Occasionally,  especially  in  children,  the  rose-spots  are  sur- 
mounted by  a  minute  vesicle  which  undergoes  desiccation. 
These  minute  vesicles  develop  at  times  upon  the  eruption  of 
scarlet  fever,  measles,  etc.,  and  invariably  lead  to  some  desqua- 
mation. When  a  relapse  occurs,  the  typhoid  spots  commonly 
reappear  in  equal  and  often  in  greater  numbers  than  during  the 
primary  outbreak. 

Typical  rose-spots  are  believed  to  occur  only  in  typhoid 
fever,  to  which  disease  they  are  peculiar.  Liebermeister  saw 
an  extensive  eruption  which  suggested  in  appearance  a  macular 
syphiloderm.  During  an  epidemic  of  small-pox  I  was  asked  to 
see  a  patient  with  an  unusually  profuse  typhoid  eruption,  the 
possibility  of  its  being  variola  having  been  under  consideration. 

Erythematous  Rashes  in  Typhoid  Fever. — Many  writers, 
including   Murchison,   Iiebermeiste*  ~*vmond,    Le 

Maigre,  Striimpell,  Osier,  Nei  have 


called  attention  to  the  occasional  occurrence  of  erythematous 
rashes  in  the  course  of  tvphoid  fever.  Curschraann  regards 
most  of  these  outbreaks  as  drug  rashes:  while  medicaments 
may  have  caused  some  of  the  rashes  reported,  it  is  not  likelv 
that  the  majority  have  had  such  a  causal  factor,  as  they  have 
developed  under  all  sorts  of  treatment.  Osier  remarks  that 
he  has  encountered  rashes  more  frequently  since  he  has  given 
up  the  use  of  quinin  in  typhoid  fever. 

These  efflorescences  appear  to  occur  much  more  frequently 
in  some  epidemics  than  in  others.  During  the  past  few  years 
in  Philadelphia  thev  have  not  been  particularly  rare.  Dr.  D. 
J.  M.  Miller  observed  10  instances  of  erythema  within  four 
months  among  250  cases  (175  adult  women  and  75  children). 
Among  350  attacks  of  typhoid  fever  in  males,  however,  but  2 
cases  of  erythema  were  encountered.  In  the  Johns  Hopkins 
series  of  829  cases  of  typhoid  fever  there  were  15  erythematous 
rashes. 

The  rashes  may  be  of  several  varieties.  There  may  be  a 
simple  erythema,  consisting  of  a  diffuse  reddish  blush  without 
punctation.  The  eruption  is  usually  of  brief  duration,  lasting 
twenty-four  hours  or  thereabouts.  It  is  most  often  seen  upon 
the  abdomen,  chest,  or  back,  and  may  extend  over  the  entire 
trunk  or  be  partial.  This  character  of  eruption  is  usually 
observed  early  in  the  course  of  the  disease — at  the  outset  or 
during  the  first  week. 

Some  of  the  rashes  are  distinct  scarlatinoid  erythemas,  at 
times  followed  by  desquamation,  either  branny  or  in  flakes. 
There  is  a  pronounced  punctated  scarlatiniform  eruption  involv- 
ing the  trunk,  and  occasionally  the  extremities.  The  erup- 
tion persists  from  two  to  ten  days  or  longer.  This  type  of  rash 
is  more  prone  to  develop  after  the  second  week  of  the  disease, 
but  may  occur  earlier.  Scarlet  fever  is  often  suspected  and 
sometimes  diagnosed,  but  we  11 -pronounced  angina  and  "straw- 
berry tongue"  are  not  present.  Furthermore,  this  rash  often 
occurs  in  persons  who  have  previously  had  scarlet  fever. 

Morbilliform  rashes  bearing  a  close  resemblance  to  the  erup- 
tion of  measles  occasionally  occur  during  typhoid  fever,  but 
are  distinctly  rarer  than  the  types  previously  described.  Such 
rashes  have  been  reported  by  Beevor,  Neumann,  and  DaCosta. 

These  rashes  are  in  all  probability  the  result  of  the  absorption 
of  intestinal  toxins.  At  times  it  would  appear  that  enemata 
favor  the  solution  and  absorption  of  toxins.  It  is  possible 
that  some  of  the  rashes  are  due  to  the  administration  of  drugs. 


TYPHOID  FEVER  539 

The  above-described  cutaneous  efflorescences  have  no  prog- 
nostic significance,  and  are  chiefly  important  from  a  diagnostic 
viewpoint. 

Urticaria. — Urticaria  is  of  comparatively  rare  occurrence 
in  typhoid  fever;  like  the  other  accidental  eruptions,  it  varies 
much  in  frequency  in  different  epidemics.  Among  600  cases 
of  typhoid  fever  studied  by  D.  J.  M.  Miller,  urticaria  occurred 
only  in  3  cases.  In  the  Johns  Hopkins  series,  it  was  observed 
3  times  among  829  cases.  On  the  other  hand,  Curschmann 
noted  urticaria  in  6.3  per  cent,  of  his  cases  in  Leipzig,  and 
Phillips  found  it  in  21  patients  among  1230  cases  of  typhoid  fever. 

Herpes. — It  has  been  long  noted  that  herpes  occurs  with 
great  infrequency  in  typhoid  fever;  indeed,  to  such  an  extent 
is  this  true  that  some  writers  erroneously  allege  that  it  does 
not  occur  at  all.  Osier's  figures  on  the  subject  enable  us  to 
judge  of  the  infrequency  of  its  development.  Among  1500 
cases  of  typhoid  fever  herpetic  outbreaks  were  found  in  20 
patients,  or  a  little  more  than  1  per  cent,  of  the  cases.  In  the 
Johns  Hopkins  series  of  829  cases  herpes  was  observed  in  29 
patients,  or  3.5  per  cent.  D.  J.  M.  Miller  observed  4  cases  of 
herpes  among  250  cases  of  typhoid  fever  examined.  Among 
Phillips'  1230  cases,  herpes  was  present  in  12  patients.  Zinn 
seems  to  have  recorded  the  largest  incidence  of  herpes  in  typhoid 
fever,  having  encountered  it  in  5  per  cent,  of  190  cases.  Many 
of  the  older  writers  maintained  that  even  when  all  the  char- 
acteristic symptoms  of  typhoid  fever  were  present,  a  case  must 
not  be  regarded  as  this  disease  if  herpes  labialis  developed. 
Some  modern  writers  refer  to  herpes  as  negatively  pathogno- 
monic of  typhoid  fever. 

Purpura  or  hemorrhage  into  the  skin  may  occur  in  typhoid 
fever,  as  it  does  in  other  infectious  diseases.  Among  Phillips' 
1230  cases,  purpura  was  noted  6  times.  It  usually  occurred 
upon  the  lower  extremities  late  in  the  disease.  In  one  patient 
the  purpura  occurred  about  the  end  of  the  second  week,  and  was 
accompanied  by  intestinal  hemorrhage.  The  termination  was 
fatal. 

Desquamation  after  Typhoid  Fever. — Louis,  Murchison, 
Dreschfeld,  Hutchinson,  Striimpell,  Osier,  Chantemesse,  Weill, 
Hutinel,  Comby,  Hare,  Riesman,  and  other  writers  have 
described  desquamation  occasionally  occurring  after  typhoid 
fever.  Weill  observed  desquamation  33  times  in  37  cases  in 
children,  and  Phillips,  extensive  desquamation  in  83  of  1230 


DISEASES   OF  THE   SKIN 

seen  chiefly  upon  the  trunk,  but  also  upon  the 

>s,  and.  rarely,  upon  the  face.     The  scaling  is 

aceous  in  character,  but  may  in  some  cases  occur 

is  most  frequently  observed  during  the  stage  of 

The   scaling  has  been   attributed   to   various 

i.  man  distinguishes  three  varieties:  (i)   Desqua- 

the  summits  of    rose-spots,  due  to  desiccation  of 

;s;  (2)  that  appearing  as  a  sequel  of  sudamina; 

•■xtensivt    furfuraceous   or   lamellar   desquamation,    repre- 

g  a   ti  ~~  to  the  shedding  of  hair. 

iner  vanei}  m;  iu  t  resulting  from  an  ante- 

>t  erythematous  ra 

lamina,  or  miliaria  crystallina,  occurs  commonly  in  the 

■se  of  typhoid  fever.     This  eruption  is  seen  in  many  dis- 

^s  in  which  sweating  occurs,  but  appears  to  be  usually  fre- 

■'ent  in  this  affection.     The  eruption  is  seen  chiefly  upon  the 

lomen  and  thorax,  and  comes  on  during  the  decline  of  the 

ver.     Curschmann  encountered  sudamina   in   98  out  of   150 

consecutive  cases  of  typhoid  fever.     The  sudaminous  eruptioi 

»  often  followed  by  desquamation. 

Miliaria  rubra,  or  prickly  heat,  occurs  at  times  in  typhoid 

fever  in  such  intense   form  as  to  lead  to  the  suspicion  of  an 

intercurrent  eruptive  fever.     On  one  occasion  I  saw  a  patient 

whose  body  was  so  thickly  beset  with  small  conic,  red  papules. 

as  to  cause  the  case  to  be  regarded  as  scarlet  fever.     Another 

patient,  during  the  latter  part  of  the  second  week  of  the  disease, 

exhibited  small  and  large,  closely  aggregated  vesicles  on  the 

entire  trunk,  and  small  conic,  vesicopustules  scattered  over  the 

face  and  arms.     This  patient  was  refused  admission  to  a  hospital 

for  fear  of  his  suffering  from  a  contagious  disease. 

Gangrenous  dermatitis  is  a  rare  complication  of  typhoid 
fever.  Many  writers  of  large  experience  do  not  mention  its 
occurrence.  In  1898  B.  F.  Stahl  published  a  report  of  10  cases 
of  gangrene  of  the  skin  occurring  among  144  cases  of  typhoid 
fever  in  soldiers  returning  from  the  Spanish -American  War. 
The  author  had  an  opportunity  of  seeing  a  number  of  these 
cases.  The  gangrene  occurred  in  large  and  small  patches 
scattered  over  the  surface  of  the  body.  Bulla'  and  erythematous 
spots  preceded  the  development  of  necrosis.  Some  of  the 
patients  suffered  also  from  furuncles  and  abscesses.  Three  of 
the  10  patients  died.  This  condition  is  not  to  be  confounded 
with  bed-sores,  which  are  not  uncommon  in  typhoid  fever. 


TYPHUS  FEVER  541 

There  is  another  variety  of  disseminated  gangrene  of  the  skin 
in  which  the  lesions  begin  as  papules  or  nodules  and  rapidly 
progress  to  vesicles,  pustules,  and  necrosis,  leaving  deep, 
punched-out  ulcers.  Such  a  type  is  illustrated  in  the  accom- 
panying photograph.  Cases  of  this  character  are  suggestive  of 
multiple  cutaneous  thrombosis  due  to  the  typhoid  bacillus. 

Furunculosis  was  observed  by  Phillips  in  45  patients  in  his 
series  of  1230  cases.  Edsall  has  described  a  series  of  cases  in 
which  furuncles  developed  about  the  buttocks. 


Fig.  133. — Dermatitis  gangrenosa  occurring  during  the  third  week  of  typhoid 
[ever.  Lesions  begin  as  papules,  develop  into  Vesicles  ind  pustules,  uid  terminate  in 
deep  necroses.  Fatal  termination.  Seen  and  photographed  hv  the  author  {patient 
of  Dr.J.HenrieLloyd). 

Stria;  atrophica:,  occurring  during  and  after  typhoid  fever, 
have  been  described  by  Wilks,  Bradshaw,  Shepherd,  Troisier, 
Northrup,  Fisher,  Sir  Dyce  Duckworth,  Kobner,  Phillips,  and 
others.  The  atrophic  streaks  usually  appear  over  or  above 
the  patellae,  although  other  regions  may  be  affected.  The  stria; 
are  at  first  pinkish,  but  ultimately  become  white.  They  are 
believed  to  be  due  to  overstretching  of  the  skin,  due  to  growth  of 
the  long  bones  during  protracted  illness. 

TYPHUS  FEVER 
The  eruption  of  typhus  fever  is  so  uniformly  present  and  so 
characteristic  of  the  disease  as  to  warrant   the  inclusion   of 
typhus  in  the  list  of  exanthematous  affections.     The  rash  may, 
in  rare  cases,  be  absent,  and  in  ol  *  ^ned  as  to 

escape  observation.     It  has  b  it 

is  seen  in  95  per  cent,  of  oil 


5+2 


DISEASES   OF   THE   SKIN 


spicuous  and  diagnostic  symptoms  of  the  disease,  a  fact  which 
has  led  to  the  use  of  such  designations  as  "spotted  fever," 
"petechial  fever,"  etc. 

The  exanthem  usually  makes  its  appearance  upon  the  fourth 
or  fifth  day  of  the  disease,  but  may  occur  as  early  as  the  second 
and  as  late  as  the  eleventh  day-  Salamon,  working  with 
Curschmann,  observed  the  rash  in  39  cases  of  typhus;  of  this 
number,  it  appeared  11  times  on  the  fourth  day,  13  times  on 
the  fifth  day,  and  5  times  on  the  seventh  day. 

The  spots  appear  first  upon  the  abdomen,  chest,  shoulders, 
and  back ;  very  soon  they  make  their  appearance  upon  the  arms 
and  legs,  even  as  far  as  the  hands  and  feet.     The  face  is  usually 


sistingof  a  poorly  del" 
"sulx-utieular  niotllii 
macules  are  pin-head 


ption,  although  in  children  at   times  the 
nlly  pronounced  to  cause  confusion  with 

it  very  abundant  upon  the  first  day,  but 
in  number  for  about  forty-eight  hours, 
meiil  cif  spots  is  present. 
up  of  two  elements — a  background  con- 
lined,  violaceous  reticulation — the  so-called 
rig" — and  the  rose-spots  or  macula?.  The 
ntil-seed-sizcd.  pale  rod  or  rosv  red 
ied   borders,  ami   scarcely  elevated 


TYPHUS  FEVER  543 

above  the  surface  of  the  skin.  In  some  cases  the  mottling  may 
be  present  without  the  spots,  but  the  converse  of  this  is  seldom 
the  case.  In  the  beginning  the  macules  disappear  completely 
upon  pressure,  but  gradually  the  color  becomes  more  dusky  or 
actually  purplish,  and  the  discoloration  can  no  longer  be  made 
to  fade  under  tension  or  pressure.  The  bluish  or  purplish 
coloration  is  evidence  of  hemorrhagic  extravasation  into  the 
skin.  At  times,  late  in  the  course  of  the  disease,  petechia  may 
develop  upon  healthy  areas  of  the  skin  without  the  previous 
presence  of  macules. 

Only  a  certain  proportion  of  rose-spots  become  the  seats  of 
hemic  extravasation.  In  general,  it  may  be  stated  that  the 
greater  the  extent  of  hemorrhage  into  the  skin,  the  more  severe 
is  the  attack.  Petechial  spots  are  most  commonly  seen  about 
the  flexures  of  joints,  particularly  the  groin,  and  on  dependent 
portions  of  the  cutaneous  surface,  such  as  the  back. 

The  duration  of  the  eruption  varies  according  to  the  amount 
of  dermic  hemorrhage.  Simple  rose-spots  may  disappear  in 
a  day  or  two;  those  showing  moderate  extravasation  fade  in 
five  or  six  days,  while  deep  purplish  petechia  may  persist  for 
two  or  three  weeks. 

During  the  process  of  fading  the  spots  pass  through  the  color 
gradations  of  blood-pigment,  showing  themselves  as  greenish, 
yellowish,  or  brownish  stains.  The  disappearance  of  the  erup- 
tion is  commonly  followed  by  a  branny  or  furfuraceous  scaling. 

During  the  evolution  of  the  eruption  the  typhus  exanthem, 
particularly  when  it  is  profuse  with  a  tendency  to  coalescence, 
may  closely  simulate  measles. 

The  individual  lesions  of  the  typhus  eruption  in  the  beginning 
bear  a  strong  resemblance  to  those  of  typhoid  fever.  They 
are,  however,  less  papular,  more  abundant,  and  later  petechial 
in  character.  The  macules  are,  at  times,  more  abundant  upon 
the  extremities  than  upon  the  trunk,  a  circumstance  that  is 
never  observed  in  typhoid  fever — indeed,  in  the  latter  disease 
spots  upon  the  arms  and  legs  are  quite  unusual. 

In  exceptional  cases  the  rash  of  typhus  may  be  absent,  con- 
stituting the  so-called  typhus  sine  exanthemate.  Murchison 
failed  to  discover  a  rash  only  55  times  in  2499  cases. 


544  DISEASES  OF  THE   SKIN 

INFLUENZA 

While  rashes  are  occasionally  encountered  in  the  course  of 
influenza,  there  is  no  characteristic  eruption  belonging  to  the 
symptomatology  of  the  disease. 

The  disease  exhibits  pronounced  functional  vasomotor 
changes,  in  which  the  cutaneous  blood-vessels  are  often  involved. 
Leichtenstern  regards  redness  of  the  skin  associated  with  hyperi- 
drosis,  more  especially  of  the  face,  as  an  important  symptom 
of  influenza.  Finkler  states  that  it  is  common  to  find  the  skin 
of  the  face  reddened  and  swollen,  probably  as  a  result  of  a 
vasoparalysis.  Sometimes  the  redness  extends  beyond  this 
region  and  involves  various  portions  of  the  body. 

A  morbilliform  or  scarlatiniform  erythema  is  occasionally 
observed  upon  the  face,  trunk,  or  extremities;  the  legs  are  less 
frequently  attacked  than  the  upper  extremities.  The  presence 
of  a  mottled  eruption  upon  the  face,  together  with  catarrhal 
symptoms,  may  excite  a  suspicion  of  measles.  Teissier  has 
described  a  series  of  cases  in  which  measles  and  scarlet  fever 
were   distinguished   with  difficulty. 

Leichtenstern  observed  a  "finely  punctate  eruption"  in  9 
per  cent,  of  his  cases;  on  the  face  alone,  in  6  per  cent.  Bristowe 
found  erythematous  rashes  present  in  6  per  cent,  of  his  cases; 
a  papular  or  scarlatiniform  rash  in  20  per  cent.  Comby 
encountered  rashes  in  6  per  cent.,  and  Barthe'lemy  in  7  per 
cent.,  of  the  cases  observed.  Hoffman  noted,  among  200  cases 
of  influenza,  5  eases  of  an  exanthem,  2  of  which  were  very  pro- 
nounced erythemas. 

In  other  epidemics  rashes  have  been  less  frequent;  Hawkins 
found  them  in  1  per  cent.,  and  Guttmann  in  3  per  cent.,  of  the 
cases  seen  by  him. 

The  erythematous  eruptions  appear  usually  during  the  early 
febrile  period.  In  rare  instances  they  may  develop  late,  even 
after  the  subsidence  of  the  fever.  Finkler  saw  an  intense 
scarlatiniform  erythema,  lasting  five  days,  make  its  appearance 
after  the  cessation  of  pyrexia. 

The  milder  erythemas  are  not  followed  by  desquamation, 
but  this  may  occur  after  the  more  persistent  rashes. 

Erythema  papulatum  has  been  observed  by  Hawkins, 
Moore,  Bristowe,  Bela,  and  Medvei,  and  erythema  multiforme 
and  erythema  nodosum  by  R.  Guiteras  and  Sehwimmer. 


DENGUE  545 

Urticaria,  usually  of  brief  duration,  has  been  mentioned 
by  quite  a  number  of  writers. 

Herpes  facialis  varies  considerably  in  its  incidence  in 
different  epidemics.  Its  frequency  is  mentioned  by  a  number  of 
writers  as  follows:  Schulz  and  Demuth,  in  25  per  cent,  of  the 
cases;  Krehl,  in  12  per  cent. ;  Bristowe  and  Petersen,  each,  in  10 
per  cent. ;  Stintzing,  in  8  per  cent. ;  Anton,  in  6  per  cent. ;  German 
Collective  Investigation  Committee,  in  6  per  cent.;  Preston, 
in  5  per  cent. ;  Leichtenstern,  in  5  per  cent,  with  pneumonia 
(105  cases),  and  in  3  per  cent,  of  334  uncomplicated  cases. 

Herpes  zoster,  occurring  either  as  a  complication  or  sequel 
of  influenza,  has  been  observed  by  Real,  Dodler,  Kollmann, 
Bilhaut,  and  Curtin  and  Watson;  the  last-named  physicians 
met  with  1 1  cases. 

Sudamina,  or  miliaria  crystallina,  is,  as  one  would  expect  in 
a  disease  frequently  accompanied  by  sweating,  not  uncommon. 
Sweating  in  influenza  may  be  severe;  it  has  been  known  to 
persist  for  months  after  the  termination  of  the  disease. 

Other  cutaneous  complications  reported  by  various  writers 
are  erysipelas,  furunculosis,  purpura,  simple  and  hemorrhagic 
pemphigus,  and  various  forms  of  staphylococcia. 

Among  rarities  may  be  mentioned  the  occurrence  of  alopecia 
areata  (Rosenstein),  vitiligo  (Simson),  and  rapid  graying  of 
hair  (Bossers  and  Bock). 

DENGUE 

Dengue  is  an  acute,  epidemic,  eruptive  fever  occurring  chiefly 
in  tropical  and  subtropical  localities.  The  onset  of  the  disease 
is  sudden,  with  high  fever,  chill,  severe  pains  in  the  frontal  and 
orbital  regions  and  in  the  joints,  bones,  and  muscles.  There 
are  two  febrile  paroxysms  with  an  intermission.  The  primary 
stage  lasts  about  three  days,  and  is  followed  by  an  abatement 
of  symptoms  for  a  period  of  two,  three,  or  four  days,  when  the 
second  febrile  paroxysm  is  ushered  in. 

Eruption. — A  primary  or  premonitory  erythema  is  some- 
times observed  at  the  beginning  of  the  disease.  This  is  of  the 
nature  of  a  vasomotor  blush,  and  may  appear  either  as  a  macular, 
patchy  rash  or  as  a  diffuse  redness.  It  may  occur  first  upon  the 
face,  accompanied  by  puffiness  of  the  skin,  or  upon  the  chest, 
abdomen,  or  knees.  Tt*+  «\sn  is  evanescent,  lasting  rarely 
longer  than 

The  9  is  far  more  constant 


546  DISEASES  OF  THE  SKIN 

and  important,  and  marks  the  development  of  the  second  stage 
of  the  disease.  It  appears  upon  the  face,  forearms,  chest,  and 
palms  of  the  hands,  but  may  become  general.  It  is  usually 
scarlatiniform  in  character,  but  not  infrequently  resembles 
measles  or  urticaria.  The  rash  lasts  from  a  few  hours  to  two 
or  three  days,  and  is  followed  by  desquamation,  either  branny 
or  in  flakes.  With  the  fading  of  the  rash  a  pronounced  degree 
of  itching  may  develop,  the  persistence  of  which  may  cause 
great  distress  during  convalescence.  The  eruption,  after  dis- 
appearing, sometimes  relapses. 

The  exanthem  is  regarded  as  a  significant  diagnostic  symptom 
of  dengue.  It  is  not  invariably  present,  but  its  frequency  may 
be  appreciated  by  the  following  figures :  von  During  noted  the 
presence  of  the  rash  in  nine-tenths  of  his  cases;  de  Brun  and 
the  Smyrna  Medical  Report  record  its  absence  only  excep- 
tionally; Charles  and  Martialis  found  it  in  two-thirds  of  their 
cases;  on  the  other  hand,  Morgan  observed  the  rash  in  only 
1 1  per  cent,  of  his  patients. 

Herpes  facialis  appears  to  be  a  rare  occurrence  in  dengue. 

Dengue  may  be  readily  confounded  with  influenza,  and  in 
some  cases  with  scarlet  fever  and  measles. 

MALARIA 

There  is  no  cutaneous  manifestation  that  is  either  constant 
or  peculiar  to  malaria. 

Herpes  simplex  occurs  commonly  in  the  course  of  the  dis- 
ease, and  is  often  of  diagnostic  importance,  inasmuch  as  it  is 
rare  in  typhoid  fever,  an  affection  with  which  malaria  may, 
at  the  outset,  be  confounded.  Griesinger  observed  herpes  in 
1 1 7  out  of  390  cases  of  malaria.  Kelsch  and  Kiener  state  that 
it  occurred  in  one-third  of  the  cases  of  "bilious  gastric"  malaria. 
Plehn,  on  the  other  hand,  noted,  among  744  cases  of  West 
African  fever,  only  one  case  of  herpes. 

The  eruption  appears  about  the  mouth  and  nose,  occasionally 
on  the  tongue  or  gums,  rarely  elsewhere.  It  may  develop 
during  the  hot  or  cold  stage,  but  also  at  other  periods.  Arthur 
Powell  regards  the  development  of  herpes  as  strong  evidence 
of  an  early  and  favorable  outcome  of  the  disease. 

Erythema. — But  little  reference  is  encountered  in  literature 
to  the  occurrence  of  erythematous  rashes  in  the  course  of 
malaria.  I  recall  the  case  of  a  young  man  sent  into  the  scarlet- 
fever  ward  of  the  Municipal  Hospital  of  Philadelphia  with  a 


EPIDEMIC   CEREBROSPINAL   MENINGITIS  547 

generalized  scarlatinifortn  erythema  of  moderate  intensity;  this 
rash  inaugurated  the  onset  of  a  typical  intermittent  malaria. 
Marchiafava  and  Bignami  speak  of  the  occurrence  of  diffuse 
scarlatiniform  rashes  in  the  course  of  pernicious  malarial  fever. 
Morton,  one  of  the  earlier  writers,  described  grave  fevers  cum 
efflorescentia  febrem  scarlatinam  simulante.  Bastianelli  and 
Bignami  refer  to  a  case  of  malaria  with  a  diffuse  scarlatinoid 
rash  covering  the  whole  body,  and  with  erythema  of  the  fauces; 
desquamation  occurred  in  large  scales,  when,  on  the  third  day 
thereafter,  the  rash  recurred.1 

A  macular  eruption  or  roseola  appears  to  be  extremely  rare 
in  the  course  of  malaria.  Such  a  case  is  reported  by  Segard. 
According  to  Ob£denaire,  Boicesco,  and  Moncorvo,  a  peculiar 
form  of  erythema  nodosum  occasionally  occurs  in  malaria  in 
children. 

Purpura. — Punctiform  hemorrhages  may  occur  in  the  skin 
in  hemorrhagic  malaria.  Bleeding  from  the  mucous  membranes 
is  likewise  seen  in  such  attacks.  Petechial  spots  are  observed 
more  particularly  in  children  and  in  persons  debilitated  by 
previous  illness. 

Urticaria  is  said  to  occur  in  malaria  about  as  frequently  as 
herpes,  although  but  little  attention  has  been  paid  to  this  erup- 
tion in  the  literature  of  the  subject. 

Pigmentation. — The  color  of  the  skin  is  often  pale  yellow, 
greenish  yellow,  earth  colored,  or  ashy  gray,  depending  upon 
the  coincidence  of  anemia  and  pigmentation.  In  chronic  cases 
intense  pigmentation  may  occur,  the  skin  acquiring  even  a 
bronze  or  a  chocolate  tint.  In  some  cases  the  integument  is 
intensely  yellow,"  from  an  associated  jaundice.  In  malarial 
cachexia  the  skin  is  dry  and  may  desquamate. 

Gangrene  of  the  skin,  noma,  acne,  and  furunculosis  have 
occasionally  been  observed  in  the  course  of  malaria. 

EPIDEMIC  CEREBROSPINAL  MENINGITIS 

The  petechial  eruption  of  cerebrospinal  meningitis  is  a 
highly  characteristic  but  inconstant  manifestation  of  the  dis- 
ease. In  the  early  epidemics,  particularly  in  this  country, 
the  eruption  was  so  prominent  a  symptom  of  the  disease  as 

1  Albert  Billet,  in  1892,  described  the  case  of  a  French  soldier  sent 
into  the  Constantine  Military  Hospital,  supposed  to  be  suffering  from 
scarlet  fever.  The  disease  proved  to  be  malaria,  with  a  scarlatinoid 
erythema  which  subsequently  recurred  twice  with  the  onset  of  parox- 
ysms.    Malarial  organisms  were  found  in  the  blood. 


adoption  of  the  term   "spotted  fever,"  a  name 

led  elsewhere  to  typhus  fever.     It  is  said  that 

iic  E  k  of  1806-07  almost  every  case  was  characterized 

■   an  kiuftion.     In  the  epidemic  of   1808-00,  however,   the 

iracteristit    rash    was   rarely   encountered.     In    Ireland,    in 

366-67,   cr     'tions   were   frequently  observed.     Cerebrospinal 

eningitis  ii     ?>crmany  seems  to  have  been  much  less  frequently 

xtrnpaniea    by    an    exanthem    than    in    America.     Latterly, 

■  disease  in  this  country  has  exhibited  the  eruption  in  only 

linority  of  tht  >ng   1 1 1  cases  studied  by  Council- 

n  and  Mallory  1  ,  hemorrhagic  spots  were  observed 

in  11  patients.      In  general,  it  may  be  stated  that  the  eruption 

«f  cerebrospinal  meningitis  occurs  in  about  one-third  or  less 

the  cases. 

fhe  eruption  appears  ordinarily  about  the  third  day  of  the 
disease,  although  it  may  occur  both  earlier  and  later.  I  have 
seen  a  well-marked  hemorrhagic  rash  develop  within  twelve 
hours  of  the  onset  of  the  malady.  The  eruption  appears  in 
the  form  of  pin -head-  to  pea-sized,  hemorrhagic,  claret -colored 
or  purplish  spots  which  do  not  disappear  tinder  digital  pressure. 
At  times,  finger -nail -sized  or  larger  ecchvmosts  apptar,  which 
subsequ:  ntly  pass  through  the  color  gradations  of  effused  blood. 
The  eruption  is  scattered  upon  the  trunk,  face,  and  extremities. 
Ordinarily  the  number  of  spots  is  small,  but  exceptionally,  a 
copious  eruption  may  be  present.  In  my  experience  profuse 
eruptions  have  occurred,  more  particularly  in  severe  and  fatal 
cases. 

In  rare  instances  a  macular  rash  bearing  some  resemblance 
to  the  eruption  of  measles  may  make  its  appearance.  North 
writes  of  cases  presenting  a  rash  resembling  "flea-bites." 
Gordon  encountered  an  eruption  resembling  measles,  but  the 
patches  were  irregular  in  size  and  shape.  Gahlberg  saw  a  case 
in  which  the  eruption  was  very  similar  to  measles.  Austin 
Flint  speaks  of  a  rose-colored  papular  eruption  looking  like 
that  of  typhoid  fever. 

Herpes  Simplex.— Herpes  may  be  regarded  as  the  most  fre- 
quent cutaneous  s\inptom  of  cere  brospinal  fever,  although 
it  is  not  its  most  characteristic  eruption-  The  herpetic  vesicles 
appear  most  commonly  about  the  nose  and  mouth,  but  are  also 
seen  at  times  upon  the  cheeks,  ears,  and  neck.  Occasionally, 
the  outbreak  is  seen  upon  some  portion  of  the  extremities.  I 
recall  a  patient  on  whom  a  patch  of  lierpcs  was  present  upon 


MILIARY   FEVER  549 

the  last  phalanx  of  the  thumb.  The  herpetic  clusters  are  at 
times  extensive,  but  frequently  are  quite  limited  as  regards 
the  area  covered.  Herpes  is  of  great  diagnostic  value  in  this 
disease,  constituting  one  of  the  important  early  symptoms  of 
the  malady.  Its  frequency  may  be  seen  by  reference  to  the 
following  figures : 

Tourdes  noted  herpes  in  60  per  cent,  of  his  cases;  Leyden, 
in  75  per  cent;  Friis  (Copenhagen),  54  of  107  cases — 50  per 
cent;  Jaffe  (Hamburg),  41  percent;  Councilmann  etal  (Boston), 
35  of  in  cases — 31  per  cent;  Leichtenstern,  26  of  29  cases — 
90  per  cent. 

The  incidence  of  herpes  varies  in  different  epidemics,  but  in 
general  it  appears  to  be  more  common  in  cerebrospinal  fever 
than  in  any  other  disease,  save  possibly  pneumonia.  Some 
writers  regard  the  occurrence  of  herpes  as  of  favorable  prog- 
nostic significance,  but  such  a  view  is  scarcely  borne  out  by 
experience. 

Sudamina,  urticaria,  scarlatinoid  erythema,  and  pemphigoid 
bullae  have  been  said  to  occur  in  rare  instances. 

MILIARY  FEVER 

Miliary  or  sweating  fever  is  a  rare  epidemic  disease,  largely 
confined  to  certain  districts  of  France,  Italy,  Germany,  and 
Austria.  The  disease  does  not  appear  to  have  been  observed 
in  America.  The  chief  manifestations  are  profuse  sweating, 
a  peculiar  eruption,  and  marked  febrile  and  nervous  symptoms. 
With  or  without  prodromes,  the  patient  exhibits,  slowly  or 
rapidly,  extreme  weakness,  pronounced  sweating,  high  fever, 
violent  headache,  epigastric  constriction,  dyspnea,  delirium,  etc. 

Eruption. — About  the  third  or  fourth  day,  sometimes  later, 
the  rash  appears,  often  preceded  by  prickling  and  formication. 
The  exanthem  may  be  of  several  varieties.  The  essential 
feature  is  an  erythema,  which  may  be  morbilliform,  resembling 
measles,  or  there  may  be  a  confluence  of  the  rubcolous  patches, 
producing  a  scarlatiniform  rash.  In  some  cases  the  eruption 
may  take  on  a  purpuric  character. 

Another  eruptive  variety  (the  one  which  has  given  the 
disease  its  name)  consists  of  minute,  closely  aggregated,  conical 
papules,  which  soon  acquire  miliary  vesicles  upon  their  sum- 
mits. In  some  of  the  epidemics  described  this  appears  to  have 
been  the  dominant  eruption. 


DISEASES  OF   THE  SKIN 

ra  present  upon  die  trunk  and  extremities  and  at 

in.ni  -  ie  face.     The  mucous  membrane  of  the  mouth 

.y  ai  ripate  in  the  eruptive  outbreak.     After  a  duration 

seve  s  the  exanthcm  undergoes  desquamation,  which 
.~y   be    eiir   r    furfuraceous   or    lamellar.      Convalescence    is 

dious   a°  uucertain.      The    mortality    varies  in   different 

>idemics,  .  averages  about  13  per  cent. 

ANGINA  AND  TONSILLITIS 

But  little  can  mi        il  literature  bearing  upon 

the  occurrence  ol  rashes  in  lollicuiar  tonsillitis  and  other  forms 
of  sore  throat,  yet  eruptions  are  sometimes  observed  in  associ- 
ation with  these  conditions. 

The  French  author,  G.  H,  Roger,  remarks  that  a  slight 
erythema,  generally  localized  to  the  thorax  and  abdomen,  is 
sometimes  seen  in  the  course  of  a  simple  catarrhal  angina. 
Care,  of  course,  must  be  exercised  to  distinguish  such  a  condi- 
tion from  a  poorly  developed  scarlet  fever. 

In  a  boy  eight  years  of  age  suffering  from  a  sore  throat  with 
a  thin  grayish  exudate  over  the  tonsils  1  observed  an  extensive 
morbilliform  eruption  so  closely  resembling  measles  that  such 
a  diagnosis  would  have  been  entertained  had  it  not  been  for 
the  complete  absence  of  catarrhal  symptoms  and  the  history 
of  a  former  attack  of  measles.  The  eruption  lasted  scarcely 
more  than  twenty-four  hours. 

Von  Lustwerk1  reports  a  case  of  septic  maculopapular 
erythema  following  follicular  angina.  At  the  termination  of  a 
follicular  tonsillitis,  a  twenty -seven -year-old  man  developed  a 
chill,  followed  by  a  symmetrically  distributed  eruption  of 
bluish-red  macules  and  papules  appearing  first  on  the  extremi- 
ties and  later  on  the  body.  The  temperature  rose  to  1040  F., 
and  persisted  for  nine  days. 

Dr.  Rose  Hirschler,  of  Philadelphia,  informs  me  that  she  has 
on  several  occasions  seen  cases  of  follicular  tonsillitis  with 
patches  of  erythema,  particularly  over  the  articulations  of  the 
extremities. 

It  is  somewhat  surprising  that  toxic  rashes  have  not  been 
more  often  reported  in  connection  with  follicular  tonsillitis, 
inasmuch  as  the  streptococcus  is  a  frequent  cause  of  such 
eruptive  phenomena. 

1  Russische  Zeitschrift  F,  Haul-  und  Yen -Krankheiten,  Band  XV, 
April,  190S. 


RHEUMATIC   FEVER  55 1 


RHEUMATIC  FEVER 

There  is  no  eruption  constantly  observed  in  rheumatic  fever, 
nor  any  cutaneous  manifestation  peculiar  to  the  disease. 

Herpes  simplex  appears  to  be  uncommon,  having  been 
observed  by  McCrae  but  6  times  in  270  cases  in  Osier's  service 
in  the  Johns  Hopkins  Hospital.  Most  writers  do  not  particu- 
larly mention  its  occurrence. 

As  would  be  expected  in  a  disease  accompanied  by  frequent 
sweats,  sudamina  are  common,  as  is  likewise  miliaria,  an 
inflammatory  sweat  eruption. 

Forms  of  erythema  are  occasionally  observed.  McCrae 
found,  in  270  cases  of  acute  articular  rheumatism,  8  instances 
of  erythema. 

As  in  other  infectious  processes,  the  erythema  may  present 
different  forms. 

The  most  common  is  a  polymorphous  rash,  occurring  as 
erythematous  rings,  which,  through  coalescence,  produce 
large  gyrate  or  map-like  configurations  occupying  considerable 
areas  of  the  trunk. 

In  other  cases  a  papular  erythema  of  the  extremities  may 
be  seen.  I  recall  a  case  of  endocarditis  and  arthritis  of  a 
rheumatic  nature  following  scarlet  fever  in  which  recurrent 
outbreaks  of  geographic  erythema  were  observed. 

At  times  a  scarlatinif orm  erythema  is  encountered  during 
a  rheumatic  attack.  Poynton  saw  a  general  erythema  of  the 
scarlatiniform  type,  lacking,  however,  the  punctiform  char- 
acter. Hallopeau  and  Roger  have  each  recorded  an  instance 
of  a  scarlatiniform  eruption  in  rheumatism. 

Urticaria  occurs  rather  rarely  in  this  disease.  In  McCrae's 
series  of  270  cases  of  rheumatism  there  were  but  two  cases. 
Striimpell  states  that  he  has  seen  several  cases  of  hemorrhagic 
urticaria,  wheals  appearing  upon  the  skin  and  hemorrhages 
taking  place  into  their  centers  and  gradually  spreading.  The 
occasional  occurrence  of  urticaria  has  been  referred  to  by  other 
writers. 

Erythema  nodosum,  characterized  by  circumscribed,  nut- 
sized,  reddish,  inflammatory  swellings  in  the  tibial  regions, 
with  subsequent  bruise-like  discolorations,  has  been  frequently 
referred  to  as  a  rheumatic  manifestation.  Erythema  nodosum 
does  occur  in  rheumatic  subjects,  and  at  times  during  acute 


552  DISEASES  OF  THE  SKIN 

attacks  of  rheumatism.  Church  observed  this  complication  in 
10  out  of  143 1  cases  of  rheumatic  fever.  It  appears,  however, 
during  other  infectious  processes,  and  sometimes  independently 
of  any  pronounced  systemic  disease.  It  is,  moreover,  closely  re- 
lated to,  if  not  a  variety  of,  erythema  multiforme.  I  regard  ery- 
thema nodosum  as  atoxic  affection  capable  of  being  produced  by 
various  infections,  of  which  the  rheumatic  is  the  most  common. 
Purpura,  or  peliosis  rheumatica,  also  known  as  Schonlein's 
disease,  is  occasionally  observed  in  the  course  of  rheumatic 
fever,  although  not  infrequently  occurring  independently 
thereof.  The  lesions  consist  of  purplish-red  patches  or  papules, 
primarily  hemorrhagic  or  later  becoming  so.  Its  relation  to 
the  rheumatic  process  is  doubtless  much  the  same  as  that  of 
erythema  nodosum.  The  joint  symptoms  accompanying  many 
of  the  members  of  the  erythema  group  are  not  necessarily 
rheumatic  in  character,  but  due  to  various  toxic  causes.  Among 
143 1  cases  of  rheumatic  fever,  Church  found  purpura  present 
in  16  patients. 

SERUM  ERUPTIONS 

The  injection  into  an  individual  of  an  alien  or  heterogeneous 
blood-serum,  1.  e.,  a  serum  derived  from  an  animal  of  another 
species,  is  often  followed,  after  an  interval  of  latency,  by  toxic 
phenomena,  including  the  appearance  of  an  eruption.  It  has 
been  proved  that  the  toxic  manifestations  are  not  due  to  the 
contained  antitoxin,  but  in  all  probability  to  certain  albuminous 
bodies  in  the  serum.  Therefore,  the  phenomena  in  question 
are  observed  after  the  use  of  antidiphtheric  serum,  antistrep- 
tococcic serum,  antitetanic  serum,  antipneumococcic  serum, 
etc.  Diphtheria  antitoxic  serum,  on  account  of  its  extensive 
use,  commands  especial  interest  and  supplies  us  with  the 
richest  data.  The  use  of  antitoxic  serum  in  diphtheria  is 
followed,  in  a  proportion  of  cases,  by  a  train  of  phenomena 
the  most  conspicuous  of  which  is  the  development  of  a  cuta- 
neous eruption. 

The  proportion  of  cases  in  which  antitoxin  rashes  develop 
is  most  variable.  Hartung  has  collected  from  the  literature 
a  series  of  2661  injections,  of  which  294,  or  11.4  per  cent., 
developed  rashes.  The  Imperial  Board  of  Health  of  Germany 
reports  4358  cases  of  diphtheria  injected  with  serum  from 
January  to  July,  1895,  with  tne  production  of  354  rashes,  or 
8.1  per  cent.     Among  78  cases  of  diphtheria  treated  in  the 


SERUM  ERUPTIONS  553 

Scarlet  Fever  and  Diphtheria  Hospital  of  New  York  in  1901, 
rashes  occurred  in  25.4  per  cent. 

The  Investigating  Committee  of  the  Clinical  Society  of 
London  collected  records  of  663  cases;  220  of  these,  or  33.1 
per  cent.,  developed  antitoxin  rashes.  Lennox  Browne  noted 
38  eruptions  in  100  cases.  According  to  Berg,  there  occurred 
within  four  months  in  the  Willard  Parker  Hospital,  of  New 
York,  82  rashes  among  337  cases,  or  24  per  cent. 

The  great  variability  in  the  frequency  with  which  antitoxin 
eruptions  develop  may  be  best  appreciated  when  it  is  stated 
that  Monti,  of  Vienna,  observed  rashes  in  52  per  cent,  of  one 
of  his  series  of  cases,  whereas  Hager  did  not  observe  a  rash  in 
a  single  instance  among  61  cases.  Serum  from  certain  horses 
gives  a  much  larger  percentage  of  rashes  than  from  others. 

In  the  experience  of  Dr.  William  M.  Welch  and  the  author 
in  the  Municipal  Hospital  of  Philadelphia  an  eruption  appeared 
in  about  20  per  cent,  of  the  patients  injected. 

Date  of  Appearance  of  Eruption. — The  rash  may  appear 
in  from  one  day  to  one  month  after  the  injection  of  the  serum. 
The  date  of  the  appearance  of  the  rash  depends  much  upon 
the  particular  serum  employed.  Among  120  antitoxin  erup- 
tions observed  in  the  Municipal  Hospital,  49  per  cent,  appeared 
upon  the  sixth,  seventh,  and  eighth  days  after  the  administra- 
tion of  the  serum.  They  were  observed  as  early  as  the  second 
day  and  as  late. as  the  twentieth  day.  Several  years  pre- 
viously the  rashes. quite  uniformly  appeared  about  the  four- 
teenth day. 

In  the  report  of  the  Clinical  Society  of  London  the  largest 
number  of  rashes  appeared  from  the  seventh  to  the  twelfth 
day. 

When  scarlatiniform  rashes  develop,  they  ate  prone  to  appear 
early — often  on  the  third  or  fourth  day. 

Character  of  the  Eruption. — The  vast  majority  of  rashes 
are  of  an  urticarial  character,  either  made  up  of  frank  wheals 
or  of  an  urticarial  erythema.  Next  in  frequency  are  the 
rashes  belonging  to  the  class  of  polymorphous  erythema. 

These  may  consist  of  irregular  marginated  and  non-elevated 
patches  of  redness,  or  may  show  a  distinct  tendency  to  annular 
or  gyrate  configuration.  It  is  not  uncommon  to  see  an  erythema 
made  up  of  small,  round,  red  patches  with  perfectly  pale  centers. 

In  other  cases  the  erythema  may  be  of  the  scarlatinoid  type, 
and  bear  a  close  resemblance  to  the  exanthem  of  scarlet  fever. 


554 


DISEASES   OP   THE   SKIN 


The  scarla Uniform  rashes  are  prone  to  develop  early — often 
from  one  to  three  days  after  the  administration  of  the  serum. 
In  other  cases  the  rash  is  a  morbilliform  erythema,  looking  not 
unlike  the  eruption  of  measles. 

Vesicular  and  bullous  eruptions   are   quite  uncommon;  I 
observed   one  well -pronounced  case,  which   is  shown  in  the 


panying  photograph, 
nfrequent,   for  of  i 


Purpuric  antitoxin  eruptions  are 
ny  hundreds  of  rashes  that  have 
occurred  in  the  Municipal  Hospital,  but  three  or  four  have  been 
characterized  by  hemorrhage  into  the  skin. 

Antitoxin  eruptions  are  frequently  polymorphous,  exhibiting 
wheals,  patches  of  non-elevated  erythema,  and  occasionally 
papules  and  vesicles.  Mixed  urticarial  and  erythematous 
lesions  are   frequently  observed. 


SERUM  ERUPTIONS  555 

Indeed,  all  the  lesions  which  may  occur  in  erythema  multi- 
forme may  be  present  in  the  rashes  following  serum  injections. 
Most  of  the  rashes  are  accompanied  by  severe  itching;  this  is 
particularly  complained  of  by  acjults,  who  are,  perhaps,  better 
able  to  give  expression  to  their  discomfort. 

Edema  of  the  skin  is  commonly  noted  in  association  with 
antitoxin  rashes.  The  face  is  puffed,  particularly  about  the 
eyelids,  and  not  infrequently  the  penis,  scrotum,  and  feet  are 
edematous. 

Among  220  rashes  recorded  by  the  Clinical  Society  of  London, 
161  were  erythematous;  37  were  urticarial;  17  were  mixed; 
and  5  were  petechial;  2  of  the  5  petechial  cases  died.  Of  33 
rashes  noted  by  Moizard,  14  were  urticarial;  9  scarlatiniform 
erythema;  9  polymorphous  erythema,  and  1  purpura. 

Distribution. — The  distribution  of  the  eruption  is  extremely 
irregular.  It  may  occur  upon  any  portion  of  the  cutaneous 
surface.  It  is  noted  with  particular  frequency  about  the  arms, 
legs,  and  buttocks,  although  the  trunk  is  scarcely  less  commonly 
attacked.     The  face  often  escapes,  but  by  no  means  always. 

The  most  frequent  region  for  the  initial  appearance  of  the 
rash  is  the  site  of  the  injection.  It  is  quite  common  for  an 
erythematous  or  urticarial  eruption  to  appear  about  the 
cutaneous  puncture  and  the  surrounding  skin  within  twenty- 
four  hours  after  the  injection;  this  frequently  disappears,  only 
to  return  some  days  later  as  the  herald  of  the  general  eruption. 

The  eruption  may  consist  of  but  a  few  scattered  patches, 
or  it  may  be  so  profuse  as  to  involve  the  greater  part  of  the 
cutaneous  surface. 

The  eruption  ordinarily  persists  for  about  forty-eight  hours, 
although  in  some  cases  it  may  last  three,  four,  or  five  days. 
The  purpuric  rashes  continue  miich  longer. 

The  eruption  following  the  use  of  diphtheria  antitoxin  is 
occasionally  subject  to  recurrence.  The  rash  may  disappear 
and  return  in  a  few  days  or  several  weeks  afterward.  Among 
134  rashes  observed  in  the  Municipal  Hospital  of  Philadelphia 
within  a  year  and  a  half,  there  were  14  recurrent  rashes.  The 
earliest  relapse  occurred  three  days  after  the  first  eruption, 
and  the  latest,  seventeen  days. 

Constitutional  Symptoms. — Antitoxin  rashes  are  commonly 
accompanied  by  constitutional  disturbance  of  a  more  or  less 
pronounced  character.  In  the  majority  of  cases  there  is 
elevation  of  temperature,  with  its  usual  concomitants.     The 


DISEASES  OF 

v  f  at  ioi°  or  io2°  F.,  but  in  rare  cases  may  reach 

i  F.     The  pyrexia  ordinarily  lasts  from  twenty-four 

>  sev  -■*o  hours,  but  may  persist  for  a  longer  period. 
eadacnc  a  a  variable  amount  of  prostration  may  be  present. 
.  very  com"  on  symptom  is  pain  in  the  joints:  adults  often 
mplain  b  ?rly  of  the  arthritic  distress.  Articular  swelling 
noted  in  s    le  cases,  but  this  subsides  in  a  few  days. 


INDEX 


Abscesses,    cutaneous,    in    scarlet 
fever,  507 
complicating  variola,  448    - 

in  chicken-pox,  485 

in  measles,  520 
Acantholysis  bullosa,  96 

nigricans,  228 
Aearodermatitis  urticarioides,  204 
Acarus  folliculorum,  237 

scabiei,  201,  202 
Acetanilid  dermatitis,  163 
Achorion  Schonleinii,  191,  193 
Achromia,  congenital,  251 
Acne,  119 

agminata,  313 

artificialis,  122 

bacterial  vaccines  in,  414 

cachecticorum,  122 

course  of,  122 

diagnosis  of,  123 

drugs,  124-127 

etiology  of,  122 

frontalis,  132 

hypertrophica,  130 

indurata,  122 

keloid,  133 

necrotica,  132 

papulosa,  121 

pathology,  123 

punctata,  121 

pustulosa,  121 

rhinophyma,  130 

rosacea,  128 
diagnosis,  131 
etiology,  130 
pathology,  131 
prognosis,  131 
symptoms,  128 
treatment,  131 

symptoms,  120 

tar,  122 

treatment,  124 

varioliformis,  132 

vulgaris,  119 

x-rays  in,  127,  405,  409 
Acnitis,  313 


Acrodermatitis     chronica     atrophi- 
cans, 256 

perstans,  81 
Acrodynia,  45 
Acromegaly,  250 
Actinomycosis,  317 
Actinotherapy,  399 
Active  hyperemia  of  skin,  28 
Acute  eruptive  fevers,  417 

infectious    diseases    accompanied 
at  times  by  eruptions,  5^6 
Addison's  disease,  chloasma  m,  223 

keloid,  262 
Adenoma  sebaceum,  291 

of  sweat-glands,  292 
A  in  hum,  279 

Air,  liquid,  in  treatment,  414 
Albinism,  2.51 
Albinos,  251 
Alibert's  keloid,  280 
Alopecia,  266 

after  small-pox,  434,  435 

areata,  269 
etiology,  270 
pathology,  272 
prognosis,  273 
treatment,  273 

circumscripta,  269 

congenital,  266 

etiology,  267 

pathology,  267 

pityroides,  267 

premature,  267 

prognosis,  268 

seborrhoica,  267 

senile,  266 

treatment,  268 
Alpha  radium  rays,  411 
Amboceptor,  328 
Ammoniated   mercury   in   psoriasis, 

150 
Anaemia,  28 

persistent,  skin  in,  28 

transient,  skin  in,  28 
Anatomic  tubercle,  309 
Anatomy  of  skin,  17 


004 


pigmrntosun.  et  atrophicum,  256 


si        at  186 

IK        foma,  2S6 

•■»  .....curotic  edema,  52 

•■—sis.  3ao 

1  ,   '77 

la,  174 
Aiu.       n  dermatitis,  163 
Anti        a     rashes,     55  2 .     See 

Se......  cruptiptis. 

Anus,  pruritus  of,  391,  393 

Area  Celsi,  169 

Argyria.  223 

Arsenic,  thloasma  from,  213 

dermatitis,  164 
Arse m  >!>■_■  11 7.0 1  in  syphilis,  3SO 
Artificial  eruptions,   170 
Asphyxia,  local,  169 
A  steatosis,  390 
Atheroma,  238 
Atrophia  cutis,  35s 

pilorum  propria,  175 

unguium,  378 
Atrophia;,  25c 
Atrophic  lines,  256 

spots,  156 
Ali(]|ilnnkrraa,  255 


pigmentosum,  256 
Atrophy,  idiopathic,  256 
of  hair,  275 
of  nail,  278 
of  skin,  255 
senile.  2.15 


Bacillus  lepra?,  361 
Bacteria]  vaccines,  413 
Balanoposthitis,  infecting,  322 
Baldness,  266 
Barbadoes  leg.  247 
Barber's  itch,  179,   189 
Basal  layer  of  epidermis,  19 
Bastard  measles,  527 

scarlatina,  527 
Beard,  ring-worm  of,  179,  189 


Beccjuerel  rays,  409 

Bedbug,  216 

Bud -sores  in  small-pox,  448 

in  typhoid  fever,  540 
I'.dl.Lil'iimii  dermatitis,   165 
Beta  radium  rays,  411 
Black  small-pox,  443 
Blackheads.  120,  236 
Blastomycosis  cutis,  315 
Blattem,  417 
Hleljs  in  scarlet   (ever,  507 
Blepharitis,  72 
Blind  boil,  ill 
Blood-vessels  of  skin,  21 
new  growth  of,  286 
Bockh art's  impetigo,  83 
Body-liee,  212 
Boils.    171.      See   Furunaihms. 

bacterial  injections  in,  413 

bliud,  122 

com  plica  l  ins;  variola,  448 
opsonic  treatment,  173.  4'3 


Boric-acid  dermatitis,  1G5 
Bot-fly,  216 
Brandy  nose,   130 
Breast,  eczema,  73 
Bromid  dermatitis,  165 


Butterfly  appearance,  296 


Calculi,  cutaneous,  238 
CitlUwiiiis,  225 
Callosity,  225 
Callus,  225 
Calvitits,  166 
Cancer,  epithelial,  36 
Cancrum  oris  in  measles,  521 
Canities,  264 

prematura,  265 

senilis,  265 

Cantharides  dermatitis,  166 
Capsicum  dermatitis,  166 
Caraat£,  199 
Carbon  dioxid  in  treatment,  414 


<•  4'5 


I  technic,  415 

i  Carbuncle,  174 

'  Carbunculus,  174 

'  Carcinoma  epilheliale,  364 

1  Cellulitis  after  vaccination 


INDEX 


559 


Cerebrospinal  meningitis,  epidemic, 

547.     See  also  Epidemic  cerebro- 
spinal meningitis. 
Chafing,  30 
Chancre,  321 
Chapping  of  hands,  60 
Charbon,  177 
Cheiropompholyx,  98 
Cheloid,  280 
Chicken-pox,  478 

diagnosis,  487 

eruption,  478 

etiology,  486 

pathology,  486 

prognosis,  491 

sequela?,  485 

stages,  477 

symptomatology,  477 

treatment,  491 
Chilblain,  160 
Chloasma,  222 

idiopathic,  222 

symptomatic,  222 

uterinum,  222 
Chloral  dermatitis,  166 
Chromidrosis,  381 
Chromophytosis,  195 
Cicatrices,  27 
Cimex  lectularius,  216 
Cinchona  dermatitis,  167 
Cingulum,   103.        See  also  Herpes 

zoster. 
Clavus,  225 

Clear  layer  of  epidermis,  18 
Coccogenic  sycosis,  134 
Cold  sore,  101 
Colloid  degeneration,  291 

milium,  291 
Comedo,  236 

extractor,  Schamberg's,  127 
Comedones,  120 
Complement,  328 
Condyloma,  flat,  331,  332 

in  hereditary  syphilis,  345 

pointed,  233,  234 
Copaiba  dermatitis,  166 
Corium,  17,  19 
Corn,  225 

Cornu  cutaneum,  226 
Corpuscles,  bulb,  22 

nerve-,  22 

of  Krause,  22 

of  Meissner,  22 

Pacinian,  22 

tactile,  22 

touch-,  22 
Coryza  in  hereditary  syphilis,  346 
Crab-lice,  213 


Craw-craw,  199 

Crural  triangle,  419 

Crustae,  27 

Crusta  lactea,  387 

Cubebs  dermatitis,  166 

Culex,  216 

Curetting  in  lupus  vulgaris,  308 

Cutaneous  horn,  226 

Cuticle,  17.    See  also  Epidermis. 

Cutis.    See  Skin. 

pendula,  249 

vera,  19.     See  also  Corium. 
Cyanosis,  29 
Cyst,  sebaceous,  238 
Cysticercus  cellulosae  cutis,  214 
Cystis  sebacea,  238 
Cytoryctes  variolar,  450 


Dactylitis,  syphilitic,  346 
Dandruff,  267,  386,  387 
Darier's  disease,  242 
Defluvium  capillorum,  267 
Demodex  folliculorum,  237 
Dengue,  545 
Depilatories,  245 
Derma,  19.     See  also  Corium. 
Dermalgia,  300 
Dermatalgia,  300 
Dermatitis,  160 

acetanilid,  163 

ambustionis,  160 

antipyrin,  163 

arsenic,  164 

belladonna,  165 

blastomycetic,  315 

blastomycotica,  315 

boric-acid,  165 

bromid,  165 

bromin,  165 

bullosa  after  vaccination,  473 

calorica,  160 

cantharides,  166 

capsicum,  166 

chloral,  166 

cinchona,  167 

congelationis,  160 

contusiformis,  36 

copaiba,  166 

cubebs,  166 

digitalis,  167 

dogwood,  161 

drug,  163 

ergot,  167 

exfoliativa,  151 
acuta,  152 
secondary,  153 
variolosa,  437 


ta,   170 

RCTHVMA,    87 

67 

gangrenosum,  87 

68,  465 

89 

barbie,  73 

F 

s,  90 

capitis,  71 
cnirum,  74 
iJeiinition,  53 

iod 

diagnosis,  Gi 

iodi 

erylhematosum,  53 

ioH-    

etiology,  60 

illary,  373 

faciei,  71 

1,   163 

fissum.  60 

HaxiITi    1&7 

from  chemical  irritants 

onium.  167 

from  mechanical  irrilan 

pillaris  capillilii,  133 

from  thennal  irritants, 

mcntary,  progressive,  1 16 

genital  turn,  73 

iuipcliginosum,  53,  56 

in  measles,  sio 

in  scarlet  fever,  507 

primrose,  161 

infantile,  73 

primula  obconica,  161 

liberorum,  75 

quinin.   167 

madidans.  58 

repens,  81 

mamma;.  73 

salicylic-acid.   167 

manuum,  72 

seborrheica,  76 

marginatum,   179,  tRo 

sodium -borate,   ids 

of  bearded  region,  73 

strychnin,  167 

of  breast.  73 

su  I  phonal,  167 

of  eyelids,  marginal,  7; 

tcrebene.   167 

of  feet,  73 

tuberculosa  acuta,  313 

of  genitals.  73 

turpentine.   [67 

or  hands.  7; 

venenata,   161 

or  legs,  74 

veronal.  l6j 

Derma  toly sis,  249 

Derma tomyoma,  385 

of  nostrils,  73 

Derma  tosclcros  is,  260 

of  penis,  73 

Dermatoses  related  to  luliercillosis, 

of  scalp,  71 

3>J 

of  scrotum.  73 

D<-mi:il<>svplii]is.  3JI 

papillnmatosum,  60 

Dermr. graph  ism,  46 

papulosum,  53.  54 

anemic,  49S 

pathology,  6: 

Diabetic  gangrene,  170 

pedum,  71 

Digitalis  dermatitis,   167 

prognosis.  63 

DioNydiamido-arseiiobcnzal  in  syph- 

pustulosum. S3.  S& 

ilis,  35" 

rubrum.  57 

Diphtheria  antitoxin,  eruption,  S5'. 

sclcrosum,  60 

553 

selmrrhiiiciim.  76.  386 

Discoid  lupus  erythematosus,  395 

diagnosis,  79 

Dissection  wound,   178 

etiology,  78 

Disseminated    lupus   crvlhematosus. 

pathology,  78 

196 

symptoms,  76 

Dogwood  dermatitis,   161 

treatmenl,  80 

Dracunculosis,  215 

squamosum,  59 

Drug  eruptions,   163 

symptoms,  S3 

Duhring's  disease.  89 

treatment,  64 

after  vaccination,  474 

tyloticum,  60 

Dysidrosis,  qS 

verrucosum,  60 

INDEX 


561 


Eczema  vesiculosum,  53,  55 

jc-rays  in,  73,  74,  80,  409 
Edema,  angioneurotic,  52 

circumscribed,  acute,  52 

in  scarlet  fever,  499 

in  serum  eruptions,  555 
Ehrlich's  treatment  of  syphilis,  350 
Elastic  skin,  249 
Eleidin,  19 
Elephant  leg,  247 
Elephantiasis,  247 

arabum,  247 

diagnosis,  249 

graecorum,  354 

treatment,  249 
Ephelides,  220 
Ephidrosis,  378 
Epidemic  cerebrospinal   meningitis, 

eruption,  547 
Epidermis,  17 

Epidermolysis  bullosa  hereditaria,  96 
Epidermophyton  inguinale,  181 
Epithelioma,  364 

deep,  365 

diagnosis;  369 

discoid,  364 

erosion,  371 

etiology,  368 

flat,  364 

infiltrating,  365 

multiple  benign  cystic,  372 

nodular,  365 

papillary,  366 

pathology,  369 

prognosis,  370 

superficial,  364 

treatment,  370 

x-rays,  372 
Equinia,  176 
Ergot  dermatitis,  167 
Eruptions  of  skin  diseases,  26 
Eruptive  fevers,  acute,  417 
Erysipelas,  156 

ambulans,  157 

chronicum,  159 

course,  157 

diagnosis,  158 

etiology,  158 

migrans,  157 

streptococcus,  158 

treatment,  158 

vaccinal,  470 

x-rays  in,  159 
Erysipeloid,  159 
Erythema  ab  igne,  29 

annulare,  32 

caloricum,  29 

circinatum,  32 

36 


Erythema,  congestivum,  29 
elevatum  diutinum,  41 
epidemic,  45 
exsudativum,  31 

multiforme,  31 
from  serum  therapy,  553 
fugax,  30 
hyperaemicum,  29 
induratum,  41 
in  angina,  550 
in  malaria,  546 
in  rheumatic  fever,  551 
in  tonsillitis,  550 
in  typhoid  fever,  538 
internal,  30 
intertrigo,  30 
iris,  33 
laeve,  30 
marginatum,  32 
migrans,  159 
multiforme,  31 

recurrent  attacks,  34 
nodosum,  36 
papulatum,  32 
paratrimma,  30 
perstans,  33 
searlatiniforme     desquaraativum, 

39 
scarlatinoides,  38 

simplex,  29 

sol  are,  29 

toxemic,  30 

traumaticum,  29 

treatment,  30 

tuberculatum,  32 

vaccinal,  466 

venenatum,  29 
Ery theme  indure'  des  scrofuleux,  41 
Erythrasma,  198 

Erythrodermias,  resistant  scaly,  115 
Erythrodermie       pityriastque       en 

plaques  diss£minees,  115 
Erythromelalgia,  391 
Essera  Vogelii,  527 
Exanthemata,  417 
Exantheme  fugace,  527 
Excoriationes,  27 
Exsudationes,  31 
Eyelids,  eczema  of,  72 


1  Face,  eczema,  71 

I      lupus  vulgaris,  304 

I  Farcy,  176 

j  Fat-globules  of  skin,  20 

'  Favus,  191 

1  Febris  rubra,  492 

1  Feet,  eczema,  72 


.'Pl'mjo.'ll*      cryst|K-- 


'■ilum,  249 
coma,  186 

apparatus.  399 
therapy,      309.     See     also 
itinolhtrapy. 
ti-skin  disease,  228 

I  condyloma,  331,  331 
in  hereditary  syphilis,  345 


ri- worms.  236 
i-uudes,  314 
Folliculitis  barbs;,  134 

decalvans,  175 
'ragilitas  erinium,  275 
I'ninil  ■csia.  363 
Freckles,  220 
French  measles,  517 
Frost-bite,  160 
Fumigations  of  mercury  in  syphili: 

.3.10 
Fungus-foot  of  India,  318 
Furuncle,  171 
Furunculosis.    171 

after  vaccination,  476 
in  chicken-pox,  435 
in  measles,  510 
in  scarlet  fever,  507 
in  typhoid  fever,  541 
treatment,  173 
Furunculus,  171 


Gab-ply,  2t6 

Gamma  radium  rays,  412 
Gangrene,  diabetic,   170 

of  skin,  167 

spontaneous,  169 

symmetric.  169 

vaccinal,  465 
Genital  lousiness,  213 
Genitals,  eczema,  73 
Genitocrural  ring-worm,  179 
German  measles.  537 
Giant  swelling,  52 


Glans  penis,  leukokeratosis,  397 
Glus^-pock,  476 
Glossitis  variolosa,  429 

in  small -pox.  429 
Glossy  skin,  255 
Glycerogelatin     jelly,     Unna's,     for 

eczema,  70 
Gnat.  216 

Goose-flesh  and  keratosis  pilaris,  242 
Grain  itch,  204 

etiology,  306 
pathology,  207 
prognosis,  209 
symptoms,  204 
treatment,  209 
Granular  layer  of  epidermis.   19 
CirLiiiuInriiii  Mm  guides,  376 
Gramilrrsis  rubra  nasi,  382 
Graves'  diseases,  chloasma  in,  212 
Grayness,  264 
,  Gmtum,  238 
Guinea-worm,  215 
Gumma,  343 
I      in  hereditary  syphilis.  346 
sporotrichotic,  319 
Gums  in  scarlet  fever,  494 
leukokeratosis  of,  397 


Hair,  23 
atrophy,  275 
follicles,  23 
grayness.  264 
hypertrophy,  243 
I      ringed,  26s 
superfluous,  243 


II;, in 


*43 


Hands, 
Harlequin  fetus,  230 
Harvest-bug,  215 
Head  lice,  209 

Hebra's     diachylon 
1,  69 


for 


pityriasis  rubra,  131 

I      seborrhcea  sicca,  386,  387 
Hetuatidrosis,  381 
Hemi-atrophia   facialis   progressiva, 

356 
Hemorrhagic,  217 
Herpes  circinatus,  179 

facialis,  101 

genitalis,   101 

J      gestationis,  89 

iris,  33 
I      labialis,  101 


INDEX 


563 


Herpes  praeputialis,  102 

progenitalis,  102 

pyaemicus,  87 

simplex,  101 

tonsurans,  179,  183 
maculosus,  153 

zoster,  103 

ophthalmicus,  104 
treatment,  108 
Hidebound  disease,  260 
Hirsuties,   243.        See  also  Hyper- 
trichosis. 
Hives,  46.     See  also  Urticaria. 
Horn-pox,  447 
Horns,  cutaneous,  226 
Horny  layer  of  epidermis,  18 
Hutchinson  teeth,  346 
Hybrid  measles,  527 

scarlatina,  527 
Hydroa,  89 

aestivale,  99 

puerorum,  99 

vacciniforme,  99 
Hydrocystoma,  382 
Hydrosis,  378 
Hyperemia?,  28 
Hyperemia  of  skin,  28 
Hyperesthesia,  390 
Hyperidrosis,  378 
Hypertrichosis,  243 

acquired,  244 

congenital,  244 
Hypertrophic,  220 
Hypertrophic  papule,  332 
Hypertrophy  of  hair,  243 

of  nail,  250 
Hypodermic  injections  of  mercury 

in  syphilis,  349 
Hysteric  gangrene  of  skin,  168 


Ichthyosis,  228 
congenital,  230 
hystrix,  229 
s£bac£,  386 
simplex,  228 
treatment,  231 
Idiopathic  hyperemia  of  skin,  28 
Idrosis,  378 
Ignis  saccr,  156 
Impetigo  contagiosa,  81 
bullosa,  83 
diagnosis,  85 
etiology,  84 
gyrata,  83 
pathology,  85 
prognosis,  86 
treatment,  86 


Impetigo  herpetiformis,  87 

in  measles',  520 

of  Bockhart,  83 

simplex,  83 

staphylococcia,  83 

staphylogenes,  83 

varicellosa,  84,  482,  485 

variolosa,  84,  435,  436,  459 
Inflammations,  31 
Influenza,  544 

eruption,  544 
Intramuscular  injection  of  salvarsan 

in  syphilis,  351 
Intravenous  injection  of  salvarsan  in 

syphilis,  352 
Iodid  dermatitis,  177 
Iodin  dermatitis,  177 
Iodoform  dermatitis,  177 
Itch,  200.     See  also  Scabies. 

barber's,  179,  189 

grain,  204 

-mite,  200-202 

straw-mattress,  204 

winter,  392,  393 
Ivy-poisoning,  161 
Ixodes,  215 


Jigger,  216 


Kaposi's  disease,  256 
Keloid,  280 

acne,  133 

of  Addison,  262 

of  Alibert,  280 

cicatricial,  281 

spontaneous,  281 
Keratin,  25 
Keratohyalin,  19 
Keratosis,  carbon  dioxid  in,  416 

follicularis,  242 

pilaris,  241 
Koplik  spots,  513 
Kraurosis  vulvae,  264 
Krause's  corpuscles,  22 
Kummerf eld's  lotion  for  acne,  126 


La  grippe,  544.    See  also  Influenza. 

La  petite  verole,  417 

La  rougeole,  512 

La  scarlatine,  492 

La  varicelle,  477 

La  ve>olette,  477 

Land  scurvy,  218 

Larynx  in  small-pox,  429 

Lax  skin,  249 


INDEX 

4 

l.i mi py- jaw,  317 
Lunula  of  nail,  25 

in  leprosy.  3S 

Lupoid  sycosis,  13B 

Lef 

Lupus  disscminatus  of  Hcbra,  206 

U["," 

See  also 

Leprosy 

erythemalodes.  294 
erythematosus,  394 
carbon  dio\id  in,  415 

Lepr—,,  ° 

.  357 

diagnosis,  298 

bacillus, 

discoid  ea,  29,1 

disseminated,  296 

diagnosis.  361 

etiology,  398 

duration,  357 

pathology,  298 

etiology,  361 

prognosis,  399 

symptoms,  295,  298 

mutilated,  360 

treatment.  299 

nerve  type,  357 

exedens,  301,  304 

nodular,  355 

exulcerans.  301,  304 

pathology.  301 

hypertrophicus.  304 

prognosis.  363 

non-exedens,  394 

symptoms,  355 

papillomatosis,  304 

vulgaris,  301 

tubercular.  355 

bacterial  vaccines  in,  414 

472 

diagnosis,  306 

*-rays  in,  362 

etiology,  305 

Uptus,  113 

of  face,  304 

autumnalis.  115 

pathology,  305 

Leukoderma,  15a 

post -vaccinal.  471 

syphilitica.  3 

14 

prognosis,  306 

l.cnk  j!;eraliB":ls  huccalis.  397 
Leukoma,  397 
Leukoplakia,  397 
buccal  is,  397 

Lichen  pilaris,  241 
planus.  .OH 
annularis,  109 
hypertrophicus,  109 


moniliformi 

scrofulosus  sci 
tropicus,  384 
urticatus,  46 
vaccinal,  467 
Lichen  ificat  ion 
1.  34 


scrofulosorum,  1 


Lines  albicautes,  256 
Liomyoma  cutis,  283 
Lips.  uLv.cma,  73 

leu  koker.11  os^  of,  397 
Liquid  air  in  treatment,  414 


Lortet-Geuoud  i 
Lotio  nigra  in  e 
Lousiness.  209 
Lues,  321 


i!-lamp,  402 


treatment.  306 

Lymph -vessel  5  of  skin.  21 

l.ynijdi:in".L'Ctodes,  289 

Lymphangioma,  289 
circumscriptum.  189 
tuberosum  multiplex,  390 

Lymphangiiimyonia.  2H6 

Lymphatic  glands  in  rubella.  528 
in  scarlet  fever.  504 

Lymphodermia  perniciosa,  376 


Maclt.^,  27 
Madura  foot,  318 
Malaria,  eruption  of,  S46 
Maseru,  512 
Measles,  312 

bastard,  527 

black,  si 9 


desquamation,  518 
diagnosis,  522 

etiology.  312 

hemorrhagic.  517 
malignant,  519 


INDEX 


565 


Measles,  hybrid,  527 

imperfect,  527 

miliary,  516 

papular,  515 

pathology,  521 

pigmentation  after,  518 

prognosis,  526 

sequelae,  519 

spurious,  527 

symptomatology,  513 

varieties,  515 

vesicular,  516 
Meissner's  corpuscles,  22 
Melanoderma,  222 
Melanosarcoma,  374 
Meningitis,  cerebrospinal,  epidemic, 

547.     See  also   Epidemic  cerebro- 
spinal meningitis. 
Meralgia  paraesthetica,  391 
Microbacillus  of  seborrhea,  123 
Microsporon    Audouini,    ring- worm 
and,  179 

furfur,  195,  197 
Miliaria,  384 

crystallina,  383 

diagnosis,  385 

papulosa,  384 

rubra,  384 

in  typhoid  fever,  540 

treatment,  385 

vaccinal,  468 

vesiculosa,  384 
Miliary  fever,  549 

tuberculosis  of  skin,  313 
Milium,  238 
Milk-crust,  55,  387 
Moist  papule,  331,  332 

in  hereditary  syphilis,  345 
Mole,  carbon  dioxid  in,  416 

pigmentary,  223 
Molluscum  bodies,  241 

contagiosum,  239 

epitheliale,  239 

fibrosum,  281 

pendulum,  281 
Monilethrix,  277 
Morbilli,  512 

confluentes,  517 

haemorrhagici,  517 
benign,  518 
malignant,  519 

laeves,  515 

miliares,  516 

papulosi,  515 

sine  exanthemate,  518 
morbillis,  518 

vesiculosi,  516 
Morbus  maculosus  Werlhofii,  218 


'  Morphea,  262 
I  Morvan's  disease,  279 
j  Morviglione,  477 
'  Mosquito,  216 
I  Mower's  mite,  215 
;  Mucous  layer  of  epidermis,  19 
membranes,  diseases,  397 
Multiple  cutaneous  tumors  associ- 
ated with  itching,  293 
gangrene  of  skin,  168 
herpetiform  chancre,  322 
Muscles  of  skin,  22 
Mycetoma,  318 
Mycosis  fungoides,  376.       See  also 

Granuloma  fungoides. 
Myoma,  285 
cutis,  285 
telangiectodes,  286 


Nifivus  flammeus,  286 

hairy,  244 

linearis,  224 

lipomatodes,  224 

pigmentosus,  223 

carbon  dioxid  in,  416 

pilosus,  224,  244 

sanguineus,  286 

spilus,  224 

tuberosus,  287 

unius  lateris,  224 

vasculosus,  286 

carbon  dioxid  in,  415 

verrucosus,  224 
Nail,  25 

atrophy,  278 

hypertrophy,  250 

ring- worm,  179,  182,  193 

tinea  favosa,  193 
Neoplasm,    inflammatory     fungoid, 

376 
Neoplasmata,  280 
Nerve  tumor,  283 
Nerve-corpuscles,  22 
Nerves  of  skin,  22 
Nettle-rash,  46 
Neuralgia  of  skin,  390 
Neuroma,  283 
Neuroses,  300 

Neurotic  gangrene  of  skin,  168 
Nevus,  223 

carbon  dioxid  in,  415,  416 
New-growths,  280 

x-rays  in,  409 
Nipples,  eczema,  73 

Paget 's  disease,  373 
Nodular  leprosy,  355 
Noli  me  tangere,  301 


■ 


Oak  dcrmatit       161 

*Kdoma  neon:    jruiti,  259 

(Estrus,      1 6 

Oil  susj      a?—    injection  of  salvar- 

san  h,  _         ■  in.  3ii 
3l)ychalro  27S 

hiychanxt.-..  *3o 
>nyciiia,  350 
in  eh  ojtry  pilosis,  150 
uychomycosis,    [79,  183,    193,   278 
favosa,  iq,i 
Opium  dermatitis.   167 

Opsonotherapy,  413 

Osmidrosis.  379 

Osteitis  in  leprosy,  360 

Otitis  media    in  scarlet  (ever.  506 

Pachvdermia,  347 
Pacinian  corpuscles,  22 
Paget's  disease  of  nipple.  373 
Palisade  layer  of  epidermis,  19 
Palms  in  hereditary  syphilis,  346 
IViiillirnlns  riilipostis,   20 
Papilla  of  skin,  19,  30 
sensory,  30 

Papillary  layer  of  corium,  19 

Papula;.  27 

Parakeratosis  variegaia,  115 

Paronychia.  250 

Pars  papillaris  of  corium,   19 

reticularis  of  corium,  19 
Passive  hyperemia  of  skin,  38 
Pediculosis,  109 

capitis,  309-3 11 

corporis,  212 

pubis,  313 
Pel  11  mis  rheiiniLitira,   377,  553 
Pellagra.  42 

diagnosis.  4s 

etiology.  44 

pathology,  44 

prognosis,  45 

symptoms,  42 

treatment,  45 
IVfh J.1-HLIS  hoot.  43 

collar,  42 

glove,  43 
Pemphigoid    blebs    in    chicken-pox, 

485 
Pemphigus,  92 


Pemphigus,  congenital  traumatic,  96 
diagnosis,  95 
etiology,  95 
foliaceus,  93 


pathology,  95 


ivptulil 


'.  344 


treatment,  96 
vegetans,  94 
vulgaris,  92 

Persistent  anemia,  skin  in,  18 
Peruvian  wart.  363 
Petechial  fever,  5+3 
Phosphor  id rosis,  382 
Mil  hirusis,  209 
lJhv>H)l.iK_v  of  skin,   17,  25 
Pian,  363 

Piebald  skill,  acquired,  25a 
I'iel.'iiliiness.  ;s" 
Piedra,  377 

Pigmentary  dermatosis,  progressive, 
116 
mole.  223 
Pigmeutationcs,  37 
Pimples.  119.     See  also  Acne. 
Pint  a,  199 


m  Pilar 


simplex,  386.  387 

versicolor,   195 
Plica  ncuropathica,  278 

polonica,  378 
Pockeu,  417 
Pinli'Icvirna,  318 
Poison-ivy  dermatitis,   161 
Polonium,  409 
Polydrosis.  37« 
Pomades  for  seborrhea,  389 
Pomphi.  37 
Pompholyx,  98 
Porokeratosis,  235 
port-wine  mark,  286 

carbon  dio\id  in.  416 
Postmortem  pustule.   178 

wart,  309 
Potassium  chlorate  dermatitis.  167 
Priddc-cells.    19 
Prickly-heat.  384 
Primrose  dermatitis.  t6i 
Primula  obcouica  dermatitis.  t6i 
Progressive  pigmentary  dermatosis, 


INDEX 


567 


Prurigo,  117 

ferox,  117 

mild,  117 

mitis,  117 

severe,  117 

treatment,  118 
Pruritus,  391 

ani,  392,  393 

bath,  393 

hiemalis,  392,  393 

scroti,  392,  393 

senilis,  392 

universalis,  392 

vulvae,  392,  393 
Psoriasis,  139 

after  vaccination,  476 

annulata,  141 

circinata,  141 

course,  142 

diagnosis,  145 

diffusa,  142 

etiology,  142 

figurata,  141 

guttata,  141 

gyrata,  141 

in  measles,  520 

inveterata,  142 

nummularis,  141 

pathology,  145 

prognosis,  146 

punctata,  141 

symptomatology,  139 

treatment,  146 

universalis,  142 
Psorospermose      folliculaire 

tante,  242 
Psorospermosis,  242 
Pulex  irritans,  216 

penetrans,  216 
Purpura,  217 

diagnosis,  219 

etiology,  219 

from  serum  therapy,  554 

fulminans,  219 

hsemorrhagica,  218 

in  malaria,  547 

in  measles,  521 

in  rheumatic  fever,  552 

in  typhoid  fever,  539 

rheumatica,  217 

simplex,  217 

symptoms,  217 

treatment,  220 

variolosa,  441,  442 
Pustula  maligna,  177 
Pustulae,  27 

Pustule,  postmortem,  178 
Pyemia  in  chicken-pox,  485 


Quincke's  disease,  52 
Quinin  dermatitis,  167 


Radiotherapy,  399,  404 
Radium,  409 

application,  412 
Raspberry  tongue  in  scarlet  fever, 

494 
Ravaglione,  477 

Ray-fungus  disease,  317 

Raynaud's  disease,  169 

Red  gum,  384 

light  treatment  of  variola,  460 

sweat,  277 
Refrigeration,  carbon  dioxid,  414 

liquid  air,  414 

treatment  by,  414 
Resistant  scaly  erythrodermias,  115 
Rete  malpighii,  19 
Reticular  layer  of  corium,  20 
Rhagades,  27 

in  hereditary  syphilis,  346 
Rheumatic  fever,  551 
Rheumatism  of  skin,  390 
Rhinoscleroma,  292 
Rhus  diversiloba  dermatitis,  161 

toxicodendron  dermatitis,  161 

venenata  dermatitis,  161 
Ringed  hair,  265 
Ring-worm,  179.     See  also  Tinea. 
|  Rodent  ulcer,  364,  383 
,  Rontgen  rays,  404.    See  also  x-Rays. 
Root-sheath  of  hair-follicle,  24 
v£g6-    Rosacea,  128,  288 
[  Rosalia,  512,  527 
Rosania,  527 
Roseola,  329 

epidemica,  527 
'      vaccinosa,  419,  466,  467 

variolosa,  418,  467 
Rose-spots  in  typhoid  fever,  537 

in  typhus  fever,  542 
Rotheln,  527.     See  also  Rubella. 
Rougeole  fausse,  527 
Rubella,  527 

complications,  534 

diagnosis,  534 

etiology,  527 

prognosis,  535 

scarlatiniform,  531 

sequelae,  534 

symptoms,  527 

treatment,  535 
Rubeola,  512,  527 

epidemica,  527 

morbillosa,  527 

notha,  527 


seu  incocta.  527 
p.-  .ou.uiosa   436 

icv<"  acid   Icrrnatitis,  167 
rl 

W  ihilis,  350 


indicai.u.i».  353 
outline  of  treatment.  354 
d-flca.  216 
roraa.  374. 
„iagnosi_s,  376 
etiology,  375 

idiopathic    multiple    hemorrhagic. 
375 
benign.  375 
primary  melanotic,  374 

turn- pigmented,  375 
treatment,  376 
x-ray  in,  376 
Sarcoples  scabici.  200,  101,  202 
Scabies.  ;oo 
diagnosis,  202 
etiology,  202 
pathology.  202 

Scalp  eczema,  71 

ring-worm.  1  7g.  183 
Scalv  ervtitrotlcrniias, 
Scar,  27 
Scarlatina.  41); 
bastard,  527 
hybrid,  .S27 
miliaris.  497 
papulosa,  496 
pern  phi  go  idea,  497 
vesicularis,  497 
Scarlet  fever,  492 
anginose,  504 
bacteriology,  307 
blood  in,  507 
eompli cat  ions,  506 
desquamation  in,  301, 
diagnosis,  308 
ear  complications,  506 
edema  in,  490 

duration,  499 
etiology,  492 
furunentoBii  in,  507 
hemorrhages  in,  504 
hemorrhagic.  SOJ 
herpes  in,  306 


'  Scarlet  lever,  incubation  period,  4 

itching  in.  409 

lymphatic  glands  in,  504 

malignant,  505 

mouth  in.  508,  515 

pathology,  507 

peeling  in.  301 

prognosis,  511 

prophylaxis.  511 

relapses.  306 

sore  throat  in,  493 

swelling  in,  409 

symptomatology,  493 

tongue  in,  493.  508 

treatment,  511 
Scha  f[nx- ken,  477 
Sch  am  berg's  comedo  extractor,    I 
St'harlach,  492 
Schoenlein's  disease.'  217 
Sclerema  udult->rum,  jtib 


Scleriasis.  260 
Sclerodactylia,  260 
Scleroderma.  260 
circumscribed,  261 

Scrofuloderma,  311 

small  pustular,  315 

x-rays  in,  313 
Scrotum,  eczema,  73 

gangrene  of,  in  variola,  449 

pruritus,  392,  393 
Scurvy,  land,  218 
Scntuium  of  tinea  favosa.  192 
Sebaceous  glands,  adenoma,  291 
Seborrhea,  3  86 

congestiva,  294 

corporis,  76,  77,  3S7 

crusted,  387 

diagnosis,  388 

etiology,  387 

oleosa,  386 

pathology,  387 

sicca,  386,  387 


-  236 


Seborrheic  c 


,  76 


I  Secretions  of  glands,  anomalies.  37S 
I  Senile  alopecia,  266 
I      atrophy,  255 
Sensibility  of  skin,  increased,  390 
Septicemia   in    variola,    prevention, 

458 
SerarnpicHl,  512 
Serum  eruptions,  351 
bullous,  354 
erythematous,  553 


INDgX 


569 


Serum  eruptions,  purpuric,  554 

urticarial,  553 

vesicular,  554 
Shampoo,  268 

Shingles,  103.    See  also  Herpes  zoster. 
Silver  nitrate  stick  in  lupus  vulgaris, 

307 
Silvery  spot,  32  2 

Skin,  anatomy,  17 

anemia,  28 

atrophy,  255 

blood-vessels,  21 

elastic,  249 

functions,  25 

glossy,  255 

hyperemia,  28 

inflammations,  31 

lax,  249 

layers  of,  17 

lymph- vessels,  21 

muscles  of,  22 

nerves  of,  22 

pallor  of,  28 

papillae  of,  19,  20 

physiology  of,  25 

-plate,  17 

stains,  27 

true,  19.     See  also  Corium. 
Small-pox,  517.    See  also  Variola. 
Smegma  praeputii,  387 
Snuffles  in  hereditary  syphilis,  346 
Sodium-borate  dermatitis,  165 
Sore  arm  after  vaccination,  463 

throat  in  scarlet  fever,  493 
Sphaceloderma,  167 
Spiradenoma  of  sweat-glands,  292 
Spirochaeta     pallida     as    cause     of 
syphilis,  347 

pertenuis,  363 
Spontaneous  gangrene,  169 
Sporotrichosis,  319 

treatment,  321 
Sporotrichotic  gumma,  319 
Sporotrichum  Schenckii,  320 
Spotted  fever,  542 

sickness,  199 
Squamae,  27 
St.  Anthony's  fire,  156 
Stains  on  skin,  27 
Steatoma,  238 
Stomatitis,  gangrenous,  in  measles, 

521 
Stone  pock,  534 

Stratum  corneum,  18 

granulosum,  19 

lucidum,  18 

subcutaneum,  20 
Straw  itch,  204 


Strawberry  tongue  in  scarlet  fever, 

494 
Straw-mattress  disease,  204 

Streptococcus  erysipelatis,  158 

Striae  atrophica  in  typhoid  fever,  541 

et  maculae  atrophies,  256 
Strophulus,  384 

albidus,  238 
Strychnin  dermatitis,  167 
Subcutaneous  glands,  22 

injection  of  salvarsan  in  syphilis, 

35i 
tissue  of  skin,  17,  20 

Sudamen,  383 

Sudamina  in  influenza,  545 

in  rheumatic  fever,  551 

in  scarlet  fever,  496 

in  typhoid  fever,  540 
Sudatoria,  378 
Sudor  urinosus,  381 
Sulphonal  dermatitis,  167 
Sumac  dermatitis,  161 
Summer  eruption,  recurrent,  99 
Sunburn,  29 
Sweat,  26 

bloody,  381 

blue,  381 

composition  of,  26 

green,  381 

red,  277,  381 
Sweat-glands,  22 

adenoma  of,  292 
Sweat-glands,  function  of,  26 
Sweating,  absence,  380 

decrease,  380 

excessive,  378 

feet,  treatment,  379 

localized,  378 

offensive  odor,  379 
Sycosis,  134 

coccogenic,  134 

lupoides,  138 

non-parasitica,  134 

parasitic,  179,  189 

vulgaris,  134 

bacterial  vaccines  in,  413 
diagnosis,  135 
etiology,  135 
pathology,  135 
prognosis,  137 
symptoms,  134 
treatment,  137 
Symmetric  gangrene,  169 
Symptomatic  hyperemia  of  skin,  28 
Syphilid,  acneiform,  336 

bullous,  344 

ecthymaform,  339 

follicular,  332 


57°                                               fati 

Syphilid,  gummatous,  342 
impetigoform,  338 
lenticular  papular,  330 
miliary,  331 

papular,  330,  332 
pigmentary,  344 
pustular,  miliary,  336 
pustuloerustaceous,  338 
squamous,  331 
lul>ercular,  340 

hereditary,  346 
varicellifonn,  336 
varioliform,  336 
Syphilis.  321 

arsenolieurol  in,  350 

congenital.  344.    See  also  Sypkilis, 

Ebrlich 's  treatment,  350 
erupt  ion,  325,  326 
etiology,  337 
hereditary.  344 

eruptions,  344 

gumma  in,  346 

treatment,  354 
in  utcro.  344 
pathology,  347 
polymorphism,  327 

primary  stage,  324 
prognosis,  347 
rhagades  in,  346 

EX 

tubercular,  serpiginous.  340 
tuberculosum,  34a 

>i ihnhmiin.  336 

Syphiloma.  343 
Syringomyelia.  279 

Tactile  corpuscles.  22 
Tar  acne.  im 
Telangiectasis.  288 

297 

Tcrt'l i-ac  ikriiiiil itis.   167 
Test.  Wnitirrlmtm,  in  syphilis.  -\2j 
Tetter,  53 

Thallium-acetate  poisoning,  1G7 
Tinea,  bald.  1S6 
circinala,  179 

etiology,  181 

pathology,  182 

prognosis,  183 

treatment,  183 
cruris,  179,  180 

prognosis,  183 

treatment,  183 
favosa,  191 

diagnosis,  193 

etiology,  193 

pathology,  193 

34K 

vaccinal.  471 

Wassermanu  reaction  in,  32 
Syphilitic  ulcers.  341 
SyjihilrxJcrma.  3?l 
bullosum.  344 
erythematosum,  329 
guiumosum.  342 
macular,  329 
palmar,  331 
papulosquamous,  331 

diagnosis.  335 
papulosum,  330 

acuminate.  330.  332 

flat,  330 

large,  331 

lenticular.  330 

miliary,  330 

moist.  33t,  332 
plantar,  331 
pustular,  acuminated,  33(1 

flat,  338 


194 

unguium  of  nails,  193 
imtirii.'3ta,  181 
kerion,  184 
microsporon.  184 
nodosa,  278 

onychomycosis.    179,    182,    193 
sycosis.  179,  189 


5.  179.  1  S3 

course.   186 

diagnosis,  187 

etiology,  186 

pathology,  1S7 

prognosis,   187 

treatment,  1S7 
trkbopbytirut,  179 

barbie,  1S9 

capitis,  183 

con™ris.  179 

cruris.   179,  180 

disseminated,  184 

unguium,  179,  182,  193 
versicolor,  195 

diagnosis,  197 


INDEX 


571 


Tinea  versicolor,  etiology,  196 
pathology,  197 
prognosis,  198 
treatment,  198 
Tongue  in  chicken-pox,  483 
in  rubella,  528 
in  scarlet  fever,  493,  508 
in  small-pox,  429 
leukokeratosis  of,  397 
Tonsillitis,  550 
eruption,  550 
erythema  in,  550 
Touch-corpuscles,  22 
Toxicodcndric  acid,  161 
Toxituberculids,  313 
Transient  anemia,  skin  in,  28 
Trichophyton,  ring-worm  and,  179 
Trichorrhexis  nodosa,  276 
True  skin,  19.     See  also  Corium. 
Tubercle,  anatomic,  309 
Tubercula,  27 
Tuberculides,  313 
Tuberculosis  cutis,  301 

dermatoses  related  to,  313 
miliary,  313 
orificialis,  311 
warty,  308 
vaccination  and,  471 
verrucosa  cutis,  308 
Tumor,  gummy,  343 

sebaceous,  238 
Tumores,  27 

Turpentine  dermatitis,  167 
Tylosis,  225 

Typhoid  fever,  bed-sores  in,  540 
dermatitis  in,  gangrenous,  540, 

desquamation,  539 
eruption,  536 
erythema  in,  538 
furunculosis  in,  541 
herpes  in,  539 
miliaria  rubra  in,  540 
purpura  in,  539 
rose-spots  in,  537 
stria?  atrophica  in,  541 
sudamina  in,  540 
urticaria  in,  539 
Typhus  fever,  eruption,  541 
duration,  543 
rose-spots  in,  542 
sine  exanthemate,  543 
subcuticular  mottling  in,  542 
pellagrosus,  44 


Ulcer,  rodent,  364 
syphilitic,  341 


Ulcera,  27 

Ulerythema  centrifugum,  294 

sycosiforme,  138 
Ultraviolet  light  larrlp,  402 
Unna's  glycerogelatin  jelly  for  ec- 
zema, 70 

microburner  in  acne  rosacea,  132 
Uranium  rays,  409 
Uridrosis,  381 
Urticaria,  46 

after  vaccination,  468 

bullosa,  47 

course,  47 

diagnosis,  49 

drug,  48 

etiology,  47 

factitia,  46 

from  serum  therapy,  553 

giant,  47 

gigans,  47 

hemorrhagica,  47 

papulosa,  46 

pathology,  48 

perstans,  47 

pigmentosa,  51 

prognosis,  49 

treatment,  49 

tuberosa,  47 
Uviol  lamp,  402 


Vaccinal  erysipelas,  470 

erythema,  466 

lichen,  467 

miliaria,  468 

rash,  466 

roseola,  466 

syphilis,  471 

ulceration,  464 
Vaccination,  458 

cellulitis  after,  463 

complications,  460 

cutaneous  diseases,  460 

Duhring's  disease  after,  474 

eczema  after,  473 

furunculosis  after,  476 

gangrene  after,  465 

impetigo  contagiosa  after,  469 

leprosy  and,  472 

lupus  vulgaris  after,  471 

pemphigus  after,  474 

psoriasis  after,  476 

sore  arm  after,  463 

tuberculosis  and,  471 

ulceration  after,  464 

urticaria  after,  468 

vaccinia    generalized    after,    461, 
462 


■1.  4U 

Variola  papules,  413 

osa.  465 

pathology,  450 

jiemphigosa,  448 

■dilation,  462 

pigmentation  in,  434 

K*to~'hr  r 

464 

pock-marks,  434 
prognosis,  458 

ol 

prophylaxis,  458 

■philis,  350 

purpurica.  441,  442 

I".  4, 

See  also   Chkktn- 

pustular  is.  448 

pustulosa  hemorrhagica,  441,  44.1 

g.iiiKr.vnosa,   I 

8.  465.  485 

rosea,  448 

aricellen.  477 

rupia  in,  436 

arioia,  417 

scars.  434 

alopecia  after.  434,  435 

prevention,  459 

bacteriology,  449 

secondary  fever  in,  430 

benigna,  445 

septic  rashes,  437 

black.  443 

seuuehc,  44B 

carbuticulosa,  448 

siliquosa,  448 

complications,  44M 

sine  esanthemate,  446 

con  flu  ens,  438 

variotis,  446 

confluent,  427,  428,  438 

spuria,  477 

conica,  44H 

stages,  417 

cornea,  447 

suppuration  stage,  425 

curymliosa,  447 

suppurative  fever  in,  430 

cryslall.ua.  44s.  477 

symptoms,  417 

decrustation  stage,  431 

tongue  in,  429 

delirium  in,  430 

treatment,  458 

desiccation  stage,  431 

umbilical  ion  in.  451,  437 

Lliii.^iui'is,  452 

vaccination,  458 

vagina  in,  430 

duration.  43; 

varieties.  438 

I'n.pliyseinutica,  44S 

verrucosa.  446 

eruption  stage,  420 

erysipelas  in,  448 

etiology,  440 

without  eruption,  420,  446 

gaiiRrene  in,  437 

Varioloid,  445 

tclnl  uitrma,  448 

eruption,  446 

glossitis  in,  4Jc) 

hemorrhagic,  444 

liair.  loss  in,  434 

Vegetating  papule.  332 

healing  in.  451      See  Pathology. 

Venereal  warts,  233.  234 

hcmnirliagic,  440 

Vcrnix  caseosa,  387 

incubation  period,  417 

Verona]  dermatitis,  167 

iiiii  i-il  -.lage.  417 

Verruca,  232 

invasion  stage,  417 

acuminata,  233,  234 

itcbing  in,  433 

digit  ata,  233 

larynx  in,  439 

liliformis,  233 

lymphatics,  448 

necrogenica.  300 

mild,  444 

peruana,  321 

miliaris.  447 

plana.  2,\2 

mitigated,  44s 

juvenilis,  333 

modified,  445 

senilis,  233 

iiini  liillosa.  448 

mouth  in,  42S 

vulgaris,  232 

nails  after,  435 

Verruga  peruana.  321 

nasal  cavities  in,  429 

Vesicula.",  --7 

nigra,  443 

Vitiligo,  252 

not  ha,  477 

diagnosis,  254 

odor  in,  428 

etiology,  253 

INDEX 


573 


Vitiligo,  treatment,  255 
Vitiligoidea,  283 
Vulva,  leukokeratosis,  397 
pruritus,  392,  393 


Wart-pox,  446 
Warts,  232 

carbon  dioxid  in,  416 

Peruvian,  363 

postmortem,  309 

venereal,  233,  234 
Wassermann    reaction    in 

327 
Wasserpocken,  477 
Water-pock,  477 
Wen,  238 

Whitening  of  hair,  264 
Whitlow,  melanotic,  375 
Wind-blattern,  477 
Winter  itch,  392,  393 


1  Wood  tick,  215 
Worms,  flesh-,  236 

Xanthelasma,  283 
Xanthelasmoidea,  51 
Xanthoma  cells,  284 

diabeticorum,  285 

multiplex,  284 

planum  palpebrarum,  283 

tuberosum,  284 
Xeroderma,  228 

pigmentosum,  256 
syphilis,    -Y-rays,  404 

j      diseases  benefited,  406,  409 

dosage,  404 

tubes,  404 

Yaws,  363 

,  Zona,  103.     See  also  Herpes  zoster. 
.  Zoster,  103.    See  also  Herpes  zoster. 


Skin,  Genito-  Urinary, 

Chemistry,  Eye,  Ear,  Nose, 

and  Throat,  and  Dental 


W.  B.  SAUNDERS   COMPANY 

925  WALNUT  STREET  PHILADELPHIA 

9,  HENRIETTA   STREET,  COVENT  GARDEN,  LONDON 


MECHANICAL    EXCELLENCE 

IkJOT  alone  for  their  literary  excellence  have  the  Saunders  publi- 
l™  cations  become  a  standard  on  both  sides  of  the  Atlantic:  their 
mechanical  perfection  is  as'  universally  commended  as  is  their  sci- 
entific superiority.  The  most  painstaking  attention  is  bestowed 
upon  all  the  details  that  enter  into  the  mechanical  production  of  a 
book,  and  medical  journals,  both  at  home  and  abroad,  in  reviewing 
the  Saunders  publications,  seldom  fail  to  speak  of  this  distinguishing 
feature.  The  attainment  of  this  perfection  is  due  to  the  fact  that  the 
firm  has  its  own  Art  Department,  in  which  photographs  and  drawings 
of  a  very  high  order  of  merit  arc  produced.  This  department  is  of 
decided  value  to  authors,  in  enabling  them  to  procure  the  services  of 
artists  specially  skilled  in  the  various  methods  of  illustrating  medical 
publications. 

A  Complete  Catalogue  of  our  Public&tioni  will  be  Sent  upon  Request 


SAl/NDEXS'     BOOKS 


StelwagonV 
Diseases  of  the  Skin 


A  Treatise  on  Diseases  of  the  Skin.     By  Henry  W,  Stelwagos, 

M.  D„  Ph.  D.,    Professor  of    Dermatology  in    the   Jefferson    Medical 
College,  Philadelphia.     Octavo  of  1195  pages,  with  289  text-cuts  and 

34  plates.      Cloth,  g6.oo  net ;   Half  Morocco,  $7.50  net. 

THE  NEW    i6lhi    EDITION 

The  demand  for  five  editions  of  this  work  in  a  period  of  five  years  indicates 
the  practical  character  of  the  book.  In  this  edition  the  articles  on  Frambesia, 
Oriental  Sore,  and  other  tropical  diseases  have  been  entirely  rewritten.  The  ne* 
subjects  include  Verruga  l'eruana.  Leukemia  Cutis,  Meralgia  Tar.  esthetic  a,  Dhobic 
Itch,  and  Uncinatial  Dermatitis. 


•*fD<r, 


tology.  I  think  ii  holds  first  pine 


■:."-.  I 


thorough  appreciation 


«,:>!  (  ;„ 


r:.i.y. 


Schamberg's  Diseases  of  the  Skin 
and  Eruptive  Fevers 


Diseases  of  the  Skin  and  the  Eruptive  Fevers.    By  Jay  F.  Schamberg, 

M.  D.,  Professor  of  Dermatology  and   the   Infectious  Eruptive  Diseases,  Philadel- 
phia Polyclinic.     Octavo  of  534  pages,  illustrated.     Cloth,  $3.00  net. 

THE   CUTANEOUS   MAN  IfE  STAT  IONS   OF  ALL  DISEASES 


"  The   acute   eruptive    fevers    constitute    a   valuable   contribuiion, 
emanating  (rom  one  who  iias  studied  these  diseases  in  a  practical  and  thorough  nj 
the  standpoint  of  cutaneous  medicine.     .     .     .     The  views  expressed  on  all  topics  are  con- 
servative, safe  to  follow,  and  practical,  and  arc  well  abreast  of  the  knowledge  si   I 
time,  both  us  to  general  and  special  p  tthology,  etiology,  and  treatment." — American  Jr»i»t 
e/  Medial  Science!. 


VRIXE  AXD   IMPOTENCE. 

Ogden  on  the  Urine 


Clinical  Examination  of  Urine  and  Urinary  Diagnosis.  A  Clinical 
Guide  for  the  Use  of  Practitioners  and  Students  of  Medicine  and  Sur- 
gery. By  J.  Bergen  Ogden,  M.  D.,  Medical  Chemist  to  the  Metro- 
politan Life  Insurance  Company,  Neiv  York.  Octavo,  418  pages,  54 
text  illustrations,  and  a  number  of  colored  plates.     Cloth,  S3.00  net. 

THE  NEW  (3d)  EDITION 

In  this  edition  the  work  has  been  brought  absolutely  down  to  the  present  day. 
Urinary  examinations  for  purposes  of  life  insurance  have  been  incorporated,  because 
a  large  number  of  practitioners  are  often  called  upon  to  make  such  analyses. 
Special  attention  has  been  paid  to  diagnosis  by  the  character  of  the  urine,  the 
diagnosis  of  diseases  of  the  kidneys  and  urinary  passages  ;  an  enumeration  of  the 
prominent  clinical  symptoms  of  each  disease  j  and  the  peculiarities  of  the  urine 
ertain  general  diseases. 


Pilcher's 
Practical  Cystoscopy 

Practical  Cystoscopy.     By  Paul  M.   PlLCHER,  M.  D.,  Consulting 
Surgeon  to  the  Eastern   Long  Island  Hospital.     Octavo  of  398  pages, 
with  233  illustrations,  29  in  colors.     Cloth,  $5.50  net. 
DIAGNOSIS  AND  TREATMENT 

Cystoscopy  is  to-day  the  most  practical  manner  of  diagnosing  and  treating 
diseases  of  the  bladder,  ureters,  kidneys,  and  prostate.  To  be  properly  equipped, 
therefore,  you  must  have  at  your  instant  command  the  information  this  book  -ivi-s 
you.  It  explains  away  all  difficulty,  telling  you  why  you  do  not  see  something 
when  something  ft  there  to  see,  and  telling  you  htrw  to  see  it.  All  theory  has 
been  uncompromisingly  eliminated,  devoting  every  line  to  practical,  needed- 
every-day  facts,  telling  you  how  and  when  to  use  the  cystoscope  and  catheter — 
telling  you  in  a  way  to  make  you  hum.     The  work  is  complete  in  every  detail. 

Bnniford  Lewii,  M.  D.,  St.  Leuii  UmvtrsUy. 

much  pleased  willi  Dr.  Pilctier'i  '  Practical  Cystoscopy.1     I  lliink  il  Is  ihc  BMI 
c  Knglista  language  now."— April  !j,  iqil. 


BOOKS    ON 


Barnhill  and  Wales' 
Modern   Otology 

A  Text-Book  of  Modem  Otology.  By  John  F.  Baknhill,  M.  D., 
Professor  of  Otology,  Laryngology,  and  Rliinoiogy,  and  Earnest 
de  W.  Wales,  M.  D.,  Associate  Professor  of  Otology,  Laryngology, 
and  Rliinoiogy,  Indiana  University  School  of  Medicine,  Indianapolis. 
Octavo  of  598  pages,  with  314  original  illustrations.  Cloth,  $5.50  net; 
Half  Morocco,  $7.00  net. 

THE  NEW   '2.1     EDITION 

The  authors,  in  writing  this  work,  kept  ever  in  mind  the  needs  of  the 
physician  engaged  in  general  practice.  It  represents  the  results  of  personal 
experience  as  practitioners  and  teachers,  influenced  by  the  instruction  given  by 
such  authorities  as  Shcppard.  Dundas  Grant.  Percy  Jakins,  Jansen.  and  Alt. 
Much  space  is  devoted  to  prophylaxis,  diagnosis,  and  treatment,  both  medical 
and  surgical.  There  is  a  special  chapter  on  the  bacteriology  of  ear  affections — 
a  feature  not  to  be  found  in  any  other  work  on  otology.  Great  pains  have  been 
taken  with  the  illustrations,  in  order  to  have  them  as  practical  and  as  helpful  as 
possible,  and  at  the  same  time  highly  artistic.  A  large  number  represent  the 
best  work  of  Mr.  H.  F.  Aitkcn. 


PERSONAL    AND    PRESS    OPINIONS 


Frank  AHport.  M.  D. 

Prvfaivr  ■'/  Otakgf,  tftrOwvttrn  University,  C/tlcagn. 

"  I  regard  it  ns  one  of  the  best  books  in  the  English  language  on  this  subject.  The 
pictures  iirn  especially  good,  particularly  as  they  arc  practically  all  original  and  not  the  old 
reproduced  pictures  so  frequently  seen." 

C.  C.  Stephenion.  M.  D. 

Profcor  of  Ophthalmology  ,mrf  Otology,  College  ef  PkysiduH  and  S*r, 


n  mudero  otology  that  c 


<*,.  Little  Roe* 
t  compare  with 


Journal  American  Medical  Aiiocintion 

"  Its  teaching  is  sound  throughout  and  u 
suppuration  of  Hie  middle  ear  and  the  masto 


DISEASES   OF   THE  EYE. 


DeSchweinitz's 
Diseases  of  the  Eye 


The  New  (6th)   Edition 


Diseases  of  the  Eye:  A  Handbook  of  Ophthalmic  Practice. 
By  G.  E.  deSchweimtz,  M.  D.,  Professor  of  Ophthalmology  in  the  Uni- 
versity of  Pennsylvania,  Philadelphia,  etc.  Handsome  octavo  of  945 
pages,  354  text-illustrations,  and  7  chromo-lithographic  plates.  Cloth, 
£5.00  net;  Sheep  or  Half  Morocco,  $6.50  net. 

WITH  3.W  TEXT-ILLUSTRATIONS  AND  7  COLORED  PLATES 
THE   STANDARD   AUTHORITY 

Dr.  deSchweiniu's  book  has  long  been  recognized  as  a  standard  authority 
upon  eye  diseases,  the  reputation  of  its  author  for  accuracy  of  statement  placing  it 
far  in  the  front  of  works  on  this  subject.  For  this  edition  iJr.  deSchweinitz  has 
subjected  his  book  to  a  most  thorough  revision.  Fifteen  new  subjects  have  been 
added,  ten  of  those  in  the  former  edition  have  been  rewritten,  and  throughout  the 
book  reference  has  been  made  to  vaccine  and  serum  therapy,  to  the  relation  of 
tuberculosis  to  ocular  disease,  and  to  the  value  of  tuberculin  as  a  diagnostic  and 
therapeutic  agent. 

The  text  is  fully  illustrated  with  black  and  white  cuts  and  colored  plates,  and 
in  every  way  the  book  maintains  its  reputation  as  an  authority  upon  the  eye. 


PERSONAL  AND    PRESS  OPINIONS 


1  Theobald.  M.D.. 

»;«/  Pnfttnr  t,f  Ophthalmology,  Jok 

is  a  work  thai  1  have  held  in  high  BsW 


i   Vitivrrsity,  P,ll'iwinrt. 

ig  lo  my  students  in  the  Johns  Hopkin 


Medical  School." 

University  of  Pennsylvania  Medical  Bulletin 

-Upon  reading  through  the  contents  ul  All  book  we  are  impressed  by  th 
fulness  with  which  il  reflects  the  notable  contribution*  recently  made  to  nplnli-.li 
No  imporunt  subject  Within  its  province  has  beeii  reelected." 
Johns  Hopkins  Hoipital  Bulletin 

■:■   eh  ,;.i.t-  ciin  be  selected  as  the  bet.     Th.'y  irt  til  tin-  product  of  ii  finished 
Mtbonblp  mdth.  ■  irk  of  bo  eweptional  ophthalmologist    The  wo*  Is  ort.unh-  one  of  ihe 
<n  ophthalmology  extant,  and  probably  the  best  by  an  American  author." 


GET 
THE    BEST 


SAUNDERS'   BOOKS  ON 


American 


THE  NEW 
STANDARD 


Illustrated   Dictionary 

Just  Ready-New  (6th)  Edition,  Entirely  Reset— A  New  Work 


The  American  Illustrated  Medical  Dictionary.  A  new  and  com- 
plete dictionary  of  the  terms  used  in  Medicine,  Surgery,  Dentistry, 
Pharmacy,  Chemistry.  Veterinary  Science,  Nursing,  and  kindred 
branches;  with  over  100  new  and  elaborate  tables  and  many  illustra- 
tions, By  W.  A.  Newman  Dorlanh,  M.D.,  Editor  of  "  The  American 
Pocket  Medical  Dictionary."  Large  octavo,  with  986  pages,  bound  in 
full  [!■  xible  leather.     Price,  S4.50  net;  with  thumb  index,  65.00  net. 

KEY  TO  CAPITALIZATION  AND  PRONUNCIATION— ALL  THE  NEW  WORDS 


dictionary 

s  the 

Mi  Kandttd."      It  defines 

hum 

■ 

1   defined  ii 

ithei    dictionary — bar    none 

-rus,  taken  1 

■In  ft 

111  niudcrn  medical  literatim 

Howard  A.  Kelly.  M.  D.. 

frofisior  of  Gynecologic  Snrgerj,,  Jolt 


Theobald's  Prevalent  Eye  Diseases 


Prevalent  Diseases  of  the  Eye.  By  Samuel  Theobalp,  M.  D.. 
Clinical  Professor  of  Ophthalmology  and  Otology,  Johns  Hopkins 
University.  Octavo  of  550pages,  with  219  text-cuts  and  several  colored 
plates.     Cloth,  $4.50  net ;   Hall"  Morocco,  g6.00  net. 

THE    PRACTITIONER'S    OPHTHALMOLOGY 

With  few  exceptions  all  the  works  on  diseases  of  the  eye.  although  written 
ostensibk-  for  the  neneral  practitioner,  are  in  reality  adapted  only  to  the  specialist ; 
but  Dr.  Theobald  in  his  book  has  described  very  clearly  and  in  detail  those  condi- 

L lions,  the  diagnosis  and  treatment  of  which  come  within  the  province  of  the  general 
practitioner.  The  therapeutic  suggestion;  are  concise,  unequivocal,  and  specific. 
It  is  the  one  work  on  the  tlye  written  particularly  for  the  general  practitioner. 
Ctuulei  A.  Oliver,  M.D.. 
Clinical  Profcliar  of  Ofhtkalmology,  Woman's  Medical  College  of  Penny /-.■.•nil, 
"  I  feel  1  can  conscientiously  recommend  it.  not  only  to  the  gene 
student,  for  whom  it  is  primarily  written,  but  also  to  the  experienced  ophthalmologist. 
»urely  Dr.  Theobald  has  accomyiliihcd  his  purpose." 


DISEASES  OF   THE  EVE. 


Haab  and  DeSchweinitz's 
External  Diseases  of  the  Eye 


Atlas  and  Epitome  of  External  Diseases  of  the  Eye.  l'-y  Dr  O. 
Haab,  of  Zurich.  Edited,  with  additions,  by  G.  E.  ueSchweinitz, 
M.  D.,  Professor  of  Ophthalmology,  University  of  Pennsylvania.  With 
101  colored  illustrations  on  46  lithographic  plates  and  244  pages  of 
text     Cloth,  $3.00  net.     Jn  Sounders'  I  hind- Atlas  Series. 

THE   NEW   (3d)    EDITION 
Conditions  attending  diseases  of  the  external  eye,  which  are  often  so  complicated, 
have  probably  never  been  more  clearly  and  comprehensively  expounded  ihan  in 
the  fbrelying  work,  in   which   the   pictorial   most  happily  supplements  the  verbal 
description.     The  price  of  the  boob  is  remarkably  low. 

The  Medical  Record.  New  York 

"The  work  is  excelli'ntljr  suited  (o  the  student  of  ophthalmology  and  to  the  practising 
pliv-i.ian      Ii  cannot  fail  to  ottniti  a  wcll-deservcd  popularity." 

Haab  and  DeSchweinitzV 
Ophthalmoscopy 


Atlas   and    Epitome  of   Ophthalmoscopy   and    Ophthalmoscopic 
Diagnosis.     By  Dr.  0.  Haab,  of  Zurich.     Edited,  with  additions,  by 

G,  E.  deSchweinitz,  M.  D.,  Professor  of  Ophthalmology,  University 
of  Pennsylvania.     With   152  colored  lithographic  illustrations  and  92 
pages  of  text.     Cloth,  S3.00  net.     In  Saunders'  Hand-Atlas  Series, 
THE  NEW   (2d)   EDITION 
The  k'reat   value  of  Prof.  Haab's  Atlas  of  Ophthalmoscopy  and  Ophthalmo- 
scopic  Diagnosis    has  been   fully   established  and    entirely  justified    an   Englbh 
translation.      Not  only  is  the  student  made  acquainted   with   carefully   prepared 
ophthalmoscopic   drawings  done  into  vvcll-cNeculed  lithographs  of  the  most  im- 
portant fundus  changes,  hut,  in  many  instances,  plates  of  the  microscopic  lesions 
e  added.      The  whole  furnishes  a  manual  of  the  greatest  possible  service. 


s  Lancet,  London 


ork  th* 


i  be  in  the  ophthalm 


8  SAUNDERS''  BOOKS  ON 

Gradle's 
Nose,  Pharynx,  and  Ear 

Diseases  of  the  Nose,  Pharynx,  and  Ear.  By  Henry  Graple, 
M.D.,  late  Professor  of  Ophthalmology  and  Otology,  Northwestern 
University  Medical  School,  Chicago.  Octavo  of  547  pages,  illustrated, 
including  two  full-page  plates  in  colors.     Cloth,  #3.50  net. 

INCLUDING  TOPOGRAPHIC  ANATOMY 

This  volume   presents  diseases  of  [he  Nose,  Pharynx,  and  Ear  as  the  author 
has   seen   them   during   an   experience  of   nearly   twenty-five   years.      In    it 
answered  in  detail  those  questions  regarding  ihe  course  and  outcome  of  diseases 
which  cause  llie  less  experienced  observer  the  most  anxiety  in  an  individual  c 
Topographic  anatomy  has  been  accorded  liberal  space. 
Penmylvnnia  Medical  Journal 


Kyle's 
Diseases  of  Nose  and  Throat 


Diseases  of  the  Noae  and  Throat.  By  D.  Hkaden  Kyle,  M.  D., 
Professor  of  Laryngology  in  the  Jefferson  Medical  College,  Phila- 
delphia. Octavo,  797  pages;  with  219  illustrations,  26  in  colors. 
Doth,  S4.00  net;  Half  Morocco,  #5.50  net. 

THE    NEW   14th)    EDITION 

Four  large  editions  of  this  excellent  work  fully  testify  lo  its  practical  value. 
In  this  edition  the  author  has  revised  the  text  thoroughly,  bringing  it  absolutely 
down  to  date.  With  the  practical  purpose  of  the  book  in  mind,  extended  1 
side-ration  has  been  given  to  treatment,  each  disease  being  considered  in  full,  and 
definite  courses  being  laid  down  to  meet  special  conditions  and  symptoms. 
Pennsylvania  Medical  Journal 

"  Dr.  Kyle's  crisp,  terse  diction  hus  enabled  Ihe  inclusion  of  nil  needful  nose  and  throw 
knowledge  in  this  buok.     The  practical  man,  be  he  special  or  general,  will  nul  s* 
for  anything  he  needs." 


GENITOURINARY  AND    NOSE,     THROAT,    ETC.  9 

Greene  and  Brooks' 
Genito-Urinary   Diseases 

Diseases  of  the  Genito-Urinary  Organs  and  the  Kidney.  By 
Robert  H.  Greene,  M.  D.,  Professor  of  Genito-Urinaiy  Surgery  at 
Fordham  University;  and  Harlow  Brooks,  M.  D.,  Assistant  Pro- 
fessor of  Clinical  Medicine,  University  and  Bellevue  Hospital  Medical 
School.  Octavo  of  605  pages,  illustrated.  Cloth,  $5.00  net;  Half 
Morocco,  $6.50  net. 

IMF;  NEW     (aft)     EDITION 

This  new  work  presents  both  the  mrdicn!  and  surgical  sides.  Designed  as  a 
work  of  <|uick  reference,  it  has  been  written  in  a  clear,  condensed  style,  so  that 
the  information  can  be  readily  grasped  and  retained.  Kidney  diseases  are  very 
elaborately  detailed. 

New  York  Medical  Journal 

""  As  a  whole  the  book  is  one  of  the  most  satisfactory  ami  useful  works  on  gi-ni to-urinary 


Gleason  on  Nose,  Throat, 
and  Car 

A   Manual   of   Diseases  of  the   Nose,  Throat,  and    Ear.     By  K. 

Baldwin  Gleason,  M.  D.,  LL.  D.,  Clinical  Professor  of  Otology, 
Medico-Chirtirgical  College.  Philadelphia.  12010  of  556  pages,  pro- 
fusely illustrated.     Flexible  leather,  $2.50  net. 

THE  NEW   <M)  EDITION 

Methods  ot  treatment  have  been  simplified  as  much  as  possible,  so  that  in 
most  instances  only  those  methods,  drugs,  and  operations  have  been  advised 
which   have   proved  beneficial,      A   valuable  feature  consists  of  the  collection  of 

f..-.iuii:i,i-. 

American  Journal  of  the  Medical  Sciences 


D, 

W 


American  Text-Book  of  Genito-Urinary  Diseases,  5y  phi  I  is,  and 
Diseases  of  the  Skin.  Edited  by  L.  Bolton  Bangs,  M.  D.,  and 
W.  A.   Hardaway,  M.  D.     Octavo.  «  "-s.  300  engravings,  20 

colored  plates.     Cloth,  S7.00  i" 


Goepp's 
Dental  State   Boards 

Dental  State  Board  Questions  and  Answers — By  R.  Max  GoEFF, 

M.D.,  Professor  of  Clinical  Medicine  at  the  Philadelphia  Polyclinic. 
Octavo  of  500  pages. 

JUST  READY 

This  new  work  is  along  ihe  same  practical  lines  as  Dr.  Goepp's  successful  si  ork 
on  Medical  Stale  Hoards.  The  questions  included  have  been  gathered  from  reliable 
SOUP  es,  Tid  emhrace  all  those  likely  to  be  asked  in  any  State  Board  examination 
in  any  State.  They  have  been  arranged  and  classified  in  a  way  thai  makes  for  i 
rapid  resume-  of  every  branch  of  dental  practice,  and  the  answers  are  couched  in 
language  unusually  explicit — concise,  definite,  accurate. 

The  practicing  dentist,  also,  will  find  here  a  work  of  great  value — a  work 
covering  the  entire  range  of  dentistry  and  extremely  weli  adapted  for  quick 
reference. 

Haab  and  deSchweinitz's 
Operative  Ophthalmology 

Atlas  and   Epitome  of   Operative   Ophthalmology.      By  Dr.  O. 

Haaii,  of  Zurich,  Edited,  with  additions,  by  G.  E.  deSuhwkinitz, 
M,  D.,  Professor  of  Ophthalmology  in  the  University  of  Pennsylvania. 
With  30  colored  lithographic  plates,  154  text-cuts,  and  375  pages  of 
text.     In  Saunders  Hand-Atlas  Series.     Cloth,  S3. 50  net. 


Dr.  Haab's  Atlas  of  Operative  Ophthalmology  wil!  be  found  as  beautiful  and 
as  practical  as  his  two  former  atlases.  The  work  represents  the  author's  thirty 
years'  experience  in  eye  work.  The  various  operative  interventions  are  described 
with  all  the  precision  and  clearness  that  such  an  experience  brings.  I' 
the  fact  that  mere  verbal  descriptions  are  frequently  insufficient  to  give  a  clear 
idea  of  operative  procedures.  Dr.  Haali  has  taken  particular  care  to  illustrate 
plainly  the  different  parts  of  the  operations. 
J  ohm  Hopkini  Hoipit.il  Bulletin 

Inscriptions  of  Ihe  various  operation*  are  so  clear  and  full  that  the  volume 
d  place  with  more  pretentious  text-books." 


Holland's  Medical 
Chemistry  and  Toxicology 

A  Text-Book  of  Medical  Chemistry  and  Toxicology.     By   James 

W.  Holland,  M.D.,  Professor  of  Medical  Chemistry  and  Toxicology, 
and  Dean,  Jefferson  Medical  College,  Philadelphia.  Octavo  of  675 
pages,  fully  illustrated.     Cloth,  $3.00  net 

THE  NEW  (3d  1  EDITION 

Dr.  Holland's  work  is  an  entirely  new  one,  and  is  based  on  his  forty  years" 
practical  experience  in  teaching  chemistry  and  medicine.  It  has  been  subjected  to 
a  thorough  revision,  and  enlarged  to  the  extent  of  some  sixty  pages.  The  additions 
in  be  specially  noted  are  those  relating  to  the  electronic  theory,  chemical  equilib- 
rium, Kjeldahl's  method  for  determining  nitrogen,  chemistry  of  foods  and  their 
changes  in  the  body,  synthesis  of  proteins,  and  the  latest  improvements  in  urinary 
tests.  More  space  is  given  to  toxicology  than  in  any  other  text-book  on  chemistry. 
American  Medicine 


li. 


■MhJ  t, 


Ivy's  Applied  Anatomy  and 

Oral  Surgery  for  Dental  Students 


Applied  Anatomy  and  Oral  Surgery  for  Dental  Students.  By 
Robert  H.  Ivy,  M.D.,  D.D.S.,  Assistant  Oral  Surgeon  to  the  Philadel- 
phia General  Hospital.     i;mo  of  2S0  pages,  illustrated.     Cloth,  Si.  50 

JUST   READY 

This  work  is -just  what  dental  students  have  long  wanted— a  concise,  practical 
work  on  applied  anatomy  and  oral  surgery,  written  with  their  needs  solely  in 
mind.  No  one  could  be  hetter  fitted  for  this  task  than  Dr.  Ivy,  who  is  a  graduate 
in  both  dentistry  and  medicine.  Having  gone  through  the  dental  school,  he 
knows  precisely  the  dental  student's  needs  and  just  how  in  meet  them.  His 
medical  training  assures  you  that  his  anatomy  is  accurate  ami  his  tcchiiic  modern. 
The  text  is  well  illustrated  with  pictures  that  you  will  find  extremely  helpful. 


SAUNDERS1    BOOKS   ON 


Wells'   Chemical  Pathology 

Chemical  Pathology.  Being  a  discussion  of  General  Path- 
ology' from  the  Standpoint  of  the  Chemical  Processes  Involved. 
By  H.  Gideon  Wells,  Ph.D.,  M.  D.,  Assistant  Professor  of 
Pathology  in  the  University  of  Chicago.  Octavo  of  549  pages. 
Cloth,  $3.25  net;   Half  Morocco,  84.75  net. 

Win.   H.  Welch,   M.  D.,  Professor  </  Pathology,  Johns  Hoptin 
"  The  work  fills  n  real  need  in  the  English  literature  of  a 


Saxe's  Urinalysis      ».».(■»»« 

Examination  of  the  Urine.  By  G.  A.  De  Santos  Saxe.  M.  D„ 
formerly  Instructor  in  Gen  ito-Uri  nary  Surgery,  New  York  Post- 
graduate Medical  School  and  Hospital,  tamo  of  448  pages,  fully 
illustrated.     Cloth,  S1.75  net. 

Froncii  Carter  Wood,  M.  D.,    Adjunct  Pre/essur  ef  Clinical  PatkoUgf   Columbia    Uni- 
versity. 

"  II  seems  10  me  lo  be  one  of  the  best  of  Ihe  smaller  works  on  this  subject ;  it  is, 
indeed,  better  than  a  good  many  of  the  larger  ones."' 

deSchweinitz   and  Randall   on  the  Eye,  Ear, 
Nose,  and  Throat 

American  Text-Book  of  Diseases  of  the  Eye,  Ear,  Nose,  and 
Throat.  Edited  by  G.  E.  de  Schweinitz,  M.D.,  and  B.  Alex- 
ander Randall,  M.D.  Imperial  octavo,  1251  pages,  with  766 
illustrations,  59  of  them  in  colors.  Cloth,  g/.oo  net;  Half  Mo- 
rocco, #8.50  net. 

Griinwald  and  Grayson  on  the  Larynx 

Atlas  and  Epitome  of  Diseases    of  the  Larynx.     By  Dr.   L, 

Grunwai.d.  of  Munich.  Edited,  with  additions,  by  Charles  P. 
Grayson,  M.D.,  University  of  Pennsylvania.  With  107  colored 
figures  on  44  plates,  25  text-cuts,  and  103  pages  of  text.  Cloth, 
$2.50  net.     In  Saunders'  Hand-Atlas  Series. 

Mracek  and  Stelwagon's  Atlas  of  Skin 

Atlas  and  Epitome  of  Diseases  of  the  Skin.     By    PsOR,    Dr. 

Franz  Mracek,  of  Vienna.  Edited,  with  additions,  by  Henry 
W.  Stelwagon,  M.D.,  Jefferson  Medical  College.  With  77  col- 
ored plates,  50  half-tone  illustrations,  and  280  pages  of  text.  In 
Saunders'  Hand-Atlas  Series.     Cloth,  $4.00  net. 


CHEMISTRY,  SKIN,  AND    VENEREAL    DISEASES.  13 

American  Pocket  Dictionary       J»«  Re»dy-N«w  (7th  i  Edition 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  ^ 
Newman  Dorland,  M.  D.,  Editor  "American  Illustrated  Medical 
Dictionary."  Containing  tile  pronunciation  and  definition  of  the 
principal  words  used  in  medicine  and  kindred  sciences.  6l0  pages. 
Flexible  leather,  with  gold  edges,  gi.co  net;  with  thumb  index, 
$1.25  net. 
jamei  W.  Holland.  M.  D., 

Proftuar  of  Mtdiiil  Chemiltry  and  Tcxieefogy.  and  Dcoh.  Jtfferson  Medial  Coltigt. 


Stelwagon's  Essentials  of  Skin  7ih  Edition 

Essentials  of  Diseases  of  the  Skin.  By  Henry  W.  Stel- 
wagon,  M.  D..  Ph.D.,  Professor  of  Dermatology  in  the  Jeffer- 
son Medical  College,  Philadelphia.  Post-octavo  of  2QI  pages, 
with  72  text-illustrations  and  8  plates.  Cloth,  #1.00  net.  In 
Saunders'  Question- Contpend  Series. 
The  Medical  Newi 

present  kntwliilce  of  diseases  of  Die  skin.  .   .   .   Conlini 


thoM  quMl  '" 


New   (7U1)   I 


tain  the  high  standard  of  ei 

Wolffs  Medical  Chemistry 

Essentials  of  Medical  Chemistry,  Organic  and  Inorganic 

Containing  also  Questions  on  Medical  Physics,  Chemical  Physiol- 
ogy, Analytical  Processes,  Urinalysis,  and  Toxicology,  By  Law- 
rence Wolff,  M.  D.,  Late  Demonstrator  of  Chemistry,  Jefferson 
Medical  College.  Revised  by  A.  Ferkee  Wither,  Ph.  G-,  M.  D., 
Formerly  Assistant  Demonstrator  of  Physiology,  University  of 
Pennsylvania.  Post-octavo  of  222  pages.  Cloth,  £1.00  net.  In 
Saunders1  Qnestio/i-Compend  Series. 

Martin's  Minor  Surgery,  Bandaging,  and  the  Venereal 

Diseases  Second  Edition,  Reviled 

Essentials  of   Minor   Surgery.   Bandaging,  and  Venereal 
Diseases.     By  Edward   Martin.  A.  M.,  M.  D.,  Professor  of  Clin- 
ical Surgery,  University  of  Pennsylvania,  etc.     Post-octavo,   166 
with   78   illustrations.       Cloth,   gi.00   net.     In    Saunders' 
Question-Compend  Series. 

Vecki's  Sexual  Impotence  New  [*b]  Edition— Preparing 

The  Pathology  and  Treatment  of  Sexual  Impotence.  By 
Victor  G.  Vecki,  M.  D.  From  the  Second  Revised  and  Enlarged 
German  Edition,      l2mo  volume  of  400  pages. 

Johns   Hopkin.  Hospital   Bulletin 


14  EVE,    EAR,    JVOSE,   AND    THROAT. 

deSchweinitz   and    Holloway  on   Pulsating    Exoph- 
thalmos 

Pulsating  Exophthalmos.  An  analysis  of  sixty-nine  cases  sol  pre- 
viously analyzed-  By  George  K.  DsSchwkiniti,  M.  D.,  and  Thomas 
B.  Holloway,  M.  D.     Octavo  of  125  pages,     ("loth,  J2.00  net. 

This  monograph  consists  of  an  analysis  of  sixty-nine  cases  of  this  affection 
not  previously  analyzed.  The  therapeutic  measures,  surgical  and  otherwise, 
which  have  been  employed  are  compared,  and  an  endeavor  has  been  made 
lo  determine  from  these  analyses  which  procedures  seem  likely  to  prove  .1 
the  greatest  value.      It  is  the  most  valuable  contribution  to  ophthalmic  luer- 

Britiih  Medical  Journal 


Jackson  on  the   Eye  Tfc*  New  (*]  Edit™ 

A  Manual  of  the  Diagnosis  and  Treatment  of  Diseases  of  the 
Eve.  By  Edward  Jackson,  A.  M.,  M.  D.,  Professor  of  Ophthalmol.^, 
University  of  Colorado,  umo  volume  of  615  pages,  with  184  beautiful 
illustrations.     Cloth,  £2.50  net. 

The  Medical  Record.  New  York 


Grant  on  Face,   Mouth,   and  Jaws 

A  Text-Book  of  the  Surgical  Principles  and  Surgical  Diseases 
of  the  Face,  Mouth,  and  Jaws.  For  Dental  Students.  By  ill  [ORICB 
Grant,  A.  M.,   M.  D.,    Professor  of  Surgery  and  of  Clinical  Surgery, 

Hospital  College  of  Medicine,   Louisville.     Octavo  of  ju  pages,  with 
-      Cloth,  52.50  net. 


Preiswerk  and  Warren's  Dentistry 

Atlas  and  Epitome  of  Dentistry.     U)    Pro*    <:     Preisv 
Basil.      Edited,  with  additions,  by  Georgi    W.    YVakkkk,  D.D.S.,  Pro- 
fessor of  Operative  Dentistry,  Pennsylvania  College  of  Denial  Surgery, 
Philadelphia.      With  44  lithographic  phtcs.   15;  tcvl-i  uts,  and  343  pages 
of  text.      Cloth.  $3.50  net,      In  Sounderf  Atlai  Series. 

Friedrich   and  Curtis  on  Nose,   Larynx,  and   Ear 

RHINOLOCV,    LARYNGOLOGy,  A\D   OTOLOGY,   ANT'    THEIK    SlONinCAMd 

in  General  Medicine.  By  Dr.  E.  P.  Friedrich,  of  Leipzig.  Edited 
by  H.  Holbrook  Cirtis,  M.  D.,  Consulting  Surgeon  to  ihc  New  York 
Nose  and  Throat  Hospital.  Octavo  volume  of  350  pages.  Cloth 
f  3.50  net. 


Wolfs  Examination  of  Urine 

A  Laboratory  Handbook  of  Physiologic  Chemistry  and 
Urine-examination.  By  Charles  G.  L.  Wolf,  M.D.,  Instructor  in 
Physiologic  Chemistry,  Cornell  University  Medical  College,  New 
York.   i2mo  volume  of  204  pages,  fully  illustrated.  Cloth.  $  1.25  net. 

Britiih  Medical  journal 

"The  methods  of  examining  the  urine  me  m*f  fully  described,  and  'here  arc  at  the 
end  of  the  book  HOC   CXhSUtye   tablet   drawn  up  10  uafal  in  luteal)  diagnosis." 

Jackson's  Essentials  of  Eye  Third  Revised  Edition 

Essentials  oh  Refraction  and  of  Diseases  of  the  Eye.  By 
Eowakd  Jackson,  A.  M..  M.  IX,  Emeritus  Professor  of  Diseases  of 
the  Eye, Philadelphia  Polyclinic.  Post-octavo  of  261  pages,  82  illus- 
trations.   Cloth,  gi.oo  net.     ///  Sounder/  Qucstion-Compend  Series, 

Johns  Hopkins  Hospital  Bulletin 

The  entire  ground  is  covered,  and  the  points  that    most   need  careful  elucidation 

Gleason's  Nose  and  Throat  fourth  Edition.  Revised 

Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  B, 
GleASON,  S.  B.,  M.  D.,  Clinical  Professor  of  Otology,  Medico- 
Chirurgical  College.  Philadelphia,  etc.  Post-octavo,  24 1  pages,  1 12 
illustrations,  Cloth.  Si. 00  net.  In  Saunders'  Question  Compends, 
The  Lancet.  London 

"  The  careful  description  wluch  is  given  of  the  various  procedure  would  be  sufficient 
10  enable  most  people  of  imp  intelligence  and  of  slight  anatomical  knowledge  to 
PUln  ■  very  good  attempt  at  laryngoscopy." 

Gleason's  Diseases  of  the  Ear  Third  Edition.  Revised 

Essentials  OF  DISEASES  OF  the  Ear.     By  E.  B.  Gleason,  S.  B., 

M.  D.,  Clinical  Professor  of  Otology.  Medico-Chiru  rgical  College, 
Phila.,  etc.  Post-octavo  volume  of  214  pages,  with  1 14  illustra- 
tions.    Cloth,  jji.oo  net.     In  Saunders  Question- Compcnd  Series. 

Bristol  Medico-Chirurgical  Journal 

"  We  know  of  ni>  other  small  work  on  ear  diseases  la  compare  »;th  this,  either  tn 
freshness  of  style  or  MnipletenBSl  rjf  infi..rmat1<m." 

Wilcox  on  Genito- Urinary  and  Venereal  Diseases 

The  New    2d)   Edition 

Essentials  of  Gemto-Urinaky  ano  Veneueal  Diseases.     By 

Starling  S.  Wilcox,  .\I-  D.,  Lecturer  on  Genito-Urinary  Diseases 

and  Syphilology,  Starling-Ohio  Medical  College,  Columbus.     1 2mo 

of  321  pages,  illustrated.     Cloth,  £  1. CO  net.      Saunders'  Compends. 

Stevenson's  Photo  scopy 

Photoscopy  {Skiascopy  or  Retinoscopy).  By  Makk  D.  Stev- 
ENSON,  M.  D.,  Ophthalmic  Surgeon  to  the  Akron  City  Hospital. 
T2mo  of  126  pages,  illustrated.  Cloth,  Si  25  net. 

Edward  Jackson.   M.  D„  Vnivtrsity  of  Coltrado. 

"  It  Is  well  written  and  will  prove  ..  valuable  help.  Your  ireitment  (if  the  emergent 
pencil  of  ImjS,  and  the  part  failing  on  the  cismiocr'i  eye,  is  decidedly  better  than  any 


LANE    MEDICAL    1.1HRARY 


"OCT  27* 


1916 
1f' 


T71     Schamberg,   Jay  Fror* 
S299     Dieecisee  of  the  6kin 
1911      ■ 27162 


DATEfoUE 


d>fk2^r