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^   ^^  '    I 


Dr.i^.C.lJickson 


it^^njt^'  ^/juM^f)^ 


J 


BY    THE    SAME   AUTHOR. 

RINGWORM  in   the  Light  of 
Recent  Research. 

PATHOLOGY— TREATMENT- 
PROPHYLAXIS. 
With    22    Micro  -  photographs    and   a 
Coloured  Plate. 

CASSELL    &    COMPANY.    Liniite<l, 

London,  Paris,  New  York  & 

Melbourne. 


DISEASES  OF  THE  SKIN 

AN    OUTLINE 

OF    THE 

PRINCIPLES    AND    PRACTICE 

OF 

DERMATOLOGY 


BY 

MALCOLM     MORRIS 


CONSULTJXO   SURGEON  TO  THE  SKIN  DEPARTMENT,  ST.  MARY  d  HOSl'lTAL,  LONDON 
C-ORRESPONDINO  MEMBER  OF  THE   K.K.    GE8ELI.SC'IIAFT   DER   AERTZE  IX   WIEN 
HONORARY   MEMBER  OF  THE   WIENER   DERMATOLOGISCHE  OESELLSCHAKT 
AND  OF  THE  SOCII^:T^    FHANi^'AIftE    DE   DERM\TOLOOIE 


With  2  Ccdtmred  Phites  mid  5S  Plain  Fitjunfx 


NEW     EDITION 


CASSELL  AND  COMPANY,  Limitkd 

HtNDON,    PARIS,    NEW  YORK  d:  MELHdURNh:.     MCMIU 


\l.\.   KKJHTS    ItESKRVKO 


First  Edition^  NnvemheVt  1893. 
Jlt'jyrfntrd  1894        Revised  1898.      RrprhUed  1895). 
Neir  KiUUrtn  1903. 


• « • 


•  • 


•  •• 


*  • 


1 1^^ 


PREFACE    TO    THE    NEW   EDITION. 


The  revised  edition  of  this  book,  which  appeared  in 
1898,  has  for  some  time  been  out  of  print.  The 
pressure  of  professional  engagements  and  of  other 
work  has  made  it  impossible  till  lately  for  the  author 
to  find  time  for  the  preparation  of  a  new  edition.  A 
good  deal  of  new  matter  has  been  added,  but  some 
redundances  have  been  removed,  and  care  has  been 
taken  not  to  alter  the  character  of  the  volume  by 
expanding  it  from  an  elementary  manual  into  a 
treatise.  Several  new  illustrations  have  been  added, 
for  some  of  which  the  author  has  to  express  his 
indebtedness  to"5Dr.  Gilchrist,  of  Baltimore,  and 
Dr.  Whitfield,  of  London.  The  index  has  been  con- 
siderably enlarged  with  the  object  of  enabling  the 
practitioner  to  see  at  a  glance  the  main  lines  of 
treatment  available  in  a  given  disease. 

The  author  has  pleasure  in  expressing  his  thanks 
to  his  friend  and  former  clinical  assistant,  Dr.  Dore, 
for  help  in  the  preparation  of  this  edition. 

M.  M. 

8,  Harlxy  Street,  London-, 
Janvai-y,  1903. 


00871 


PREFACE   TO   THE   SECOND    EDITION. 


-•o*- 


The  first  ©iition  of  this  work  went  out  of  print  more 
than  a  year  ago,  but  owing  to  the  pressure  of  other 
engagements  the  author  has  been  unable  till  lately 
to  find  time  for  the  preparation  of  a  new  one.  The 
text  has  been  thoroughly  revised,  and  a  considerable 
amount  of  fresh  matter  has  been  added  in  various 
places.  In  the  section  on  Diseases  of  the  Skin  due 
to  Disorder  of  the  Nervous  System,  the  treatment 
is  given  after  the  description  of  the  several  diseases. 
It  is  thought  that  this  arrangement  will  be  found 
more  convenient  than  that  adopted  in  the  former 
edition,  in  which  the  treatment  of  all  the  diseases 
included  in  the  section  was  placed  in  one  chapter. 
Some  new  illustrations  have  been  introduced,  which 
it  is  hoped  will  increase  the  usefulness  of  the  work. 
It  would  have  been  easier  to  make  the  book  larger ; 
the  (Hfficulty  has  been  to  keep  it  from  swelling  to  a 
bulk  that  would  altogether  change  its  character. 

The  author  desires  to  express  his  gratitude  to 
Dr.  James  Gallowav  and  Dr.  Arthur  Whitfield  for 
valuable  help  in  the  revision  of  the  work.  He  has 
to  thank  Mr.  Colquhoun  for  two  new  coloured  plates 
of  micro-organisms,  and  Dr.  Patrick  Manson  for  the 
use  of   blocks  representing  elephantiasis  and  tinea 

• 

^mbricata. 

M.  M. 

Harlky  Street,  W. 
October,  1898. 


CONTENTS. 


CHAPTER  I.  PACJE 

Pathology  of  the  Skiu    .  .  .  .  .  .1 

OHAPTEK  II. 
Classification       .  .  .  .  .21 

CHAPTER  III. 
Principles  of  Diagnosis  .  .  .  .  .26 

CHAPTER  IV. 

Affections  of  the  Skin  Dei>endeiit  ou  Nerve  Disorder. — ClaHsi- 

fication  of  Dermatoiieuroses  .  ,  .  .49 

CHA1>TER  V. 

Affections  of  the  Skin  Dependent  on  Xerve  Disorder  {con- 

tinued). — General  Principles  of  Treatment  .  .       .)7 

CHAPTER  VI. 

Affections  of  the  Skin  Dependent  on  Nerve  Disorder  {nm- 

tintted). — Sensory  Neuroses  of  the  Skin    .  .63 


X  CONTENTS. 

CHAPTER  Vil.  PAGE 

Affections  of  the  Skin  Dependent  on  Xerve  Disorder  {con- 

iinued). — Angio-Neuroses  .  .  .  .  .77 

CHAPTER  VIII. 

Affections  of  the  Skin  Dependent  on  Nerve  Disorder  {con- 
tinued). — Erjrthema — Purpura,  or  Peliosis,  Rheumatica — 
Lupus  Erythematosus — Rosacea — ^Pellagra  — Acrodyuia .      88 

CHAPITER  IX. 

Affections  of  the  Skin  Dependent  on  Xerve  Disorder  {coit- 
^i«?/e^).— Dermatitis  Herpetiformis — Herpes  Gestationis 
— Impetigo  Herpetif onnis  — Cheiropompholyx — Pemphi- 
gus—Hei-pes.  .  .  .  .  .128 

CHAPTER  X. 

Affections  of  the  Skin  Dependent  on  Nerve  Disorder  ico)i  - 
eluded) .  —  Sclerodermia — Morph(Ba — Lichen  — Porokera- 
tosis— Parakeratosis  Vaiiegata — PitjTiasis  Rubra  Pilaris 
—  Congenital  Ichthyosiform  Erythrodermia  —  Leuco- 
dermia — Raynaud's  Disease — Dermatitis  Repeus — Dia- 
betic Gangrene— Hysterical  Gangrene — Glossy  Skin — 
Atrophy  of  the  Skin —Charcot's  Bed-sore — Trophic  Ulcei-s 
— Morvan's  Disease — Syringomyelia — (Edema     .  .167 

CHAPTER  XI. 
Artificial  Eruptions        ......     202 

CHAia^EK  XII. 
Ec2ema    ........     23(i 

CHAPIER  XIII. 
Eczema  {cuncluded). — Treatment  ....     273 


CONTENTS.  xi 

CHAPTER  XIV.  PAGE 

Psoriasis  ........     288 

CHAPTER  XV. 

Pityriasis.  .  .  .  .  .  .  .     .SOS 

CHAPTER  XVI. 
Local  luoculable  Diseases. — Animal  Parasites  ,  ,    821 

CHAPTER  XVII. 
Local  luoculable  Diseases  {continued). — Vegetable  Parasites,     337 

CHAPTER  XVIII. 

Local  luoculable  Diseases  {concluded).-  -Oi\iev  Micro-orgau- 

isms  ...,...,     372 

CHAPTER   XIX. 

Geueral  luoculable  Diseases. — Scrofulodermia — Tuberculous 
Ulcers — Verruca  Necrogenica  —  Erythema  luduratum 
Scrof  ulosorum — Tuberculides — Lupus  Vulgaris .  .       409 

CHAPTER  XX. 
General  luoculable  Diseases  (con fi nurd). — Syphilis    .  .     447 

CHAPTER  XXI. 

General  luoculable  Diseases  {concluded). — Leprosy — Yaws — 

Glanders       .......     477 

CHAPTER  XXII. 

Diseases  of  Skin -glands  and  Epidermic  Appendages  (Hair 

and  Xails)    .......     505 


XIV 


LIST    OF   ILLUSTRATIONS, 


» 


j> 


Tinea  Imbricata  .... 

Author's  Case  of  Favus 

Section  of  Pustule  in  Impetigo  Contagiosa 

Actinomycosis  ..... 

Elephantiasis  Arabum  of  Foot 

Elephantiasis  of  Legs   .... 

Elephantiasis  of  Mamma 

General  Tuberculide     .... 

General  Tuberculide,  showing  Strumous  Ulcei-s 

Lupus  Vulgaris  with  Epithelioma 

Microscopic  Section  of  Nodule  of  Lupus  VulgariB 

Follicular  Syphilide      .... 

Corymbose  Syphilide    .  ...  7 

Circinate  Squamous  Syphilide . 

Annular  Syphilide  in  a  Negro . 

Syphilis  of  Sole  of  Foot ;  Nodular  Late  Syphilis 

Nodular  Leprosy  #  .  .  . 

Pinna  of   the  Ear  of  a  Person    suffering  from  Nodular 
Leprosy       ..... 

Claw-like  Hand  in  Nerve  TiCprosy 

Chronic  Glanders 

Microscopic  Section  of  a  Comedo 

Trichorrhexis  No<lo8a   .... 

Fibroma  ...... 

Von  RecklinghauKi'n*s  Diseasf ...  7 

Myoma  Cutis      ..... 

Large  Hairy  Mole  and  sovrral  Benign  Fibrous  Tunioui's 

Angiokenitoma  ..... 


TAUE 

To  face  365 


367 

372 

399 

40.) 

.       406 

.      407 

To  face  421 

,,  Fig.    24 

To  face  427 

43o 

455 

o  farr  Fig.     27 

To  face  457 

457 

Tn  face  464 

.       481 

482 

.       487 

.       503 

To  face  515 

.       530 

To  face  551 

face  Fig.    39 

to  fact  oo3 

558 

5()0 


LIST   OF    ILLUSTRATIONS. 


XV 


Lymphangioma  Circimiscriptuni 

Bhinoscleroma  ..... 

Microscopic  Section  of  MoUuscum  Contagiosum 

Keratosis  Follicularis    . 

Acanthosis  Xigricaus    . 

Cancer  en  Cuirasse 

Microscopic  Section  of  Epithelioma 

Rodent  Ulcer    . 

Rodent  Ulcer  (late  stage) 

Microscopic  Section  of  Rodent  Ulcer 

Multiple  Sarcoma  of  the  Skin  . 

Mycosis  Fungoides  of  the  Face 

Mycosis  Fungoides  of  the  Fore-arm 

Kaposi's  Disease 

Tylosis  in  Father  and  Daughter 


PAOB 

.     To  face  562 

.      571 

.      To  face  573 

„       576 

„       579 

„       591 

ro/w6'Fig.    49 

.      To  face  596 

TofaceYig.    51 

.     To  faceb^Q 

598 

.      602 

.      603 

.       606 

.      To  face  613 


t) 


rATIlOUHiY    OF    THE   SKIN,       [chap.  i. 


AnoniiilioH  of  Hocretioii  play  a  large  part  in  the 
piitli<»l(»|^y  of  \\\v.  Hkiii.  Retention  of  secretion,  caused 
by  nn'clijiniciil  olmiruction  or  nervous  influence,  is 
frocjiKMitly  tlin  Htarting-point  of  inflammatory  pro- 
(•-(»HHCH.  Thus  th(^  Hiniple  comedo  readily  gives  rise  to 
ilio.  aciH*<  piiHtuli'.  Kxc(;ssive  or  diminished  secretion 
\H  ofio.ri  d(^p<'nd(Mit  on  abnormal  states  of  the  nerve 
ccnlrcH  or  pcriplH^ral  norves.  Profuse  sweating  may 
\n\  \\\{\  r(\Hnlt/  of  norvo  exhaustion,  or  of  the  presence 
in  the-  blood  of  toxic;  matters  calling  for  elimination. 
An  ('xccMHivc.  secn^-tion  of  sebum  is  often  the  starting- 
point  of  the  inflammatory  process  in  eczema  sebor- 
rhauc-um. 

Like  all  other  tissues,  the  skin  is  liable  to  inflam- 
mation, and  the  process  is  essentially  the  same  as  in 
other  organs.  The  classical  signs  of  inflammation,  as 
given  by  Celsus — redness,  swelling,  heat,  and  pain — 
are  particularly  manifest  in  the  skin.  A  characteristic 
feature  of  inflammation  of  the  skin,  however,  is  that 
tlie  disorder  of  sensation  generally  expresses  itself  in 
th(*-  form  of  *Yc^i??//  rather  than  of  pain.  The  general 
definition  of  inflammation  given  by  Burdon-Sander- 
son* — "  the  succession  of  changes  which  occurs  in 
a  living  tissue  when  it  is  injured,  provided  that  the 
injury  is  not  of  such  a  degree  as  at  once  to  destroy  its 
structure  and  vitality  " — appUes  to  the  skin  as  to 
other  tissues.  The  essential  part  of  the  process  is 
increased  diapedesis  of  whit-e  corpuscles,  with  escape 
of  liquid  exudation  from  capillaries  and  small  veins 
and  accumulation  of  these  bodies  causing  obstruction 
in  the  lymphatics.  The  higher  degrees  of  inflamma- 
tion are  marked  by  stasis  in  the  capillaries,  veins, 
and  small  arteries  ;  if  this  condition  persists  a  certain 
time  it  induces  necrosis.  If  the  necrosed  part  lique- 
fies, the  leucocytes  which  have  left  the  channels  of 
the  affected  vessels  find  their  way  in  large  numbers 

*  Holmes's  "System  of  Surgery." 


^pto. 


.]  INFLAMMATION. 


into  the  uecrotdc  liquefied  tissue,  and  the  result  is 
the  lormatioti  of  an  abscess.  The  process  by  which 
leucocytes  are  attracted  by  irritant  materials, 
whether  these  be  products  oi  micro-oi^aniamB  or 
of  any  other  kind,  is  termed  "'  chemio taxis,"  and 
the  power  which  the  leucocytes  display  of  engulfing, 
and  in  some  cases  destroying,  "foreign  bodies,  such 
as  bacteria,  is  termed  "  phagocytosis."  Intense  irri- 
tation of  the  kind  referred  to  in  the  living  ti^ues  is 
usually  caused  by  the  products  of  micro-organisms, 
and  some  investigators  restrict  the  term  "  pus  "  to 
necrotic  liquid  containing  dead  leucocytes  and  pus 
cocci ;  and  although  chemical  irritants,  such  as 
croton  oil,  cause  a  similar  liquid  to  collect,  they  would 
not  tall  that  pus,  inasmuch  as  no  pyococci  are  present 
in  it.  Stasis  is  due  to  the  increased  lOBistance  caused 
by  the  alteration  of  the  waits  of  the  minute  blood- 
vessels and  lymph-tub ea  consequent  on  leucocytes 
becoming  adherent  thereto.  The  first  step  in  recovery 
from  inflammation  is  the  cessation  of  stasis  followed 
by  restoration  of  the  blood  circulation.  Before  stasis 
diaappears,  however,  hiemoglobin,  or  blood-corpuscles, 
frequently  escape  from  a  capillary  into  the  surronnd- 
ing  tissue,  with  the  result  that  pigmentation  of  a 
more  or  less  permanent  character  is  left  behind.  Ac- 
cording to  Virchow,  the  pigment  is  always  derived 
from  the  blood,  and  is  at  fiist  held  in  solution  in  the 
plasma  which  bathes  the  tissues.  In  the  skin  some 
of  it  is  taken  into  the  deeper  epidermal  cells,  some 
into  the  branched  connective-tissue  cells,  which, 
according  to  Ehrmann,  communisate  with  the 
former.  Pigment  may  also  lie  free  in  the  tissues  in 
the  form  of  h^motoidin  granules  or  crystals. 

Slighter  degrees  of  the  inflammatory  process,  if 
long  persistent,  result  in  hyperplasia,  which  must  be 

■ply  distinguished  from  true  hypertrophy.  In 
case   the   extravasated  leucocytes  and   the 


PATHOLOGY   OF   THE   SKIX. 


Im. 


proliferated  connective- tissue  cells  take  tfieir  plae 
after  differontiation  as  permanent  parts  of  the  tissui 
Hhort  of  this  hyperplsfiia  the  results  of  inflammation 
may  be  seen  in  tuberculous  foci  and  in  guramatnUB 
leHioDs.  Since  the  real  nature  of  tuberculosis  has 
been  determined,  and  the  difference  between  abscess 
formation  and  caseation  has  been  shown  to  be  only 
one  of  degree,  it  appears  more  logical  to  include 
tuberculous  and  gummatous  lesions  among  inflam- 
matory infections.  The  increase  in  substance  whicfi 
accompanies  theee  conditions  is  due  to  the  fact  that 
the  inflammatory  cells  remain  for  a  time  as  a  tissue 
of  embryonic  type  previous  to  either  of  the  two  pos- 
sible terminations^icatriaation  or  caseation.  Other 
pathological  procesaes  in  the  skin  have  in  recent  years 
been  shown  to  be  of  inflammatory  nature.  An  in- 
stance of  this  is  seen  in  the  case  of  xanthoma,  which 
was  formerly  classed  among  new  growths,  though 
its  general  resemblance  to  atheroma  had  long  beea 
noticed. 

All  degrees  of  dermatitis  may  be  set  up  by  the 
application  to  the  skin  of  irritants,  such  as  mustard 
oil,  in  solutions  of  varying  strength.  The  shghtest 
irritation  causes  temporary  hyperemia,  in  which  it 
would  be  Impossible,  on  simple  inspection,  to  say 
that  exudation  had  taken  place.  The  microscope, 
however,  shows  the  process  to  be  really  inflamma- 
tory. By  usiug  progressively  stronger  irritants, 
papules,  vesicles,  bullte,  and  other  lesions  may  be 
produced.  On  removing  the  irritant,  recovery  takes 
place  with  a  gr«ater  or  less  amount  of  desquamation. 
Microscopic  examination  of  an  inflammatory  papule 
shows  that  the  cells  of  the  rete  are  swollen,  while  their 
nuclei  are  somewhat  indistinct,  and  sometimes  elon- 
gated or  divided.  The  corium  is  inflitrated  with 
small  round  cells,  which  are  most  thickly  clustered 
around  the  separate  vascular  areas  ;    hence  the  irre- 


] 
I 


r.]     VESICULATION    AND    PUSTULATION.      S 

gular  protrusion  of  the  epidermis  into  papules.  To 
these  changes  in  the  corium  is  due  one  of  the  most 
marked  appearances  of  the  inflamed  cutis,  viz.  the 
swelling,  elongation,  and  flattening  of  the  papillas. 

A  further  degree  of  irritation  will  transform  the 
papule  into  a  vesicle  ;  the  latter  lesion  is  due  to 
separstion  of  the  layers  of  the  serrated  cells  of  the 
rete  and  accumulation  of  clear  fluid  containing  leu- 
cocytes in  the  clefts.  In  the  process  of  separation 
Kome  of  the  rete  ceils  are  drawn  out  into  fusiform  or 
filiform  figures,  forming  a  nieshwork  in  the  vesicle. 
The  involution  of  a  vesicle  may  begin  by  absorption  of 
the  fluid  without  breach  of  the  superficial  epidermic 
layer,  or  the  vesicle  may  burst,  leaving  a  rod  surface 
secreting  serous  fluid,  and  formed  by  the  papillary 
layer  of  the  corium,  which  is  generally  covered  by 
the  deepest  layer  of  the  epidermis ;  this  is  termed 
exGorialion.  In  more  severe  cases,  not  only  the  whole 
of  the  epidermis,  but  part  of  the  corium,  ia  destroyed  ; 
this  is  ulceration.  If  the  irritant  action  is  maintained, 
the  contents  of  the  vesicle  are  more  and  more  charged 
with  corpuscles,  becoming  opaque  and  afterwards 
puriform  ;  thus  the  vesicle  is  transformed  into  a 
pustule.  The  contents  of  a  pustule  of  this  kind  must 
be  distinguished  from  pus  engendered  by  the  irrita- 
tion of  producte  of  pyogenic  cocci. 

Umbilication  of  vesicles  or  pustules  takes  place 
in  several  ways.  Thus  the  fluid  may  not  fully  dis- 
tend the  cleft  in  which  it  lies,  and  the  network  of 
elongated  rete  cells  may  cause  a  dimpling  (primary 
ambilication  of  Auspitz  and  Von  Basch),  or  com- 
mencing absorption  may  cause  a  similar  flaccidity 
of  the  sac  ;  or  again,  a  scab-covered  umbilication  Js 
often  seen  after  rupture.  That  pus  can  be  absorbed 
without  being  discharged  on  a  surface  is  proved  by 
'  ifrequent  absorption  of  a  collection  of  pua  in  the 
Trior  chamber  of  the  eye  without  perforation  of 


PATHOLOGY    OF   THE   SKIN.        [chap.  i. 

the  cornea.  DeBqiiamtition  in  superficial  dermatitis 
is  analogous  to  excessive  mucous  accretion  in  catarrhal 
afiections  of  mucous  membranes.     This  is  the  course ' 

ventB  in  a  typical  case  of  traumatic  dermatitis ; 
an  inflammatory  process  may  be  set  up  in  the 
akin  in  various  ways.  Thus,  the  retention  of  secre- 
tion in  a  sebaceous  gland  may  induce  perifoUicuiitis, 
which  the  presence  of  micrococci  may  cause  to  be- 

le  pufltuiar.  Slight  injuries,  such  as  those  In- 
flicted by  the  itcb  mite  or  by  lice,  may  also  become 
infected  by  pyogenic  organisms.  More  intense  in- 
fective processes  are  seen  in  the  case  of  erysipelas. 

Abnormal  vascular  or  nervous  conditions  in  the 
skin  render  it  more  vulnerable.  This  is  especially 
seen  in  the  lower  limb,  owing  to  the  disadvantages 
in  point  of  blood  and  nerve  supply  entailed  by  the 
greater  distance  which  separates  it  from  the  heart 
and  the  central  nerve-organs  as  compared  with  other 
parts  of  the  body.  The  lower  limbs  show  a  marked 
proclivity  to  inflammation  of  all  degrees  of  severity 
when  they  are  the  seat  of  varicose  veins,  or  when 
they  are  paralysed  owing  to  affections  of  peripheral 
nerves  or  the  spinal  cord.  Circulatory  inadequacy 
may  be  due  to  abnormal  conditions  of  the  heart  or 
lungs.  There  is  a  special  vulnerability  of  the  skin, 
as  well  OS  of  the  other  tissues,  which  is  associated 
with  the  so-called  strumous  diathesis.  This  vul- 
nerabiUty  of  tissue  manifests  itself  in  slowness  of 
repair  after  injury,  and  in  a  toarked  tendency  to 
become  infected  by  pyogenic  cocci  and  tubercle 
bacilli. 

The  influence  of  disordered  nerve  action  in  pro- 
ducing inflammation  of  the  skin  is  displayed  in  such 
conditions  as  herpes  and  urticaria.  Other  examples 
ot  lesions  dependent  on  nervous  disorder  are  seen 
in  acute  bed-sore,  anaesthetic  leprosy,  perforating 
nicer,  etc.,  where  severe  lesions  are  directly  traceable 


i 


[.]        BESI'LTS  OF  ll^fLAMMATinN. 


inflammatory  conditions  of  the  peripheral  nerve 

.ks  or  tiieir  origin  in  the  spinal  cord. 

The  results  of  inflammation  vary  according  to  the 
severity  of  the  process  and  the  structural  peculiarities 
of  the  part  affected.  Pigmentation  is  a  marked 
feature  in  syphilitic  lesions,  and  in  all  lesions  on  the 
leg  when  the  veins  are  varicose,  and  when  there  is 
therefore  a  tendency  to  disintegration  of  red  blood- 
corpuacles. 

Thickening  of  the  epidermis  is  a  frequent  result 
of  inflammation,  and  the  increased  rapidity  of  pro- 
liferation of  epidermal  cells  leads,  in  eczema  and 
certain  other  conditions,  to  the  formation  of  visible 
Hcales  and,  when  the  nails  are  afiected,  to  pitting  or 
thickening. 

Degeneration  of  the  skin  takes  place  naturally 
old  age,  the  corium  becoming  thinner,  and  the  ski 
darker  owing  to  increase  of  pigment.  The  elastic 
tissue  is  altered  in  its  anatomical  appearance  and 
loses  its  function.  A  peculiar  degeneration  of  the 
elastic  tissue  is  associated  with  the  disease  known  as 
"  xanthoma  of  Balzer."  Degeneration  of  morbid 
products  takes  place  in  xanthoma  when  the  inflam- 
matory cells  become  loaded  with  fat,  and  in  the 
peculiar  eoUojd  degeneration  of  the  skin  which  some- 
what resembles  xanthoma,  but  is  due  to  rhjingea  in 
the  waifs  of  the  blood-vessels. 

It  is  no  longer  possible  to  draw  a  hard-and-fast 

^e  between  inflammations  and  new  growths.     The 

Ksbid  formations  seen  in  tuberculosis,  syphilis,  and 

Bere,  a  few  years  ago,  classified  as  tumours 

now  placed  in  a  special  group — General  In- 

Diseases.     The  view  that  cancer  and  sarcoma 

infective  diseases  is  held  by  some  pathologists 

hole  subject  of  the  etiology  of  these  con 

loiu  h  still  shrouded  in  obscurity.    Papillomatous 
tho   (wart«,  horns,  etv.)  may  result   from 


He^ 


PATHOLOGY    OF    THE   SKIS.        [cv 


I 


by  irritating  agenta,  such  as  strong 
Be  commonly  from  prolonged  irrita- 
te adao-OTganisms.  From  the  epidermis  and 
pi  mill  other  epithelial  growths,  such  as  adenoma 
ami  epithelioma  (in  what  may  be  called  the  dermato- 
logical  sense  of  the  term),  may  aciac.  From  the 
CDfiam  may  develop  various  growths  (fibroma, 
mjrxoma,  myoma,  etc.]  as  well  as  those  of  malignant 
type  Buch  as  corclnomata. 

Parasitic  affections  are  rommon.  Suppuration  is 
usually  the  result  of  mlcrobic  infection,  and  parasites 
of  various  kinds  are  present  in  ringworm,  favus,  itch, 
etc.  The  list  of  such  affections  will  no  doubt  be 
extended  by  further  research. 

The  importance  of  the  indirect  effects  oi  the 
punctures  made  by  head  lice  has  already  been  referred 
to ;  the  body  louse  and  the  pediculus  pubis  are  the 
most  common  among  other  external  parasites.  In 
flome  persons  the  bitee  of  bed-bugs  are  followed  by 
tevnn:  urticaria.  The  connection  between  mosquitoes 
uul  the  tilaria  Hanguinis  hominis  has  been  established 
iy  Patrick  Maodon.  In  tropical  America  and  on  the 
went  cuMt  uf  Africa  a  parasite  resembling  the  com- 
Bon  fl«ii — the  chigoe  or  jigger  (Rhyncoprion  pene- 
tnVM) — luiUAes  an  alTection  of  the  skin  which,  if 
not  properly  treated,  may  go  on  to  inflammation  and 
mure  ut  Ipjw  extensive  gangrene.  The  bot-fly 
(<KiitruM),  even  in  Great  Britain,  occasionally  deposits 
it)  ctUV  '»  '''■f  human  skin,  thus  setting  up  an  acute 
boil-like  affection.  And  simUar  parasites  may  pos- 
sibly pve  fine  to  the  form  of  rash  known  as  "  creep- 
ing." The  CysticercuB  cellulosB  has  been  found  in 
the  aubcutuneouH  tissue,  and  the  echinococcus,  the 
Ifver  fluke  and  Bilharzia  hromatobia  have  all  been 
obaerved  at  one  time  or  another  in  isolated  cases. 
Bewdes  the  common  mites,  Acarus  scabiei  and  Acarus 
folliculorum,  the  harvest   bug  (Leptus  autumnaUs) 


PROTOZOA.  9 

occasionally  gives  rise  to  inflammatory  papules  hy 
boring  into  the  akin.  The  commoner  of  these  para- 
sites will  be  more  fully  dealt  with  in  connection  with 
the  lesions  which  they  cause. 

In  addition  to  the  animal  parasites,  to  wliich 
reference  has  just  been  made,  it  has  been  proved  that 
certain  of  the  protozoa  are  endowed  with  pathogenic 
properties,  and  are  capable  of  causing  definite  diseases 
in  man  and  in  the  lower  animals.  The  family  ot  pro- 
tozoa which  has  had  the  greatest  amount  of  attention 
paid  to  it  as  a  possible  cause  of  disease  is  that  of  the 
sporozoa,  of  which  the  coccidium  oviforme,  the  cause 
of  the  well-known  adenomatous  disease  of  the  liver 
and  intestines  in  rabbits,  is  a  familiar  type.  Many 
of  these  small  organisms  have  very  indistinct  features 
and  are  often  difficult  of  recognition,  and  on  account 
of  the  resemblance  of  structure  observed  in  the  skin 
to  certain  protozoa,  it  has  been  strongly  held  by  many 
observers  tbat  protozoa  are  actually  present,  and  are 
the  cause  of  certain  cutaneous  affections.  Perhaps 
the  disease  as  to  which  the  greatest  amount  of  evi- 
dence has  been  brought  forward  in  support  of  its 
protoBoal  origin  ia  moUuBCum  contagiosum.  In  the 
central  portions  of  the  little  mollusca  are  numerous 
rounded  bodies,  sometimes  known  as  "  the  molluscum 
bodies,"  which  have  certain  resemblances  to  encysted 
protozoa.  These  bodies  are  stated  to  be  caused  by 
the  penetration  of  the  infecting  organism  into  the 
epithelial  cells,  where  they  increase  in  size,  coming 
to  occupy  the  greater  portion  of  the  cell,  and  then 
forming  an  encysted,  intracellular  protozoon. 

Certain  similar  bodies  found  in  Paget's  disease  of 
the  nipple,  in  carcinoma,  and  even  in  sarcoma,  have 
been  held  by  different  observers  to  be  examples  of 
similar  modes  of  parasitic  infection. 

Of  the  many  authors  who  have  carefully  worked 
at  the  subject,  not  one  has  been  able  to  bring  forward 


PATHOLOdY    OF    THE   SKIK. 


F 

^^H  convincing  evidence  as  to  the  parasitic  character  of 

^^H  the  bodies  la  question.     One  ol  the  main  obstacles 

^^^K  in  the  way  of  pioof  is  that  it  has  been  very  diiEcult 

^^^1  to  cultivate  tlieae  true  parasitic  protozoa  outside  the 

^^H  body,  and  in  the  case  of  the  hypothetical  protozoa  of 

^^^P  molluscum  contagiosum,   etc.,  a  successful  cultiva- 

^^^  tioa  has  not  been  made. 

The  question  is  not  yet  settled,  but  the  balance  of 


who  hold  that 
the  result 
1  the  cells 


e  for  the  most 


evidence  is  still  in  favour  of  thos 
the  molluscum  and  cancer  "  bodies  " 
of  exceptional  pathological  changes  v 
themselves. 

Morbid  Anatomy. 

Pathological  changes  in  the  skin  a 
part  appreciable  by  the  sight  or  the  touch, 
the  groBs  anatomy  of  akin  lesions  constitutes  the  most 
important  part  of  symptomatology,   and  must  be 
firmly  grasped  by  ever)'one  who  intends  to  hold  him- 
self responsible  for  the  recognition  of  the  infective    ] 
fevers  and  of  all  diseases  that  affect  the  skin. 

The  complexity  of  the  normal  anatomy  of  the    i 
skin  results  in  a  corresponding  complexity  of  morbid  J 
forms,  or,  as  they  are  termed,  lesions  of  the  skin. 
These   elementary   lesions   are   primary   when   they  j 
result  from  a  pathological  process  before  or  at  it«  J 
fullest  evolution,  and  secondary  when  they  resulfc,] 
from  the  more  or  less  complete  subsidence  of  that  1 
process.     Thus  each  vesicle  in  a  case  of  herpes  Boster  J 
is  a  primaiy  lesion,  and  the  scars  which  may  remain  A 
in  the  place  of  the  same  vesicles  are  secondary  lesions- 
It  should  be  noted  that  identical  lesions  may  ba  I 
at  one  time  primary,  at  another  secondary.    The  | 
surface  of  the  healthy  skin  is  the  habitat  of  a  varied   ] 
»8eemblage  of  living  organisms,  animal  and  vej 
Many  of  the  flora  and  some  of  the  fauna  are  jioten-  ] 
tially  or  actually  pathogenic,  and  thus  the  variety  c" 
skin  lesions  is  further  increased. 


PRIMARY    LESIONS. 


r 

^^^^ft    Here  it  will  be  convenieTit  to  give  a  list  of  eiemen- 
^^^^■irr  lesions  with  definitions  of  the  tc^rms  used. 
^^^F    Primary  lesions.— A    macule   is    a   portion  of 
I  the  skill  altered  in  colour  and  having  a  definite  outline 

without  marked  elevation. 

Some  macules  are  diatinctlv  inflammatory  in 
nature,  others  are  non-inflammatory.  The  former, 
in  the  slightest  degree  of  development,  are  areas  of 
hypertemia,  which  disappear  on  pressure  or  at  death. 
Such  are  the  rose  spots  of  enteric  fever  in  their  earliest 
stage ;  later  they  may  become  papular.  Some 
macules,  sucli  as  those  of  syphilitic  roseola,  leave 
a  brown  stain  when  the  intravascular  blood  is  re- 

I'  moved  by  pressure  or  stretching.    Non-i  nil  anima- 

te^ macules  are  due  either  to  over-development  of 
■iood- vessels,  as  seen  in  capillary  nievi,  or  to  pig- 
■ieiitaiy  changes, 
fc  The  passage  of  blood,  or  of  the  colouring  matter 
b  the  blood,  into  limited  areas  of  skin  constitutes 
PBother  variety  of  macule.  These  are  termed  vibices 
iriien  linear  ;  ecehymoses,  or  petechicE,  when  pimctate. 
There  may  be  excess  or  deficiency  of  the  normal 
pigment  of  the  skin  (whether  that  of  the  rete  or  of 
the  corium)  over  a  limited  area.  Freckles  are  an 
example  of  excess  (hy perch romasia)  ;  leucodermic 
patches,  of  deficiency  (ach romasia). 

A  papule  is   a   solid  elevation   of  the  skin  not 

I la^?er  than  a  pea.     Papules  may  be  produced  by 

^^^fl^lflammation,  as  in  papular  eczema.  Inflammatory 
^^^^Bnpules  may  be  pointed,  roimded,  or  depressed  in 
^^Hfee  centre  either  from  their  having  formed  round  a 
^^^*gweat-duct  or  as  the  resiilt  of  a  secondary  change, 
'  as  in  molluscum  contagiosum.    A  papule  may  be  non- 

inflammatory, such  as  those  which  result  (1)  from 
oxceasive  comification  round   the   mouths  of   hair 
Uicles,  or  (2)  from  retained  secretion — as,  for  in- 
mce,   comedones — or   (3),    when   pathological   in 


I 


12  PATHOLOGY    OF    THE   SK/X.         [chap.  i. 

degree  or  persistence,  the  elevation  of  a  hair  follicle 
by  an  erector  muscle  may  constitute  a  papule,  as  in 
severe  goose-skin. 

Tuherde  is  the  term  applied  to  a  solid  elevation 
of  the  akin  when  larger  than  a  pea.  This  use  of  the 
term  must  be  sharply  distinguished  from  its  specific 
pathological  sense — i.e.  a.  nodule  caused  by  cell- 
infiltration  due  to  the  action  of  tubercle  bacilli  on 
the  tissues. 

Wheids  are  a  special  variety  of  papule  or  tubercle. 
They  are  met  with  in  urticaria,  and  are  marked  by  a 
round,  or  oval,  or  irregular  shape,  a  paie  centre  and 
a  red  periphery.  They  usually  appear  suddenly  and 
disappear  rapidly,  and,  except  in  urticaria  pig- 
mentosa, without  leaving  a  trace;  they  are  generally 
accompanied  by  intense  itching.  They  are  the  result 
of  a  circumscribed  o?dema  of  the  skin  due  to 
angio-neurotic  irritation. 

Tunwurs  are  very  large,  solid  elevations  of  the  skin. 

Yeaides  are  elevations  of  the  skin  not  larger  than 
a  pea  and  containing  more  or  less  clear  liquid.  They 
are  superficial  (as  in  eczema,  etc.),  or  deep  (as  in 
herpes  zoster,  etc.),  according  as  the  liquid  collect* 
between  the  layers  of  the  epidermis  or  in  the  coriura. 
Inflammatory  vesicles  are  usually  developed  from, 
papules,  and  may  pass  on  to  a  pustular  stage  or  sub- 
side, leaving  secondary  lesions.  Non- inflammatory 
vesicles  are  due  to  the  passive  accumulation  of  fluid 
between  the  lavers  of  the  epidermis. 

B/e6s,  or  bull»,  are  elevations  of  the  skin  filled 
with  liquid  and  larger  in  size  than  peas.  They  occur 
in  pemphigus  and  other  conditions. 

Pustules  are  elevations  of  the  skin  containing  pus. 
They  always  develop  from  vesicles,  and  are  usually 
surrounded  by  a  ring  of  inflammatory  hyperiemia 
(areola). 

Secondary  lesions. — These    arc    due    to    mc- 


SECONDARY  LESIONS. 


lical  injurieB,  such  as  scratch- marks,  or  form  in 
^.le  courBe  of  the  involution  of  primary  lesiona.  In 
'ihe  Becond  category  we  may  recognise  four  chief  pro- 
desquamation,  hypertrophy  (persistent  in- 
filtration), scar  formation  (atrophic  infiltration),  and 
pigmentation.    Thus  we  have  : — 

(1)  Scales,  or  squamK,  resulting  from  the  subsi- 
dence- of  macules  or  papules,  or  forming  on  a  hyper- 
femic  base.     The  process  is  termed  desquamation. 

(2)  Pigmentation  may  remain  after  almost  any 
lary  lesion. 

(3)  Excorialions    are    left    after    the    rupture    of 
licles  or  pustules. 

(4)  Ulcers  remain  after  the  destruction  by  any 
itory  process  of  the  whole  thickness  of  the 

um  or  deeper  tiBsuee. 

(5)  Fissures  or  rent«  (rhagadea)  are  a  variety  of 
in. 

(6)  Sea6a  or  orusUe  result  from  tlie  drying  of  liquid 
)n  the  surface  of  the  skin.     Tlius  they 

tttny  be  left  after  the  cessation  of  hcemorrhage  (blood 
scab),  after  the  rupture  of  a  vesicle  {serum  scab),  or 
of  a  pustule  (pus  scab),  or  they  may  be  formed  of 
sebaceous  matter,  or  be  caused  by  a  parasitic  growth 
Scabs  may  consist  of  a  commingling  of 
3  dried  exudations. 
Thickenivg  (hypertrophy)  may  rusult  from  the 
it   involution    of    inflammatory    exudations, 
'.  chronic  eczema,  or  elephantiasis. 
)  ScaTS  are  the  result  of  the  complete  involution 
I  inflammatory  infiltration  which  has  been  of 
icient  intensity  to  destroy  part  of  the  coriiun,  and 
may  remain  after  such  a  leaion  as  an  uieer. 

Bacteriology  of  the  Skin. 
Vegetable  fungi  pfay  a  moat  important  part  in  the 
)r  modification  of  skin  diseases,  and  on 


^ 

» 


U  PATHOLOGY    OF    TUE    SKIN.         [chat.  I. 

the  recognition  of  the  exact  etiological  lattore  in  auch 
cases  must  largely  depend  our  success  ia  treating 
theae  affections. 

It  haa  long  been  known  that  tinea  tonaurans, 
favus,  and  pityriaaia  versicolor  depend  respectively 
on  fungi  which  resemble  each  odier  in  belonging 
to  the  group  Ascomyoetes,  and  in  the  poasession  of 
branched  septate  iiyphte,  which  form  sporse,  or 
conidia,  by  succeasive  separation  of  small  oval  bodies 
at  the  estremities  of  the  branches.  Since  the  methods 
of  research  have  been  improved  by  Pasteur,  Koch, 
Sabouraud  and  others,  our  knowledge  of  the  relation 
of  vegetable  fungi  to  the  production  of  disease  has 
been  immensely  expanded.  Koch's  four  postulates 
have  been  succeaafully  applied  to  the  parasites  men- 
tioned above,  and  therefore  it  is  now  definitively 
estabUshed  that  they  are  the  direct  causes  of  the 
diseases  with  which  they  are  associated. 

It  will  be  of  advantage  to  recall  here  those  postu- 
lates, which  are  as  follow  :— 
'    1.  The  micro-organism  must  be  found  in  the  blood, 
lymph,  or  diseased  tissue  of  the  man  or  animal  sufier- 
ing  from,  or  dead  of,  the  disease. 

2.  Pure  cultures  of  the  micro-organism  must  be 
obtained  in  suitable  artificial  media  outside  tiie 
animal  body,  and  a  number  of  sub-cultures  must  be 
made  from  the  original  culture. 

3.  Part  of  a  pure  culture  obtained  in  this  way 
must  reproduce  the  disease  when  introduced  into  the 
Wly  of  a  healthy  animal. 

i.  From  the  animal  thus  infected  the  same  micro- 
oi^anism  must  again  be  recovered. 

The  application  of  these  rules  haa  been  of  the 
greatest  service  to  pathologists.  In  some  diseases,  it 
is  true,  which  are  believed  to_be  due  to  vegetable 
parasites,  the  third  and  fourth  of  these  postulates 
bavc  not  yet  been  fulfilled.    Yot  instance,  in  leprosy 


I,]  NATURAL  SUPPURATION.  IS 

f  numbers  o!  peculiar  bacilli  are  present  in 
the  lesions.  Owiag,  however,  to  the  fact  that  animals 
are  but  slightly,  if  at  ail,  susceptible  to  the  infection, 
it  has  hitherto  been  impoasibie  to  inoculate  them 
with  this  disease.  Nevertheless  the  causative  rela- 
tion, between  the  parasite  and  the  disease  must  be 
looked  upon  as  settled. 

Natural  suppuration.— For  natural  suppura- 
tion Shatt«ek  hiis  suggested  the  convenient  term 
"  pyosis."*  Under  this  term  are  included  a  number 
of  closely  allied  speciiic  affections  caused  by  the 
pyogenic  bacteria  which  are  normally  present  on  the 
ekin.     Tlieae  organisms  are  :— 

1.  Streptopoi^ous  (ot 


Micrococci  were  first  observed  in  pus  by  Ogston, 
and  the  part  which  they  play  in  the  causation  of  the 
suppurative  process  was  soon  fully  established.  The 
demonstration  of  this  fact  paved  the  way  for  the 
introduction  by  Lister  of  the  antiseptic  system  which 
has  revolutionised  surgery. 

The  streptococcus  of  erysipelas  resembles  that  of 
suppuration  in  shape,  and  it  ia  now  generally  believed 
to  be  identical  with  it,  the  effects  which  it  produces 
being  modified  by  the  fact  of  ite  being  limited  to  the 
corium.     The    readiness    with    which    a    superficial 
erysipelas  passes  into  a  suppurating  cellulitis  affords 
confirmation  from  the  clinical  side  of  the  view  that 
both  affections  have  a  common  cause,     ft  has  been         ^H 
proved  that  the  commonest  form  of  spreading  gan-         ^| 
^ne  is  also  caused  by  the  streptococcus  pyogenes.         ^H 
^^^^_    The  great  majority  of  suppurative  processes  tn  the         ^H 


Ill 


I'ATHOWnY    OF    THE   SKIS. 


skin  are  set  up  by  staphylococci,  especially  B.  aureus 
and  S.  albua.  Thus  the  irritation  cauBed  by  retained 
sebum  determines  a  certain  amount  of  inflammation 
thiu  in  turn  excites  an  increased  growth  within  the 
tissues  of  the  pyococci  always  present  there.  The 
result  is  suppuration.  As  a  consequence  of  a  similar 
sequence  of  events  In  the  hair  foJiiclea  of  the  beard  or 
other  parts,  sycosis  is  induced.  Boils  and  carbuncles 
are  also  due  to  staphylococci.  Impetigo  contagiosa 
is  another  effect  of  the  same  cause.  In  this  condition 
streptococci  and  staphylococci  often  find  their  way 
into  the  skin  through  the  punctures  made  by  head 
lice  or  from  scratching. 

Infection  by  pyococci  is  often  secondary  to  some 
other  aftection.  Thus  in  variolous  pustules  the 
Streptococcus  pyogenes  is  found  ;  but  that  oi^anism 
is  not  the  cause  of  small-pox,  the  specific  virus  of 
which  still  remains  undetected.  In  the  same  way 
simple  eczema  often  bcMmes  complicated  by  sup- 
puration due  to  the  presence  of  staphylococcus. 
The  frequent  comphcation  of  skin  affections  with 
processes  set  up  by  pyococci  is  of  the  greatest  prac- 
tical importance.  Thus  a  rapidly  ulcerating  lupus 
i^  greatly  benefited  by  simple  local  antiseptics. 

To  what  extent  simple  papiliomata  may  be  due  to 
inicro-organisma  it  is,  in  the  present  state  of  know- 
lodge,  impossible  to  say.  The  inflammatory  papilio- 
mata of  syphilis  and  yaws  and  gonorrhceal  warts 
suggest  that  the  crops  of  excrescences  which  some- 
times arise  suddenly,  and  disappear  as  rapidly  as 
they  came,  may  be  due  to  the  irritation  of  micro- 
organisms. 

Koch's  discovery  of  the  nature  of  tuberculosis 
shed  a  brilliant  light  on  several  affections  of  the  skin 
which  are  now  known  to  be  of  tubejculous  nature. 
Lupus  vulgaris  is  now  known  to  be  a  true  tuberculosis 
of  the  skin.    As  the  diseased  tissue  is  built  upon  the 


1 


I.]  MACTEHIOWGY.  17 

tuberculous  plan,  it  contains  the  bacillua  tuber- 
culosis, and  produces  tuberculoBie  in  susceptible 
animals  on  inoculation.  The  fosi-moTtein  wart,  which 
is  not  uncomnaon  on  the  hands  of  dead-house  porters 
and  butchers,  has  been  shown  to  be  pathologically 
identical  with  lupus  verrucoaus,  and  to  be  due  to  the 
tubexde  bacillus.  Other  forms  of  tuberculous  lesion 
of  the  integument  will  be  described  under  the  head  of 
Tuberculosis  of  the  Skin. 

The  bacillus  of  leprosy  has  already  been  referred 
to.  It  bears  a  close  resemblance  to  that  of  tubercle, 
the  chief  difference  being  the  greater  ease  with 
which  the  former  can  be  stained.  With  regard  to 
sypliilis,  the  remote  lesiona  of  which  so  greatly  re- 
semble those  of  tuberculosis,  the  question  of  its  para- 
sitic origin  has  not  yet  been  definitively  decided. 
Iiustgarten  and  others  have  described  bacteria  as 
being  present,  but  organisms  found  have  been  shown 
to  be  of  accidental  occurrence,  or  have  not  been 
proved  to  be  in  any  causal  relationship  to  the  disease. 
The  clinical  evidence,  however,  is  so  suggestive  of  the 
virus  being  of  microbic  origin  as  to  justify  the  inclusion 
of  syphilis  with  tubercle  and  leprosy  in  the  same 
group  of  inoculable  diseases.  In  another  disease 
belonging  to  this  group  (glanders),  a  pathogenic 
organism,  bacillus  mallei,  has  been  found  ;  it  is  of 
about  the  same  size  as  the  tubercle  bacillus,  is  easily 
obtainable  in  pure  culture,  and  has  been  inoculated 
with  positive  results  into  horses,  sheep,  guinea-pigs, 
rabbits,  and  mice.  The  fate  which  befell  the  Russian 
investigator,  Helman,  the  discoverer  of  mallein,  may 
be  taken  as  a  proof  that  the  glanders  vims  is  also 
inoculable  in  man.  Experimental  inoculation  gives 
rise  to  a  spreading  ulcer  with  a  hard  base  at  the 
point  of  infection  ;  numerous  small  ulcers  next  appear 
around  it,  and  finally  the  infection  is  generalised,  pro- 
ducing enlargement  of  glands,  characteristic  nodules 


18  I'AriiOWGY    OF    THE   SKIN.         [cb 

in  the  viscera,  and  nodules  and  ulcers  on  the  nasal 
septum.  In  all  these  lesionB  the  specific  bacilli  are 
found. 

Rhinoscleroma,  a  rare  afEectiou  which  attacks 
r^hiefly  the  upper  lip  and  the  nasal  mucous  mem- 
brane, is  another  example  of  a  disease  caused  hy  a 
micro-organism.  The  specific  bacillus  is  found  in. 
the  form  ot  cocci,  or  short  rods,  surrounded  by  defi- 
nite capsules,  and  closely  resembles  the  pneumo- 
bacillus  of  Friedlander.  Malignant  pustule  is  another 
parasitic  disease  which  may  in  the  first  instance  attack 
the  skin.  In  that  case  the  disease  remains  local  for 
a  time  sufficient  to  allow  of  its  being  removed  by 
free  excision. 

Skin  wounds  may  be  infected  by  tSie  bacillus  of 
diphtheria  ;  and,  inasmuch  as  periplieral  neuritis  may 
foUow  such  an  infection,  there  is  clinical  as  well  as 
bacteriological  evidence  of  the  identity  of  the  afEec- 
tion  in  the  skin  and  in  the  throat. 

Emphysematous  gangrene  (malignant  cedema) 
has  been  proved  to  be  caused  by  a  particular  micro-' 
organism.  The  bacilli,  which  are  short  and  broad, 
bear  some  resemblance  to  thoBo  of  anthrax  ;  but  th 
are  motile,  and  wiU  not  grow  with  a  free  supply 
oxygen.  This  bacillus  has  a  wide  distribution,  ita. 
spores  being  found  in  hay  and  in  the  surface  soil. 

Actinomycosis  has  been  foimd  to  flourish  luxU' 
riantly  in  the  skin,  though  in  most  of  the  cases  of 
CUlAneous  actinomycosis  hitherto  reported  the  disease 
appears  to  have  involved  the  skin  by  spreading  from 
underlying  viscera. 

Vandyke  Cart«r,  Kanthack,  Crookshank,  Boyco, 
Surveyor,  Vincent,  and  others  have  found  that  thai 
affection  known  as  Madura  foot,  or  mycetoma,  fa' 
caused  by  a  fungus  in  many  respects  resembling 
that  of  actinomycosis. 

One  of  the  hyphomycetea  (Aspergillus  niger)  ig 


I 


CHAP.  I.]  BACTERIOLOGY.  10 

BOTnetimcia  found  growing  on  the  Buperficial  layera 
of  the  epidermis.  The  extertifll  meatus  of  the  ear 
is  the  place  where  it  isHisually  met  with,  but  Delepine* 
has  reported  a  case  in  which  the  skin  of  the  leg  was 
the  seat  of  the  fungus.  AspetgilluH  niger,  bs  a.  rule, 
is  merely  a  saprophyte  ;  but  in  certain  instances 
it  takes  on  a  pathogenic  character,  and  may  cause 
perforation  of  the  tympanic  membrane.  D.  WJn- 
iieldt  of  Brooklyn  haa  reported  a  case  of  "  favus- 
like  eruption  of  the  oral  mucous  membrane  caused 
by  Aspergillus  nigrescens." 

A  special  form  of  dermatitis  caused  by  blasto- 
mycea  has  been  described  by  Hyde,  Montgomery, 
Gilchrist,  and  Stokes.J 

With  regard  to  the  acute  specific  fevers,  there 
are  obvious  difficulties  which  stand  in  the  way  of 
any  attempt  to  satisfy  Koch's  postulates.  Cocci,  or 
bacilh,  are  foimd  in  most  cases,  but  no  conclusive 
proof  is  yet  forthcoming  that  they  stand  in  a  causal 
relation  to  the  processes  with  which  they  are  asso- 
ciated, 

In  addition  to  the  pathogenic  bacteria,  many 
saprophytic  organisms  are  found  on  the  skin.  The 
bacillus  fcctidua  (Thin)  is  the  cause  of  the  disagree- 
able odour  emitted  by  the  feet  of  certain  individuals, 
and  in  pure  cultures  it  generates  a  similar  stench. 
Bacilli  are  found  in  "blue"  sweat,  and  one  form  of 
"red"8weatisdue  to  the  presence  of  micro-orgaoiBms.§ 

The  vast  numbers  in  which  moulds  and  bacteria 
mav  he  found  on  the  surface  of  the  skin  may  be 
gathered  from  the  fact  that  Taenzer  found  no  fewer 


20  PATHOLOGY   OF   THE  SKIN,        [chap.  i. 

than  eighty  species  of  bacteria  present  in  the  scales, 
crusts,  and  discharge  in  a  case  of  eczema  sebor- 
rhaucum.*  Hohein,f  in  the  course  of  an  investigation 
of  the  })acteria  on  the  surface  of  the  body,  found  that 
from  a  quarter  oi  a  centimetre  square  of  woollen  rai- 
ment (),709  colonies  developed  in  a  plate  culture  by 
the  end  of  two  days,  and  by  the  end  of  four  days 
more  the  colonies  were  innumerable.  Gallowav  states 
that  a  description  of  all  the  species  of  bacteria  of 
the  skin  would  probably  involve  notes  of  all  the 
species  of  bacteria  at  present  identified  by  bacteriol- 
ogists. The  reader  who  wishes  to  study  this  subject 
in  detail  is  referred  to  the  list  of  organisms  found  in 
association  with  various  diseases  of  the  skin  given  by 
the  writer  just  named  in  his  valuable  article  on 
Bacteria  of  the  Skin  in  Allbutt's  "  Svstem  of  Medi- 
cine." 

It  may  be  noted  that  organisms  grow  more  luxuri- 
antly in  parts  such  as  the  scalp,  the  axillae,  the  groins, 
and  other  regions  where  they  are  protected  from  in- 
fluences injurious  to  them,  and  where  they  find  con- 
ditions, especially  warmth  and  moisture,  favourable 
to  their  growth.  These  regions  are  accordingly  often 
the  sites  of  origin  of  infective  diseases  of  the  skin. 

*  Jfonatsh.  /.  prakt.  Derm.,  1888,  Bd.  vii.,    Xo.  17,  p.  818. 

t  Quoted  by  Gallowav,  Allbutt's  *'  System  of  Medicine,"  vol. 
Iviii.,  p.  900. 


CLASSIFICATION, 


Classification  is  a  good  servant  but  a  bad  master, 
and  the  student  must  never  allow  himself  to  be  be- 
guiled into  thinking  that  any  system  of  pigeon-holing 
is  an  Ariadne's  thread  which  will  guide  him  safely 
through  all  the  mazes  o£  the  pathology  of  the  skin. 
There  can  be  no  finality  in  the  ciassiiication  of 
cutaneous  affections  till  finality  of  knowledge  of  their 
causation,  clinical  phenomena,  and  patholoirical  aHini- 
ties  has  been  reached.  At  present  all  attempts  at 
classification  must  be  provisional,  shifting  with  the 
prevailing  currents  of  scientific  thought  and  liable  to 
give  way  at  any  moment  under  the  pressure  of  in- 
creasing knowledge.  In  these  circumstances  the  best 
classification  is  not  the  most  complete  and  most  sym- 
metrical, but  that  most  likely  to  be  practically  use- 
ful for  purposes  of  treatment,  by  grouping  diseases 
according  to  their  proved  or  probable  etiological 
affinities. 

The  earhest  attempt  to  classify  diseases  of  the  skin 
was  made  by  Hieronymus  Mercurialia  in  the  first 
book  on  dermatology  ever  published.*  Hia  classifica- 
tion waa  purely  regional,  skin  afteetions  being  divided 
into  those  of  the  head  and  those  of  other  parts.  This 
simple  arrangement  waa  followed  nearly  two  cen- 
turies later  by  Daniel  Turner,t  and  afterwards  by 
Alibert  (1806),  who  made  two  principal  genera  of 

•  "  De  Morbis  Cutdjieis,"  l-i7'2, 
"A  TreatiBe  o(  Diieaaes  luddetil;  tn  the  Skiii.^'  1712. 


22  CLASSIFICATION,  [chap.  n. 

cutaneous  diseases,  those  of  the  head  (which  he  called 
leignes)y  and  those  of  the  body  (which  he  called 
dartres).  The  former  he  subdivided  into  five,  the 
latter  into  seven  species,  each  with  several  varieties 
based  on  differences  in  the  appearance  of  the  lesion. 
Til  us  a  H('Ai\y  eruption  on  the  trunk  was  a  dartre 
aquameuse,  one  with  crusts  a  dartre  crustacee,  each 
})eing  still  further  qualified  according  to  shape, 
moisture  or  dryness,  etc.  Affections  too  impartial  in 
their  attacks  on  the  skin  to  be  confined  within  the 
limits  of  a  particular  region  were  grouped  in  somewhat 
haphazard  fashion  as  ^fhtiides,  syphUides,  scroftdides, 
fHorideSy  cancrdides,  etc. 

S(;ientific  classification  may  be  said  to  have  begun 
with  Plenck,*  who  took  as  the  basis  of  his  classification 
the  predominant  objective  feature  of  the  disease,  in- 
cluding, however,  the  results  of  the  evolution  of  the 
process  as  well  as  the  primary  lesions.     He  grouped 
affecitions  of  the  skin  under  fourteen  heads  as  follows  : 
(1)  Macules,  (2)  Pustules,  (^)  Vesicles,  (4)  Bullae,  (5) 
Papules,  (0)  Crusts,  (7)  Scales,  (8)  Callosities,  (9)  Excre- 
scences, (10)  Ulcers,   (11)  Wounds,   (12)  Cutaneous 
insects,  (1  *>)  Diseases  of  the  nails,  (14)  Diseases  of  the 
hair.  Willan  somewhat  modified  Plenck's  classification, 
grouping  skin  lesions  in  the    following    "  orders  "  : 
(1)  Papules,  (2)  Scales,  (3)  Exanthemata,  (4)  Bullae, 
(5)  Pustules,  (6)  Vesicles,  (7)  Tubercles,  (8)  Macules. 
To  these  Willan's  pupil,  Bateman,  added  a  ninth 
group.  Dermal  excrescences.f    Passing  over  Joseph 
Frank's  (1821)  absurd  classification  of  skin  diseases 
into  acute  and  chronic,  we  come    to   Erasmus  Wil- 
son, who,  as  an  anatomist,  naturally  looked  for  a 
basis    of    classification    in    anatomy.     He    grouped 
cutaneous  affections  according  to  the  structure  in 

^  ''Doctrina  de  Morbis  Cutaucis,"  Vienna,  1776. 

t ''  Practical  Synopsis  of  Cutaneous  Diseoses,"  London,  1815. 


CHAP,  n-l  BEBRAS    CLASSIFICATIO!^.  23 

which  they  took  tlieir  origin,  making  four  divisions  : 
(1)  Diseases  of  the  derma,  (2)  Diseases  of  the  sudori- 
parous glands,  (.3)  Diseases  of  the  sebiparous  glands, 
and  (4)  Diseases  of  the  hair  and  hair  follicles.  Mean- 
wbiie  the  French  school,  of  which  Bazin  may  be 
taken  aa  the  representative,  attempted  to  classify 
skill  diseases  according  to  certain  constitutional  states 
of  which  they  were  supposed  to  be  an  expression.  To 
make  such  a  scheme  anything  like  complete,  how- 
ever, it  was  first  necessary  to  create  diatheses  to 
account  for  a  large  number  of  affections,  which  were 
accordingly  put  down  to  the  credit  of  sundry  mythical 
dyscrasiffi,  "  herpetic,"  "  dartroua,"  etc.  In  18i5 
Hebra  published  a.  scheme  of  ckssilicatioa  based  on 
the  more  solid  ground  of  pathology.  He  divided 
affections  of  the  skin  into  twelve  classes  corresponding 
to  the  structural  changes  in  the  tissues  of  the  body 
generally,  which  formed  the  foundation  of  Rokitan- 
sky's  classification  of  the  results  of  pathological  pro- 
ceases.  Thus,  according  to  Hebra,  a  disease  of  the 
skin  falls  under  one  or  other  of  the  following  heads  : 
(1)  Hypersemias,  (3)  Anaemias,  (3)  Anomalies  of  secre- 
tion of  glands,  (4)  Exudations,  (5)  Hfemorrhages,  ((i) 
Hypertrophies,  (7)  Atrophies,  (8)  Neoplasms,  (il) 
Pseudoplasms,  (10)  Ulcerations,  (11)  Neuroses,  (12) 
Diseases  caused  by  parasites. 

From  what  has  been  said  it  will  be  seen  that 
the  classification  of  the  English  school  was  mainly 
objective,  that  of  the  French  school  diathetic,  and 
that  of  the  Vienna  school  anatomico-pathological,  in 
character.  A  classification  according  to  processes 
was  attempted  by  Auspitz,  and  after  him  by  Bron- 
Bon,  but  scientific  though  such  a  system  undoubtedly 
ix,  in  the  esisting  state  of  our  knowledge  it  is  impos- 
sible to  carry  it  out  satisfactorily.  At  the  present 
day  Hebra's  classification  is  generally  adopted,  with 
some  slight  modifications,  by  Enghsh  writers. 


CI^SSIFUATIOX. 


r 

^^H  In  the  pivswt  work  no  form*]  ^rittfat  of  daaai-] 

^^H    fiontion  is  propounded,  but  an  attempt  is  i 
^^H     group  thu  disoasK  describMl  in  accoidAoc*  with  dio] 
^^^L    tendency  of  modem  pathok^ical  reseazdt— tbat  i 
^^^r    to  say,  tttiolugirnlly.     Thr  lines  followed  an  n 
^^V     those  traced  out  by  I'nna  i 

^^^       SubjCctB    in    tlie   MonaUkrSie   far   pmbueie  DermO''^ 

r  tologie.     Thus   the   affections  in  die  prodnction  ot  i 

whioli  disorder  of  the  ner\'ous  system  mai 

I ably  be  held  to  be  the  leading  factor,  form  o 

^^^^  t)ie  eruptions  due  to  artificial  ifiitation.  exteniai  or 
^^^^  internal,  a  second ;  those  caused  by  medicinal  sub- 
^^^H  Btanccs,  a  third,  A  large  and  composite  group  is 
^^^H  made  up  of  affections  which,  differing  in  every  other 
^^^B  leapect,  are  linked  togetJier  by  the  fact  tliat  th^ 
^^^^  are  the  result  of  the  action  of  panisit«s.  TfaeM 
^^^F  may  give  rise  to  .constitutional  infe<^tion,  as  well  as 
^^^  local  reaction,  constituting  a  group  of  general  inocul-  ] 
able  diseaseB ;  or  they  may  produce  only  local  ' 
leaiouB,  forming  a  group  of  local  inoiulable  diseases. 
DiBeases  of  which  the  etioiog>'  is  at  present  obscure, 
or  altogether  unknown — such  as  eczema,  psoriaaiH, 
pityriasis  rubra,  and  new  growths — are  for  &» 
present  necessarily  left  unclassified. 

The  progress  of  medical  science  lies  almost  entirely 

in  the  discovery  of  causes.     As  these  become  known, 

fresh  groups  of  diseases  will  naturally  be  formed. 

The  outhne  of  a  scheme  here  sketched  must  not  be 

I      looked  upon  as  a  classification  of  skin  diseases,  but 

■  only    as   a   provisional    arrangement  which   has  at 

■  least  the  advantage  of  bringing  into  strong  relief 
E  the  chief  point  to  which  treatment  is  to  be  directed. 
B    Thus,  if  it  is  known  that  an  affection  is  of  nervous 

■  origin,  that  fact  of  itself  at  once  supplies  the  leading 
I  Indication  for  treatment.  If  the  lesions  belong  to 
H     tilu  category  of  artificial  eruptiouH  or  drug  rashes,  it 

■  tollowN  naturally  that  in  order  to  remove  the  effect 


CHAP.n.]     ETIOLOOIGAL    CLASSIFICATION.  25 

we  must  suppress  the  cause.  A  disease  belonging 
to  the  general  inoculable  group  requires  general  as 
well  as  local  treatment,  while  one  belonging  to  the 
local  inoculable  group  can  be  dealt  with  by  local 
measures  alone.* 

*  For  a  fuller  account  of  the  various  schemes  of  classification 
of  diseases  of  the  skin  that  have  been  proposed,  the  reader  is 
referred  to  an  address  delivered  by  the  author  as  president  of  the 
section  of  Dermatology  at  the  annual  meeting  of  the  British 
Medical  Association  held  at  Montreal  in  the  autumn  of  1897,  and 
published  in  the  liritinh  Medical  Journal  of  September  18th,  1897, 
p.  G97  et  sqq. 


26 


CHAPTER   III. 

PRINCIPLES    OF    DIAGNOSIS. 

The  diagnosis  of  any  case  of  skin  disease  implies 
an  adequate  knowledge  not  only  of  the  nature  and 
evolution  of  the  lesions  by  which  it  manifests  itself, 
but  of  the  process  of  which  these  are  the  result. 
When,  in  addition  to  this,  the  cause  which  is  the 
motor  of  the  pathological  mechanism  can  be  dis- 
covered, the  diagnosis  is  complete.  It  is  not  enough 
to  recognise  that  an  eruption  is  papular,  vesicular, 
or  pustular  ;  as  a  rule,  the  individual  lesion  by  itself 
is  no  more  an  index  of  the  disease  which  produced  it 
than  a  single  brick  is  of  the  building  of  which  it  forms 
a  part.  Each  case  must  be  studied  in  all  its  rela- 
tions as  a  clinical  entity,  not  as  a  mere  illustration 
of  a  hypothetical  type.  Facts  must  be  observed 
with  an  open  mind  and  a  resolute  endeavour  to  see 
things  as  they  are,  and  not  to  be  misled  by  names. 
The  object  of  the  present  chapter  is  not  to  enumerate 
all  the  points  which  differentiate  one  affection  from 
another,  but  to  set  forth  the  principles  of  a  diag- 
nostic method  which  may  enable  the  observer,  if 
not  to  decide  at  once  what  the  particular  disease 
before  him  is,  at  least  to  say  with  greater  or  less 
probability  what  it  is  not. 

Examination  of  the  patient. — The  first  thing  neces- 
sary is  to  make  a  thorough  examination  of  the 
patient.  This  should  always  be  done  in  clear  day- 
light ;  in  the  dusk,  colour,  which  is  always  a  most 
valuable  guide  in  the  diagnosis  of  skin  affections, 
becomes  invisible ;    and  by  artificial  light  it  is  so 


IL]    EXAMINATION    OF    THE    PATIENT.      27 

clianged  as  to  be  misleading.  All  the  lesions  should 
be  seen,  and  the  ideal  plan  is  fo  have  the  patient 
completely  stripped  ;  in  the  case  of  females,  how- 
ever, we  must  generally  be  content  with  inspecting 
the  affected  parts  piecemeal.  On  no  account  should 
the  practitioner  ever  allow  himself  to  be  betrayed 
into  giving  an  opinion  on  the  nature  of  a  akin  lesion 
which  he  has  not  had  an  opportunity  of  seeing.  The 
examination  should  in  the  first  instance  be  purely 
objective  ;  no  rehance  should  be  placed  on  state- 
ments made  by  the  patient,  but  all  possible  informa- 
tion should  be  got  from  the  study  of  the  lesions 
themselves.  When  this  has  been  done,  the  patient's 
deposition  may  be  taken,  but  it  is  most  important 
that  no  questicdis  of  a  leading  nature  should  be  put, 
and  statements  as  to  the  history  and  course  of  the 
lesions  must  always  be  carefully  checked  by  the 
results  of  objective  examination.  The  interrogatory 
should  be  particularly  directed  to  the  following 
points : — ^What  is  the  chief  symptom  complained  of  ? 
When,  in  what  form,  and  where  did  the  eruption 
first  show  itself  ?  Does  it  come  and  go,  or  is  it  con- 
stant !  What  are  the  general  features  in  the  de- 
velopment of  the  lesions — has  there  been  "  weeping," 
discharge  of  matter,  etc.  %  In  interpreting  the 
patient's  answers  allowance  must  be  made  for  in- 
accuracy of  description  and  misuse  of  terms  :  thus 
even  well-informed  persons  will  include  under  the 
term  "  blister "  not  only  vesicles  and  buUse  but 
wheals.  The  nationality  of  a  patient,  or  the  fact 
of  his  having  resided  in  the  tropics  or  other  regions 
where  certain  diseases — such  as  leprosy,  "  spotted 
sickness,"  etc.— are  endemic,  is  often  a  moat  im- 
portant link  in  the  chain  of  evidence.  Moreover, 
the  occupation  of  the  patient  should  always  be 
noted.  The  other  relevant  points  of  the  medical 
history  should  be  ascertained  in  the  ordinary  way. 


I  PRINCIPLES   OF   DIAGNOSIS,      [cm 

In  Btudying  an  eruption,  not  only  the  shape,  colour, 
and  appearance  of  the  lesions,  but  their  place  and 
mode  of  origin,  their  distribution,  their  arrangemoDt 
.   in  groups  or  otherwise,  the  pigmentation  which  they 
'   leave  behind  them,  the  present*  or  absence  of  i 
'    duration  ia  aod  around  them,  their  individual  and 
oorporate  life-history,  the  presence  or  absence  of  local 
rise  of  temperature  or  the  other  classical  signs  c 
inflammation,  and  the  general  symptoms,  If  any,  by 
which  their  development  is  preceded,  accompanied, 
or  followed,  must  be  taken  into  account. 

Thus  certain  diseases  aimost  invariably  begin  i 
particular  parts,  as,  for  example,  psoriasis  on  th 
elbows  and  knees,  and  aeborrhceic  eczema  on  the 
scalp.  In  some  aSectlons,  as  in  hchen,  the  element- 
ary lesion  remains  unchanged  and  unmingled  with. 
other  forms  throughout ;  in  others,  as  in  erythec 
multiforme  and  dermatitis  herpetifomtis,  it  und< 
goes  various  transformations,  and  lesions  of  the  most 
diverse  type  are  present  at  the  same  time. 

The  lesions  may  be  aymmetricoi  in  distribution, 
or  the  reverse  ;  they  may  be  grouped  or  isolated  and 
irregularly  scattered  about.  Symmetry  may_be_tliB 
eflect  of  an  irritant  circulatiijg  m  thg^bloodceKeain 
,■111(1  ;i-1mm.'  iT(r  nii."sTiIoi  TKe  tiasues  at  correspond- 
inv  I'll-  ■■!'  i  ■  ■  I  iitnjieoiisSjriaceiiay-e_eqii8l_poB'e.rB 
')!  ■  Ijrnre^symmetry  J3__a_chara^teristic 

TiT  iI'.iil;  r.i-lii  ■  (111!  eruptions  of  specific  fevers j  and 
generally  of  skin  lesions  due  to  constitutional. dia- 
turtftBce^ 

On  the  other  hand,  lesions  dependent  on  other  than 
constitutional  causes  are  often  asymm^rical :  exempli- 
\  fications  of  this  law  are  seen  in  herpes  zoster,  local 
'  dieeases  such  as  ringworm,  tertiary  syphilis,  growths 
I  such  as  ncevi,  etc.  Sometimes  lesions  follow  the 
I  lutural  linej  of  cleavage  in  the  skin ;  this  may  _ 
r  haps  be  explained  by  the  fact  that  the  cutaneous 


'  per-        ■ 
neouB       ^M 


CHARACTER    OF    LESIONS.  20 

blood-veasels  and  nerves  run  along  these  lines.  In 
many  cases  tlic  arrangement  of  lesions  in  a  particular 
way  may  be  accounted  for  by  structural  conditions  : 
thus  new  patches  of  lupus  frequently  develop  in  the 
track  of  lymphatic  vessels  communicating  with  pre- 
esistent  foci,  and  the  lesions  of  antesthetic  leprosy 
correspond  with  the  direction  and  branching  of  a 
nerve  trunk.  In  the  majority  of  caaes,  however,  it 
is  impossible  to  account  for  the  concentric  rings  and 
patches  of  irregular  outline  in  which  lesions  tend  to 
group  themselves,  unless  these  complex  figures  may 
be  thought  to  represent  some  related  conditions  of  the 
central  nervous  ayatem  which  haa  a  common  origin 
with  the  epidermis  in  the  epiblaat  of  the  embryo. 

The  evolulwn  of  lesions  is  important  in  regard 
to  diagnosis,  as  a  knowledge  of  their  mode  of  spread- 
ing and  of  the  phases  through  which  they  pass  enables 
u3  to  recognise  the  identity  ot  lesions  differing  widely 
in  appearance.  Many  lesions,  as  in  seborrhceic 
eczema,  tinea  tonsurans,  etc.,  increase  in  size  by 
peripheral  extension.  Some,  while  continuing  to 
spread  at  the  edge,  undergo  involution  in  the  centre, 
as  in  erythema  iris ;  in  others,  again,  as  in  tinea 
imbricate,  estension  takes  place  simultaneously  in 
a  centripetal  as  well  as  in  a  centrifugal  direction, 
the  area  of  healthy  skin  enclosed  by  the  primary 
ring  of  eruption  being  gradually  converted  into  a 
uniform  patch.  When  neighbouring  rings  in  their 
expansion  meet  each  other,  the  part*-  in  contact  dis- 
appear, the  remaining  s^menta  forming  broken, 
curved,  or  wavy  lines,  or  irregular  festoon-like  figures 
which  sometimes,  as  in  the  so-called  erythema  mar- 
ginatum, continue  to  advance  at  the  edge  indepen- 
dently. 

Much  of  the  history  of  the  aflection  is  sometimes 
IfWlitten  in  the  lesions  themselves  or  in  their  results. 
t  instance,  yellowish  scabs  imply  previous  puatula- 


I 

r  I 


PRINCIPLES   OF    DIAayOSIS.      [ohap.  m. 

tion  ;  the  record  of  a  discliarge  may  often  be  seen  in 
etiffened  linen ;  every  stain  aod  scar  hears  its  own 
witness  to  those  who  have  eyes  to  read  such  signs. 
It  la  in  the  earlier  stages  of  an  affection  that  lesions 
axe  most  likely  to  be  seen  in  their  typical  character 
unmodified  by  natural  evolution  or  artificial  changes. 
The  edge  of  a  patch  must  always  be  examined  with. 
particular  attention,  for  it  is  there,  when  the  process 
is  active,  that  lesions  can  be  seen  in  their  original 
(orm.  Hence  the  edge  of  a  patch  very  often  supplies 
&.e  key  to  the  nature  of  a  disease  wtdch  in  the  absence 
of  such  evidence  it  would  be  dif&eult,  if  not  impos- 
sible, to  identify  with  certainty.  The  apple-jeJly 
nodules  of  lupus,  the  red,  moist  surface  of  ecsema, 
the  glistening  papules  of  lichen  ruber  planus,  the 
yellow  cups  of  iavus,  are  generally  to  be  found  at 
the  edge  of  areas  of  disease  when  elsewhere  all  typical 
lesions  have  been  swallowed  up  in  the  secondary 
changes  accompanying  the  evolution  of  the  procesB. 

The  observer  must  carefully  discriminate  between 
the  lesions  which  are  the  direct  result  of  the  morbid 
process  and  those  which  are  the  consequence  of  modi- 
fying influences,  such  as  scratching  (wheals,  excoria- 
tions, blood-crusts,  dermatitis],  scarring,  with 
atrophy  or  hypertrophy,  thickening  of  the  epidermis 
(keratosis),  secondary  inoculation  of  pus  cocci  or 
other  infective  material,  and  local  treatment,  whether 
soothing,  stimulating,  caustic  or  surgical.  It  must 
be  borne  in  mind  that  two  or  more  affections  may 
oo-exiat  (tor  instance,  scabies  with  syphilis  or  psori- 
asis), and  in  such  cases  of  mixed  disease  it  usually 
happens  that  one  condition  more  or  less  completely 
overshadows  the  other :  thus  scabies  may  mask 
syphilis,  and  syphiliH  may  more  or  less  completely 
i^guise  lupus  vulgaris. 

In  studying  an  eruption  it  is  always  well  to 
compare    correapondiog    parts    together — arm    with 


1 


n.]     RASHES  OF  INFECTIOUS  FEVERS.        31 

arm,  leg  with  leg,  ear  with  ear,  and  bo  forth.  Con- 
comitant lesiona  of  mucous  membranes  and  enlarge- 
ment of  lymphatic  glands  must  be  looked  for.  and  all 
stains,  scara,  and  other  marks  of  past  or  present 
disease  must  be  noted.  Lastly,  an  estimate  must 
be  formed  of  the  state  of  the  patient's  health,  apart 
from  hia  skin  affection. 

There  are  certain  aSections  which  can  at  once 
be  diagnosed  by  the  presence  of  lesions  pecnbar  to 
themselves.  Thus,  burrows,  from  the  distal  end  of 
which  the  itch  mite  can  be  extracted,  are  pathogno- 
monic of  scabies  ;  nits  on  the  hair  and  "  htemorrhagic 
spots,"  of  pediculosis  ;  broken  hairs,  of  ringworm  of 
the  scalp  ;  sulphur-yellow  cups,  of  favus  ;  apple-jelly 
nodules,  of  lupus  vulgaris  ;  and  fiat,  glistening,  pur- 
plish papules,  of  lichen  ruber  planus.  In  all  these 
cases  the  changes  incidental  to  the  progress  of  the 
disease  may  so  far  modify  the  characteristic  lesion 
as  to  make  it  difficult  of  recognition ;  but,  whenever 
found,  it  is  conclusive  as  t^o  the  nature  of  the  disease. 

In  cases  of  less  obvious  nature  the  first  step 
towards  the  identification  of  the  disease  is  the  elimi- 
nation of  conditions  which  are  clearly  "  out  of 
court."  In  the  case  of  chronic  processes,  congenital 
malformations,  such  as  xerodermia,  must  first  be 
excluded.  In  the  presence  of  an  acute  eruption 
the  practitioner  must  guard  himself  against  ridiculous, 
and  possibly  disastrous,  error  by  considering  the 
possibility  of  its  being  the  rash  of  an  infectious  fever. 
In  practice  it  is  comparatively  seldom  that  such  a 
question  arisea ;  the  epidemic  prevalence  of  the 
disease,  the  fact  of  exposure,  and  the  presence  of 
grave  constitutional  disorder,  generally  leave  little 
room  for  doubt  as  to  the  nature  of  a  febrile  exan- 
them.  Now  and  again,  however,  the  practitioner 
finds  himself  confronted  with  a  case  in  which  a  diag- 
Qoais  has  to  be  made  almost  entirely  on  the  evidence 


neasy  1 


k 


PRINCIPLES    (IF    DIAGNOSIS. 


of  the  eruption  itself  ;  and  this  is  not  always  a 
matter,    even    for   the   most    experienced.     A 
aummsry  nf  the  main  features  of  the  rashes  of  the  ] 
principal   infectious    fevers — scarlet   fever,    i 
rotheln,  enteric  fever,  amall-pos,  chicken-pox,  and  I 
typhus — will  therefore  not  be  out  of  place  here.  Erysi- 
pelaB  must  also  be  included.     The  rashefi  occaBiooally  4 
Been  in  diphtheria,  influenza,  cholera,  and  cersbio- 
spinal  meningitis  do  not  concern  ub,  as  they  i 
merely  accidental  phenomena,  presenting  no  charac*  ' 
teristic  features,  and  are  never  likely  to  be  a  ; 
of  difficulty  in  diagnosis. 

The  rash  of  scarlatina  shows  itself  on  the  first  o 
second  day,  its  appearance  being  heralded  by  general   i 
febrile  disturbance  of  a  more  .  or  leas  severe  kind. 
It  is  erythematous  in  character,  consisting  at  Sist  < 
of  a  multitude  of  tiny  led  points,  which  soon  coalesce   | 
into  a  diffused  redness  of  a  tint  like  that  of  a  boiled 
lobster.     The   redness    disappears   on  pressure, 
very  severe   cases   the   eruption  presents   a  porple 
mottled  appearance  ;  it  is  purpuric  in  character,  and 
i.^  therefore  not  obliterated  by  pressure.     It  is  usnally 
bright  red,  but  sometimes  dusky ;    sometimes  it  is 
general,   in  other  cases  scattered  in  patches.     The 
rash   usually  comes   out   first  on   the   chest,   belly, 
neck,  wrists,  or  back,  and  spreads  to  the  limbs ; 
comes  out  in  fresh  crops  on  one  part  of  the  body, 
while  fading  in  another.     It  generally  disappears  by 
the   tenth   or   twelfth   day.     Desquamation  always 
follows,  and  is  directly  proportionate  in  its  abundance 
to  the  intensity  of  the  rash.     Sometimes  the  eruption 
is  so  faint  and  transient  as  to  escape  recognition. 
The  tskin  affections  most  likely  to  be  mistaken  foi   ' 
the  exanthem  of  scarlet  fever  are  certain  forms  of 
erythema,     especially    that    described    by    French  * 
writers  as  "  desquamative  scarlatiniform  erythema" 
urticaria  when  the  wheals  have  disappeared,  leaving  1 


RASHES    OF    INFECTIOUS    FEVEIIS.      33 

small  red  spots ;  belladonna  or  other  medicinal 
rashes  ;  and  pityriaais  rnbra.  In  doubtful  cases  the 
chief  guides  must  be  the  presence  or  absence  of  the 
characteristic  strawberry  tongue,  sore  throat,  and 
fever.  Between  the  tenth  and  the  twentieth  day 
of  the  illness  the  occurrence  of  albuminuria  may 
reveal  the  nature  of  the  disease.  The  history  of  a . 
previous  attack  is  not  absolutely  conclusive  against 
its  being  one  of  scarlet  fever.  Exposure  to  contagion 
must  also  be  taken  inta  account. 

Tlie  rash  of  measles  comes  out  oo  the  fourth  day, 
and  almost  always  appears  first  on  the  face.  It  con- 
sists of  raised  red  spots  or  patches  ;  the  latter  often 
ran  together,  and  have  a  marked  tendency  to  assume 
a  crescentic  or  circular  outline.  The  rash  spreads 
from  the  face  to  the  body,  and  from  the  latter  to  the 
limbs.  It  usuaUy  fades  on  preasurc,  but  in  serious 
cases  it  is  dusky,  and  even  petechial ;  there  is  usually 
considerable  swelling  of  the  skin  o£  the  face.  Desqua- 
mation occasionally  occurs.  The  eruption  with  which 
it  is  most  likely  to  be  confounded — apart  from 
typhus,  rotheln,  and  the  early  stage  of  hsemorrhagic 
small-pox — is  that  due  to  copaiba.  The  character- 
istic symptoms  of  measles^ fever,  coryza,  and  coT^h 
— will  usuaUy  prevent  its  being  nus taken  for  a  skin 
aftection. 

The  rash  of  r'ilheln  sometimes  resembles  that  of 
measles,  sometimes  that  of  scarlatina  ;  occasionally 
it  begins  with  measles  and  ends  by  resembling  scarlet 
fever.  The  rash,  however,  does  not,  as  a  rule,  tend  to 
assume  the  crescentic  shape  so  markedly  as  that  of 
measles,  nor  has  it  the  same  preference  for  the  face. 
It  comes  out  on  the  second,  third,  or  fourth  day, 
sometimes  on  the  first ;  it  may  be  accompanied  by 
sore  throat,  but  without  the  patches  and  ulceration 
on  the  tonsils  characteristic  of  scarlet  fever.  Some 
enlargement  of  the  posterior  cervical  glands   is  a 


PSINCIPLES   OF   DlAQNOalS.     [chat,  n 

constant  sign  and  is  of  great  diagnostic  importance. 
The  eruption  disappears  in  three  or  four  days.     It  is 
most  likely  to  be  confounded,  apart  from  scarlet  fever   . 
or  measles,  with  copaiba  rash. 

The  enteric  fever  rash  is  not  as  a  rule  conapicuous, 

;  occuTH  chiefly  on  the  abdonaen  and  back,   and 

insists  of  lose-red  lenticular  spots  shghtly  raised 

id  fading  on  pressuie.     They  appear  in  euccpsaive 

crops,  each  crop  lasting  some  four  or  five  days.     It 

seldom  appears  earlier  than  the  seventh  day.     From 

the  dermatologist's  point  of  view,  the  main  thing 

'  in  connection  with  rose  spots  is  not  to  mistake  them 

for  flea  bites  or  vice  versA,  an  error  which  I  have 

known  to  occur.     The  great  point  of  distinction  iH 

that  typhoid  spots  have  not,  as  a  rule,  a  central  dark 

red  point  of  htemorrhage.     Flea  bites,  moreover,  are 

generally  more  numerous  than  rose  spots.     The  two 

kinds  of  spots  may,  of  course,  co-esist. 

The  typhus  rash  appears  from  the  fourth  to  the 
seventh  day.  The  eruption  consists  of  a  general 
mottling  with  spots,  usually  red,  slightly  elevated,  a>t 
first  disappearing  on  pressure,  but  in  a  day  or  two 
ceasing  to  do  so.  They  ultimately  become  bluish  or 
brown  in  colour,  distinct  petechia  or  subcutaneona 
haemorrhages  becoming  developed  in  the  spots.  The 
general  appearance  of  the  typhus  rash  is  fairly  i 
expressed  by  the  term  "  mulberry  rash."  It  first  ^ 
appears  on  the  front  of  the  trunk,  sometimes  on  the  i 
s  and  hands. 

The  sfnall-fox  eruption  generally  appears  on  th«  I 
third,  sometimes  on  the  second,  fourth,  or  fifth  day.W 
The  true  variolous  eruption  is  occasionally  preceded  I 
by  a  roseolar  rash  resembling  that  of  scarlatina.  It  1 
first  appears  on  the  face,  especially  the  upper  part,  [ 
and  on  the  wrists,  and  extends  over  the  back  andj 
limbs.  The  eruption  consists  of  hard  red  papule* 
which  can  be  felt  embedded  in  the  skin  like  i      " 


a.]  RASRES    OP    INFECTIOUS    FEVERS.       35 

shot.  In  a  day  or  two  they  become  vesicular,  then 
pustular,  and  an  inflammatory  zone  develops  around 
them.  The  centre  of  each  pustule  is  generally  um- 
bilicated,  though  this  is  not  constant.  In  mild 
attacks  the  pustules  remain  discrete,  in  severer  cases 
they  are  confluent.  Maturation  occurs  about  the 
ninth  day.  As  the  pustules  dry  up  or  burst,  scabs 
are  formed  which  on  separation  leave  dark  stains, 
acars,  and  "  pits,"  the  number  and  depth  of  which 
are  usually  proportionate  to  the  severity  of  the 
disease.  In  bad  cases  hemorrhage  takes  place  into 
the  skin,  and  into  the  interior  of  the  pustules.  The 
mucous  membranes,  especially  that  of  the  mouth,  are 
not  untrequently  invaded.  In  motlified  small-pox  the 
eruption  may  resemble  that  of  the  unmodified  disease, 
the  lesions,  however,  being  leas  abundant  and  rarely 
confluent ;  or  it  may  consist  of  merely  scattered 
pimples,  which  abort  without  vesication  or  pustula- 
tion.  lu  slight  cases  of  modified  small-pox  the 
aborted  pimples  may  be  mistaken  for  acne  in  persons 
subject  to  the  latter  afiection.  Pustular  syphihdes, 
when  accompanied  by  constitutional  disorder,  may 
be  mistaken  for  small-pox  pustules.  The  iodide  of 
potassium  rash,  especially  when  pustular,  may  simu- 
late variola.  The  umbihcation  of  the  true  sma!l-pox 
pustule,  together  with  the  constitutional  disturbance, 
is  the  chief  guide  to  a  correct  conclusion. 

The  eruption  of  ckicken-'pox  bears  considerable 
likeness  to  that  of  small-pox,  but  it  is  essentially 
veaieuiar,  only  occasionalJy  becoming  pustular.  There 
are  no  hard  ahotty  papules.  The  commonest  situa- 
"tiona  are  the  face,  the  shoulders,  the  back,  and  the 
scalp.  Slightly  raised  red  spots  generally  precede 
the  vesicles.  The  rash  usually  comes  out  within  the 
first  twenty-four  hours,  There  is  often  scarcely  any 
~"  ititntional  disturbance.  When  the  eruption  of 
lella  becomes  pustular  it  may  be  confounded  with 


PRINCIPLES   OF    DIAGNOSIS,      [chap. 

a  pustular  sypliilide,  but  the  absence  of  Itching  is  8 

I  point  of  distinction. 

In  the  great  majority  of  casea,  aB  already  aaid, 
there  is  little  real  danger  of  a  purely  cutaneous 
afiection  being  mistaken  for  the  exanthem  o{  an 
eruptive  fever,  or  vice  versd.  It  is  only  when  tlie  o 
stitutional  disorder  ia  so  slight  as  to  escape  observa- 
tion that  any  difficulty  as  between  a  symptomatic 
and  a  purely  cutaneous  eruption  can  occur.  It 
just  these  slight,  ill-naarked  cases,  however,  that  c 
etitute  a  danger  to  the  community,  and  if  the  prac- 
titioner has  any  doubt  he  will  do  well  to  isolate  the 
patient  at  home  for  two  or  three  days.  A  precipitate 
notification  of  the  case  as  one  of  infectious  disease 
with  removal  of  the  patient  to  a  fever  hospital  is  not 
unlikely  to  lead  to  the  supposed  fever  or  some  other 
infectious  disease  being  contracted  at  the  hospital 

Eryeipdas  is  usually  ushered  in  by  considerable 
constitutional  disturbance  (rise  of  temperature,  head- 

'  ache,  and  often  vomiting).  The  eruption,  which  is 
erythematous  in  character,  starts,  in  the  majority 
of  cases,  from  a  wound ;  in  other  cases,  from  the 
margin  of  a  natural  orifice  where  the  skin  and  mucouB 
membrane  meet.  In  simple  cutaneous  erysipelas  it 
may  spread  over  the  ekin  like  fluid  on  blotting-paper, 

I   as  a  red  rash  with  a  well-defined  edge.     When  the  j 
underlying   connective   tissue    is   involved   there   : 
swelling  proportionate  in  amount  to  the  depth  to    ■ 
which  the  process  extends.     The  eruption  does  not 
ocour  in  patches,  but  there  ia  a  variety  of  the  a 
tjon  in  wliitth  the  inflammation  moves  from  place  to 
place,  remaining  only  for  a  short  time  in  each  locality" 
(erifiiipKiaa  M"-"). 

Zymotic  tovcm  and  erysipelas  having  been  elimin- 
ated, leigned  nujiliona  muot  next  be  excluded.  In 
BUfih  Cftwio  the  Ifwloiid  are  always  on  a  part  of  the  body   , 

k  aaiiily  acoMNihlo  t^i  tlm  pntinnt,  the  front  of  the  chest,   , 


proof 

erupt 

K 


n.]  SYPHILITIC  LESIONS.  37 

the  arms,  and  tlie  thiglia  being  the  regions  most  fre- 
quently operated  upon.  Moreover,  the  lesions  have 
not  the  characters  of  Nature's  handiwork,  nor  do 
they  conform  to  the  type  of  any  known  disease. 
They  generally  give  evidence  of  their  artificial  origin 
in  the  regularity  of  their  outline  and  in  the  absence 
of  any  commencing  elementary  lesions  likely  to  de- 
velop into  the  conditions  present.  The  subjects  are 
invariably  persons  of  highly  neurotic  temperament, 
the  large  majority  of  them  being  young  women. 

The  nest  group  to  be  considered  is  the  class  of 
■al  inocutable  diseases,  particularly  tuberculosis, 
_  _ihilis,  and  leprosy.  Tuberculous  lesions,  with  the 
«xception  of  lupus,  are  as  a  rule  associated  either 
with  the  well-known  signs  of  the  scrofulous  dia- 
thesis or  with  actual  tuberculous  disease  in  the  lungs 
or  elsewhere.  There  is  no  feature  per  se  distinctive 
of  a  tuberculous  lesion  in  the  skin,  except  the  apple- 
jelly  nodule  of  lupus  vulgaris.  The  diagnosis  must 
therefore  be  made  from  concomitant  circumstances. 

Syphilitic  lesions  usually  betray  their  nature  in 
their  appearance  ;  but  no  disease  is  more  likely  to 
perplex  the  inexperienced,  on  account  of  the  protean 
character  of  the  lesions  which  it  causes  and  the  ex- 
traordinary closeness  with  which  it  often  imitates 
those  produced  by  other  affections.  There  are  certain 
general  features  more  or  less  characteristic  of  syphili- 
tic lesions  which,  taken  singly,  are  inconclusive, 
but  cumulatively  have  a  force  amounting  almost  to 
proof.  These  are,  in  the  case  of  most  secondary 
eruptions,  symmetry  of  distribution,  erratic  localisa- 
multiformity  of  lesion,  absence  of  itching, 
to  a  lesser  extent,  peculiarity  of  colour  and 
!.     With  regard  to  localisation,  syphilis  should 

'ays  be  suspected  when  lesions  resembling  those 

'acteristic  of  other  diseases  are  found  in  situa- 
generaUy  avoided  by  the  latter.    Thus  a  patch 


^V      S8 


PPINGIPLES    OF    DIAGNOSIS.      [cHAP.m. 

esemblmg  psoriasis  ia  probably  syphilitic  ii  there  are 
not  and  have  not  been  any  simUar  lesions  in  the 
aituations  most  afiected  by  paoriasis,  especialiy  the 
tips  of  the  elbows  and  the  fronts  of  the  knees.  Poly- 
morphism ia  a  character  common  to  all  secondary 
syphilitic  lesions,  except  macular  and  erythematoua 
syphiiidea.  A  livid  colour  like  that  of  the  lean  of 
raw  ham,  tending  with  the  lapse  of  time  to  become 
brown  and  coppery,  is  always  Buggestive  of  syphilis, 
but  ia  by  no  means  pathognomonic.  The  same  may 
be  said  with  regard  to  the  shape  of  lesions.  Bo^ 
eruptions  and  ulcers  due  to  syphilis  have  a  tendency 
to  assume  a  horseshoe  outline  ;  this  by  itself,  how- 
ever, is  not  distinctive  of  syphilis.  Squamous 
syphilides  have  sometimes  indefinite  objective  charac- 
ters, but  their  nature  will  be  lecognisable  in  the  light 
of  a  clear  history  of  a  primary  sore  and  subsequent 
aigna  of  constitutional  infection.  It  must  be  remem- 
bered that  syphilis  often  co-exists  with  other  akin 
affections  :  thus  a  squamous  syphilide  may  be  found 
as  it  were  grafted  on  seborrhcea.  There  are  also  fre- 
quently to  be  found  other  co-existing  evidences  of 
the  disease,  such  as  falling  out  of  the  hair,  sore  throat, 
pains  in  the  bones  ;  or  marks  of  its  presence  in  the 
form  of  Bears  or  enlarged  glands  in  the  sub-occipital . 
region,  groins  and  other  parts,  or  nodes  on  the  shine, 
«tc.  In  late  tertiary  syphilides  tlie  distinctive  features 
*te  ubaenco  of  symmetry,  their  marked  tendency  to 
Bprcnd  tH.>r]iigiiKiUNly  and  to  ulcerate.  Furthermore, 
they  arc  followed  by  scarring,  and  on  the  scalp  by 
total  cleHt^ut^tion  of  hair. 

In  dUdpcctcd  leproHy  the  first  rough  test  is  the 
prcaenco  of  nntesthesia  in  the.  lesions.  The  patient's 
prcritiUN  IilMtory  in  renpfi-t  n!  residence  in  an  affected 
area  may  afford  coniirmatory  evidence. 

Tlie  next  cutt*gory  of  diseBses  to  be  excluded  i»' 
the  local  inooulaUe  group,  cumpTi»ing  those  caused  by 


a.]    LOCAL    INOCULABLE    DlfllSASES.  3« 

(1)  animal  aad  (2)  vegetable  parasites,  and  (3)  those 
caused  by  other  micro-organisms.  In  the  first  of 
these  subdivisions  the  affection  of  greatest  practical 
importance  is  scabies.  Here  conclusive  proof  is 
afforded  by  the  presence  of  the  acarua.  The  burrows 
must  be  looked  for  in  the  webs  between  the  fingers, 
and  about  the  wrists.  The  fact  that  there  are  no 
lesions  on  the  face  m  a  given  case  is  presumptive 
evidence  that  the  disease  is  itch.  The  presence  of 
nits  on  the  hairy  parts,  or  of  the  ciaracteristic 
"  hEemorrhagic  spots,"  is  conclusive  of  pediculosis, 
"mong  the  vegetable  parasitic  diseases  the  most  im- 
__  ortant  are  ringworm,  favus,  and  tinea  versicolor. 
Each  of  these  afiections  has  characteristic  features, 
by  which  it  can  at  once  be  identified.  Thus  in  ring- 
worm the  broken  hairs  on  the  scalp,  the  circinate 
lesions  on  the  body,  and  the  presence  of  the  special 
fungus,  are  conclusive.  Favus  is  recognised  by  the 
sulphur-yellow  cups  and  mousy  smell ;  tinea  ver- 
sicolor by  the  characteristic  fawn-coloured  spots  al- 
most exclusively  seen  on  covered  parts  of  the  body 
did  in  adults.  In  the  third  subdivision  contagious 
Inpetigo  is  recognisable  by  the  isolated  scabs  with- 
|it  inflammatory  halo,  looking  as  if  they  had  been 
^ck  on  with  gum  (Tilbury  Fox). 
.  The  skin  diseases  of  nervous  origin  are  recognisable 
titer  by  the  lesioiLS  being  distributed  in  correspond- 
_  ice  with  the  area  of  diatribution  of  a  particular 
root,  as  in  herpes,  or  by  their  occurring  in  persons  of 
markedly  neurotic  temperament,  or  as  the  result  of  a 
definite  injury  to  the  nervous  system,  or  of  mental 
^^^^^^ock. 

^^^^L  New  growths  on  the  skin  may  be  confounded  with 
^^^^Hgodiilai  formations  of  tuberculous,  syphilitic,  or 
^^^^^^rotic  nature,  with  the  swellings  of  erythema 
^^^^Bodosum,  or  with  abscesses  and  cyste.  Erythema 
^^^^modosum  may  be  identified  by  its  localisation  (lege 


alts 
■Mi     "Im 

Ui    Each 


sicoloi 
most 

II  ii 
pet 
'i" 
ick 
Tl 
hei 
ee 


PRINCIPLES    OF   DIAGNOSIS. 


I 

^^^B  history,  and  the  speedy  Bubsidence  of  the  sweUings ; 
^^^H   collections  of  fluid  by  fluctuation  or  thrill. 
^^^1  Having  by  this  process  of  exclusion  come  to  a, 

^^^B  decision — subject,  of  course,  in  many  cases  to  le- 
^^^r  vision  in  the  hght  of  fuller  knowledge — -as  to  what 
I  the  affection  is  not,  the  nest  step  is  to  form  a  judg- 

ment, or,  rather,  a  working  liypothesis,  as  to  what  it 
ia.  In  the  first  place  it  must  be  noted  whether  the 
eruption  is  gencial  or  localised  ;  next  the  natoie  and 
distribution  of  the  lesions  must  be  observed  in  gieatez 
detail  than  haa  already  been  done.     General  enip- 

i| tions,  being  associated  with  some  alteration  in  the 

^^^f  condition  o!  the  blood,  are,  as  a  rule,  more  or  leas 
^^^B  symmetrical.  A  difiuse  red  rash  is  seen  in  scarlet 
^^^B  fever,  measles,  and  the  period  of  invasion  in  syphilis ; 
^^H  guch  an  eruption  often  accompanies  the  development 
'  of  nodules  in  tubercular  leprosy ;    it  occurs  in  urti- 

caria, erythema,  eczema,  pityriasis  rubra,  and  follows 
the  internal  administration  of  various  drugs — 
chloral,  belladonna,  copaiba,  antipyrin,  mercuiy, 
opium,  nux  vomica,  quinine,  tar,  stramonium,    sul- 

Siional  itnd  Balicylic  acid,  and  the  salicylates.     The 
iagnoBJH  muflt  be  made  by  the  clinical  history,  the 
dcgrno  iind  ehnrw^ter  of  the  constitutional  distnrb- 
I'knco,  and  the  nature  of  the  associated  symptoms. 
''  Tliim,  fn  itypliilitid  roNeola  there  will  be  a  history  oi 
■■-fti.n,  irilriT('i-m"nt  of  glands,  sore  throat,  etc. 
ii'.i'  ii.i  '■  |.i'wy  there  will  be  found  more  or  less, 
'  ii''      .li'.iniit.ioM  nt  tho  erythematous  patches, 

I'll.     Mi|iii(iji"d    by   some   functional  diaordei: 

l.lii'  yliitnl"  r>(  till!  itfT<'i'.l.«Ml  nkin,  and  by  abolition 

oiHlUtli'li   III  NHnxittiiin.     In  the  case  of  scarlet 

I  tev«r  urid  iiikiikIkb  t,lu>  i\nU<  iif  invasion  is  important, 

I  uid    Mm  (ithnr   (inltiln  nlriiixly   indicated   must  be 

[|    liiUf    H'Xfililil),     lllffiitn    ri^d    rafllies    due 

■  Imvn  n'ltlitFiH  i<liKrtti'f«TlHfic  nliout   them,  and' 


IP.  m.]     ERUPTIOSS  ON    THE    SCALP.  41 

mly  by  the  exclusion  oE  other  pos- 
mbined  with  examination  of  the  urine 
and  such  circumstantial  evidence  as  can  be  gleaned 
from  associated  symptoms,  the  discovery  of  bottles, 
and  so  on.  The  more  purely  cutaneous  affections, 
such  as  urticaria,  eczema,  etc.,  will  be  recognised  as 
the  lesions  develop  into  typical  forms. 

In  tlie  diagnosis  of  localised  eruptions  we  have, 
generally  speaking,  fewer  side-lights  from  constitu- 
tional disturbance  and  clinical  history  to  guide  ub. 
There  are,  however,  certain  features  charfccteriaing 
lesions  in  particular  situations  which  often  furnish  a 
clue  to  their  nature.  The  following  is  a  summary 
of  these  as  they  relate  to  eraptioos  of  different 
types — ^erythematous,  papular,  vesicular,  bullous, 
pustular,  wheals,  ulcers,  and  dry  scaly  lesions — 
when  limited  to  a,  particular  part,  such  as  the  scalp, 
the  face,  the  hands  (especially  the  palm),  or  the 
genitals. 

Scalp. — On  the  scalp  the  chief  difficulty  in  diag- 
nosis is  with  regard  to  pustular  lesions  and  dry  scaly 
eruptions.  Of  the  pustular  type  the  chief  are  con- 
tagious impetigo  and  pustular  syphllides.  The  dis- 
tinctive feature  of  the  former  is  that  the  lesions  are 
not  surrounded  by  a  zone  of  hypenemia,  but,  as 
already  said,  look  as  though  they  were  stuck  on  with 
gum;  on  the  other  hand,  in  the  case  of  pustular 
ayphilides,  when  the  scab  is  picked  off  there  is  usually 
an  ulcer  underneath,  in  the  older  lesions.  In  pustular 
eczema,  again,  the  course  of  the  disease  is  different ; 
there  is,  or  has  been,  "  weeping,"  especially  behind 
the  ears,  and  the  lesions  are  not  isolated  like  those  of 
contagious  impetigo.  In  lupus  erythematosus  there 
are  often  crusts  which  resemble  scabs  ;  they  are  not, 
however,  formed  by  the  drying  up  of  pustules,  but  by 
sebaceous  matt«r  ;  moreover,  on  picking  off  a  portion 
of  the  crust  its  under  surface  will  be  seen  bristling 


FnmCIFLES    OF   DlAONOSia.     [CBA 

with  prickle-like  projections,  correspcmding  to   the 
dilated  orificea  of  dueta  which  they  have  plugged, 

A  dry  scaly  eruption  of  the  scalp  is  either    « 
borrhoea,   aeborrhceic   eczema,   psoriasia,    tinea   totf 
surana,  favus,  or  a  squamous  syphilide,  which  agaj 
may  be  secondary  or  tertiary.  The  diatinctive  featoi 
of  seborrho^a  is  that  there  is  no  redness  oi  sign  c 
inflammation  under  the  scales.    In  seborrhtpic  eczema^ 
on  the  other  hand,  the  surface  beneath  the  scales  ii 
red,  and  each  patch  has  an  erythematous  zone  arounC 
its  edge.     Moreover,  the  scalp  alone  is  seldom  afiectect;, 
and  the  disease  spreads  downwards  to  the  face,  th» 
back,  and  the  chest.     Psoriasis,  also,  is  present  ill' 
other  parts,  especially  on  the  elbows  and  kneea,  an^ 
has,  as  a  rule,  spread  upwards  to  the  scalp.    In  tht&[ 
situation  it  generally   occurs  in  localised  patcha^ 
and  in  typical  cases  the  scales  have  a  characteristii 
silvery  grey  appearance.     It  may  here  be  said,  hoW' 
ever,  that  Uttle  reliance  can  be  placed  on  mere  difEi 
encea  in  the  character  of  the  scales  in  any  of  the  coH" 
ditions  here  referred  to,  when  they  occur  on  hai^ 
parts.     Eingworm  and  favus  can  always  be  recog- 
nised by  the  distinctive  characteristics  abeady  men 
tioned,  and,  if  there  be  any  doubt,  it  is  removed  b 
the  detection  of  the  fungus  with  the  microscope, 

la  the  case  of  secondary  squamous  syphilldeB 
there  is  nothing  characteristic  in  the  appearance  a 
the  lesions,  and  the  diagnosis  can  be  made  only  ^ 
the  history,  the  presence  of  more  distinctive  lesions  O 
marks  elsewhere,  and  the  effect  of  specific  treatmem^ 
In  the  case  of  tertiary  squamous  sypbilidea  there  ji 
often  no  other  concomitant  lesion  to  guide  one 
the  characteristic  serpiginous  outline  and  the  matka 
tendency  to  ulceration,  followed  by  scarring, 
autficiently  distinctive. 

Face. — Red    patches    limited    to   the   face,    i 
especially  affecting  the  cheeks   and  the  nose — tb 


0H4P.  ni.l       ERVPTIom   ON    THE    FACE.  43 

Bo-called  "  flush  area  "—may  be  erysipelas,  erythema, 
lupuB  erythematosus,  rosacea,  or  lupiw  vulgaiia. 
Erythema  comes  on  suddenly  ;  the  patch  has  a  well- 
defiued  edge,  and  the  eruption  is  not  accompanied  by 
conHtitutional  disturbance.  Erysipelas,  on  the  other 
hand,  is  accompanied  by  more  or  less  severe  febrile 
phenomena  ;  the  patch  has  a  well-defined  edge,  which 
advances  rapidly  while  the  process  is  in  the  active 
stage ;  the  affected  skin  ia  tense  often  to  such  a  degree 
as  to  cause  great  pain  on  movement.  Both  in  ery- 
thema and  in  erysipelas,  vesicles  and  bullie  may  form 
on  the  inflamed  surface.  Lupus  erythematosus  is 
much  slower  in  its  course  than  either  of  the  affections 
Just  named ;  the  patch  has  often  a  characteristic 
outline  like  a  butterfly  with  expanded  wings  ;  there 
is  almost  invariably  more  or  less  atrophic  scarring  in 
the  centre,  and  on  detaching  a  portion  of  the  crusts 
tags  of  sebaceous  matter  will  be  seen  projecting  from 
its  under  surface.  Lupus  vulgaris  can  in  most  cases 
be  recogniseil  by  the  characteristic  apple -jelly 
nodules ;  if  these  are  not  at  first  visible,  they  can 
often  be  brought  into  view  by  stretching  the  skin,  or 
by  pressing  the  blood  out  of  it  with  the  finger.  In 
rosacea  there  is  no  defined  edge,  the  surface  is  knobby 
with  papules  and  pustules,  and  is  traversed  by  small 
varicose  veins,  and  there  is  no  scarring.  Most  of  the 
conditions  that  have  been  mentioned  may,  be  more 
or  less  closely  simulated  by  syphilis  ;  there  is  always 
something  wanting,  however,  which  makes  the  imita- 
tion imperfect.  Thus  the  absence  of  acute  general 
symptoms  differentiates  a  syphihtic  lesion  from  ery- 
sipelas ;  the  absence  of  sebaceous  plugs  from  lupus 
erythematosus  ;  the  absence  of  apple-jelly  nodules 
from  lupus  vulgaris  ;  and  the  absence  of  dilated  veins 
on  the  affected  surface  from  rosacea. 

Ulcers  on  the  face  may  be  scrofulous,  lupous, 
syphilitic,    oi    malignant.    Scrofulous    ulcers    are 


PRINCIPLES   OF  DIAGNOSIS,      [chap.  m.. 

mostly  seen  in  children  of  atrumous  aspect 
elderly  people  with  marks  of  lesions  dating  from 

"y  life.  They  have  no  absolutely  distinctive 
characters,  but  the  edge  is  often  undermined  and  the 
surrounding  akin  blue  and  of  low  vitality.  In  lupus, 
ulceration  is  extremely  chronic  ;  the  edge  of  the  aore 
is  generally  more  or  lees  rounded,  and  the  process  is 
very  superficial,  never  extending  to  the  bones. 
Syphilitic  ulceration,  on  the  other  hand,  frequently 
attacks  the  bones  of  the  face  and  is  more  rapid  in  its 
course.  Rodent  ulcer  usually  occurs  in  persons  be- 
yond middle  life,  and  often  attacks  the  face  about 
the  outer  edge  of  the  orbit  or  the  side  of  the  nose. 
The  ulcer  is  rounded  in  outline,  has  a  firm  raised 
"  rolled "  edge  and  a  depressed  centre  with  little 
appearance  of  granulation,  and  a  scanty  inofiensive 
discharge ;  the  process  is  almost  painless.  In  epi- 
thelioma, on  the  other  hand,  the  edge  is  everted  and 
very  hard ;  the  base  of  the  ulcer  is  foul  and  rough- 
enoi  with  granulations  ;   the  neighbouring  glands  ai«] 

'  irged  ;    pain  is  often  very  severe,  and  the 
process  is  more  rapid  and  more  aggressive. 

Nodular  leaions  on  the  face  may  be  due  to  till 
culosis,  syphilis,  or  leprosy.     The  tuberculous  (liqtattl 
nodule  has  a  characteristic  gelatinous  or  apple-jelt] 
appearance,  which  once  seen  cannot  be  mistaken  6 
anything  else.     Nodular  syphiJides  may  be  secoQdai 
or  tertiary  manifestations.     In  the  former  case  th( 
are  generally  solitary  or  very  few  in  number ;    tfe( 
are  coppery  m  colour,   and  are  usually  aasocial 
with    other    syphilitic    lesions    elsewhere.     In 
tertiary  form  they  are  frequently  dotted  thickly 
the  face,  especially  on  the  forehead,  down  the  m 
and  on  the  nose  ;    they  often  coalesce,  giving  rifle 
a  diffuse  infiltration  which  is  apt  to  break  down  ial 
ulr.yrs,  at  tlio  edge  of  which  younger  nodules 
visible,     Qummata  are  painless  and  develop  rapidly 


1 

i 


CHAP,  m.]   ERUPTlOm   ON   FACE   AND   HANDS.     45 

when  they  break  down  isBue  is  giyen  to  a  puriform 
fluid,  and  a  cavity  ia  left  which,  if  the  patient  is 
left  untreated  or  is  out  of  health,  may  spread. 
There  is  no  induration  or  turning  out  of  the  edge,  and 
no  involvement  of  neighbouring  glands.  Leprotic 
noduicB  develop  slowly  ;  they  are  yellowish -brown  in 
colour,  and  may  attain  the  size  of  a  hen's  egg.  They 
are  at  iirst  hypenesthetic,  but  when  fully  developed 
usually  aiiFesthetic.  Their  formation  is  in  most  cases 
associated  with  a  presumption  of  leprosy  from  the 
co-existence  of  other  signs  of  the  disease,  and  from  the 
fact  of  a  patient  having  lived  in  a  region  where  it  is 
endemic. 

Small  tumours  on  the  face  may  be  moUuscum 
contagiosum,  miUum,  adenoma  aebacetun,  or  xan- 
thoma tuberosum.  In  molluscuni  contagiosum  each 
growth  has  a  central  depression  in  which  there  is  a 
small  opening  out  of  which  a  substance  lite  sebaceous  . 
matter  can  be  squeezed.  This  substance  consiBta 
of  particles  of  new  growth.  Milium,  on  the  other 
hand,  has  no  external  opening ;  but  when  it  is 
pricked  exit  is  given  to  sebaceous  matter.  Adenoma 
sebaceum  is  usually  congenital,  and  occurs  with 
neevoid  conditions.  Xanthoma  tuberosum  is  of  a 
yellowisli  pearly  colour ;  when  it  is  pricked  nothing 
can  be  squeezed  out,  the  growth  being  composed  of 
connective  tissue. 

Hands. — The  eruptions  limited  to  the  bands  are 
principally  vesicular,  bullous,  or  dry  and  scaly  in 
character.  Artificial  dermatitis,  from  contact  with 
irrhating  aubstancea,  such  as  lime,  etc.,  must  first  be 
excluded,  Vesicular  lesions  are  present  in  eczema, 
cheiropompholyx,  and  scabies.  In  eczema  the  lesions 
tend  to  run  together,  the  disease  spreads  to  other 
parte,  and  there  is,  or  has  been,  "  weeping."  In 
cheiropompholyx,  on  the  other  hand,  there  may  be 
discharge,  but  there  is  no  weeping ;   the  lesions  do 


40  PRINCIFCES    OF   DIAGNOSIS,     [chap.ii 

■•  not  tend  to  run  together  as  in  eczema,  and  there  i 
no  eruption  in  other  parts.  The  afiection  nina  i 
more  or  less  regular  course,  and  shows  a  marked  ten 
dency  to  recur.  In  acabiea  tlie  lesions  are  iaolateds 
the  characteristic  burrows  and  acari  at  once  establish 
the  nature  of  the  afiection. 

Dry  scaly  eruptions  are  mostly  localised  on  the 
palm.  Both  hands  or  only  one  may  be  afiected.  In 
the  former  case  the  afiection  may  be  psoriasis,  eczema, 
syphilis,  lichen  ruber  planus,  serodermia,  or  keratosia. 
It  is  impossible  to  diagnoae  the  nature  of  the  e 
from  the  dry  scaly  character  of  the  eruption  aloneiS 
Psoriasis  is  indicated  by  the  presence  of  characteristHi  I 
lesions  elsewhere,  notably  on  the  elbows  and  knee 
and  perhaps  on  the  scalp  ;  or  there  may  be  a  histo 
of  an  eruption  on  these  parts.  In  eczema  there  i 
a  history  of  "  weeping  "  in  the  part  itself,  or  e' 
toua  lesions  are  present  in  other  situations,  Liotiei 
ruber  planus  of  the  palm  is  also  associated  wit&] 
similar  lesions  in  other  parts.  If  it  is  a  sec 
syphilitic  lesion,  there  will  be  a  history  of  ii 
and  other  signs  of  the  disease.  Serodormia  ic 
always  congenital.  Keratosis  is  also  sometimes  oo» 
genital,  in  which  case  it  is  to  be  regarded  as  a  ion 
of  xerodermia ;  and  the  affection  of  the  palms  i 
generally  associated  with  dryness  and  hardness  ( 
the  skin  in  other  parta.  On  the  other  hand,  kra 
tosis  may  be  the  result  of  a  previous  inflammators 
process,  such  as  dermatitis,  eczema,  or  of  ) 
taken  internally  ;  the  history  in  such  cases  will  g 
the  olne  to  the  nature  of  the  affection.  Scaly  e 
tions  affecting  one  palm,  if  syphilitic,  are  terti 
It  is,  as  a  rule,  only  by  such  side-lights  as  have  b 
mentioned  that  the  nature  of  a  dry  scaly  eruptioi 
of  the  palm  can  be  recognised.  The  eruption  itB^ 
however,  often  presents  definite  features  which,  evm 
in  the  absence  of  collateral  evidence,  shoi  " 


OKiP.  HI.]      ERUPTIONS    ON    THE    GENITALS.        47 

suggest  the  nature  of  the  process  of  which  it  ia  a  pro- 
duct. In  psoriasis  and  lichen  ruber  planus  the  acalea 
are  usually  massed  in  small,  hard,  circumscribed, 
corn-iike  patches  ;  but  in  acute  cases  of  the  latter 
affection,  the  whole  hand,  both  palm  and  back,  may 
be  uniformly  affected  with  general  thickening  and 
cedema.  In  eczema  there  is  not  only  scaling,  but 
thickening  and  often  fissures.  Syphilitic  patches  are 
irregular  in  shape,  and  often  cracked  on  the  surface  ; 
the  scales  are  not  piled  np,  but  peel  off  ;  the  lesions 
spread  serpiginously.  In  xerodermia  there  is  com- 
paratively little  scaling  ;  the  akin  is  dry  and  polished. 
In  keratosis  the  thickening  ia  very  marked,  especially 
round  the  circumference  of  the  palm,  the  hollow  of 
the  hand  being  generaUy  less  affected. 

Nails. — Lesions  of  the  nails  may  be  due  to  psori- 
asis, eczema,  lichen  ruber  planus,  syphilis,  favus,  or 
ringworm.  Most  of  these  affections  can  bo  diagnosed 
only  from  the  co-existence  of  characteristic  lesions  in 
other  situations.  In  the  case  of  ringworm  and  favus 
the  fungus  can  be  detected  by  examining  scrapings 
of  the  affected  nail  with  the  microscope. 

Gantats. — A  vesicular  eruption  about  the  genitals 
of  either  sex  may  bo  herpes,  eczema,  or  scabies.  The 
first  of  the^e  is  characterised  by  tiny  vesicles  grouped 
on  an  inflamed  base  ;  when  suppuration  occurs  it  may 
simulate  a  soft  sore,  but  the  discharge  is  not  auto- 
inoculable.  Eczema  usually  begins  in  vesicles  which 
are  arranged  in  groups ;  it  ia  aggravated  by  chafing 
(as  between  the  scrotum  and  the  thigh),  and  shows  an 
erythematouB  surface  which  may  be  moist  or  dry  and 
scaly,  but  is  always  inilamed  and  angry  ;  the  itching  . 
is  almost  intolerable,  and  pustules  and  various  other 
secondary  lesions  are  produced  by  scratching.  In 
scabies  the  lesions  are  scattered  about,  not  grouped 
as  in  eczema  ;  here  again  the  typical  appearances  are 
generally  more  or  less  destroyed  by  scratching,  but 


48  PRINCIPLES    OF   DIAQNOSIS.      [ci 

careful  search  will  reveal  burrows  and  acari.  Ring- 
worm  afEectiag  the  perinBeum  and  genitals  (eczema 
margiDatum)  can  be  identified  by  its  fungua. 

Ulcere  of  the  genitals  are  chiefly  venereal.  Th» 
nyphilifcic  or  infecting  sore  ia  distingniahed  by  it» 
raised  edge,  indurated  base,  and  the  fact  that  it  i». 
usually  single  ;  the  non-infecting,  or  soft  sore,  by  tte 
irr^ularity  of  ita  shape,  the  absence  of  hardening, 
and  the  fact  that  it  is  usually  multiple.  Squamous 
and  other  secondary  ayphiHdes  about  the  genitals  arre 
to  be  recogniaed  by  the  absence  of  itching  and  other; 
aymptoma  of  the  disease. 

In  concluding  this  rapid  survey  of  the  aalii 
-points  which  the  observer  should  take  as  his  guidf 
in  the  diagnosis  of  skin  affections,  I  wish  on 
to  emphasise  the  fact  that  in  the  majority  of  ii 
they  will  only  aufBce  to  eatabhah  a  frimA  fade  oai 
as  regards  any  particular  diaeaae.     The  object  I  bai 
had  in  view  haa  not  been  to  give  a  full  account  oi  ^ 
the  features  which  differentiate  one  aSection 
another,  but  to  put  the  student  in  the  way  of  "  reck<mT 
ing  up  "  a  case  in  a  simple,  rapid,  and  logical 
By  the  procesa  of  exclueion  which  has  been  brieflfi 
but  I  hope  sufficiently,  illustrated,  the  observer 
it  he  failx  at  once  to  identify  the  disease,  at  least 
able  to  rediK'it  the  ease  before  him  to  a  group  of  affec*' 
tions  havin(<  >'|iih«  afhnitiea  with  each  other,  the  study 
of  which  lie  Clin  then  pursue  in  detail,  in 
treating  of  them.    The  chapter  is,  in  fact,  intended: 
1a  be  an  introduction  to  the  right  use  of  presumptiv* 
evideni'i',  and  of  cliiex  xupplicd  by  the  disease  iteeK 
.  to  the  identifioutinn  of  affeetione  of  the  skin.     It 
hardly  bn  neeMnary  t^)  n^pcat  that  a  diagnosis  of  tba 
kind  here  refiirrml  tji  mnMt,  ns  a  rule,  be  regarded 
mnrnly  proviMJoiml  iin(il  it  haa  been  confirmed  by  tbeij 
reMulbt  of  a  utii'ly  '■[  lli«  ''.am'  in  nil  itn  bearings. 


IcnONS  OF  THE  BKIN  DEPENDENT  ON  NEBVE 


Classification  op  Dehmatoneugoses,  -' 
The  diseases  treated  of  in  the  following  chapters  are 
generallj'  described  separately  as  difEerenfc  forms  of  in- 
flammation of  the  skin.  An  attempt  is  here  made  to 
group  them  together  by  the  bond  of  a  primary  cause 
common  to  them  all.  Widely  different  from  each 
other  as  herpes  and  leucodermia  may  appear  to  be 
in  every  other  respect,  the  essential  etiological  factor 
—namely,  disturbance  of  innervation — is  the  same 
in  both.  Erythema,  pemphigus,  herpes,  and  perhaps 
lichen,  may  be  regarded  as  connecting  links  between 
simple  vaso-motor  disturbance,  as  represented  by  urti- 
caria on  the  one  hand,  and  the  results  of  grave  struc- 
tural lesions  of  the  nervous  system,  as  displayed  in 
Raynaud's  disease  and  diabetic  gangrene,  on  the 
other.  In  studying  this  chapter  the  reader  will  do 
well  to  draw  a  sharp  line  of  demarcation  between  the 
clinical  and  pathological  farts  herein  set  forth  and 
the  chain  of  theory  by  which  it  is  sought  to  bind  them 
together.  The  former  rest  on  a  awe  foundation  of 
observation  and  experience  ;  the  latter,  like  all  chains, 
is  only  as  strong  as  its  weakest  hnk. 

The  skin  aSections  dependent  on  lesion  or  func- 
tional disorder  of  some  part  of  the  nervous  system 
may  provisionally  be  classified  under  the  following 


m 


60  NEUROTIC  AFFECTIONS  OF  THE  SKIX.   [cBiP.a 

1.  Pure  sensory  disturbances— ansesthesia,  hy] 

seatheaia,  parsoathesia,  pruritus. 

^  Pure  motor  disturbances — "  goose-skin," 
traction  of  the  muscles  and  the  hair  follicles, 

3.  Pure  vaso-motor  disturbances  caueing  abni 
mal  contraction  or  dilatation  of  the  arterioles  suppl;^ 
ing  the  skin — e.g.  urticaria,  certain  forma  of  erythei 
circumscribed  cedema,  cutaneous  htemorrhages, 

4.  Trophic  disturbances  causing  local  disorders  a, 
nutrition.     This    class    includes    certain   erythei 

"  gloasy    skin,"    pellagra,    certain    eczemas,    zos 
pemphigus,    and    certain    forma    of   ulceration 
gangrene — perforating  ulcer,  bed-sore  (Charcot),  Hsq 
naud's  disease,  and  some  varieties  of  cedema,  sclei 
dermia,   and  other  abnormalities   of  pigmentatii 
Certain  lesions  of  the  nails,  such  as  "  splitting,"  ' 
long  to  this  category. 

5.  Glandular  disturbances,  which  fall  naturally,  i 
accordance  with  the  kind  of  gland  affected,  into  t" 
following  subdivisions  ;  {a)  sweat-  glands — hyj 
drosis,  hsematidiosis,  etc.  ;  (6)  sebaceous  gla. 
rosacea,  Beborrhoaa  ;  (c)  hair  foUides — baldness,  (^ 
ness.  It  will  be  convenient,  however,  to  consid^ 
these  conditions  in  a  separate  chapter. 

It  must  be  borne  in  mind  that  this  classificatii 
is  still  largely  of  a  tentative  character  ;   but  it  e 
be  found  useful  as  a  help  in  the  provisional  airanj^ 
raent  of  observed  facts. 

As  to  the  connection  of  afiectiona  of  the  skin  w 
lesions  of  particular  parts  of  the  nervous  system,  littjl 
ia  yet  definitely  known.  That  the  brain  is  large^ 
concerned  in  the  development  of  certain  cutaneom 
affections  is  shown  by  the  frequency  with  ' 
erythema,  dermatitis  herpetiformis,  and  lichen  rabc| 
planus  can  be  directly  traced  to  violent  menta" 
emotion.  Pigmentary  changes  are  also 
result  of  nervous  shook — a  fact  illustrated  by  I 


CKAF.  iv.]  CUTANEOUS    ERUPTIONS.  51 

whitening  of  the  hair  which  Bometimes  takes  place 
under  the  stress  of  aorrow  or  anxiety,  or  even  sud- 
denly under  the  influence  of  a  great  fear.  The  com- 
parative frequency  of  leucodermia  in  the  insane 
and  in  epileptics  is  probably  attributable,  at  least  in 
some  measure,  to  abohtjon  or  suspension  of  cerebral 
control.  Facts  have  been  recorded  which  seem  to 
indicate  that  severance  of  nervous  communication 
with  the  brain  may  affect  the  distribution  of  an 
eruption.*  The  brain  acts  on  the  skin  through  tlie 
medium  of  the  sympathetic,  and  its  influence  in  the 
production  of  cutaneous  eruptions  is  measured  by  the 
degree  to  which  it  iohihita  the  vaso-motor  centre. 
In  the  majority  of  cases  no  vbible  changes  in  the 
eucephalon  have  been  found  in  relation  with  lesions 
in  the  skin.  Boumeville  and  Poirier  have,  however, 
reported  a  case  in  which  partial  discoloration  of  the 
akin  was  associate*!  with  a  tumour  in  the  left  fronto- 
parietal lobe.f 

Cutaneous  eruptiona  are  frequently  associated 
with  lesiona  of  the  spinal  cord,  the  posterior  columns 
of  which  play  a  leading  part  in  the  nutrition  of  the 
skin.  Any  abnormal  condition  which  afEecte  them 
is,  therefore,  not  unlikely  at  some  stage  of  the  process 
to  find  an  echo  in  the  integument.  This  is  especially 
the  case  in  locomotor  atasy,  in  which  skin  lesions  of 
the  moat  varied  kinds  are  of  common  occurrence.  In 
the  early  stages  erythema  simplex  and  erythema  no- 
dosum, urticaria,  papular  eruptions,  eczema,  herpes 
zoster,  pemphigus,  pustules,  ulcers  and  gangrene,  have 
been  met  with ;  their  appearance  is  usually  coincident 
with  exacerbation  of  the  lightning  pains,  and,  aa  a 
rule,  their  distribution  is  limited  to  the  course  of  the 

It  flyet.iim  Etioloiricully 
I  ■  :   mill,,,  vul.  vii.   (IStl-SSi.  p. 

+  I'ligrfs  ifiUifnl,  1879. 


52  NEUROTIC  AFFECTIONS  OF  TME  SKIN.   [ohap. 

nerve  along  which  the  pain  is  felt.*     In  the  lal 
stages  of  ataxy,  perforating  ulcer  of  the  foot,  shed- 
ding of  the  great  toe  nail,  leucodermia,  petechia  and] 
ecchymoses,    unilateral   swelling,   and   cedema  hav«. 
been  observed.     It  ia  probable  that  eclerosia  of  th*' 
posterior  columns  is  the  particular  condition  moat 
frequently  associated  with  skin  eruptions:    but 
even  in  ataxy,  such  eruptions  are  not  the  rule  but 
the  exception,  it  would  seem  that  something  besides 
the  lesion  of  the  cord  is  required  for  their  production. 
In   some   cases   of   acute   disease    characteriaed   1^ 
bullous   eruptions   {Sohwimmer,   Meyer),   the   most 
striking  lesion  in  the  cord  was  scleiOHis  of  the  colmnitf 
of  Goll.    As  to  the  relation  of  disease  of  the  of 
divisions  of  the  cord  to  affections  of  the  skin,  ■ 
pathological  evidence  is  at  present   ambiguous 
negative. f    In  spinal  meningitis  herpetic  and  pe 
phigoid  eruptions  are  not  uncommon ;  and  Erb 
that  herpes  and  huUw  are  often  associated  with 
compression  of  the  cord.    In  both  caaes  the  si 
lesions  are  probably  in  direct  relation  with  cht 
in  the  posterior  columns  or  the  issuing  nerves. 
eruptions  may,  however,  occur  in  connection 
disease  in  the  cord — aa  in  the  case  of  acute  ascei 
paralysis— where  no  visible  lesions  are  to  be  foim^' 

The  influence  of  disease  of  the  spinal  coid  oa 
cutaneous  eruptions  is  well  demonstrated  in  caeea  o^} 
Byringomyelia,  especially  in  that  variety  of  it  know'S' 
as  Morvan's  disease.^ 

Barensprung  has  shown  that  herpes  zoster  ia  the: 

•  CrooiCBr,  lui:.  cif.,  p,  STjO. 

+  Sdiwiimuer'B  cases  are  reported  iu  liia  "Dieiit__.^_ 
Denuttlonoaeii,"  a  work  in  which  the  nerrous  origin  of  re 

leaionB  wiis  (iret  fully  (iiaciiBaed  and  illustrated  b 

cases.     (Tiemiii.  189-5.) 

1  Ubiran:  Gat.  Siidom.,  IBSS,  No.  36  ei  tgg 
Adiacd,  "  Arch,  de  M^d.  Espffrimaiit.,"  1890-1895 ;  Sehl^ 
'■Sjiingomyelia"  (Vieunn,  1895.) 


.te»fl 
ed-H 

ttur^l 
oa«B 


CHAP.  IT.]  CUTANEOUS  SMUPTIONS.  53 

direct  effect  of  inflammation  of  the  spinal  ganglia 
corresponding  to  the  nerves  in  the  area  of  distribu- 
tion of  which  the  eruption  occurs.  In  some  caaea, 
however,  herpes  zoater  seems  to  depend  on  a  lesion 
of  the  posterior  spinal  roots,  the  cord  and  the  gang- 
lion being  to  all  appearance  healthy.  Herpes  fron- 
talis has  been  found  associated  with  inflammation 
of  the  Gasserian  ganglion,  or  hfemorrhage  into  that 
body  (£apoBi).  In  other  cases  herpes  has  seemed  to 
be  due  to  injury  or  neuritia  of  the  trunk  itself 
(Dubler) ;  but  in  these  cases  it  is  obvious  that  the 
inflammation  may  easily  have  extended  upwards  to 
the  spinal  ganglion.  The  same  may  be  said  witli 
regard  to  other  cases  in  which  herpes  is  a  consequence 
of  peripheral  irritation. 

The  skin  leaiona  that  have  been  observed  to  follow 
gunshot  and  other  injuries  to  nerves  are  a  very  per- 
sistent variety  of  erythema  resembling  abscess  and 
described  by  some  writers  as  erythema  nodosum, 
herpes,  bullte,  ulceration — simple  and  perforating— 
eczema,  "  glossy  skin "  (Weir-Mitchell),  defects  of 
hairs  and  nails,  pigmentary  changes,  chronic  cedema, 
and  a  condition  resembling  ichthyosis.  The  eruption 
of  hullffi  on  the  fingers  and  toes,  which  often  accom- 
panies the  shooting  pains  in  the  early  stage  of  antes- 
thetic  leprosy,  may  be  gi'ouped  under  this  head,  as 
they  are  caused  by  inflammation  of  the  nerves  of 
the  limb. 

In  cases  of  skin  eruption  (pemphigus,  leuco- 
dermia)  the  cutaneous  nerves  in  the  neighbourhood  of 
the  afEected  part  have  sometimes  been  found  to  be  in 
a.  condition  of  atrophic  parenchymatous  neuritis ; 
but  it  is  doubtful  how  far  in  such  cases  the  peripheral 
lesion  has  been  independent  of  central  changes.  It 
must  be  recollected  that  in  many  forms  of  so-called 
periplieral  neuritis  the  nerve  changes  are  in  reality 
degenerative,  and  secondary  to  influences  acting  on 


S4  NEVPOTWJFFECTJOysOFTBESKlN.  [cbjp.  « 

the  cell  in  the  cerebro -spinal  axis,  of  which  1 
axis  cyUnder  process  is  only  the  remote  peripheral 
prolongation.  It  seems  to  me  at  any  rate  probahlt 
that,  as  Crocker  says,  the  cutaneous  nerves  do  no 
give  way  until  the  central  influence  is  weakened^ 
The  direct  evidence  as  to  the  influence  of  lesions  o 
the  sympathetic  in  the  production  of  akin  eruptionf 
is  inconsiderable. 

Eruptions,  such  as  erythema  of  a  transient  kind 
urticaria  and  rosacea,  may  also  be  caused  by  refle: 
irritation  from  some  distant  part,  especially  tb 
uterus,  the  stomach,  and  the  intestines. 

Many  of  the  eruptions  associated  with  nervoi 
lesions  are  modified  by  the  fact  that  the  skin,  6» 
prived  of  efficient  trophic  control,  becomes  an  easji 
prey  to  bacteria  of  various  kinds,  including  the  pia 
cocci.* 

To  sum  up,  the  action  of  tiie  brain  on  the  t 
varies  according  as  its  control  over  tlie  ■■ 
systpm  is  increased  or  diminished.     In  the  cord,  ' 
fibres  that  regulate  the  nutrition  of  the  skin  i 
bound  up  with  the  sensory  fibres,  and  consequent^ 
are  in  the  posterior  columns  ;  outside  the  cord  &e^ 
run  through  the  posterior  roots  and  spinal  ganglu) 
with  the  sensory  fibres,  and  lesions  of  one  oi  m^ 
of  these  may  be  followed  by  eruptions  on  the  aki)^ 
It  must  be  borne  in  mind  that  precisely  similar  leraoiji 
in  a  nerve  centre  may,  in  different  individuals  or  i 
the  same  person  at  different  times,  produc 
different  effects  on  the  skin,  and  still  more  o 
produce  none  at  all.     There  are,  as  already  i 
other  conditions  which  have  a  determining  influent 
on  the  development  of  eruptions,  of  which  nothing  i 
at  present  known. 

Besides  the  various   modes  of  influence  of 

*  Galloway,  Iliit.  Jouni,  uf  Ueniml..  voi.  vii.,  pp.  3M-30a». 


CHAP.  iv.|  CUTANEOUS    ERUPTIONS.  55 

nervous  system  upon  the  skin  wliieh  have  been  re- 
ferred to,  cutaneous  leaiona  may  be  indirectly  of 
nervous  origin,  when,  owing  to  injury  or  to  the  condi- 
tion of  impaired  nerve  force  conveniently  designated 
by  the  term  "  neurasthenia."  the  innervation  of  the 
tissues  is  defective,  and  the  skin  and  other  parts  are 
therefore  more  vulnerable  than  in  the  normal  state. 

Of  skin  leaions  in  connection  with  hysteria  and 
other  neurotic  conditions  there  is  not  much  to  be  said 
in  the  present  state  of  knowledge.  Among  the  forms 
of  cutaneous  afiection  which  have  been  observed  in 
connection  with  hysteria  are  erythema,  urticaria,  pem- 
phigus, dermatitis,  pigmentation,  hyperidrosis,  chrom- 
idrosia,  and  hmmatidrosis.*  There  is  nothing  charac- 
teristic in  the  lesions.  One  point  of  difficulty  in  the 
subject  is  to  eliminate  the  element  of  fraud  or  uncon- 
scious deception  in  such  cases.  Charcot'!'  l^^s  recorded 
several  cases  of  what  he  calls  "  hyst«rical  cedema," 
which  may  ulcerate  and  simulate  cancer  ;  under  the 
name  "  unilateral  swelling  of  hysterical  hemiplegia  "  J 
a  simikr  condition  has  been  described  by  Weir- 
Uitchell ;  and  Rcnaut  has  described  a  "  gangrenous 
armaria  "  of  purely  neurotic  origin.^ 

It  has  already  been  stated  that  in  the  production 
of  skin  lesions  the  nerve  centres  operate  mainly 
through  the  agency  ol  tJie  vaso-motor  system.  In 
all  cutaneous  eruptions  of  nervous  origin  the  mechan- 
IBEO  of  their  production  is  the  same.  The  process  is 
"  angio-neurotic  "  in  character — that  is  to  say,  a 

■  A  larga  niunljer  of  easel 
ID  whicli  recover;  took  place  a. 


I  Amer.  Jouni.  Ned,  Sri,,  vol.  Ixxxviij.,  I88J. 

}  Mfdn-im-  MoJi-nH-,  Feliruaiy  20, 1 890.  Heo  ulao  Mai  Jaauph, 
"MultipU  Neurotic  Gangrene  o!  the  Skin"  {AnlU-  f.  llnimil. 
H.  Ssph..  Bil.  uai„  Hft.  3,  June,  IB96). 


w 


60  NEUROTIC  AFFECTIONS  OF  THE  SKIN.   [chat,  i 

diaturbance  propagated  from  the  centre,  or  reflected 
from  the  periphery,  sets  up  a  corresponding  disturb- 
ance in  the  vaao-motoc  centres  in  the  spinal  cord, 
with  tho  result  that  the  circulation  at  certain  parta 
ia  thrown  into  disorder.     The  blush  of  shame  and  the 
pallor  of  fear  illustrate  the  effect  of  mental  emotion  , 
— i.e.  disturbance  of  the  higher  cerebral  centres — on   \ 
the  vaso-motor  system,  and  through  it  on  the  skin. 
The  rashes  of  fevers  and  the  eruptions  caused  by    ■ 
certain  drugs  exemphfy  the  action  of  the  cerebro- 
spinal centres  on  the  integument ;    these  centres  are  J 
in  the  first  place  irritated  by  the  poisonous  material  j 
circulating  in  the  blood,  and  this  irritation  reacts  ] 
through  the  vascular  system  on  the  skin.     The  efiect  | 
of  peripheral  irritation  is  illustrated  by  the  c 
quences  which  in  some  persons  follow  contact  with  I 
certain  species  of  hairy  caterpillars.     Inte 
hypertemia,    quickly   followed   by   the   development  J 
of  a  wheal,  is  the  first  result  of  the  direct  irritation  of  J 
the   sensory   filaments,     Soon,    however,    when   the  I 
peripheral  irritation  has  had  time  to  make  itself  felt  1 
in  the  centres,  an  answering  disturbance  is  exciteofl 
in  parts  around  the  original  seat  of  irritation,  ana,! 
this  may  reach  anch  a  pitch  that  scratching  will  ac, 
once  bring  out  an  abundant  crop  of  similar  lesioiiBi.,! 
A  good  example  of  reflex  angio -neurosis  is  found  iaf 
urticaria,  in  which  the  irritation  of  the  pneumogastrioJ 
nerve  by  the  offending  agent — e.g.  ahell-fiah  i 
stomach — is  reflected  from  the  centre  to  the  s 

The  character  of  the  lesion  produced  by  dia-l 
ordered  innervation  in  any  particular  case  is  to  som^fl 
extent  a  question  of  the  degree  of  vascular  disturb^ 
ance  ;  but  that  other  elements  of  a  lesa  simple  natorel 
ate  concerned  in  the  process  is  proved  by  the  facl;l 
that  in  varicella  or  pemphigus  exudation  may  c 
without  precedent  hyperemia. 


AFB 

m 


CHAPTER    V. 

AFFECTIONS  OF  THE  SKIN  DEPENDENT  UN  NERVE 
DISORDER  {eoaliaiied). 

General  PBiNCiPtGa  of  Treatment, 
the  treatinent  of  akin  affections  dependant  on. 
oerve  disorder  there  are  certain  general  principles 
applicable  to  all  alike,  besides  special  measures  which 
are  more  particularly  indicated  in  some  of  them.  The 
latter  will  be  described  sepa,rately. 

In  all  cases  the  first  thing  to  be  aimed  at  is  to 
soothe  the  nervous  disturbance  which  is  at  the  root 
of  the  mischief.  Attention  must  next  be  paid  to  any 
imderlying  constitutional  state  or  functional  disorder 
which  tends  to  aggravate  the  skin  ajfection.  Lastly, 
symptoms,  subjective  and  objective,  must  be  reheved. 
Treatment  must  therefore  be  general  (including 
hygienic  measures,  as  well  as  internal  medication) 
and  local. 

For  the  soothing  of  the  nervous  irritability  an 
essential  element  in  treatment  is  physiological  rest. 
Excitement  of  any  kind,  violent  mental  emotion  or 
anxiety,  overwork,  and  especially  worry,  should  as 
far  as  possible  be  avoided.  A  skin  afiection  that 
defies  ail  treatment  while  the  patient  is  harassed  by 
business  cares  will  often  quickly  disappear  it  he  takes 
a  hohday.  Change  of  scene  and  healthy  amusement 
are  powerful  factors  in  restoring  tone  to  the  over- 
strained nervous  system.  Exercise,  always  well 
within  the  limits  of  endurance,  promotes  the  restora- 
km  oE  the  functional  efficiency  of  the  skin  ;    and  I 


.  NEUMOTW  AFFECTIONS  OF  THE  SKIN.  [ohap. 


have  Been  the  greatest  beaefit  follow  a  course  oJ 
massage.  If  the  cutaneous  phenomena  bi 
panieii  by  a  high  degree  of  aervoua  excitability, 
sedative  drugs  must  be  uaed,  but  only  with  the  great- 
est discretion  both  in  the  choice  of  the  drug  and 
the  quantity  administered.  Chloral  and  bromide  ol 
potassium  are  generally  contra -indicated,  on  account 
of  their  tendency  to  cauae  skin  eruptione 
cotic  be  imperatively  called  for,  ofium  is 
least  objectionable  and  the  most  efficient ;  it  may  be 
given  by  tlie  mouth,  or  in  suppository.  ParaldAyi^- 
miiy  be  administered  when  opium  is  unsuitable 
may  be  given  in  a  single  dose  of  half  a  drachm  to  a' 
drachm,  repeated,  if  need  be,  in  half  an  houi.  It  lias 
the  special  advantage  in  the  kind  of  cases  under  con- 
>ideiation  that  it  has  no  effect  on  the  skin.  In  laaa- 
tion  it  is  very  useful  in  a  dose  of  15  grains  given  at 
bedtime.  Phenacetiti  and  aiUifyrin,  in  doses  of  5 
til  1 1)  grains,  are  also  useful.  Cannabis  indica  is  some- 
timoM  a  useful  sedative,  but  must  be  administered 
with  firnut  cuution.  On  the  whole,  sedatives  must 
bfl  tdolced  upon  as  necessary  evils,  and  should  nev^j 
bn  given  except  in  response  to  the  clearest  indicatiotuj 
Norvo  tonics,  on  the  other  hand,  are  generally'" 
moNl  uitnful.  ThoHii  on  which  I  place  the  greatest 
rflliiiicn  lire  jMini up— combined  with  belladonna — 
arnnnic,  and  valftian.  Quinine  and  belladonna  raxy 
hi)  glvpii  ill  ti  pill  oompoHi^d  of  gr.  \  of  sulpkaie  of 
jrtitnin«  with  gr.  j|  of  exlraet  of  bdiadonna,  or 
mixluro  acintAlntng  tm  droja  of  the  tindvre  of 
imna  to  f,j  af  th*  tinotwe  of  qHiriint.  Valerian 
hn  ijlvnti  ill  II  mixture  compoainl  of  \\\x  of  tit 
of  w$lmian  with  tm  niiml  riunnliti/  of  tincture  of 
fiPtida,  ^•*  "/  immi'imui  tpirit  of  lavendrr,  and  i 
to  V',  til"  rlimi'  Ui  bn  t.iiki'li  every  three  h( 
I  pill  cdliMillilntI  iw/mtitnifc  of  tine  gr.  /.  eoinpound 
atafwtitla    pill    urt.    ij,    to    wnlre    one    fiiU,    one 


I 


T.]  TREATMENT  OF  OUTAXEOVS  NEUROSES.  59 

two  to  be  taken  every  foui  hours.  Valerian  may 
be  combined  with  quinine  in  a  pill  composed  of 
vaierianale  of  zinc  gr.  j,  sulphate  of  quinine  gr.  \, 
compound  rhubarb  jnU  gr.  j,  and  extrad  of  gentian 
gr.  j.  Arsenic  is  best  given  in  the  form  of  Fowler's 
solution.  Three  {gradually/  increased  to  five  or  even 
eight)  minims  in  a  wineglass  of  water  should  be  taken 
three  times  a  day,  after  meals  ;  or  a  pill  composed  of 
arseniate  of  sodium  {gr.  ^-f  to  -jK,]  and  quinine  {quin. 
suljih.,  gr.  J)  may  be  given.  Arsenic  may  also  be 
given  in  the  form  ol  the  "  Asiatic  pill,"  much  used 
on  the  Continent.  The  following  is  the  formula  : 
Arsenious  acid  gr.  6()J,  powdered  black  pepper  ^lie, 
gum  Arabic  and  water  q.s.  To  be  divided  into  800 
pills,  each  of  which  contains  gr.  i',  of  arsenious  acid. 
In  all  cases  of  skin  disease  with  marked  nervous 
symptoms,  any  functional  disorder  of  internal  organs 
that  may  be  a  source  of  reflex  irritation  must  be 
dealt  with  by  appropriate  measures.  The  bowels 
must  be  regulated,  digestive  disturbance — whether 
hepatic  or  gas tro- intestinal — must  be  remedied,  and, 
in  women,  menstrual  irregularity  or  other  uterine 
trouble  must  be  corrected.  The  constitutional  con- 
ditions most  frequently  associated  with  skin  affections 
of  neurotic  origin  are  gout,  rheumatism,  and  glyco- 
suria ;  these  must  be  treated  on  general  medical 
principles.  As  regards  diet,  the  guiding  principle 
must  be  to  forbid  all  food  of  a  stimulating  or  con- 
stipating character,  a  sound  practical  rule  being  that 
the  patient  should  avoid  whatever  causes  flushing 
of  the  face  lasting  for  some  time  after  a  meal.  Total 
abstinence  from  alcohol  should,  as  a  rule,  be  en- 
joined. The  clothing  should  be  loose  and  not  too 
heavy,  and,  generally  speaking,  the  patient  should — 
especially  when  in  bed — ^keep  himself  as  cool  as  poa- 
'ble,  short  of  discomfort. 
[  Local   treatment  resolves   itself   into   protection 


P60  NBUBOTIO  AFFECTIONS  OF  THE  SKIN.  [ohaj.  v,  ^M 

of  the  afiected  parts  from  the  air,  the  subduing  of  ^| 

infiammation,  the  relief  of  itchin;^,  and  the  cnie  of  ^| 

secondary    lesions    caused    by    scratch iug    and    the  ^H 

inoculation    of    pyogenic     material.     The    mflamed  ^H 

surface  may  be  protected  by  dusting  thickly  over  ^H 

with  powders,  such  as  oxide  of  zinc  1  part,  to  3  parts  ^^ 


^ 


of  -powdered  rice,  starch,  maize,  or  kaolin  ;  or  boric 
add  reduced  to  fine  ■powder  1  part,  to  3  parts  of  rice, 
starch,  kaolin,  or  white  fvUer's  earth  ;  or  X\\xv}  of 
creosote  in  3/  of  kaolin.  A  hot  fomentation  should  be 
applied  over  the  powder  bo  as  to  vaporise  the  creosote 
and  keep  the  part  in  an  antiseptic  atmosphere. 
Another  useful  powder  is  the  following :  SalicyUc 
acid  3  parts,  powdered  talc  87  parts,  powdered  starch 
10  farts.  Powders  are  beat  applied  by  dusting  a 
muslin  bag  previously  filled  with  them  over  the  part. 
Unna's  powder-bags  may  also  be  employed.  They 
are  made  of  old  used  linen  or  other  material  not  too 
thick,  the  pieces  being  evenly  cut  and  sewn  together 
in  the  form  of  a  bag,  except  at  one  border,  which  is 
left  open  so  that  the  bag  may  be  partly  filled  wif^ 
lice  or  potato  meal.  When  closed,  the  bag  is  sewn 
with  quilt  stitches  through  and  through,  in  order  to 
beep  the  powder  evenly  distributed ;  it  is  thea' 
placed  on  the  affected  skin  and  tied  in  position.  Fatty-  ■ 
substances  must  not  be  applied  to  the  skin  at  the  same 
time,  as  they  fill  up  the  interstices  of  the  bag.  For 
the  arms  and  legs  two  sleeves,  or  the  lege  of  a  p&iz  : 
of  fine  drawers,  stockings,  etc.,  one  placed  within^ 
the  other,  with  the  space  between  filled  with  powdOT, 
should  be  used.  For  the  genitals  the  bag  can  be-- 
fastened  on  with  a  suspensory  bandage  ;  a  broad  1 
muslin  bandage  can  be  used  for  the  body,  and  bi^ 
can  be  shaped  into  masks  for  the  face.*  Sedative 
aatringent  lotions  are  preferable  when  much  heat  and'  ■ 

"  Sulected  Moiiofjraphs  011  Decmatology,"  New  Sydenham 
Sooietr.    London,  1BB3;  p.  73. 


v.]TREATMENT  OF  CUTANEOUS  NEnSOSES.61 

irritataon  are  complained  of.  The  most  generally 
useful  is  calamine  lotion,  composed  of  pTepared  cala- 
mine 511;,  ox*rfe  of  zinc  5»j,  pure  glycerine  ?,jss,  and 
rose-water  5PJ ;  carbolic  acid  may,  if  it  seem  desirable, 
be  added  to  this  lotion.  Le.ad  lotions  are  also  very 
serviceable  :  ii\x  to  vi\xxx  of  the  solution  of  ike  subace- 
tate  with  glycerine  niirtt  and  water  ^j ;  or  51/  of  the 
solution  of  the  subacdate  with  Jt;  0/  fresh  tnUk  may  be 
applied  by  means  of  a  piece  of  rag  kept  wet  with  the 
lotion.  The  following  is  an  excellent  lotion  when 
there  is  much  hypereemia  :  Svbnitrate  of  bismuth 
gr.  X,  oxide  of  zinc  ^ss,  glycerine  w\xv,  hyd.  ferchlor. 
gr.  i,  rose-water  3;'.  Cooling  ointments  such  as  "  cold 
cream,"  and  the  unguentum  plumbi  subacetatis,  are 
often  of  service  in  allaying  heat  and  ledncing  local 
congestion.  The  following  is  the  formula  of  an  ex- 
cellent cold  cream  :  R  CercB,  cetacei,  aa  I'O,  d. 
atnygdal.,  aq.  rosarum,  da  lO'O.  M.  Other  useful 
formulffi  are:  ^-  Lanolin,  anhyd.  10,  adif.  benzoat. 
20,  aq.  rasa  30  (Uona) ;  H  Lanolin,  anhyd.  10,  adif. 
benzoat.  20,  aq.  colds  30 ;  and  ^  Lanolin,  anhyd.  10, 
adip.  bernoat.  20,  %.  plumbi  subacetatis  30.  The 
following  is  recommended  by  Jamieson  as  a  most 
useful  soothing  ointment :  Zinci  carbonatis  '^j,  acidi 
iolicylip-i  grs.  x,  vaselini  5/,  cerali  Galeni  {cold  cream) 
ad  5/.  M.  Boracic  acid  ointment  is  an  excellent  ap- 
plication, especially  in  moist  part^,  as  between  the 
thigh  and  scrotum.  It  should  be  prepared  as  follows  : 
Paraffin  (135°  or  140°)  5  parts,  vaseline  15  parts,  and 
boric  acid  in  fine  powder  4  parts  (Martindale).  The 
substance  which  is  pexhaps  more  effectual  than  any 
other  for  the  reduction  of  hypersemia  is  ichthyol. 
This  may  be  applied  as  an  ointment  (10  to  20  per 
cent.),  or  a  paste  prepared  as  follows :  R  Sulpho. 
idahydate  of  ammonium  VO  to  3'0 ;  water,  glycerine, 
^  dextrine,  of  each  10-0;  mix,  unth  gentie  heat 
ma) ;  or  ichthyol,  grs.  x  to  5/,  lanolin,  vaselin,  zinc 


62  NEUROTIC  AFFECTIONS  OF  THE  8KI^.  [ohap.  v. 

exide,  ptdo,  amyli,  da  '^ij  (Ihle).  Ichthyol  may  also 
be  applied  in  the  form  of  a  super-fatted  soap  as 
a  salve  muslin,  or  in  a  glycerine  jelly.  The  best  for- 
mula for  the  latter  is  that  of  Unna :  Gelatine  15'0, 
zinc  oxide  10*0,  glycerine  30'0,  water  40*0.  To  this 
2  j)er  cent,  sidpho-icJuhyolate  of  ammonium  is  added. 
Other  substances,  such  as  resorcin,  tar,  salicylic  acid, 
etc.,  may  be  applied  in  the  same  excipient. 

The  results  of  scratching  and  inoculation  of  pus 
cocci  must  be  dealt  with  on  general  principles,  the 
leading  indication  being  to  make  the  parts  thoroughly 
antiseptic.  For  this  purpose  a  useful  appHcation  is 
boracic  acid  ointment,  prepared  as  already  described. 
Unna's  mercury  carbolic  or  salicylic  plaster-muUs,  or 
resorcin  in  the  form  of  ointment  (2  to  10  per  cent.), 
are  also  of  service. 


CHAPTER   VI. 


AFFECTIONS  OF  THE  SKIN  DEPENDENT  ON  NERVE 
DISORDER  {continued). 

SeNSOHV  NEUKOaES   OF  THE   SkIN. 


The  sensibility  ol  tlie  skin  may  be  i 
disordered,  or  abolished  without  any  visible  lesion  to 
account  for  the  subjective  phenomena.  When  itching 
is  present,  secondary  lesions  produced  by  scratching 
can  nearly  always  he  seen ;  but  these  are  the  efiect 
and  not  the  cause  of  the  sensory  disturbance. 

HyperEBSthesia.  —  Hyperiestheaia  of  the  skin 
18  met  with  in  certain  nervous  afiectious  ;  the  exces- 
sive aensibihty  may  be  general  or  limited  to  the  area 
of  distribution  of  a  particular  nerve.  The  increased 
keenness  of  the  pain-sense  is  often  accompanied  by 
a  greater  or  lesser  degree  of  diminution  of  tactile 
sensibility.  In  hysteria  the  sensibility  of  the  skin  is 
often  greatly  exaggerated,  a  characteristic  point  being 
that  the  hypenesthesla  ia  very  inconstant,  both  in 
position  and  in  duration.  This  painful  sensation  is 
produced  by  light  stroking  rather  than  by  firm  pres- 
sure. 

Actual  neuralgic  pain  in  tlie  skin  is  not  uncommon 
in  locomotor  ataxy,  and  sometimes  it  seems  to  be  fche 
result  of  cold.  It  is  generally  localised  in  hairy  parts, 
and  niffling,  or  even  touching,  the  hair  sometimes 
causes  much  discomfort,  of  a  character  akin  to  the 
pain  of  so-called  "muscular  rheumatism,"  Spon- 
taneous pain  in  the  toes,  followed  by  patchy  red 


'    64  NEUROTIC  AFFECTIONS  OF  THE  SKIN,  [obai 

discoloration  of  the  skin,  and  aggravated  by  warmth, 
has  been  described  by  Weir-Mitchell  under  the  name 
of  "  erythromclalgia."     The  pain  was  so  severe  in  the 
case  which  formed  the  basis  of  his  description  that  the 
'  patient  submitted  to  amputation  of  one  of  his  toes. 
AnEBSthesia. — Loss   of   sensibility  depends   on 
various  central  and  peripheral  nerve  lesions,  and,  as 
a  rule,  lies  beyond  the  province  of  the  dermatologist. 
It   is   a   prominent   symptom   of  non-tuberculated 
'  leprosy,  in  which  the  absence  of  common  sensibility 
I  is  often  associated  with  increased  sensitiveness  to 
I  cold.    Owing  to   this,   the   lepers   in  Norway   fre- 
quently inflict  on  themselves  severe  bums  by  press- 
ing their  hands  and  feet  against  the  bars  of  the  grst«. , 
Antesthesia  is  sometimes  a  symptom  of  hysteria  ;  in 
that  case  it  is  apt  to  shift  about  very  suddenly  from 
one  part  of  the  body  to  another. 

Pruritus. ^ — The  term  "  pruritus  "  is  not  synony- 
mous with  itching  in  the  language  of  dermatology. 
Itching  is  the  general  term  which  includes  the  par- 
ticular variety  pruritus.    Itching  may  be  caused  by 
parasites,  or  by  certain  definite  skin  lesions  ;  pruritoB 
is  itching  without  any  visible  cause  to  account  for  it. 
It  ia  a  true  sensory  neurosis  due  to  some  functional' 
disorder  of  the  related  nerves  independently  of  any 
ve  of  irritation  on  the  surface.*     The  symptom 
_■  be  so  mild  as  hardly  to  interfere  with    thff 
patient's  comfort,  or  it  may  be  so  severe  and  per- 
sistent as  to  endanger  his  life  from  sleeplessness,  (M 
his  reason  from  the  nervous  irritability  which  H 
'  aggravated  by  errors  of  diet 


It  is  usually  aggravated  by  errors 

ID,  in  a  pupCT  on  "  The  Sannation  of  Ituhing," 
ilected  Monographs  on  Dermatology"    (New  SylloiUiaa 
,  Loudon,  1893,  p.  209  'll"/9_.),  oomea  to   tho  oondod^ 
(he  dislurbanoB  m  pturituo  a  of  the  natnrB  of  a  dyia 


Ottii'.  V(.l  PEUBITVS.  ng 

by  the  warmth  of  the  bed,  and  by  mental  excitement. 
The  strongest  will  cannot  keep  the  patient  from  seek- 
ing relief  in  scratching,  and,  as  a  matter  of  fact,  the 
itching  often  ceases  when  excoriation  has  been  pro- 
duced. 

Pruritus  may  be  general  or  local.  Of  the  former, 
three  varieties  are  described— pruritus  universaliB, 
pruritus  hiemaiis,  and  pruritus  senilis.  In  the  first 
of  these  the  itching,  though  affecting  the  whole  body, 
is  not  felt  all  over  the  surface  of  the  akin  at  one 
and  the  same  time  ;  it  is,  fortunately,  also  subject  to 
remisBions.  The  causes  are  mostly  constitutional 
— gout,  rheumatism,  jaundice  and  functional  derange- 
ment ot  the  liver,  diabetes,  Bright'e  disease,  cancer  of 
the  stomach  or  liver,  dyspepsia,  uterine  disease,  and 
pregnancy.  Many  safferers  from  universal  pruritus 
are  the  subjects  of  lithsemia  or  oxaluria.  The  afiec- 
tdon  oft«n  begins  in  cold  weather,  but  it  is  by  no 
means  confined  to  the  winter.  Pruritus  hiemaiis,  on 
the  other  hand,  according  to  Duhring,  begins  between 
October  and  January,  and  ceases  about  April  or  May. 
The  itching  generally  affects  the  extensor  surfaces 
of  the  limbs,  especially  the  thighs,  but  the  whole 
surface  of  the  skin  may  be  involved.  The  itching  is 
worst  on  going  to  bed  and  on  leaving  it,  probably 
owing  to  the  sudden  change  ot  temperatm-e  in  each 
case.  During  the  day,  when  the  patient's  attention 
ia  otherwise  engaged,  he  ia  but  bttle  troubled.  In 
this  form  of  pruritus,  though  the  exciting  cause 
seems  to  be  cold,  tJie  patients  are  generally  of  goutj- 
or  rheumatic  antecedents  or  inheritance.  Many  of 
them  are  uf  neurotic  constitution,  and  are  the  subjects 
of  hay  fever.     Others  have  a  naturally  dry  and  thick 

Pruritus  senilis  is  probably  the  expression  of  senile 
changes  in  the  skin.  It  begins  usnally  after  the  age 
of  Ii5,  aud  is  extremely  peraistent.     A  remarkable 


00    NEUROTIC  AFFECTIONS  OF  THE  SKl^■.   [chap,  v 

feature  in  this  form  of  pruritus  ia  that  acratchin 
leaves  little  or  no  mark  (Brocq). 

The  loca!  varieties  of  pruritus  affect  the  anus,  tht 
vulva,  the  sciotum.  the  nares,  the  palms  of  the  handsel 
and  the  soles  of  the  feet.     In  most  cases  some  locoll 
cause  of  irritation  will  be  found  if  carefully  looked  7 
for.     Thus  pruritus  ani  may  be  due  to  htemorrhoidB, 
to  the  presence  of  scybala  in  the  rectum,  to  aacajidea, 
to  fissures,  etc. ;    sometimes  it  appears  to  depend  on 
dietetic  errors,  notably  the  abuse  of  coffee.     PruritoB 
of  the  vulva  may  be  caused  by  ovarian,  uterine  c 
vaginal  disease,  and  especially  by  the  passage  of  lai^ 
quantities  of  sugar  in  the  urine.     It  is     ' 
climacteric  symptom.     In  young  children  prurita 
may  be  due  to  the  presence  of  ascarides  in  the  rectu 
Pruritus    of    the    scrotum,    apart    from    eczema    ■ 
intertrigo,    is   rare ;     when  present,    however, 
a  most  distressing  affection.     The  point  of  maxima] 
intensity  of  the  itching  is  the  raphe  (Brocq).  Pruritu) 
narium  is  generally  a  trivial  affection ;  those  subje( 
to  it  are  usually  of  gouty  strain.     The  itching  i 
sometimes   brought  on  by  the  motion  of  a  caniara 
Pruritus  palmanim  et  plantarum  is  very  rar 
sufferers  are  mostly  gouty.    In  women  it  i 
times  associated  with  uterine  disorders.    The  affeq 
tion  is  symmetrical,  and  is  often  extremely  tronl^ 

When  pruritus  is  complained  of,  the  first  thing  i 
Imi  doiin  is  to  exclude  all  possible  sources  of  p 
irritation—  lico,  bugs,  fieaa  et  hoc  genua  omne. 
in  this  matter  must  be  taken  for  granted ;  lice  a. 
itoh  arn  ttomt-timpH  found  in  the  most  unexpected  qui 
tnrs.  Tim  wtimtion  of  the  scratches  must  be  note 
H  the  «li(HildorH  arn  marked,  especially  in 

p(<oi]lii,  tlin  pMnoneo  of  pediculi  must  be  suap 

if  tim  wrinU  utkI  iiitcrUlRital  spaces,  the  burrtjwSjl 
tho  aoarun  kv.Mm  mu»t  Im  very  carefully' looked  i 


piiAp.  VI.]        TREATMENT  OF  PRURITUS.  07 

Id  all  caaes  of  local  pruritus  tlie  parte  muat  be  ex- 
amined for  the  cottditiona  that  have  been  mentioneil 
as  often,  producing  it.  The  urine  muat  be  examined 
and  the  constitutional  state  inquired  into.  It  is  a 
sound  rule  of  practice,  however,  to  fall  back  on 
genera!  causes  for  pruritus  only  when  minute  in- 
vestigation fails  to  reveal  any  local  source  of  irrita- 
tion. 

In  the  treatment  of  pnuituB  the  first  indication 
h  to  discover  and  remove  any  local  source  of  irrita- 
tion. Silk,  or  the  beat  merino-silk,  underclothing 
should  be  aubatituted  for  flannel.  In  the  intense 
itchiog  about  the  anna,  vulva,  and  meatus,  tliat  makea 
life  a  miaery  to  some  patients,  careful  examination 
will  often  reveal  a  definite  focus  of  irritation  recog- 
nised by  the  sufferer  as  the  point  from  which  the 
trouble  starts.  There  may  be  nothing  to  see  at  the 
spot  indicated ;  or  slight  localised  congestion  or  a 
tiny  excoriation  may  be  visible.  In  such  cases  the 
application  of  menthol  or  cocaine  will  generally 
relieve  the  itching  for  a  time.  When  mdder  measures 
fail  the  best  plan  is  to  destroy  the  focua  of  irritation. 
For  many  years  I  have  been  in  the  habit  of  destroy- 
ing the  point  to  which  the  source  of  irritation  is  re- 
ferred by  touching  it  with  Paquelin's  thermo-cautery, 
after  having  applied  cocaine.  Whenever  itching 
about  the  genitals,  especially  about  the  orifice  of 
the  urethra,  is  complained  of  by  a  person  of  either 
sex.  the  urine  shoidd  be  examined  for  sugar.  Irrita- 
tion due  to  glycosuria  may  be  reheved  by  the  applica- 
tion of  menthol,  or  the  parts  may  be  bathed  with 
water  as  hot  as  can  be  borne,  and  after  drying  smeared 
with  iciithyol  ointment  (lU  per  cent.).  In  other  caaes 
it- may  be  found  that  the  irritation  is  cauaed  by 
ascarides,  hemorrhoids,  or  leucorrhcea.  These  vari- 
ous conditions  must  be  treated  with  auitabie  reme- 
dies.    Very   common  causes  of  local  irritation  are 


68   NEUROTIC  AFFECTIONS  OF  THE  SKIN,   [csa 

pediculi  and  itch-mites,  the  methods  for  detecting 
and  destroying  wliich  are  described  eisewhere. 

If   no   local    cause    can    be    discovered,    gene 
measures    must   be    employed-     The    patient's    diet 
must  be  carefully  regulated,  abstinence  from  coffee, 
tea,  and  sugar,  in  paiticolar,  being  enjoined,   and 
alcohol  being  absolutely  forbidden.     It  will  be  well 
■  also  if  the  patient  can  be  induced  to  esclade  shell- 
[  fish,  pickles,  and  all  highly  seasoned,  ealted,  or 
served  food  from  his  dietary  ;    white  meats,  g 
vegetables,  and  light  milk  puddings  should  form  Hs 
bill  of  fare,  and  he  should  drink  nothing  but  aerated 
waters.     If  there  be  any  evidence  or  reasonable  sufr- 
picion  of  gout,  salicylate  oj  soda  should  be  given  in  tJie . 
ordinary  doses  ;    a  combination  of  ealomd,  gwiiaovm, 
and  sulphurat&i  antimony  in  the  form  of  FlnmiseE'» 
pill    is    also    often  of  great     service.      Such    o 
are  likely  to  derive  benefit  from  a  course  of  sul|duw 
I"  waters — particularly  those  of  Harrogate  (Old  Sulpliiif 
[  Well),  Strathpefier,  fichinznach,  Aix-les -Bains,  and; 
P  Luchon.     In  senile  pruritus,  indifferent  waters,  such 
I  as  those  of  Bath,  Buxton,  or  Gastein,  are  more  likely 
I  to  be  serviceable. 

I  As  regards  internal  medication — apart  from  the 
I  nerve  tonics  and  sedatives  that  have  been  mentioned  i 
I  — earbdic  acid  and  cannabis  indica  are  the  drugs 
Imost  generally  useful.  Brocq  speaks  well  of  tfcfti 
Pformer ;  he  gives  it  in  pills  containing  from  5  to  lOi 
I  centigrammes  of  the  acid  combined  with  extract  t ' 
I  gentian,  and  with  digestive^  or  anti-arthritic  remedtt 
k  according  to  the  indication.  The  amount  of  csrblA. 
I  acid  taken  daily  is  from  20  to  60  cenligrammetf 
i  &e  pills  are  taken  at  the  beginning  of  a  meal,  wateiv 
K  BOup  or  food  being  swallowed  immediately  afttt-; 
r  wanis.  Carbolic  acid  may  also  be  given  in  piUs  eom* 
f  msed  of  absoliae  phenol  grs.  ij,  glycerine  t!ij,  poif^ 
[  iered  marsh-malloui  grs.  iij  [to  make  one  piU) ;   o    "  " 


CHAP.  ix|        TREATMF.ST  OF  I'RUIilTI-S.  m 

perlea  ol  carbolic  oil,  each  containinj^  gr.  j.  of  earboUo 
acid.  Cannabis  indica  is  partiicularly  recommended 
by  Bulkley  in  senile  pruritus  ;  he  begins  with  len 
minims  of  the  tincluTe,  usually  increased  by  degrees 
to  twenty  or  ewn  thirty,  three  times  a  day.  The 
drug  should  be  given  largely  diluted,  and  its  effect 
should  be  watched.  The  same  writer  also  speaks 
well  of  a  combination  of  tincture  of  gdsemium  and 
tincture  of  nux  vomica.  Ichtkyol  is  often  an 
efficient  remedy  ;  it  may  be  given  in  doses  of  grs. 
i)HS.  m  the  form  of  capsule,  tabloid,  or  coated  pill. 
Digitalis  and  ergot  are  both  occasionally  of  service. 
Anlipyrin  in  doses  of  ten  to  fifteen  grains  is  some- 
times very  useful,  but  ite  action  is  uncertain.  The 
subcutaneous  injection  of  nitrate  of  pUocarpin 
(?''■  I'ii).  once  a  day,  is  often  of  the  greatest  service, 
owing,  no  doubt,  to  the  moistening  of  the  skin  which 
it  produces. 

As  a  rule,  however,  it«hing  can  be  relieved  only 
by  external  remedies.  When  pruritus  is  general, 
Turkish  hatha  often  give  great  relief,  owing  to  their 
diaphoretic  action  and  the  thorough  removal  of 
effete  epidermic  material  which  results.  Continuous 
emollient  or  alkaline  baths  are  also  most  useful. 
The  former  may  consist  of  bran  "2  to  fi  lb.,  potato 
starch  1  ft.,  or  linseed  1  lb.  in  30  gallons  of  water  ; 
the  latter,  of  bicarbonate  of  soda  Jj;  to  $x,  or  carbonate 
of  potash  31/  to  3t)j',  or  borax  ^iij,  in  the  same  quantity 
of  water.  I  have  kept  a  highly  neurotic  patient 
suffering  from  intense  itching  in  a  bran  bath  for 
severai  days  almost  continuously  in  comparative 
comfort.  An  excellent  bath  for  lessening  the  sensitive- 
ness of  the  skin  is  made  by  mixing  jij  of  sulphurated 
potash  with  30  gallons  of  water.  All  the-se  baths 
should  Ite  taken  warm,'and  the  skin  may  afterwards  be 
Tub)>ed  with  the  lather  of  medicated  soap  or  smeared 
with  an  ointment.     Beginning  with  the  simplest  and 


70  NEUEOTIC  AFFECTIONS  OF  THE  SKIN.   [ohap.  ^ 

most  generally  available  remedies,  an  excellent  ap-J 
plication  is  jilain  hot  water.     A  sponge  dipped  in  tliisl 
and  partly  squeezed  out  should  frequently  be  fijmly  ■ 
pressed  on  the  itching  part  at  short  intervals,     Tbia 
method  is  particularly  useful  in  itching  of  the  anoaf 
and    scrotum.     When    other    applications    are 
ployed,  it  ia  a  good  plan  always  to  bathe  the  parttl 
with  hot  water  before  putting  on  a  fresl 
The  application  of  a  coohng  lotion  or  ointment  giyeS'l 
more  relief  if  preceded  by  the  local  use  of  hot  wateia 
as  described  ;    indeed,  sudden  alternations  of  hefttf 
and  t'old  are  of  themselves  useful  in  relieving  itcbi 
Simple  evaporating  lotions  hardly  ever  fail  to  afford] 
temporary  relief ;    they  should  be  applied  by  i 
of  pieuea  of  linen  or  lint  kept  constantly  wetted  witl 
the  solution.    A  good  evaporating  lotion  may  ' 
made  by  mixing  ordinary  vinegar  with  an  eqoal^ 
quantity  of  water.    A  better  application  consists  of 
equal  parts  of  eau-de-cologne  or   spiritus  ammoniw 
aromalicue  and  water.      An  excellent  auti-praritic 
lotion  ia  liquor  plumbi  s«6aeeteiM  51/  to  5iii,  distilled 
water  to  ^viij,  or  ^j  of  the  solution  of  the  subacetale  in 
5»/  of  fresh  milk. 

Alkaline  lotions  are  also  useful ;  they  should  be 
applied  after  the  part  bas  been  washed  and  dried. 
Among  such  lotions  may  be  mentioned  the  follow- 
ing :  Borax  Ji/,  glycerine  Jss,  water  1  quart ;  car- 
bonate of  potash  5j/,  water  %viij  ;  bicarbonate  of  soda 
S)  (W  5V,  glycerine  ^jsa,  eider-flower  water  50/. 

-One  of  the  most  effectual  local  agents  is  carbolic 
add,  which  may  be  used  in  a  watery  solution  {grs.  ij 
to  iv  ad  3/)  or  in  the  form  of  a  lotion  composed  of 
5/  of  the  acid  and  ^ij  of  pure  glycerine,  with  water 
to  %viii,  or  ae  a  liniment  containiruj  1  part  of  carbdiv . 
acid  in  \9  of  olive  oU.  The  following  is  a  uaefullotion  : 
Acid,  carbd.  '^j,  glycerin,  pur.  '^ij,  sp.  vini  red.  5*1/, 
aq.  camph.  3  v.    Compresses  eoaked  in  these  lotione 


PHAP.  VI.]        TREATMEyi   OF  FRVHITI  S  71 

should  be  applied  every  hour  or  two  Carbolic  acid 
may  be  combined  with  cocaine  in  an  ointment  or  a 
lotion,  A  useful  formula  for  the  former  is  acid 
carbol  v\xx,  hydTochlorate  of  cocaine  grs  x,  vaseline 
3/  ;  and  for  the  latter,  ac%d.  carbd.  ys,  cocmne  ^ss, 
aq.  laurocerasi  3;,  aq.  rosw  %%].  These  should  be 
applied  several  times  a  day.  Carbolic  acid  may  also 
be  advantageously  combined  with  mercury  in  an 
ointment  as  follows  :  Hyd.  percM.  grs.  ij  to  v,  acid. 
carbol.  nyxx,  oi.  olivm  5/,  benzoated  oxide  of  zinc 
ointment  5/-  Brocq'a  carboliaed  pomade,  consisting 
of  ijTS.  XV  of  carbolic  acid,  5  drachms  of  lard,  and  lU 
drachms  of  lanolin,  is  an  excellent  apphcation.  He 
recommends  that  after  it  has  been  applied  the  pa.rts 
should  be  well  dusted  with  starch  powder. 

Among  local  applications  one  of  the  most  valuable 
is  menthol,  which  leaves  the  parts  numb  and  cold 
for  some  time,  to  the  great  comfort  of  the  patient. 
This  may  be  apphed  either  by  rubbing  the  affected 
surface  with  the  solid  cone  previously  wetted  with 
alcohol  or  water,  or  better  in  a  solution  of  Ti  to  1(J 
grains  in  one  ounce  of  dilute  alcohol.  It  may  also 
conveniently  be  used  in  the  form  of  soap.  Menthol 
and  eucalyptol  soap  is  particularly  useful.  The  re- 
freshing coolness  caused  by  menthol  is,  however,  often 
replaced  after  a  time  by  heat,  tingling,  and  even 
slight  pain,  somewhat  resembling  the  re-eatablish- 
ment  of  the  circulation  after  partial  froat-bite. 

Another  most  useful  anti-pruritic  remedy  is  coca- 
ine, which  can  be  used  either  alone  or  combined  with 
almost  any  other  substance.  The  most  convenient 
form  for  general  use  is  in  an  ointment  with  lano- 
vaseline  or  boric  acid  ointment  as  a  base.  In  pruritus 
ani  a  half-grain  suppository  of  cocaine  will  usually 
give  relief. 
mChlorolorm  is  also  serviceable  in  allaying  itching. 

lay  be  employed  in  the  form  of  an  oiti'ment  con 


w 


NEUSOTW  AfFEOTIONS  OF  TllK.  SKIX.   [chu 


taining  5/  to  '^vj  of  lanolin,  or  as  a  lolion  of  v\xv  to  %iv 
of  distilled  water,  and  put  into  an  eight-ounce  bottJe, 
so  that  it  can  be  thoroughly  shaken  up  before  use, 

CMoral  is  also  beneficial  as  a  local  application ; 
a  solution  of  the  drug  in  epirit  or  eau- de-cologne  may 
be  sprayed  on  the  affected  part  after  it  has  been 
exposed  for  some  time  to  hot  steam  and  then  dried. 
Equal  parts  of  chiora!  and  camphor  nibbed  up  to- 
gether make  a  good  anti -pruritic  application. 

Hydrocyanic  acid  is,  in  my  opinion,  much  over- 
rated as  an  anti-pruritic.  It  may  be  used  iu  the 
form  of  a  lotion  containing  5^7  of  dUtUe  hydrocyanic 
add,  5;  of  borax,  '^viij  of  rose-waieT  ;  or  '^jss  of  ht/dro- 
cyanic  add,  solution  of  acetate  of  ammonia  %j,  with 
rose-water  to  '^viij.  A  much  used  lotion  is  the  follow- 
ing, recommended  by  the  late  Mr.  Startin :  Borax, 
carbonate  of  ammoma,  of  each  ^jss,  glycerine  3;',  diliUe 
hydrocyanic  add  5w/,  water  Ixvf  ;  to  be  usml  diluted 
1  to  four  times. 

Salicylic  acid  can  be  apphed  diluted  with  gly- 
cerine or  alcohol,  or  as  an  ointtnent  containing  grs. 

Wit  to  XV  of  the  acid,  vasdine  and  carbonate  of  xino  of 

KnkA  5;,  and  cold  cream  to  ^j. 

Br    Mercurial  ajijilications    are    extremely    valuable. 

■  Among  them  may  be  mentioned  black  wash,  which 
may  be  used  either  alone  or  in  a  vehicle  of  mucilage 
of  tragacanth,  as  follows  :  Lot.  nigrce,  liq.  calcie,  M 
Sit),  mucHag.  tragacanth.  5/.  The  following  is  an 
excellent    application :     Hyd.    perchlor.    grs.    v,    «p. 

5W11J..  A  useful  lotion  may  also  be  prepared  as  fol- 
lows :  Hyd.  perchlor.  gr.  ij,  glycerine  38*,  ag.  ckloro- 
formi  ad  3W1/,  Citrine  ointment  freely  diluted  is 
often  of  service  in  pruritus  senilis.  Mercury  may  be 
combined  with  hydrocyanic  acid,  as  in  the  following 
formula :  IjE  Dilute  hydrocyanic  acid  ^j.  corroHve 
suUimale  gr.  j,  dder-fiower  ivater  %vj. 


(.■HAP.  VI.]         TREATMENT  OF  FRUIurVS.  73 

The  most  convenient  form  of  applying  lar  is  the 
liquor  picis  earbonis,  which  may  be  used  diluted 
with  water  or  spirit  to  the  proportion  of  I  in  1  or 
weaker  ;  or  combined  with  Bolution  of  suhaoetate  of 
lead,  one  or  two  draelima  of  cash  in  ^viij  of  rose-water. 
Lotio  picis  earbonis  may  ako  be  used  with  calamine 
lotion  aa  a  vehicle  (5ij  of  the  former  to  ^viij  of  the 
latter).  Liquor  rvsci  ileiergens,  a  solution  of  oleum 
nisei  in  spirit,  can  be  used  in  the  same  way  as  lotio 
earbonis. detergens.  Tar  may  also  be  apphed  in  the 
form  of  ointment  as  follows :  l^t  Tar  5/,  camjihorie 
</r».  X,  adipia  5/  ;  or  in  pastes. 

Naphtho!  is  useful  in  the  form  of  a  soap  or  an  an 
ointment,  prepared  as  follows  :  Napklkol  iS  ijrs.  /v, 
lanotini  •,{/,  ung.  simpl.  3;. 

Nitrate  0/  HUver  in  solution  (grs.  v  to  xv  in  ^j 
of  water  or  spiritus  ietheris  nitroai)  often  gives  rehef. 
Benzoin  in  the  form  of  compound  tincture  painted 
on  with  a  camel-hair  firush,  or  a  solution  of  benzoic 
acid  3ij  in  ^viij  of  diluted  alcohol,  appbed  by  means 
of  compresses,  is  also  useful. 

Ichlkf/ol  may  almost  always  be  used  with  ad- 
vantage. It  is  well  to  begin  with  a  weak  solution, 
BUcb  as  1  in  l(i,  and  gradually  increase  the  strength 
up  to  equul  parts.  The  efiect  is  often  increased  by 
the  addition  of  a  small  quantity  of  precipitated  aul- 
phur.  Ichthyol  may  also  be  applied  in  ointment 
soap,  or  salve-mull. 

Aconttine  was  succeaetu!  in  the  hands  of  Sir 
Thomas  Watson,*  and  I  have  not  untrequently  had 
reason  to  be  autisfied  with  the  effect  of  unguentum 
aoonitime,  which  leaves  a  numhness  very  agreeable 
to  patients. 

In  conclusion,  a  word  of  warning  in  regard  to 
the  choice  of  a  remedy  to  commence  with  may  not 

•  "Priudplpi  ami  Priiclice  of  Ptijdie,"  4th  cJitiou  (Louiioii. 


74  NEUROTIC  AFFECTIOSS  OF  THE  SKIN.   [chap,  vt 

be  out  of  place.  If  the  akin  he  greatly  infUmod  and 
excoriated,  or  if  any  eczematoid  lesions  have  been 
produced  by  scratching,  it  will  be  well  to  begin  local 
treatment  with  iohlkyol,  which  does  not  irritate,  but, 
on  the  contrary,  has  a  marked  sedative  effect.  Spiritn- 
oua  solutions  or  apraya  should  never  be  applied  when 
the  skin  is  broken,  as  they  cause  considerable  smart- 
ing and  thus  intensify  the  mischief. 

Prurigo,*  though  looked  upon  by  Hutchinson  as 
merely  "  a  peculiar  irritabilitj'  ia  which  a  variety  of 
causes  may  evoke  the  symptoms  to  which  that  name 
has  been  given,"t  is,  in  my  opinion,  entitled  to  a 
place  in  nosology  as  a  distinct  clinical  entity.  The 
cliaracteristio  lesion  is  an  eruption  of  discrete  slightly 
raised  papules ;  these  are  at  first  of  the  same  colout 
as  the  skin,  but  afterwards,  when  subjected  to  im- 
tetion  by  scratching,  they  become  reddened  and  in- 
crease in  size.  There  is  often  a  blood-crust  at  the  top._ 
The  papules  are  most  abundant  on  the  extensor  sur- 
faces of  the  limbs,  but  they  also  occur  on  the  chest 
(back  and  front),  the  lower  part  of  the  belly,  tlia 
sacral  region,  and  the  buttocks.  They  are  rarely 
on  the  flexor  aspecte  of  limbs,  and  tliey  occur  sparsdj^^ 
on  the  face.  The  itching  is  intense,  and  secondary 
changes  in  the  skin,  produced  by  scratching,  are  very 
marked.  Besides  these,  other  lesions  often  develo]^ 
which  may  resemble  those  oi  eczema  (except  tbaf 
the  Qexor  surfaces  are  generaUy  spared)  or  urticRlia^ 
Pustules  and  sores,  often  accompanied  by  consider' 
able  enlargement  of  the  femoral  and  axillary  glandl'^ 
are  not  infrequent.  In  a  severe  type  of  pmrigS 
(called  by  Hebra  ferox,  to  distinguish  it  from  the*^ 
I    prurigo  mitis  of  Willan,  which  is  the  ordinary  form 

[  "  Fur  »  diitiwaioii  of  the  charaeter  of  this  atf  ectioii ,  1 

I     Whit*-,  Pnyue,  Seiwer.  and  otiiers,  rirff  '•  Tmiiwictiotia 
L      liiteniat.  Derniat.  Cod^hbh,  London,  ]H%." 
t  ■'  ThB  I'edigrwj  of  DiMiatie,"  p.  Bl. 


OKAP.  «.]  PRURIGO.  75 

of  the  disease)  the  elementary  leeiona  are  more  de- 
veloped and  more  mimerouB,  and  the  skm  in  certain 
part^,  notably  tlie  legs  and  forearms,  gives  a  sensa- 
tion to  the  touch  like  coarse  brown  paper  or  a  nutmeg- 
grater  (Crocker).  Poverty'and  insanitary  conditions 
of  life  are  pTodisposing  ca,uaeB,  and  males  ate 
more  often  afiected  than  females.  Prurigo  generally 
begins  in  the  firat  year  of  hfe,*  when  it  shown 
itself  in  the  form  of  lichen  urticatus.  After  a  time, 
however,  the  wheals  decrease  both  in  size  and  in 
number,  the  eruption  meanwhile  assuming  a  papular 
character,  which  it  retains.  The  affection,  unless 
treated  in  the  very  early  stage,  generally  lasts  the 
whole  of  the  patient's  life,  becoming  b^er  or  worse, 
however,  under  the  influence  of  season,  the  state  of 
the  health,  etc.  Pathologically,  prurigo  is  a  neurosis 
of  the  skin  expressing  itself  tlirough  the  medium,  of 
the  vaso-motor  apparatus  in  an  inflammatory  pro- 
cess, which  passes  through  the  ordinary  phases  and 
gives  rise  to  secondary  changes.  These  may  be 
summed  up  as  consisting  of  what  French  writers  call 
"  lichenisation  "  i  the  skin  gradually  becomes  hyper- 
trophied  and  indurated  as  the  result  of  chronic  in- 
flammation. The  diagnosis  is  made  partly  by  a 
process  of  exclusion,  partly  by  the  sum  of  the  clinical 
facts.  Other  itching  conditions,  such  as  scabies, 
pediculosis,  etc.,  are  excluded  by  the  absence  of 
the  characteristic  lesions.  The  positive  characters 
are  tliat  the  disease  dates  from  infancy,  and  that  it 
ap|>ears  in  the  form  of  a  papular  eruption  which 

•Vidul  j"  ConsiiiLTntiona  anr  1b  Pnirigo  du  Halira,"  J™.  (/' 
JJrrm.  rt  4'  S<jp'i.,  St!j,li'tiihi'i  (Jrtuber,  18ii2)  suys  that,  like 
flenniet  and  th..' iii,i|..iii;.  ..t  liu'!  licrmatologistB,  he  has  bbuu 
tbe  affvetiaD  bi.';:  i  1 1  "t  ttu  and  fiftuen,  and  even 

liitor.     InOtiB'if    I.      !■  ■.■■-.;  Hymptamn  ol  tlia  disease 

shinred  tbemwli'       '  i  v  tive.      In  uine  cubgs  oitod 

by  EhUre  («»//.  ■'■    ■'    •■■.  /  /'r    Derm.  »l  fl»  S„i.l:,  \mD 

ifie  affection   coiniiitiifi.J    liutiifLii   tiftuen  and  thirty    years  of 


70  XKVIiOTIC  AFFECTIONS  OF  THE  SKIN,  [chap,  vl 

aiTcdts  (ihiefly  the  extensor  surfaces  of  limbs.  A 
|)jithofi;iiomonic  feature  is  the  nutmeg-grater-like 
if<?<»lirig  of  the  skin  on  the  outer  side  of  the  legs  and 
foroarniH.  The  glandular  enlargement,  which  in  the 
groin  ()ft(m  attains  a  very  large  size,  is  another  dis- 
iinctivt^  feature.  The  disease  can,  as  a  rule,  be  cured 
only  in  the  very  earliest  stage — that  is  to  say,  in 
childhood,  before  it  has  become  inveterate.  As 
aln^ady  said,  however,  it  is  subject  to  spontaneous 
rc^niissions,  and  it  can  always  be  greatly  mitigated 
l)V  treatment. 

The  treatment  of  prurigo  must  be  conducted 
on  the  lines  laid  down  for  pruritus.  In  addition  to 
\\\{\  internal  and  external  remedies  for  itching  already 
descrihcd  in  detail,  a  liberal  supply  of  nutritious  food 
is  always  of  the  greatest  importance,  especially  in 
\\\iy  case  of  children.  Of  the  various  local  applica- 
tions, HtrotKj  tar  in  lotion  or  ointment  is  the  most 
generally  useful.  Cod-liver  oil  and  iron  may  also 
l)c  given  in  most  cases  with  advantage. 


ANGlO-NEUBnSES. 

Urticaria. — The  characteristic  lesion  of  urticaria 
iH  >L  wiieal  or  raised  patch  o(  sldn  flattened  oothesur 
face,  firm  to  the  toucb,  and  at  first  uniformlj  red 
in  colour,  but  afterwarda  white  and  bloodless  m  the 
centre,  with  a  bright  red  border,  which  often  has  an 
areola  of  erythematous  redness  outside  it  Some 
times,  however,  the  patch  rema,ins  red  throughout 
When  the  wheal  subsides  the  centre  becomes  red  and 
the  border  pale.  When  wheals  are  numerous  their 
areolfe  become  confluent,  so  that  the  white  centres 
stand  out  boldly  on  a  red  ground.  Wheals  vary 
in  sise  from  a  threepenny  piece  or  smaller  to  a  florin 
or  even  a  four-ahilling  piece.  The  lesion  is  seen  in 
its  most  tvpieal  form  in  the  wheal  which  is  caused 
by  the  stinging  pettle,  whence  the  name  "  urticaria  " 
[urtica,  nettle),  or  nettle-rash. 

Urticaria  comes  on  quite  suddenly,  the  appear- 
ance of  the  eruption  being  accompanied  by  intense 
itching  and  burning.  Scratching  gives  some  mo- 
mentary relief,  but  is  followed  by  the  development 
of  large  numbers  of  fresh  wheals,  which  spring  up,  so 
to  speak,  under  the  patient's  fingers,  or  may  arise 
at  a  distance.  Sometimes  the  affection  is  purely 
local,  but  in  severe  cases  the  skin  eruption  is  usually 
iated  with  some  degree  of  fever  and  systemic 


7B  .VBUKOTICAFFECTIOSSOFTHESKIX.  [ciiap.  vu. 

disturbance,  Tlie  individual  whealB  last  only  a  tew 
hours  at  moat,  and  disappear,  leaving  no  trace  of 
their  presence.  Fresh  crops,  however,  may  continue 
to  appear,  and  the  attack  may  last  for  some  daje. 
In  some  cases  the  eruption  comes  out  in  successive 
drops  day  after  day,  ior  weeks  or  months  or  even 
years.*  To  this  form  of  urticaria  the  term  "  chronic  " 
18  usually  applied  ;  but  as  there  is  no  difierence  in 
respect  of  the  severity  of  the  local  symptoms  between 
it  and  the  more  common  short-lived  variety  (urtioana 
fugax]  which  has  already  been  described,  it  would  be 
more  logical  to  call  it  UTticaria  perstans.  In  certain 
cases  not  only  the  duration  of  the  disease  but  that  of 
the  individual  wheal  is  considerably  prolonged.  Cosea 
of  this  kind  have  been  reported  in  which  wheals  on 
the  limbs,  the  back,  and  the  belly,  varying  in  size 
from  a  lentil  to  a  haricot  bean,  persisted  for  three 
months. t 

Urticaria  may  attack  any  part  of  the  cutaneous 
surface,  and  sometimes  invades  the  mucous  mem- 
branes of  the  mouth,  tongue,  pharynx,  possibly  oJ 
the  bronchi  and  stomach  (Pringle).  This  probably  j 
aSorda  an  explanation  of  its  frequent  associatioit  1 
with  asthma,  the  same  causes  determining  an  attack  J 
of  both  affections.  The  wheals  have  no  definitftj 
arrangement,  and  are  never  symmetrical.  Them:il 
may  be  only  a  few  on  some  particular  part  of  the  body;.  J 
or  they  may  cover  nearly  the  whole  of  its  surfac©- 1 
A  striking  feature  of  urticaria  when  it  has  obtained'! 
a  hold  on  the  patient  is  that  the  slightest  contact  witiil  I 
the  clothing  or  the  least  scratch  will  at  once  bringj 
out  a  crop  of  wheals  on  any  part  of  the  skin ;  evesf 
when  the  rash  is  not  present  the  patient  can  oft^lfl 
write  liis  name  with  his  hnger-nails  on  appaveBlj^fl 


CHAP.  VII.1  URTICARIA.  71) 

healthy  parts  of  his  skin,  especially  on  the    back 
{urticaria  jaclkia).* 

Several  varieties  of  urticaria  have  been  described, 
according  to  the  size,  configuration,  and  structuial 
peculiarities  o£  the  characteristic  lesions.  Thus  the 
wheals  may  be  small  and  on  their  subsidence  leave 
gapulea.  Hence  the  name  urticaria  ■payulosa.  It  is 
to  Colcott  Fox  that  we  owe  the  proof  of  the  urticarial 
nature  of  these  lesions  and  their  identification  with 
the  lichen  urticatus  of  Bateman  and  the  lichen 
strophulus  of  Rayer  and  Biett.f  Urticaria  pupuloaa 
'\A  chiefiy  met  with  in  ehiidien.  The  lesions  are,  aa 
a  rule,  no  larger  than  a  lentil,  and  on  the  top  of  each 
is  a  tiny  red  point  or  inflammatory  papule,  which  is 
usually  covered  with  a  darkish  scab,  the  result  of 
scratching.  If  the  red  papule  is  not  at  first  visible, 
it  can  always  be  brought  into  view  by  pressure,  when 
the  colour  fades  from  the  circumference  of  the  papule, 
leaving  a  minute  red  spot  in  the  middle.  The  erup- 
tion affect  all  parts  of  the  body,  but  shows  a  certain 
preference  for  the  trunk.  It  is  sometimes  markedly 
vesicular  in  character,  closely  simulating  varicella.J 
Fresh  crops  of  lesions  come  out  at  night,  and  cause 
Buch  intense  itching  that  sleep  is  impossible,  I  have 
seen  some  cases  in  which  the  general  symptoms  were 
very  severe.  The  disease  may  last  for  several  years, 
becoming  milder  or  practically  remitting  in  winter, 
and  returning  with  the  wanner  weather,  or  vice  versii. 
Urticaria  papulosa  may  be  looked  upon  aa  a  connect- 
ing link  between  urticaria  and  prurigo.  I  agree  with 
Dr.  Colcott  Fos  in  thinking  that  its  actual  transi- 

•  Thia  coniiitiou  hue  bi?pu  thuroughlj  stuiiieii  bv  Barthi-leiny 
iiihw  Ktw!"  eur  ie  Jlitvio(/riiiJii:ii- .  vol  L,  Paris,  l'89a.  See  ftlso 
the  CMC  o£  a  "Feiume  AiitnpTii.pliiquo"  (Kaposi,  traiialalpd  liy 


so  XKIROTIC  A  FFKCTIOXS  OF  THE  SKIN,  [chap.  vn. 

lion   into  prurigo,    if   it   ever   occurs,  is   extremely 
rare. 

\VluM\  oniinarv  urticaria  attacks  parts  like  the 
ovolids.  ^io^>tum,  etc..  where  there  is  much  loose 
connect ivo  tissue  which  offers  comparatively  little 
n*sist^\noe  to  the  diffusion  of  the  iafiltratioii,  it  is 
termed  uriicaria  adenuifosa.  The  cpdema  as  a  rule 
comes  on  suddenly,  to  the  great  alarm  of  the  patient, 
especially  when  mucous  membranes  such  as  those 
of  the  tongue  and  throat  are  involved  ;  but  it  seldom 
lasts  loncer  than  twentv-four  hours.  Alcoholism 
t\\\d  neurotic  inheritance  seem  to  be  predisposing 
causes.*  The  condition  sometimes  occurs  indepen- 
dently of  urticaria  in  the  form  of  circumscribed 
swellings  of  varying  consistency,  which  develop  in 
the  K>ose  tissue  of  the  scrotum,  penis,  and  eyelids ; 
it  is  also  seen  in  the  hands  and  feet,  and  on  the  fore- 
head. To  tliis  condition  the  name  of  angio-neurotic 
micma  has  been  given.  The  exciting  causes  are 
the  same  as  in  urticaria,  from  which  the  affection 
differs  in  the  fact  that  its  seat  is  not  the  skin, 
hut  the  subcutaneous  tissue.  The  attack  generally 
subsides  under  treatment,  but  ther^  is  great  liability 

to  recurrence. t 

Crfi'caria  gifjas  is  a  form  of  the  disease  character- 
isinl  by  the  development  of  patches  of  localised 
oedema  of  large  size.  They  are  hard  to  the  touch, 
like  the  biceps  muscle  when  strongly  contracted. 
There  is  usually  no  nnlness  of  the  surface,  and  itching 
is  seldom  complained  of.  The  swellings  last  a  day 
or  two,  and  subside  as  quickly  as  they  came.  The 
disease  is  often  described  as  the  acute  circumscribed 
o?dema  of  Quincke. 

*  ."^i «  it'port  c»f  a  case  of  acute  ciroumscriboil  aHloma  of  tho 
bkin  ill  au  alc-»lu»lic  subject,  bv  Oppcnheimcr  {DtNtath,  iMrt/. 
n  'n,  h t  u.^c/i )  i  ft,  Xo.  3,  1  S&(5 \         * 

t  For  al)stract  of  seven  c:i5os  rej^orted  l>y  Ono|X)wici:  and 
Barucli  sec  Brit.  Junrn  of  Ihrm.,  1S1H.»,  p.  40.\ 


ciiip.  VII.]  URTICARIA.  81 

When  efluaioa  of  blood  takes  place  into  the  wheals, 
the  conditioD  is  sometiiaes  termed  urtiearia  hcemor- 
Thagica  or  pttrpura  urticaTis  ;  when  bulliE  form  on 
the  snrtace,  it  is  sometimes  spoken  of  as  urticaria 
buUota.  nrtricaria  pigm&ilona  presents  sufGciently 
marked  characteristics  of  its  own  to  require  separate 
description. 

The  causes  of  urticaria  may  be  classified  as  pre- 
disposing,  estemal,  and  internal.  Among  predispos- 
ing causes  are  aex — females  being  eonsiderably  more 
liable  to  the  afiection  than  males ;  age — infants, 
owing  to  the  irritabih'tv  of  their  skin,  being  pfirticu- 
larly  prone  to  nettle-rash  ;  the  neurotic  tempera- 
ment ;  indigestion  ;  gout ;  functional  and  organic 
disease  of  other  organs,  notably  th.;  uterus  and 
ovaries,  aud  of  the  nervous  system.  In  infants  urti- 
caria ie  often  associated  with  rickets  and  dilatation 
of  the  stomach.*  Malaria  is  so  strong  a  predisposing 
cause  that  some  writers  make  a  special  variety  of  the 
afiection,  under  the  name  of  "paludal  urticaria." 
Urticaria  is  often  associated  with  jaundice,  rheu- 
matism, purpura,  and  oc^^asionally  co-exists  with 
albuminuria  and  glycosuria.  Violent  mental  emo- 
tion may  be.  sufficient  of  itself  to  bring  on  an  attack. 
Among  external  causes  are  local  irritants,  such  aa  the 
stings  of  nettles,  jelly-fish,  or  wasps;  the  bites  of 
insects,  such  as  bugs,  mosquitoes,  etc,  ;  contact  with 
or  even  proximity  to  certain  liairy  caterpillars  ;  the 
direct  application  of  cold  to  the  skin,  and  especially 
sudden  alternations  of  temperature.f 

Among  internal  causes  are  certain  articles  otjfood 
which  irritate  the  alimentary  canal  and  roflcxly  the 
skin  (tlirough  the  pnoumogastric  nerve).  Every 
variety  of  idiosyncrasy  is  displayed  by  patients  in  this 

•  Fniik  mid  Oruuii/ioh :  Manaf^. /.  prakl.  Ikyi:,  Febmaiy 
Irt.  TS3I. 

t  Crickti :  ■*  Distiises  ol  tlie  Skiu,"  'Ini  ad.,  p.  Ki, 


82  NKUIlliriC  AFFECTIONS  OF  THE  SKIN,  [ci 

rBHpcci ;  liut  to  shell-fish,  especially  mussels,  crabs, 
«nil  lobBters.  must  be  asBigned  the  chief  place  among 
dietiitic  irritants.  Among  other  svibstancea  which 
odUBft  urticiiria  in  certain  individuals  may  be  men- 
tioned pork,  almonds,  strawberries,  parsley,  mush- 
Tfiiimw,  (ind  ontmfal.  Certain  medicinal  substances  also 
ciiii  .■  Liiri,-.iri:i    Tlicse  ajc  dealt  with  in  thechaptt 

■    \ -Ill    l.Mii'lions."     [See  -p.  202.)     Among    the 

iiii'iii  il  .  I..  I  ■■  ul  t.ite  affection  should  also  be  men- 
tiiiniil  ilii'  jiM-iriici'  of  hydatid  cysts,  and  especially 
ti[  Mn'ir  lUiid  loiiti'uts,  in  the  abdominal  cavity  ;  and 
wornw. 

Pathologically,  urticariais  a  result  of  reflex  vaso- 
motor didturhaiice.  Stephen  Mackenzie  places  the 
nervous  centre  of  the  reflex  mechanism  in  the  dense 
plpxus  o(  fine  nerve  fibres  in  the  superficial  layer 
of  the  corinm.  The  wheal  is  simply  a  circumscribed 
cpili^ma  of  the  skin  due  to  paralytic  dilatation  of  the 
HTterioles,  followed  by  exudation  of  serum  and  migra- 
tion of  leucocytes.  According  to  Neisser,*  the  pro- 
cess consists  in  an  increased  secretion  of  lymph  in  the. 
neighbourhood  of  the  capillaricB  of  the  skin  ;  this  in 
itfl  turn  causes  compression  of  the  vessels,  a  fact  which 
explains  the  white  centre  of  the  wheal.  The  varia- 
i  tions  in  the  siee  and  other  characters  of  the  wheal  are 
,   duo  to  the  different  depths  to  which  the  infiltratioiL 

EMnotrates.     In   ordinary   urticaria   only   the  upper 
,yer  of  the  integument  is  affected,  while  in  urticaria 
s  the  whole  thickness  of  the  skin  is  involved,  and 
he  oedematoiis  variety  infiltration   takes  plaoo 
'  into  the  loose  meshes  of  the  Bubcutaneous  areolar 
tisane. 

The  diag'nosls  of  urticaria,  as  a  rule,  presents  ao 
I  difficulty,  the  sudden  ouact,  the  presence  of  wheals, 
'  and  the  fugitive  nature  of  the  eruption  being  the  eha- 

Vo'l.ii"'"""!/"-  dfudch.  ilirmaM.  Gmrlhrh.,  1889,  p,  2S3. 


1 
I 


OHiP.  Wl-i        URTICARIA  PIGMENTOSA.  1*3 

racteristica  of  the  disease.  In  certain  cases,  liowever, 
in  which  the  wheal  is  aurmouated  by  vesiclea  or  bullfe, 
urticaria  may  for  a  time  simulate  pemphigus,  or  the 
first  stage  of  dermatitis  herpetiformis  ;  and  if  the 
constitutional  symptoms  are  well  marked,  the  rash 
may  at  first  be  mistaken  for  that  of  scarlet  fever,  or 
even  for  erysipelas.  The  course  of  the  eruption, 
however,  soon  reveals  the  true  nature  of  the  afioc- 
tion.  Urticaria  papulosa  is  frequently  confounded 
with  scabies,  hut  the  distribution  of  the  lesions  anil 
the  absence  of  the  characteristic  burrows  are  suffi- 
cient to  exclude  that  disease. 

The  prognosis  is  always  favourable,  although,  as 
has  been  said,  in  some  rare  cases  the  duration  of  the 
disease  may  be  more  or  less  prolonged. 

Urticaria  pigmentosa.  —  Urticaria  pigmen- 
tosa ia  usually  classed  among  the  an gio-neu roses,  but, 
on  account  of  the  very  special  character  of  the  exuda- 
tion which  accompanies  it,  it  is  doubtful  whether  it 
is  properly  placed  in  this  category.  The  affection 
b^ns  very  soon — generally  a  few  days — after  birth, 
hardly  ever  later  than  the  third  month.  The  essen- 
tial feature  is  the  appearance  of  raised  patches  some- 
what conical  in  shape  and  red  or  pink  in  colour  ;  these 
afterwards  become  flattened  on  the  top,  and  their  hue 
deepens  gradually  to  dark  brown.  In  a  case  under 
the  care  of  Mitchell  Bruce  and  Galloway,  which  was 
carefully  studied  by  H.  K.  G,  J.  Brongersma,*  super- 
ficial scarring  was  noted  in  the  centre  of  the  patches; 
this  feature  in  the  lesions  of  the  disease  had  pre- 
viously been  reported  by  Hallopeau  to  the  Freuch 
Dermatological  Society  on  May  12th,  \mL  The 
individual  lesions  do  not  disappear  like  the  wheals 
of  ordinary  urticaria,  but  i)eTsi8t,  while  others  come 
out  in  aucceaaive  crops.    When  the  disease  is  fully 

•  Diit.  J'imr:  of  I/rn«.,  May.  IBHii. 


^^H   M  SECROTIC  AFFECTIOSSOF  THE  SKIS.  [ciiAr.vii.  ^| 

^^^H    deTelo]>ed  l^e  child  is  ^K>tt«d  with  more  or  less  pro-  ^H 
^^^V    miDent  patches  vaiying  in  size  from  a  split  pea  to    ^H 
^^^      a  sixpenny -piece,  and  in  colour  from  bright  ted  to     ^^ 
daric  brown,  according  to  the  age  of  the  wbeaL     The 
parte  usually  affected  are  the  front  and  sides  of  the 
chest,  the  biack.  the  beUy.  and  the  limbs ;    tJie  face 
IB  not  always  spared.     The  disease  is  usually  markedly 
symmetrical,  in  contrast  with  ordJaarv  urticaria,  a 
point  illostrated  in  a  remarkable  manner  in  a  case 
^^_       shown  by  me  at  the  Clinical  Societv. 
^^^^  At  Yarying  intervals,  especially  in  summer,  the 

^^H     morbid  process  seems  to  be  quickened  into  fresh 
^^^r     activity.     At  such  times  the  patches  become  intensely 
^^^       congested.     Vesicles  and  bulla-  may  develop  on  theit 
surface,  and  new  lesions  appear  on  parts  of  the  skin 
previously  healthy.     These  phenomena  are  accom- 
panied by  intolerable  itching,  and  the    scratching    ^^ 
which  is  the  result    adds  fnel  to  the  fire,     fn  some  ^H 
cases  the  raised  red  patt'hes  predominat« ;   in  othen  ^H 
the  flattened  pigmented  lesions.     I'sually  tlie  two  ^H 
forms,  which,   as  already  said,    represent  difEerent  ^H 
stages  of  the  same  process,  coexist  in  varying  pro-  ^^k 
portions.  ^^k 

The  natural  tendency  of  the  disease  is  to  die-  ^H 
appear  as   the   patient  grows   older.    Three  well-  ^H 
defined  stages  can  be  recognised  in  the  large  majoritjT  ^| 
.  of  cases.     There  is  a  period  of  activity,  during  which  ^H 

^^K  successive  crops  of  the  eruption  continue  to  appeai.^^| 
^^^b  This  lasts  about  a  year,  occasionally  longer.  Nextl''^^| 
^^^B  follows  a  period  lasting  from  two  to  live  years,  dniing-^^f 
^^^B  which  the  disease  is  more  or  less  stationary.  Lastly,  ^^^ 
^^^B  there  is  a  period  of  retrogression,  during  which  tlie  ^H 
^^^B     apots  gradually  fade  away.     This  may  last  seveidl  ^^k 

^^^H  Urticaria  pigmentosa   is  believed  by  most  der>^^| 

^^^1  matologista  to  be  essentially  a  form  of  vaso-motor^H 
^^^^  disturbance,  with  the  special  feature  that  the  locol^H 


TRKATMEST  OF   VRTICAIIlA,  86 

inliltration,  whirh  gives  rise  to  the  distinctive  lesions, 
is  largely  made  up  of  the  cells  called  hy  Ehrlich 
MaatzeUen.  These  cells  exist  in  such  large  numbers 
in  the  pigmented  spots  that  sections  especially  stained 
for  their  recognition  assume  a  reddish  colonr  owing 
to  the  reaction  given  by  the  mast  rell  to  granules.* 
In  the  case  of  a  child  suffering  from  urticaria  pig- 
mentosa, Gilchristf  showed  by  experiment  that  in  the 
skin  which  appeared  normal,  as  well  as  in  the  legions, 
mast  cells  were  present  in  considerable  numbers. 
Brongersma  is  of  opinion  that  the  prime  cause  of 
the  disease  is  not  a  congenital  increase  of  the  vaso- 
motor irritability  of  the  skin,  but  "  a  congenital  in- 
cxeased  tendency  for  the  connective  tissue  to  change 
into  mast  cells,"  the  urticarial  wheal  being  a  secondary 
symptom.  He  thinks  it  possible  that  mast  cell 
granules  which  are  seen  lying  free  in  the  lymph  spaces 
are  degenerative  products,  and  that,  gaining  access 
to  the  blood,  they  act  as  a  toxin  which  i^  capable  of 
producing  the  changes  in  the  superficial  circulation 
which  give  rise  to  the  urticaria. 

The  clinical  diagnosis  of  the  condition  rests 
chiefly  on  the  appearance  and  mode  of  evolution  of 
the  wheal-like  patches  and  the  persistence  of  their 
pigmentation. 

In  the  tpeatmenl  of  urliearia  the  first  tiling 

to  be  done  is  to  discover  and,  if  possible,  remove  the 
cause  (errors  of  diet,  especially  shell-6sh,  worms, 
parasites,  or  other  source  of  reflex  irritation).  If 
the  attack  is  distinctly  traceable  to  indigesrion.  or 
to  poisoning  by  mussels,  etc.,  an  emetic  should  be 
given  if  the  symptoms  are  very  severe  ;  in  milder 
cases  a  smsrt  saline  purge  will  cle-anse  the  intes- 
tinal canal  of  the  tosins  which  are  the  cause  of  the 

•    Li'ana:    " HiatopnthQlogr   of   tlie   Diseases  of  tlie   Skii.." 
I.  hy  Norman  Walker  ■  p.  'Jj.i  (Edinburgh,  l8aS). 
'•  11  Syiiini  £iill.,  vA  vii.,  July  ISMfi. 


86  NEUROTIC  AFFECTIOXS  OF  THE  SKIX.  [ch*p.  vn. 

trouble.  The  patient  should  be  kept  on  a  bUind, 
unirritating  diet  for  a  few  davs,  if  fever  be  preaent ; 
and,  especially  if  t!ie  urticaria  be  of  malarial  origin, 
quinine  in  full  doses  may  be  given  with  advantage. 
If  there  be  any  reason  to  suspect  a  gouty  element  in 
the  case,  it  must  be  dealt  with  on  general  principles, 
alkalies  being  particularly  useful.      Wright,  of  St. 

(Mary's  Hospital  Medical  School,  who  calls  urticaria 
"  a  serous  hemorrhage,"  recommends  calcium  chloride 
in  doses  of  gr.  xx  three  titnee  a  day.  The  itching 
may  be  allayed  by  means  of  any  of  the  local  applica- 
tions recommended  for  the  treatment  of  proritna, 
simple  evaporating  lotions  generally  being  sufficient 
for  the  purpose.  Brocq  recommends  that  the 
patient's  body- linen  should  be  impregnated  with 
starch  powder,  and  that  he  should  sleep  in  fine  sheets 
sprinkled  with  the  same  material.  It  is  most  import- 
ant to  prevent  chill.  For  this  reason  it  is  well,  when- 
I  ever  the  patient  will  submit  to  such  a  course,  to  keep 
[  him  in  bed.  I  have  known  patients  derive  benefit 
Irom  exchanging  a  linen  for  a  fiartne)  nightdress, 
£xcBSsive  heat  should  also  be  avoided.  The  clothing 
should  be  light,  and  the  underclothing  especially 
should  not  be  of  such  a  nature  as  to  cause  irritation 
of  the  skin.  The  efiects  of  scratching  must  be  dealt 
I   with  as  already  indicated. 

I         In  chronic  cases  the  bowels  must  be  caiefally 

regulated,  and  any  constitutioaal  stat«   that  may 

appear    to    be    associated    with    the    skin    affection 

should  be  treated  on  general  principles.     VinV'"""  '"" 

very  often  beneficial.    AU   food   of  a   stimulating 

character,  and  alcohol  in  any^form,  must  be  avoided. 

,  When  these  general  measures  prove  unavailing,  an 

I  attempt  may  be  made  to  act  directly  on  the  vaso- 

I  motor   centres    by    means    of   sulphate    o[    alroyfa, 

L  which  may  be  given  internally  as  a  pHl,  containing 

I  f  ■  r^  ^  9^'  ^io>  f^  sugar  of  milk  and  glycerine  of 


CHAP,  vn-l        URTICARIA    PIOME-VTOSA.  87 

tragacanih.  This  pill  should  be  given  at  night.  The 
drug  may  also  be  administered  by  Bubcutaoeous  in- 
jection (gr.  yJ-j,  very  cautiously  increased).  Zrhthjfri 
in  gradually  increasing  doses  is  one  of  the  best  drugs 
at  our  disposal.  Chronic  m'ticaria  which  has  re- 
sisted all  medical  treatment  is  often  cuied  by  the 
rest  and  freedom  from  worry  given  by  a  hoHday.  A 
sea  voyage  is  efficacious  when  other  means  tail. 

For  urticaria  pigmentosa  various  kinds  of 
treatment  have  been  tried,  without  producing  any 
appreciable  modiScation  of  the  morbid  process. 
Belladonna  internally,  and  atropine  in  hypodermic 
injections,  have  been  recommended  ;  but  the  clinical 
evidence  at  present  available  is  insufficient  to  war- 
rant a  definitive  judgment  as  to  the  efficacy  of  this 
method.  The  itching  may  be  relieved  by  the  mea- 
sures that  are  found  useful  in  ordinary  urticaria. 
Apart  from  this,  the  principal  indication  is  to  build 
up  the  general  health  on  as  sohd  a  foundation  as 
possible. 


CHAPTER    VIII. 

^J^KKKCTIONS  OF  THE  BKIX  UKl'EXDEXT  ON  NERVE 
DISORDKR  {coatinacd]. 

I  Erythema — Purpura,  or  Peliosis,  Rheomatica— 
Erythematosus — Rosacea— Pellagra 

Erythema.— Erythema  striotlr  meBBB  nothing  more 

I I  than  superficial  redness,  disappearing  on  pressute ; 
I.  that  h  to  say,  a  local  congestion  of  the  eldn.  A  good 
t  ileal  of  confusion  as  to  the  natms  of  the  affection  has 
['been  caused  by  the  fact  that  different  stages  of  the 
I  Baniu  piocesR  have  been  described  as  distinct  diseases, 
<  mid  a  further  element  of  perplexity  has  been  im- 
,  ported  into  the  subject  by  classifying  the  rashes  of 

infectious  diseases  as  varieties  of  erythema.     Kry- 
thcrnatouB  they  doubtless  are  anatomically,  bnt  they 

i  no  independent  existence  as  pathological  pio- 
cessea,  and  it  is  illogical  to  consider  them  apart  from 
the  diseases  ofwhich  they  are  mauife^tatioUB.  The 
eruption  of  an  infectious  fever  is,  in  fact,  the  resale.' 
of  the  irritation  of  certain  s[>eciiic  poisonous  matte»' 
circulating  in  the  blood.  The  eruptions  caused  lay 
certain  drugs,  which  are  often  erythematous  in. 
appearance,  are  the  result  either  of  a  Ipxic  action:' 
of  the  chemical  substance  on  the  nerve  centres,  or  ol^ 
direct  britation  of  the  peripheral  ends  of  the  nerveS 
supplying  the  integument.  These  will  also  be  dealt' 
with  in  Chapter  XI.  (Artificial  Eruptions), 

Erythema,  as  a  substantive  disease,  shows  itaeli 
under  various  forms,  all  of  which  may,  however,  be 


CHAP.  VLii.]  ERYTHEMA.  89 

grouped  under  two  heads  :  viz.,  (a)  hijpercEmic.  (ft) 
inflammaloTy.  In  the  former  category  the  meohaniBin 
ol  the  process  consists  in  localised  vascular  dis- 
turbance, which  gives  rise  to  hyperEemia — at  first 
active,  but,  if  the  cause  persists,  soon  becoming 
passive  owing  to  vasomotor  paralyais.  The  colour 
of  the  ftflected  area  of  skin,  which  at  the  outset  is 
bright  scarlet,  changes  as  the  blood  stream  he<?omes 
more  sluggish  to  dull  red,  deepening  as  the  tendency 
to  stagnation  increases  to  livid  blue  or  purple.  In 
correspondence  with  the  variations  in  the  blood  cur- 
rent, the  skin  at  first  feels  hot  both  to  the  patient 
and  to  the  observer  ;  but  the  heat  subsides  as  the  con- 
gestion assumes  a  passive  character,  and  often,  es- 
pecially in  the  extremities,  the  local  temperature  falls 
below  the  norma!  point.  In  erythema  of  the  inflam- 
matory type  the  retardation  of  the  blood  current 
goes  on  to  stasis,  exudation  of  serum  takes  place, 
leucocytes  escape  inttf  the  tissues  around  the  vessels, 
and  sometimes  subcutaneous  hemorrhages  occur.  In 
this  way  the  various  lesions — -vesicles,  bullie,  oedema, 
and  pigmentation — seen  e.g.  in  erythema  multiforme, 
are  produced.  If  the  inflammatory  process  is  severe 
it  gives  rise  to  more  serious  lesions,  such  as  local 
asphyxia,  ulceration,  sloughing,  and  even  gangrene. 
Widely  different  as  the  hyperwmic  and  inflammatory 
forms  of  erythema  are  in  their  clinical  aspects,  patli- 
olagically  no  definite  boundary  tine  can  be  drawn 
between  them. 

With  regard  to  the  etiolog'y  of  erythema,  indivi- 
dual predisposition  is  a  necessary  condition  of  its 
development.  This  predisposition  appears  to  be 
simply  an  exceptional  iostubility  ot  the  vaso-motor 
aysWm,  rendering  it  unduly  susceptible  to  irritation. 
The  irritation  may  be  direct,  as  by  the  action  of 
cold  or  heat,  acrid  discharges,  certain  vegetable  or 
chemical  substances  (rhus  toxicodendron,  mustard, 


90  liEUROTlC  AFFECTIO/fS  OP  THE  SKIN.   (chaP.^ 

aiseoic,  etc.),  the  bites  or  stiuga  or  mere  contact  oi 
certain  insects  (fleas,  bugs,  hairy  caterpillars),  coarse 
flannel  or  dirty  imderclothing  ;  or  indirect— i.e.  i 
fleeted  to  the  nerves  of  the  skin  from  internal  orgs 
more  particularly  the  organs  of  digestion  and  t 
female  genital  apparatus.  It  is  also  sometimes  J 
manifestation  of  the  rheumatic  poison.  It  is  i  ' 
always  possible,  however,  to  trace  an  attack  of  ery 
thema  to  any  distinct  cause  ;  in  such  cases,  no  doubtJ 
sources  of  irritation  of  one  or  other  of  the  kinds  jue" 
nientioiied  are  present  if  only  they  could  be  found. 

Hyper.«mic  Erythkma. 

Of  the  hypersemic  type  of  erythema  there  i 
several  varieiiea. 

Erythema  simplex  is  characterised  by  patchc 
of  redness,  at  first  scarlet,  afterwards  pinkish  in  hue 
These  may  come  out  on  any  part  of  the  cutaneoild 
surface,  showing  a  preference,  however,  for  the  t 
and  portions  of  the  skin  which  are  in  contact  with  a 
other  or  exposed  to  the  air.     The  affected  parts  6 
hot  to  the  hand,  and  the  patient  complains  of  a  sensa. 
tion  of  burning  or  itching ;    but  there  is  seldom  any^ 
fever  or  systemic  disturbance.     The  redness  gradU' " 
ally  fades  and  iinslly  disappears,  leaving  no  discolora- 
tion   behind.     Slight    desquamation    often    accom- 
panies the  subsidence  of  the  eruption.     The  aSection 
may  last  an  indefinite  time.     The  diagnosis,  as  a     '    ~ 
presenbi  no  difficulty.     Erysipelas  may  be  exclude 
by  the  absence  of  serious  constitutional  disorder,  I 
the  mildness  of  the  local  symptoms,  and  especially  b 
the  fact  that  the  reddened  area  is  not  raised  aiul  i 
not  bounded  by  a  sharply  defined  edge.      From  u 
caria,  on  the  other  hand,  erythema  simplex  ia 
tiated  by  the  absence  of  the  characteristic  wheals  &] 
by  the  comparatively  persistent  nature  of  the  eruptit 


vm.)  ERYTHEMA.  fil 

A  variety  of  erythema  ainiplex  which  deserves 
special  mention  on  account  of  its  recurrent  character 
shows  itself  in  the  form  ot  congestive  redness  of  the 
checks  and  nose.  This  recurs  again  and  again,  and 
mav  finallv  become  permanent.  {See  Rosacea,  p. 
121.) 

Erythema  fug^ax  is  simply  a  more  transient 
variety  of  erythema  simples.  Patches  ol  redness 
come  out  suddenly  on  the  face  or  body,  and  disappe-ar 
in  a  day  or  two.  In  children  the  eruption  is  usually 
the  result  of  reflex  irritation,  as  by  teetliing  or  dis- 
order of  the  intestinal  tract  by  unsuitable  food,  or 
worms.  In  adults  it  is  sometimes  associated  with 
mental  emotion.  The  redness  may  be  either  diffuse 
or  scattered  over  the  body  in  irregular  patches  of 
varying  size.  Under  this  head  may  be  placed  tlie 
fleeting  rashes  described  by  some  authors  under  the 
designation  of  "  roseola." 

Eiythema  Solare,  or  sunburn,  appears  to  be 
an  effect  of  the  light  rather  than  of  the  heat  of  the 
sun  ;  the  violet  rays  are  thought  by  some  to  be 
the  actual  agents  in  its  production.*  The  electric 
light  has  been  found  to  cause  an  erythema  indis- 
tinguishabie  from  sunburn  (Cliarcot).  The  effect  of 
other  forms  of  energy  related  to  light  shown  in  tlie 
various  forms  of  erythema,  and  even  more  severe 
lesions,  caused  by  the  Rbntgen  rays,  are  only  now 
becoming  known.  A  number  ot  cases  have  been 
reported  in  which  the  X-rays  have  produced  a  severe 
and  circumscribed  form  of  dermatitis.-f  Actual 
burns  of  all  degrees  of  severity,  even  to  charring  of 
the  deeper  tissues  ot  the  limb,  have  also  been 
recorded. 

•Bowlen.   Bril.  Jam-nal  of  lln-m.,  Tol.  v.,  No,  8;  vol.  is. 

t  For  a  ilatailed  ai^raunt  o!  this  sabject,  with  bibliography,  ii-i- 
3.  C.  Gilchrist.  Bull.  Ji.hnK  Hopkim  HmpUal,  vol,  i-iu.,  No.  71, 
p,  17  ;   Budcliile  Cropltar,  Bi-il.  Mrd,  Joni'h,,  Jnnunry  'inii,  18B7. 


HEVROTW  AFFECTIONS  OF  THE  SKIN.    [™ar^ 

Erythema    intertrigo,    as   the   name   implies, 
itiiirs  in  parts  where  two  opposed  Burfacea  of  skin 
cliate  eat'.ii  other  (inuer  aspect  of  thighs,  groins,  axillee,.  ^ 
undur  pendulous  breasts,  at  tKe  lower  part  of  fchO- 
abdomen,  etc.),     lofants  and  fat  persons  a  '_ 

liable  to  the  affection ;  in  the  former  the  eniptioiW 
is  (lommonest  on  the  parts  which  are  chafed  by  thM 
napkins.  The  affected  surface  is  reddened  and  g' 
there  is  no  exudation,  but  the  epidermis  is  geoeially-l 

Home  extent  macerated  by  sweat.     Intertrigo  1»T| 
differ enl/iated  from  eczema  by  the  absence  of  "  weep- 
ing."    In  the  case  of  young  children  it  is  sometimes 
dilTicult  to  distinguish  intertrigo  from  the  erythema 
of  coogonital  syphilis.     The  eruption  is  very  similu^ 
in  both  affection^  ;  but  while  in  intertrigo  the  rednea 
is  usually  limited  to  the  parts  covered  by  the  napki 
in  congenital  syphilis  it  extends  down  the  legs,  ofb 
to  the  heels  and  soles  of  the  feet.*     The  chief  poiH 
of  distinction,  however,  is  that  if  the  affection  i 
syphilitic  other  characteristic  lesions  are  sare  to  I: 
present. 

Erythema  paratrimma  is  a  term  sometin 
iised  to  denote  the  efEoct  of  long-continued  pressoi 
on  a  particular  part  of  the  skin,  as  from  long  contimi'- 
a  nee  in  a  recumbent  position.  The  mechanical 
effects  of  pressure  are  aggravated  by  the  irritation  of 
urine  and  fsBces  when  the  patient  is  not  properly 
nursed,  and  by  conditions  which  lower  the  vital  _ 
power,  particularly  by  Icaiona  of  the  spinal  cord 
which  interfere  with  the  nutrition  of  the  part.  ' 

form  of  erythema,  if  not  carefully  attended  to, 
certain  to  end  in  bed-sore. 

Erythema  scaplatlniforme  is  a  febrile  i 

tion  characterised  by  an  eruption  closely   reBembyul 
that  of  scarlet  fever,  but  not  contagious,     T' 

•  Crocker  :  "  D[aeaseg  of  tlio  Skin,"  2nil  ed„  p.  62, 


vin.]  ERYTHEMA   SCARLATISIFOBME.  113 

is  marked  by  shivering  and  ayBtemit  diKturbanue, 
which  is  accompanied  or  quickly  followed  by  the 
appearance,  on  the  trunk  or  elsewhere,  of  efflor- 
escences, vivid  red  in  colonr  and  variable  in  size. 
Theae  often  run  together  so  as  to  cover  extensive 
areas  of  skin.  The  tongue  is  foul  and  has  a  more  oi 
less  distinct  "  strawberry  "  appearance,  and  there  is 
uBualSy  some  reddening  of  the  fauces,  with  soreness 
of  the  throat.  The  fever  speedily  subsides,  and  be- 
fore the  eTuptiou  haa  begun  to  fade  desquamation 
begins.  The  average  duration  of  the  aSection  is 
from  two  to  six  weeks,  but  in  some  cases  it  lasts 
much  longer.  Two  distinct  types  of  erythema  scar- 
la  tini  forme  can  be  recognised  clinically— one  running 
a  more  or  less  definite  course  and  disappearing  after 
a  few  weeks  ;  the  other  severer  and  more  prolonged. 
Relapse  is  not  uncommon,  a  fresh  crop  of  eruption 
coming  out  before  the  first  has  disappeared.  Ery- 
thenia  scarlatiniforme  shows  a  marked  tendency  to 
recur,  sometimes  every  year,  sometimes  at  shorter 
intervals.  Those  subject  to  it  can  generally  tell 
beforehand  when  an  attack  is  impending.  Various 
complications — pulmonary,  cardiac,  renal,  etc. — 
have  been  described  in  association  with  erythema 
scarlatiniforme,*  but  it  appears  more  probable  that 
such  conditions,  or  the  drugs  employed  to  combat 
them,  may  have  been  the  exciting  cause  of  the  skin 
afEection. 

The  etiology  of  the  disease  ia  by  no  means  chiar. 
A  certain  idiosyncrasy  on  the  part  of  the  patient  is 
required,  and  among  the  exciting  causes  one  of  the 
most  potent  appears  to  be  exposure  to  a  very  high 
temperature.  Crocker  f  has  seen  it  in  connection 
witli  sewer-gas  poisoning.     In  a  large  number  of  the 

•  Booiier  ami  Doj-'H^e  Freiidi  trariflliitinu  n£  Kapoai,  2dJ  eel, 
fiDUBawsottlieBkiu,-'  2Qdml.,  Londou,  181)3,  p.  liO. 


194    XEUROTIC  AFFECTWXS  OF  THE  SKIX.    [cbap.  ' 
cases  reported  by  French  dermatologiste — to  whom  I 
we  are  chiefly  indebted  for  the  recopoition  of  the  I 
disease — the  use,  internaily  or  est«raally,  of  ceitain  .J 
drugs,  notably  mercury,  would  seem  to  have  played  J 
an   important   part   in   its   causation    {see   ChaptaAl 
XI.) ;    but  the  fact  that  erythema  scarlatiniform*^ 
may    occur   when    the    possible  influence   of   i' 
or  toxic  agents  of  any  kind  can  be  absolutely  ex-^ 
eluded  justifies  ua  in  placing  it  provisionally  among;  I 
the  erythemata  proper.     Rheumatism,  ague,  syphilisf'-J 
and  alcoholism  have  been  indicated  as  possible  cause 
of  the  aSection,  but  in  all  these  cases  it  is  obviouHil 
that  the  real  source  of  the  mischief  may  be  mercury,  ' 
quinine,  salicylate  of  soda,  or  some  other  drug. 
Erythema  scarlatinifonne  derives  its  chief  import- 
ance feom  its  resemblance  ta  scarlet  fever.      This  is 
80  close  that  the  most  experienced  observer  may  be 
unable  to  give  a  definite  opinion  as  to  the  nature  of 
the  rash  during  the  first  few  days.     The  most  striking 
point  of  distinction  is  the  early  commencement  of 
^^_       desquamation  in  erythema  acarlatini forme,  and  the  . 
^^^L      fact  that  it  begins  when  the  eruption  is  stiU  in  t' 
^^H      florid  stage — as  early  as  the  second  day,  if  the  patdiea 
^^^H      are  carefully  examined  with  the  lens.*  and  at  late 
^^^H     on  the  third  or  fourth  day.     Again,  in  scarlet  level 
^^^^     the  eruption  does  not  last  longer  than  ten  dayra 
^^^K     whereas  in  erythema  scarlatiniforme  it  persista  save 
^^^B     weeks,  and  sometimes  indelinitely.     In  the  case  oii 
^^^H     person  who  has  had  previous  attacks,  the  histozy  wiH 
^^^B     often  be  helpful ;   but  in  all  cases  it  will  be  eafeet  U 
^^^P     isolate  the  patient  till  the  diagnosis  is  clear. 
^^^       probable  that,  in  some  at  least  of  the  cases  in  which  ' 
recurrence  of  scarlet  fever    has    been  reported,  the 
disease  in  one  or  other  of  the  attacks  has  really  been 
erythema    scarlatiniforme.     From    pityriasis    rubra, 

*  Betnior  and  Dojon:  Oji.  oit.,  vol.  i.,  ji.  341. 


vni.]  ERYTHEMA.  95 

to  which  the  affection  under  connideration  bears  cou- 
aiderable  resemblance,  it  may  be  distiiiguished  by 
the  ieas  general  difEusion  of  the  acalineaa  and  by  the 
repetition  of  the  desquamative  process. 

Rubeoloid  erythema— that  is,  an  "  ephe- 
meral "  eruption  of  measlea-like  character — has  been 
described  by  Besnier ;  but  he  himself  admits  that 
when  "  abortive  measles  without  catarrh,  rubeola,  and 
the  unlimited  Beriea  of  modified  roseohe  are  eliminated, 
there  remain  very  few  true  lubeoliform  erythemata."* 
I  only  mention  it  here,  on  the  authority  of  that  dis- 
tinguished dermatologist,  as  affording  a  possible  cluo 
to  errors  of  diagnosis  which  ocoaaionally  occur. 

Inflammatoky  Erythema, 

Under  this  heading  may  conveniently  be  grouped 
certain  diseases  which,  differing  in  some  particulars, 
are  all  characterised  by  lesions  of  an  inflammatory 
erythematoua  nature. 

Erythema  pernio,  or  chilblain,  is  characterised 
by  the  development  of  small  patches,  dusky  red  or 
bluisli  in  colour,  and  slightly  raised.  These  generally 
form  on  the  hands  (edge  and  dorsum  of  fingers)  and 
feet  (heel  and  outer  edge,  especially  on  the  little 
toe) ;  but  they  may  occur  at  any  part  distant  from 
the  heart  where  tlie  local  circulation  is  much  exposed 
to  the  influence  of  cold  air  (nose,  ears,  cheeks).  Sub- 
jectively, the  symptoms  are  great  tenderness  of  the 
affected  parts,  and  itching  which  becomes  almost  im- 
bearable  when  they  get  warm.  The  subsidence  of  tlie 
infl&mmationis  frequently  followed  by  desquamation. 
It  neglected,  the  akin  often  breaka,  and  ulcers  of 
greater  or  lesser  extent  may  form,  particularly  in 
under- fed  or  tuberculous  children.  Chilblain  is  more 
1  in  childhood  and  old  age  than  in  adult  life. 
•  Op,  dt,,  vol.  i..p,  337, 


w 


» 


m    NEUHUTIC  AFFKCTIOS.'i  OF  THE  SKIS,    [chap. 

It  hiis  been  suggested  that  the  disease  is  of  tuberculous 
origiu  •  ;  but  tiiere  is  no  cogent  evidence  of 
connection ,     Scrofulous    children    are    undoubtedly 
more  liable  than  others  to  chilblains  ;   but  that  is  < 
account  of  the  aniemia  which  is  su  pronounced 
feftture  in  the  tuberculous  diathesis.     The  disease  is  a 
result  of  local  disorder  of  the  circulation.     The 

at  first  contracted  under  the  influence  of  cold  : 
but  this  condition  soon  gives  way  to  dilatation  from 
motor  paralysis,  and  the  other  phenomena  of 
the  inflanunatory  process  follow  in  due  c 

In  connection   with  chilblain,  frOSt-bite,  which. 
is  pathologicaUy  a  more  advanced  stage  of  the  same 
process,  may  conveniently  be  considered.      The  first 
effect  of  the  cold  is  to  blanch  the  part  (fingers,  noeo, 
or  other  extremity)  by  constriction  of   the  vessels  _ 
dilatation  follows,  and  the  part  becomes  congested 
and  swollen,  assnming  a  peculiar  violet  colour.     Some 
itching  and  pricking  are  iKUally  complained  of.     In 
the  milder  cases  the  skin  soon  recovers  ite  natural 
appearance  ;    but  sometimee  the  capillaritw  remain 
dilated,   causing    permanent  erythema, 
cases  vesicles  form.     This  is  a  sign  of  ominoos  imports' 
The  severer  degrees  of  frost-bite,  in  which  gangreiu 
of  a  part  occurs,  belong  rather  t*  the  domain 
general  surgery  than  to  that  o(  dermatology. 
Erythema    keratodes.  —  Under     this 
Brookef  has  described  a  rare  form  ol  sharply  circni 
scribed  chronic  erythema  of  the  paim-s  and  sol4 
leading  to  overgrowth  of  the  horny  tissue,  and 
panied  by  codcma  and  tenderness,  which  ii 
considerably  with  movement.     Besides  the  lesions 
the  palms  and  soles,  more  or  less  horny  erythematoi 
nodules  are  seen  on  the  back  of  the  finger  joints. 

*  Coziu  and  Ifforeaco :  Cougrfs  Intern,  (le  DemotoL  at  4 
Ryphilii  lonu  i.  Paris  en  IHMl) ;  roniplff-Knidut,  p.  5U. 
i  Brit.  JoHi-n.  of  bfrmatulugy,  18U1,  p.  335  »(  *}?■ 


I 


VUL]  KKYTUtiMATA.  07 

aSection  lieginfi  with  the  devetopmeDt  on  the  palms 
and  soles  of  red  patches,  which  speedily  coaleace.  Tho 
thickening  of  the  epithelium  quickly  follows  the  first 
signs  of  inffammation.  The  surface  of  the  skin  is 
smooth  and  the  furrows  are  well  preserved.  The  pro- 
grew  of  the  affection  Li  gradual ;  it  responds  readily 
to  treatment,  hut  tends  to  relapse.  In  this  respect  it 
difiers  from  the  affection  described  by  Beanier*  under 
the  name  of  heratodermia  eryth&nalosa  ^mmetnca, 
which  ia  continuous.  Brooke  thinks  that  the  sym- 
metry of  the  lesions,  in  conjunction  with  the  syn- 
chronous implication  of  both  hands  and  feet,  indicates 
a  central  tropho -neurosis  as  the  cause.  Dubrcuilh, 
however,  who  has  recorded  a  similar  case,'!'  points  out 
that  the  symmetry  of  the  lesions  is  no  proof  of  such 
an  origin,  and  that  the  rapid  and  complete  cure  of 
the  affection  hy  treatment,  mainly  local,  does  not 
accord  witli  the  hypothesis  of  a  central  neurotic 
origin. 

Erythema  multiforme  is  an  inflammatory 
affection  of  the  akin  characterised  by  a  polymorphous 
eruption,  in  which  papular,  vesicular,  bullous, 
nodular,  cedematous,  and  htemorrhagic  elements  tire 
mingled  together,  or  sucueed  each  other,  ao  as  to  form 
s  clinical  picture  that  in  kaleidoscopic  in  its  infinite 
variety.  As  Beenier  and  Doyon  truly  say,  "  You 
may  pass  twenty  years  of  your  medical  life  iu  observ- 
ing and  collecting  cases  of  erythema,  and  each  year 
will  bring  you  forms  which  you  have  never  before  secTi. 
Kot  only  does  this  variety  defy  all  complete  descrip- 
tion, but  categories  ad  infinitum  would  be  needed  if 
one  wished  to  classify  all  the  facts  in  methodical 
series.  The  authors  who  have  attempted  to  do 
Bu  have  invariably  failed,  and  have  only  succeeded 
in    producing     undigested     and     useless    compila- 


98    XECRtiTlC  APFECTiOXS  OF   THE  SKIX.    [CK»r 

tions."*  All  that  can  be  done  here  is  to  tndictite  the 
salient  points — the  types  of  the  different  forms  as- 
sumed by  the  proress  in  the  varirms  stages  of  ite  evo- 
lution. To  these  t>Tiital  forms  distinctive  names 
have  lieen  given,  as  erylhana  jiapuUnum,  erythema 
annuiare.  and  so  forth.  These  names  serve  a  ueelnl 
purpose  a£  indicating  the  predominant  character  of 
tlie  lesions  in  a  particular  case  or  at  a  given  time.  It 
must  be  clearly  nnderstood,  however,  that  they  denote, 
not  different  diseases,  but  phases  in  the  same  process. 

The  eruption,  which  is  generally  more  or  less  sym- 
metrical in  distribution,  first  shows  itself,  as  a  rule, 
on  the  back  of  the  hand  and  the  dorsum  of  the  foot ; 
it  may,  however,  appear  on  any  part  of  the  body. 
In  the  progreaa  of  the  disease  the  forearm  and  arm, 
the  leg  and  the  thigh,  and  the  trunk  and  &ice  may 
be  invaded.  In  exceptional  cases  the  mucous  mem- 
brane of  the  mouth  and  pharynx  and  the  conjunctiva 
mav  suffer.  At  the  height  of  the  attack  the  tongue 
is  sometimes  greatly  swollen.  The  backs  of  the 
bands  seldom  e-scape :  otherwise  the  disease  follows 
no  rule,  either  as  to  the  extent  of  surface  over  whkli 
it  is  distributed  or  as  to  the  points  which  it  sdects 
for  attack. 

Erythema  multiforme  is  often  ushered  in  by  rise 
of  temperature,  congestion  of  the  pharynx,  gastio- 
intestinal  disturbance,  and  other  signs  of  ^vtemic 
disorder.  Pain  in  or  about  one  or  more  of  the  joints 
is  perhaps  the  most  constant  of  these  premonitory 
symptoms.  Any  or  all  of  them,  however,  may  be 
absent,  and  the  temperature  may  be  below,  instead 
of  above,  the  normal  standard.  The  eruption,  aa 
already  said,  is  markedly  polymorphous  not  only  in 
the  form  but  in  the  nature  of  the  lesions.     As  Jamte- 

nndstKm,  ind  ed.,  loiue 
tootiH>t«. 


i 


ERYTHEMA    Ml'LTIFORME.  m 

son  points  out,*  however,  in  their  evolution  a,  gradual 
rise  from  simple  to  more  complex  forms  can  usually 
be  traced.  Thus  the  commencement  of  the  process 
is  marked  by  the  appearance  of  a  crop  of  ptipules  no 
lai^er  than  a  pin's  head,  of  a  bright  red  colour,  which 
'  fades  on  pressure,  aad  is  hard  and  distinctly  hot  to  the 
tonch  {erytkema  papuialum].  These  papules  quickly 
spread  centrifugaJly  so  as  to  form  snnal!  tubercles 
{erythema  tuberctilafum) ;  or,  if  closely  grouped  to- 
gether, they  may  coalesce  and  form  raised  patches 
of  the  size  of  a  threepenny  or  aixpenny  piece.  Eat^li 
paffh  presents  a  sharply  defined  border,  and  has 
around  it  an  areola  of  congested  skin ;  the  centre  iu 
of  a  less  vivid  red  than  the  edge,  and  its  tint  soon 
deepens  to  violet,  then  to  purple.  Bullte  occasionally 
develop  on  the  patches,  and  after  a  time  shrink  and 
form  scabs.  The  eruption  may  disappear  in  a  few 
days,  leaving  behind  it  only  a  slight  brownish  dis- 
coloration. More  commonly  the  centre  of  the  patch 
undergoes  absorption,  while  the  edge  continues  to 
advance.  In  this  way  rings  of  varying  circumfer- 
ence are  formed,  the  centre  of  which  is  depreaaed  and 
pale  or  bluish-red  in  colour,  while  the  edge  is  raised 
and  of  a  florid  scarlet  hue  {erythema  annulare).  These 
rings,  as  they  enlarge,  come  tn  contact  with  others. 
This  leads  to  the  disappearance  of  the  eruption  at 
the  points  where  the  edges  meet,  so  that  only  seg- 
ments of  the  pre-existing  circles  remain,  either  iso- 
lated or  variously  joined  in  the  form  of  curves  or 
wavy  lines  {erythema  gyratum).  Some  of  these  may 
continue  to  spread  as  narrow  raised  bands  with  a 
sharply  defined  edge  (erythema  mar^inalum).  A.s 
fresh  crops  of  papules  continue  to  come  out  from  day 
to  day,  several  or  all  of  the  phases  that  have  been 
dMcribed  may  be  present  in  one  case  at  the  same 

imaaes  of  thf  Skill"  (EdiiibiirBU.  IS8S),  [■.  sr. 


100   XECBCfTlC  AFFECTIOXS  OF  THE  SKIS.  [chap. 

time.  The  multiformitv  of  the  lesions  mav  be  still 
further  increased  hy  the  formation  of  vesicles  and 
bulla?  on  the  patches  and  on  the  centre  and  borders 
of  the  rinsrs.  by  sc^^bs.  and  by  escape  of  the  colouring 
matter  of  the  blixni  or  actual  haemorrhage  beneath 
the  epidermis.  The  average  duration  of  the  indivi- 
dual lesion  in  erythema  multiforme  is  little  more  than 
a  week,  but  the  process  a^  a  whole  usually  lasts  a 
month  or  six  weeks :  and  as  recurrence  is  very  com- 
mon and  often  takes  place  at  short  intervals,  the 
,  duration  of  the  disease  may  sometimes  appear  to  be 
indefinitely  prolonged. 

A  particular  form  of  en'thema  multiforme  re- 
quires separate  mention,  because  its  appearance  is 
so  characteristic  as  almost  to  entitle  it  to  be  classed 
as  a  distinct  disease,  and  because,  as  a  matter  of 
fact,   it  often  occurs  indeix^ndentlv  of  anv  of  the 

*  •  • 

other  lesions  that  have  been  described.  This  is 
erythema  iris,  which  is  met  with  under  two  tvpical 
forms.  One  of  these  begins  as  a  small  red  spot.  On 
this,  in  a  few  hours,  a  vesicle  forms,  and  around  the 
vesicle  a  zone  of  reiiness  quiikly  de\elop8.  The 
central  vesicle  soon  dries  m^.  loavinc  a  small  scab, 
and  a  ring  of  sctH^ndary  vesi«"lcs  forms  on  the  red  zone 
encircling  it.  When  the  central  scab  separates,  the 
skin  underneath  presents  a  blue,  congested  appear- 
ance, which  takes  some  time  to  disappear.  The 
proi^ess  here  descrilunl  may  be  repeated  several  times, 
the  concentric  rings  of  vesicles  and  reddened  skin 
producing  an  appear«\nce  nut  uiilik,^  a  target.  There 
mav  be  onlv  a  single  lesion  vi  xh*^  kind,  or  there  mav  be 
several  scatteriHi  about  the  >\rists.  arms,  and  legs. 
On  the  lingers,  owing  pn^bably  to  the  anatomical 
]>et  uliarities  oi  the  part,  tlie  t:irget-like  appearance 
is  not  so  well  markeil.  The  other  form  is  charac- 
teri>tHl  by  the  develi>pment  of  a  large  central  bulla 
^urroundinl  by  a  ring  of  vesicles  of  considerable  size  ; 


it]  ERYTHEMA    MULTIFORME.  101 

Bence  the  misleading  name  of  heppes  iris  in  often 
applied  to  it.  Another  ring  of  vesiclea  may  develop 
outside  the  first,  and  outside  the  second  there  is 
aometimes  a  third.  The  intervening  circles  uf  "kin 
are  of  a  purplish  hue.  In  both  these  forma  the 
process  is  essentially  that  of  erythema  multiforme  the 
vesication  being  only  an  accidental  compbcation 

Although,  as  has  been  stated,  erythema  iria  mav 
occur  independently  of  any  other  form  of  eruption 
it  is  often  associated  with  the  more  ordmarv  le^ioiw 
o(  erythema  multiforme.  In  my  own  evperieare  it 
is  more  apt  to  occur  alone  iu  cold  weather  in  police 
men  and  other  persons  whose  occupation  mvolves 
a  good  deal  of  exposure.  The  condition  ruuM  a 
definite  c(.urse.  lasting  from  two  to  three  weeks  j,nd 
leaving  only  a  brown  stain  behind  it. 

The  subjective  symptoms  in  erythema  multifurme 
are  not,  as  a  ride,  of  any  importance.  The  te\  er  does 
not  always  subside  with  the  appearance  of  the  erup- 
tion, and  in  that  case  some  degree  of  imdake  may  be 
complained  of ;  but  this  seldom  persists  for  more 
than  a  very  few  days.  There  is  not  generally  any 
itching  or  burning,  and  when  such  sensations  are 
present  they  are  never  very  severe.  In  children 
pyrexia  and  the  other  constitutional  symptoms  are 
more  marked  than  in  adults,  and  the  lesions  are  apt 
to  he  more  severe,  the  vesicles  becoming  transformed 
into  pustules,  and  being  followed  by  scarring. 

CGnically  there  are  two  types  of  erythema  multi- 
forme— viz.,  the  ordinary  form,  which  runs  a  benign 
course  and  ends,  after  a  longer  or  shorter  series  of 
relapsett.  in  complete  recovery  ;  and  a  severe  form, 
characterised  by  visceral  manifestation  of  various 
kinds,  gastro- intestinal  crises,  acute  nephritis,  hse- 
morrhage  from  the  mucous  surfaces,  pericarditis  and 
'  icarditis.     This  form  usually  ends  in  death. 

"   I    etiolog'y  of  erythema  multiforme,  though 


i 


UB  xMcgoTic  ArrxcTJOSS  or  rar  ssis.  \ciur. 

«tai  otnCBK,  Us  gndoalh- hMl  Bm  i^t  abed  «■  it. 

VwobMy  many  caasea  prodaoe  atmikr  nn^ts  io  tliis 

disfsse.  uid  Htuiy  bold  tlut  toxic  maieAi  dicidatiBg 

tbe  blood  is  the  diief  caiue  of  the  symptoms  4^ 

eiytkMna  mnltifonoe.  wfaile  ib^uaatisni  b  little  eoa- 
MTDcd  in  its  caasation.* 

Tie  pathalogy  of  "  idiopatliic  "^  enrtbena  raolti- 
fonne  is  aiuiim«d  np  in  the  statement  tbat  the  pro- 
cess is  angio-neurotie  in  its  rutttue.  It  difteis  from 
hTperemic  erythema  only  in  tbe  fact  that  exudation 
is  a  far  more  pioDounoed  feature  tban  it  is  in  tbe 
latter.  In  tbe  severer  form  the  fkin  lemons  are  Mtmn- 
dazy  in  septic  and  suppurativa  ]»ocesses  in  tbe  visoxa. 
Thus  they  have  been  observed  in  cases  of  cyatitia 
from  stricture,  of  rectal  chancre  |Finger),  of  dipb- 
theria.  of  cholera,  etc. 

Tbe  diagnosis  seldom  presents  any  difficulty,  tbe 
appearance  of  er\-thejna  iris  Iteing  so  characteristic  as 
to  make  it  impo^ble  to  mistake  it  for  anything  else, 
and  the  multiformity  of  the  lesions  in  other  cases 
being  sufficient  to  differentiate  the  disease  from  other 
conditions.  Occasionally  urticaria  of  the  papular 
variety  bears  some  resemblance  to  erythema  papu- 
latum.  but  the  latter  can  usually  be  identified  by 
tbe  absence  of  itching,  bv  the  longer  persistence  of 
the  lesions,  and  by  the  fact  that  tbey  leave  stains. 
In  the  papular  stage  of  eczema,  again,  the  itching 
is  a  very  marked  feature. 

Tbe  prognosis  is,  in  Uie  vast  majority  of  caaes, 
good  as  regards  tbe  particular  attack  ;  but  recuireiwo 

•CtTeiel:  "  Trans.  Intemat  Congras  of  Ddrmat  .  1896  " ; 
Il&ckouie:  "  TraiH.  latemat  Caiigren  of  DenuaL,  1896"; 
Oalsr:  "  On  Uw  Vuceral  Coniplicationc  of  Errthema  Eladatinat 
Unltiioniie"(Ai«rr;rai,JemrH.tflitJfnliea1anenn;Oeea^hn, 
ISSa) ;  Finger:  "Beittac  xur  Autioloeie  ud<1  pathologudhsB  I 
Aaaitiiaie  dea  Erytbenui  Mnltiformp  "  (II.  Intpmatioiuilm  Der*  ] 
DiAtnkwischer    Congrew  ol.gehBlten    iu  Wien  iiii  Jtim   1891).    ' 

Wien,  I893,p.  T;*. 


vm,]  ERYTHEMA    yOUOSUM.  103 

is  almost  certain,  and  it  \&  quite  impossible  to  predict 
that  the  patient  will  remain  free  from  the  disease. 
If  serioua  complications  opcur,  the  torecast  must  be 
based  on  tliem,  not  on  the  skin  afiection. 

Erythema  nodosum  is  characterised  by  the 
formation  of  node- like  swellings  on  the  legs  and  feet, 
leas  frequently  on  the  forearms,  thighs,  buttocks, 
and  over  the  saapulse,  and  in  rare  cases  on  the  tare. 
The  distribution  of  the  swellings  is  generally  sym- 
metrical ;  they  come  out  in  crops  of  two  or  three 
at  a  time,  the  first  point  of  attack  generally  being 
the  leg.  along  the  tibia.  Their  appearance  is  preceded 
and  a<!Companied  by  a  greater  or  lesser  degree  of  con- 
stitutional disturbant^e.  one  constant  symptom  being 
pain  of  a  rheumatic  character  about  the  joints,  espe- 
cially of  the  lower  limbs.  The  swellings  are  oval 
in  shape,  and  lie  with  the  long  axis  corresponding 
to  that  of  the  limb.  They  have  no  well-defined 
border,  and  vary  in  size  from  a  walnut  to  a  hen's 
egg.  At  first  bright  red  in  colour,  they  soon  become 
bluish  in  the  centre  and  purple  at  the  circumference, 
and  as  they  subside  they  exhibit  the  various  changes 
of  tint  that  are  seen  in  a  bruise.  They  are  not,  as 
a  rule,  painful,  but  are  very  tender  on  pressure.  Firm 
and  tense  in  the  beginning,  they  soon  soften  and  give 
a  sensation  somewhat  resembling  fluctuation  tii  the 
finger,  but  they  never  suppurate  The  individual 
swellings  last  about  a  fortnight ;  but  as  fresh  ones 
come  out  in  successive  crops  for  two  or  three  weeks, 
the  duration  of  the  affection  averages  from  three  to 
six  weeks. 

Er>'thema  nodosum  is  very  rare  after  the  age  of 
twenty,  and  girls  show  a  greater  proclivity  to  it  as 
I'ompared  with  boys  in  the  ratio  of  about  two  to  one 
It  id  more  common  in  the  spring  and  the  autumn 
tliaii  at  other  seasons  of  the  year  Exposure  to  cold, 
and  especially,  according  to  Crocker   to    bnne-laden 


ln4    XEUROTIC  AFFECTIUXS  OF  THE  SKIX.  [cm 

winds,  may  be  an  exciting  cause.  Stephen  Mac- 
kenzie* lias  shown  from  an  analysis  of  108  casea. 
that  erythema  nodosum  ia  frequent!}'  associated  with 
rheumatism.  Even  when  there  are  no  actual  rhea-- 
matic  lesions  tlie  patienta  often  present  the  signs  of 
the  rheumatic  diathesis.  The  aSection  is  aometimoa> 
complicated  by  endocarditis  or  some  other  acute  car-- 
diac  mischief.  One  attack  predisposes  to  others,  and' 
in  those  subject  to  it  the  disease  is  apt  to  recur  yearly< 
at  the  eame  season.  The  pathology  is  that  of  hyper- 
cemic  erythema.  Local  vaso-motor  disturbance  ia 
followed  by  inflammatory  efEusion  of  fluid  and  escape 
of  white  blood  corpuscles. 

There  is  seldom  any  room  for  doubt  as  to  ths 
nature  of  the  aSection.  Tiie  appearance  of  the  lesions 
and  their  association  with  pains  in  the  joints  are 
characteristic.  I  have,  however,  known  instances  ia 
which  erythema  nodosum  on  the  face  has  been  mis- 
taken for  tubercular  leprosy.  It  must  also  be  ■ 
distinguished  from  a  form  of  erythema  of  the  le^. 
to  which  young  girls  are  sometimes  subject.  The 
latter  affection  is,  however,  much  more  chronic  i 
course,  and  may  last  for  months.  Its  characterislio 
feature  is  the  appearance  on  the  legs  of  indurated 
patches  of  infiltration,  red  or  livid  in  hue,  which 
often  break  down,  leaving  ulcers  very  similar  to  ter- 
tiary syphilitic  lesions.  This  erythematous  afiection 
appears  t*i  be  often  a  result  of  fatigue  from  standing 
tooJong:  the  patients  are  always  weakly  and  anemic 
Mention  should  also  be  made  of  another  variety  of 
node-like  swelling  which  is  of  not  infrequent  occur- 
rence in  the  legs  of  young  women  suffering  fiom 
varicose  veins  ;  these  swellings  are  nodules  due  to 
capillary  phlebitis.  In  neither  of  those  afFections, 
however,  are  there  any  concomitant  rheumatio'  I 
ej-mptoms. 

•  "  Cliii.  Soc.  TraiiB,,"  vol.  nil.,  p.  'M. 


Hpt]     TREATMENT   OF   THE   EHYTnEMATA.       llir. 

The  prognosis  in  uncomplicated  cases  of  erythema 
nodosum  is  always  favoorablc,  the  diaeaae  tending  to 
Buhside  spontaneously  after  running  its  course.  It  is. 
however,  as  already  said,  not  uulikely  to  recur.  If 
any  serious  cardiac  complication  he  present,  the 
prognosis  miist  be  based  on  that,  and  not  on  the  skin 
afiection. 

Treatment  of  the  Erythemata.-  -For  eri/the- 
*fta  simplex  no  treatment  is  required  heyond  the  re- 
moval of  any  obvious  source  of  irritation.  Itehing 
may  be  relieved  by  the  treatment  described  under 
the  head  of  Pruritus  {p.  67  et  sqq.].  In  interlrign  the 
opposing  surfaces  should  be  separated  by  small  pads 
of  lint  or  cotton-wool,  placed  above  and  below  the 
diseased  area,  or  by  the  interposition  of  a  muslin  bag 
tilled  with  powder  as  already  described.  As  in  tlie 
situations  where  intertrigo  is  apt  to  occur  decom- 
position of  the  secretiona  is  likely  to  take  place,  with 
the  result  of  greatly  intensifying  the  irritation,  the 
parts  should  frequently  be  washed  with  n  solution  of 
boracic  acid  {gra.  10  Co  15  in  3/  of  distilled  water),  then 
carefully  dried,  and  finally  thickly  dusted  over  with 
Aome  protective  powder.  In  the  case  of  infants  the 
strioteat  cleanliness  must  be  enjoined  ;  napkins  must 
be  changed  as  soon  as  tliey  are  wet ;  other  conditions 
Icoepiiig  up  irritation — such  as  diarrhcea  or  worms — 
DUUt  be  treated  by  appropriate  remedies. 

In  commencing  erythema  paratrimma  (bed-sore) 
the  ptessure  must,  as  far  as  possible,  be  neutralised 
by  the  use  of  air-cushions  or  circular  pads,  or  by  keep- 
ing the  patient  on  a  water-bed.  The  greatest  atteii- 
doD  most  be  paid  to  local  cleanliness,  and  the  nutri- 
tioB  of  the  affected  area  should  be  kept  up  liy  fre- 
quent washing  with  stimulating  applications — such 
U  a  mixture  of  brandy  or  rectified  spirit  and  white 

^,  camphorated  spirit  of  wine,  etc.     II,  in  spite 


lOfi    NEUROTIC  AFFECTIONS  OF  THE  SKIN.  [chip. 

I  of  this,  a  bed-Boie  {orms,  it  miiat  be  treated  on  general 
,  surgical  principles. 

In  scarlalimform  erythema  the  cause  must  first, 
if  possible,  be  removed  ;   in  other  respects  treatment 
must  be  symptomatic.     It  is  most  important,  for  ob- 
vious reasons,  to  avoid  the  use  of  all  drugs  that  have 
I   the  property  of  causing  rashes  (see  Artificial  Erup- 
tions,  p.    202)  ;     Besnier    has  even    recorded    fatal 
I   results  from  this  cause.     Locally  cooling  and  sooth- 
I  ing  applications  {simjde    or   boracic  acid  ointment, 
I  calamini  liniment,  etc.)  are  grateful    to  the  patient 
1  and  may  do  some  good.     Payne*  finds  quinine  in 
,   large  doses  (grs.  ss-xxx  a  day)  and  sodium  scUicylate 
very  efRcacious. 

In  the  treatment  of  erythema  pernio  (chilblain)' 
the  principal  indication  is  to  stimulate  the  circutatioitT 
'  I  the  affected  region.  For  this  purpose  the  parts 
should  be  kept  warm  ;  and,  unless  the  feet  are  dis- 
abled, brisk  walking  exercise  should  be  taken.  One 
of  the  best  local  remedies  is  iodwie,  applied  in  the  form 
of  the  tincture.  Friar's  balsam  and  camphorated 
■spirits  are  also  exceUent  remedies.  One  point  of  gie&t 
importance  is  to  dry  the  part  as  thoroughly  as  poe- 
sible  after  washing.  If  vigorous  friction  with  a  toweI_ 
or  piece  of  lint  canbeborne,  it  will  be  useful.  Ulcera-' 
tion,  should  it  occur,  must  be  treated  on  general 
surgical  principles.  If  the  patient  is  aneemic,  ferru- 
ginous Ionics  should  be  given,  and  if  the  heart?* 
action  ia  weak,  it  may  with  advantage  be  strengthened 
by  the  administration  of  digitalis.  As  regards  pK' 
vention,  the  only  thing  likelv  to  he  effectual  is  to 
keep  the  circulation  active  by  warmth  (woollea' 
gloves  (or  the  hands,  thick  worsted  stockings  for  ' 
feet),  and  especially  by  vigorous  exercise.  The 
may  also  be  hardened  by  the  use  of  toilet  vinegar  ii 
the  water  used  for  washing. 

•  IMI.  J<.i-ni.  U,r,wtoln!if,.  May.  18!H. 


vm.]     TREATMENT   OF   THE   ERYTHEMATA.       107 

In  the  milder  cases  of  frost-bite  care  should  be 
taken  not  to  warm  the  parts  too  quickly.  Rub- 
bing with  snow  is  recommended,  and  this  must  be 
continued  till  the  circulation  begins  to  be  restored. 
lehthyd,  owing  to  its  influence  on  hyperemia  and 
circulatory  anomalies  generally,  is  of  great  service  ; 
it  may  be  taken  internally  and  used  locally,  a  10  per 
cent,  salve  being  rubbed  into  the  affected  part. 
Massage  and  galvanism  are  valuable  adjiincte  in  the 
treatment. 

Erythema  keralodes,  according  to  Brooke,  yields 
readily  to  the  internal  administration  of  iehthyol 
(\T\iij)  in  capsules  thrice  daily,  and  the  constant 
application  of  an  ointment  containing  ichlhyol  and 
mlicylic  acid.  Dubreuilh  cured  his  case  with  iodide 
of  potassium  internally  (given  on  the  hj-pothesis  that 
the  affection  was  syphilitic),  and  the  application  of 
diachylon  ointment  fo  which  20  per  cent-,  oj  salieylic 
acid  had  been  added. 

Brythetiio  multiforme  rune  a  definite  course,  and 
is  not  much  influenced  by  treatment.  The  symp- 
toms may,  however,  generaUy  be  mitigated  by  the 
exhibition  of  drugs  that  have  a  directly  sedative 
action  on  the  nervous  system,  such  as  opium,  heUa- 
donna,  quinine,  used  in  the  manner  already  described. 
Arsenic  is  often  of  service  when  the  iidlammatory 
symptoms  are  not  intense  ;  if  they  are,  antimony 
should  be  given  in  the  form  of  vinum  antimonitde 
lu\iij  to  n\v  in  J;  of  vnter).  The  diet  should  be  of 
the  plainest  and  least  stimulating  character,  and 
alcohol  must  be  forbidden.  When  there  are  gastro- 
iat«stinal  complications.  inte.Htinal  disinfection  by 
»alol,  etc.,  ia  advisable.  The  calamine  lotion  already 
mentioned  is  the  best  local  application  to  relieve  the 
paiB  and  burning.  In  cases  of  toxiemic  origin  the 
ment  of  the  constitutional  condition  is  of  the 
mportance. 


108  NEVnOTIC  AFFECTIONS  OF  THE  SKIN,   [chap.^ 

The  chief  indications  in  the  treatment  of  erj/thema 
nodosum  are  rest  and  the  neutrahsation  of  the  effecta 
of  the  ^rheumatic  poison  if  tliere  be  evidence  of 
its  presence.  Salicylate  of  soda  in  doses  of  from  HL 
to  15  grains,  according  to  age,  should  be  given  thre 
times  a  day  for  this  purpose.  When  the  swelling  a 
other  local  symptoms  have  subsided  an  iron  Umie  I 
generally  indicated.  Rest  in  bed,  with  elevation  fl 
the  affected  limbs,  in  addition  to  the  apphcation  i 
soothing  or  cooUng  lotions,  is  necessary.  The  s 
ings  should  never  be  opened,  however  distinctly  theW 
may  fluctuate. 

Purpura  is  an  advanced  stage  in  the  angio-  * 
neurotic  process.  Like  dropsy,  it  is  not  a  substantive 
disease,  but  the  result  of  pathological  processes  that 
may  occur  in  a  number  of  different  morbid  conditions. 
Some  confusion  is  still  not  unfrequently  caused  by  a 
survival  of  the  erroneous  view  of  the  older  authors, 
who  looked  upon  purpura  as  an  independent  noso- 
logical entity.  It  is  in  reality  nothing  more  t' 
the  extravasation  of  blood  into  the  cutis.  This  n 
take  place  either  as  a  mechanical  effect  of  ovel 
dilatation  or  as  the  result  of  changes  in  the  blood  fl 
in  the  vessels,  or  of  impaired  nerve  control. 
iitemorrhage  gives  rise  to  different  appearancfis  in  i 
skin ;  hence  various  names  have  been  given  to  [ 
puric  lesions,  according  to  their  shape.  Thus  i 
extravasation  may  cause  spots  or  funda,  lines  « 
vibices,  amaU  patches  or  jwteohim,  or  diffuse  patchoii 
ecckymones  or  bruises.  In  all  these  forms  the  not' 
of  the  lesion  is  that  it  cannot  be  obliterated  by  pra 
sure  with  the  finger,  showing  that  the  diecoloratiiHtfl 
due  to  effused  biood,  not  to  congestion.  The  lesioT 
so  far  as  it  concerns  the  dermatologist,  is  r^erredt 
in  dealing  with  the  various  affections  in  whicb  1 
occurs,  but  it  may  also  be  a  symptom  of  certain  t< 


viiL]  PELIOalS   RUEUMATICA.  lOH 

conditions,  bucU  aa  the  exanthema tous  fevers,  some 
drug  eruptions,  and  scurvy.  It  sometimes  occurs 
in  connection  with  various  visceral  bwmorrhages — in 
the  brain,  lung,  retina,  and  gaatro-inteatinal  canal.* 

Purpura,  or  peliosis  rheumatica,  is  an  acute 

diaetise,  the  symptoms  of  which  are  pains  Jn  the 
joints^,  with  pHrpnric  spota  appearing  in  patches, 
especially  in  the  neigtibourhood  oi  the  joints  in  which 
tlie  pain  ia  most  seyere.  It  bears  a  general  resem- 
blance to  some  forms  of  erythema  multiforme,  but 
the  articular  pain  is  generally  more  pronounced,  and 
the  sub -epidermic  hiemorrhagea,  iostead  of  being 
occaaional,  are  constant,  and  form,  the  only  lesion  of 
the  skin.  The  onset  of  the  afiection  is  sometimes 
marked  by  constitutional  disturbance  ;  swelling  of 
the  joints  with  pain  comes  on,  and  a  day  or  two  later 
the  eruption  appears,  usually  during  the  night.  The 
wts  always  come  out  on  the  knees  and  ankles,  and 


3  or  ceases  on  the  appt  

The  lesions  consist  of  slightly  raised  papules 
patches,  bright  red  at  first,  but  not  fading  od  pressure. 
They  soon  change  colour,  becoming  purplish  and 
then  black  ;  they  are,  in  fact,  obvioualy  htemor- 
rh»({ea.  aad_exhibit  the  usual  d iscoloration  of  the  skju 
canaed  by  extravaaa ted  blood.  The  affection  in  the 
acato  atage  tasta  only  a  few  days,  but  recurrence  may 
take  ylace  in  two  or  three  weeks  ;  and  this  may  be 
repeated,  so  that  the  affectioii  may  altogether  last 
several  weeks  or  even  months.  The  pathology  of 
the  diiieaBe  is  obsture,  but  the  general  trend  of 
oyinion  is  that  rheumatism  plays  no  part  ia,  its 
ttauaation,  arul  that  the  pains  in  the  jointa  are 
caused    by  the  effused    blood.     Stephen    Mackenrie, 


110  NEUROTIC  AFFECTIONS  OF   THE  SKIN.   [< 


1 


however,  still   holds  the  belief  that  it  is  of  rheu- 
matic nature.* 

Women  are  more  often  aflected  than  men.     The 
disease  is  most  common  between  the  agea  of  twenty  . 
,  .and  thirty,  b.ut  is  not  unknown  in  children.  j 

Pathologically,  the  disease  is  of  angjo -neurotic 
nature,  the  process  being  carried  a  step  beyond  exu- 
dation of  aerum  or  effusion  of  htemoglobin,  as  in 
erythema  multiforme,  and  actual  hsemorrhage  taking 
place.  Why  hemorrhage  should  be  a  constant  phe- 
nomenon is  not  clear,  though  it  may  be  conjectured 
that  it  IB  due  to  some  alteration  in  the  constituents 
of  the  blood  dependent  on  an  unknown  cause. 

Peliosis  rheumatics  can  hardly  be  mistaken  for 
any  other  disease,  the  combination  of  pain  in  the 
jointe  with  a  purpuric  eruption  around  them  being 
almost  absolutely  distinctive. 

As  regards  prognosis,  in  uncomplicated  cases  re- 
covery ia  certain,  but  recurrence  is  almost  as  certain. 
Wnen  grave  complications  are  present,  they  must  bo 
taken  into  account  in  forecasting  the  issue  of  the 
disease. 

The  treatment  may  be  summed  up  in  the  follow- 
ing recommendations: — Rest  in  the  horizontal  position 
until  the  lesiooB  have  disappeared  ;    the  administrar-" 
tionof  cLu[ninp,  mm^and  other_toni(;H  ;   andj '" 
3ief! 

Lupus    erythematosus  —  ulerj'thema    cental  1 
fugum  (Unna) — or,  as  I  should  prefer  to  call  it,  ery- 
thema otTophicans,  is  an  inflammatory  proceas  giving 
rise  to  cellular  infiltration,  ending  in  atrophy  of  the 
afiectcd  part  of  the  skin.     It  begins  by  the  appear- :| 
ance  of  "primary  eruptive  spots"  (Kaposi),  ch^ra 
terised  by  a  red,  elevated  hypenemic  and  infiltrateAfl 

•  Sir  Stephen  Mnekcniie :  "  Ou  the  Holatioiialiip  of  E 
Rheiimatica  lo  Erf  thema  Exudntivam  Mnltiformo  "  (Hnl.  J 
l/rfm..  vol,  viii.,  1896,  p.  116). 


Tnj.]  LUPUS   ERYTHEMATOSUS.  Ill 

Itorder,  with  a  centaral  scar-like  depreaaion,  wIlicIl  is 
either  smooth  or  covered  with  a  dry,  firmly  adherent 
acab  or  thin  papery  greyish  scales  (Jamieaon).  These 
small  red  spots  fade  on  presisure.  The  distribution 
ol  the  lesions  is  frequently  synmietrical.  Saalfeld* 
holds  that  in  the  majority  oE  cases  the  starting-point 
of  the  disease  is  a  more  or  leas  marked  seborrlitt^a. 
When  the  disease  attacks  a  part  provided  with 
acbaceons  glands,  the  skin  is  usually  covered  with 
small  adherent  ncalea  of  aebum,  which  at  the  margin 
of  the  patch  plug  the  dUated  orifices  of  the  glands, 
thus  forming  numerous  comedones.  In  parte  where 
the  adherent  scales  become  detached,  these  plugs  are 
seen  hanging  from  their  under  surface  aa  thread-like 
tags.  In  some  cases  this  sebaceous  covering  is  absent, 
and  then  the  erythematous  character  of  the  lesion  is 
more  evident.  The  affected  area  is  often  surrounded 
hy  a  zone  of  dilated  blood- veesels.  In  its  evolution 
the  procesa  conforms  to  one  of  two  principal  types — 
spreading  either  by  the  peripheral  enlargement  of 
single  spots  (lupus  erythemalosua  dincoides),  or  by  the 
Buccesaive  appearance  of  fresh  crops  of  spota,  which 
coalesce  and  form  patches  of  considerable  size  {lupus 
erythematosus  aggregalus  oidisseminalus) .  The  former 
may  also  be  distinguished  as  the  "  slow -spreading," 
the  latter  as  the  "  eruptive,"  form  of  the  disease. 

Crocker'l'  describes  a  "  telangiectic  "  form,  "in 
which  there  ia  no  marked  change  of  the  surface  ex- 
cept persiatent  circumscribed  redness,  which  close 
inspection  shows  to  he  due  to  dilated  vessels."  This 
is  commonly  situated  symmetrically  on  both  cheeks, 
the  affected  area  being  very  much  of  the  size  and 
shape  of  the  red  patch  which  the  ciown  paints  on  hia 
face ;  it  is  not  very  noticeable  to  the  eye,  though 

•  Oirmal.  ZritieiriJ't,  Bci.  viii..  Hi^ft  3.     [AbBlractcd  in  Sril. 
t  "  DweMSB  of  ibe  Skiu,"  -iiid  ed,  ji.  192. 


vui.]  LUPUS   EHYTHEMATOSUS.  113 

seventeen  of  the  discoid  type,  and  found  albumen  in 
seven.  Five  of  these  were  of  the  disseminated  variety , 
and  the  disease  was  in  an  active  stage.  ]n  a  fatal 
case  in  which  they  had  the  opportanity  of  making  a 
po8t-raortem  examination,  parenchymatous  nephri- 
tis was  found.  They  are  inchned  to  beheve  the 
albuminuiia  to  be  of  toxic  origin.*  Kaposi  describes 
cases  in  which  the  constitutional  derangement  is  so 
great  that  the  disease  often  ends  in  death  I  ha\  i> 
never  met  with  such  cases  in  my  own  praLtire  nor 
have  1  heard  of  such  in  the  practice  of  other  Enghsli 
dermatologists,  and  I  can  only  conjcLture  that  in 
these  cases  the  local  affection  had  become  compli 
cated  by  erysipelas  or  some  other  acute  infective 
process  grafted  upon  it. 

On  the  other  hand,  a  constitutional  stat«  may  in 
certain  cases  tend  to  cure.  Fordyce  mentions  a  case 
of  the  disseminate  type  which  disappeared  during 
pregnancy,  leaving  only  atrophic  patches. f 

Pringle  X  has  recorded  a  case  in  which  multiple 
epithelioma  developed  on  lupus  erythematosus  in  a 
woman  aged  3().  He  refers  to  similar  cases  published 
by  Rieasmeyer  and  J.  Dyer  in  America,  by  StJ.ip- 
ford  Taylor  in  this  country,  and  by  Kreiblich  of 
Vienna.  A  case  has  also  been  reported  by  E.  Hol- 
laender,§  who  points  out  that  the  conjunction  of 
carcinoma  with  lupus  erythematosus  is  much  less 
malignant  than  with  lupus  vulgaris. 

LnpuB  erythematosus  may  be  distinguished  from 
other  varieties  of  erythema  by  the  slowness  and 
persistence  of  the  process.  The  lesion  itself,  with  its 
I  central  cicatrix,  surrounded  by  a  raised 

t.  Jtur.  Dtitii,,  Octobur,  l!l[U. 
m.  eui.  Bivl  Uen.  Urin.  Dh.,  March,  18%. 
Ht  Janrn.  Burin.,  Jnmiiirv,  'yo;i. 

mlelosUehi  ZtiiAr-hrifi,  Bd.  v[i.    (Alutnicted  iii   llrir. 
—.,  1901,  p.  101) 


in   NEUROTIC  AFFECTIONS  OF  THE  SKIN,  [char! 

red  border,  studded  with  comedones,  is  Bufficiently 
chamcteriatic  to  eoable  it  to  be  identified  on  the  face. 
On  the  hands,  however,  it  often  resembles  chilblain 
so  closely  that  the  diagnosis  must  rest  chiefly  on  the 
fact  that  chilblain  disappears  in  the  summer,  and  in 
the  winter  usually  yields  readily  to  treatment. 

In  rosacea  the  lesion  has  no  central  cicatrix  and 
no  scab  adhering  to  its  surface.  Ringworm,  which 
occasionally  simulates  lupus  erythematosus,  runs  a 
more  rapid  coun^e,  and  its  lesions  present  the  char- 
actcrtHtic  fungus  when  examined  microscopically. 
The  points  of  distinction  between  lupus  erythematosus 
and  lupus  vulgaris  are  of  special  interest  and  import- 
ance. They  will  be  fully  discussed  under  "  Lupof 
vulgaris  "  (p.  i'l'l  el  sqq.),  but  the  chief  points  o 
be  summarised  here  us  follows  :— 1.  In  lupus  erythe* 
inatoBus  the  primary  lesions  are  minute  red  points  ; 
lupus  vulgaris,  soft  apple-jelly  nodules.  '1.  Ulceri 
tion,  which  never  occult  in  lupus  erythematoeuH,  ■ 
u  lupus  vulgaris.  .'!.  Lupus  erythemato 
r  penetrates  below  the  surface  ;  lupus  vulgai 
often  attacks  the  deeper  parts  (cartilage,  etc.) ;  heiK 
the  old  division  of  lupus  into  exedeng  and  »i 
4.  While  lupus  erythematosus  always  develops  ; 
or  after  puberty,  lupus  vulgaris  almost 
ably  shows  itself  before  that  period. 

The  etiology  of  lupus  erythematosus  is  oba 
Sex  appears  to  be  a  predisposing  factor,  two-thirds  9 
more  of  the  subjects  of  the  disease  being  womeBi 
Of  71  cases  under  the  observation  of  J.  H.  Sequeiri 
and  H.  Balean,  only  11  were  males,  a  proportion  e 
ft4''i  females  and  1&'4  per  cent,  males.  Many  of  th* 
females  attacked  are  chlorotic.  and  a  tuberculous  ii 
heritanee  or  tendency  is  sometimes  associated  wid 
the  disease.  Sequeira  and  Balean  found  tiiht  j 
eighteen  of  the  said  cases  there  was  evidraioe  C 
tuberculous  disease.     The  two  varieties  of  lupus  e^g 


VULJ  LUPUS   ERYTHEMATOSUS.  115 

thematosus  exhibited  startling  differenueK  in  their 
relation  to  tuberculosis.  The  discoid  form  was  aaao- 
ciated  with  tuberculosis  in  18  per  cent,  of  the  uases, 
and  there  was  a  history  of  tuberculosis  in  the  family 
of  about  40  pel  cent.  On  the  other  hand,  the  dis- 
Heminated  form  was  aaaooiated  with  the  presence  of 
tuberculous  disease  in  TO  per  cent.,  and  there  was  a 
history  of  tuberculosis  in  the  family  in  80  per  cent. 
They  tliink  therefore  that  there  is  strong  evidence  in 
favour  of  lupus  erythematosus  disseminatus  being  of 
tuberculous  origin,  or  that  the  presence  of  tuberculo- 
sis modifies  and  intensifies  the  course  of  the  disease.* 
In  the  great  majority  of  cases  that  have  come  under 
my  own  observation,  however,  the  patients  have 
shown  no  sign  whatever  of  constitutional  taint  or 
weakness.  Lupus  erythematosus  seldom  begins  be- 
fore twenty-five  or  after  forty-iive.  In  eight  of  the 
cases  reported  by  Sequeira  and  Balean  the  ilisease 
began  before  the  age  of  sixteen,  and  twenty-eight 
before  the  twenty -lirat  year.  Its  immediate  starting- 
point  is  often  a  congestive  seborrhoea  of  the  nose, 
occurring  either  spontaneously  or  as  a  seque!  of 
eryfupelas,  amall-pos,  or  scarlet  fever.  The  imme- 
diate cause  of  the  affection  is  some  local  disturliMiiie 
of  the  circulation  ;  this  may  be  due  in  some  cases  to 
an  ejcternal  agency,  such  as  cold  or  heat^a  circum- 
stance which  helps  to  explain  the  marked  preference 
shown  by  lupus  erythematosus  for  exposed  parts  of 
the  body,  such  as  the  face  and  hands.  In  the  case 
of  a  nurse  under  my  care  the  starting-point  was  a 
iQuaquito  bite.t  In  a  ease  reported  by  Whitehouse  tin- 
applioa.tiou  of  a  cantharide«  plaster  is  said  to  have  been 
the  exciting  cause. f     In  other  casee  the  circulatory 

•  J.  H.  SoqUBira  aud  H,  Bftleoo:  "  Lupus Eiythemutofliia :  A 
Cliniml  Study  of  Seienty-one  Case&"  fiiit.  Janrn.  Drriii., 
Ootober.  IWI. 


I  Quoted  by  Ssqueii 


iittTv.  ISlKl. 


t 

9 

r   ■ 


lia    NEUROTIC  AFFECTIONS  OF  THE  SKIN.   [chap.  ^ 

disturbance  is  doubtless  due  to  nerve  disorder.  L, 
Perrin,  of  MarseilleH,  has  recorded  the  case  of  a  girl 
aged  eighteen  who,  after  a  violent  tnentat  shock  at 
the  time  of  the  earthquakes  of  1887,  followed  hy  tem- 
porary mania  and  suppression  of  menses,  developed  I 
lupus  erythematosus  of  the  disseminate  varie^. 
Perrin  thinks — and  I  am  disposed  to  agree  with  hinl 
^that  the  nervous  shock  here  paved  the  way  for  the 
onset  of  the  disease.  Sequeira  and  Balean  think  that 
the  peculiar  limitation  of  the  areas  affected  affords 
strong  support  to  the  an gio- neurotic  theory  of  the 
disease. 

The  pathologrical  process  is  essentially  inflam- 1 
matory  in  nature.  According  to  Veiel,*  the  primary 
and  essential  feature  of  the  disease  is  an  accumulation 
of  blood  corpuscles  in  the  dilated  capillaries  in  the 
papillary  layer  and  the  corium,  with  cell  infiltration 
in  the  neighbourhood  of  the  blood-vessels.  The  most 
recent  researches  have  proved  that  the  inflammatory 
process  begins  in  the  blood-vessels  of  the  superficial 
layers  of  the  cutis.")" 

Microscopic  sections  show  heaping  up  of  small 
cells  which  have  escaped  from  the  vessels  by  dia- 
pedesis.  These  cells  are  especially  abundant  around 
the  hair  follicles  and  the  sebaceous  and  sudoriparous 
glands.  The  small  vessels  become  thickened,  and 
proliferation  of  connective- tissue  corpuscles  and 
epithelium  takes  place.  According  to  Schoon- 
heid,}  mast  cells  are  present  in  tlie  infiltration,  but 
in  inconstant  numbers. 

Oranular  and  fatty  degeneration  and  disintegra- 
tion of  the  cellular  elements  occur,  resulting  in  the 

•  "TCBiis.  Inleniot.  MeJ.  Cougr™,  London,  I8S1,"  vol.  iii-, 
t  Cf.  Vtuia's  "  Hiitopiitbulun  of  DiBonscsof  tho  Bkui."    Eng 


Tniu.  1H96,  p,  lOTl 


boloBT 


'.,{.207 


Uiil.  ani  Qim.  Vevt.-- 


.  >'(!/;'*.,  Dec.,  ISIOO. 


w 


LVFOS  ERYTHEMATOSUS.  117 

formation  of  a  thin  scar-like  cutis  destitute  of  glanda 
or  hair  follicleH,  covered  by  an  atrophied  epidermic 
layer.  la  short,  the  process  presents  the  usual 
characters  oi  slow  inflammation,  the  only  feature 
that  can  be  called  characteristic  being  the  peculiar 
cicatricial  atrophy  to  which  it  leads.  The  scarring  is 
only  superficial. 

There  is  at  present  no  coni^lusive  evidence,  either 
clinical,  anatomical,  or  bacteriological,  that  lupus 
erythematosus  is  of  tuberculous  nature.  Sequeira 
and  Balean,  in  spite  of  the  relative  frequency  with 
which  an  association  of  the  disseminate  form  with 
tuberculosis  was  noted  in  their  cases,  call  attention 
to  the  significant  tact  that  lupus  erythematosus  is 
very  rarely  seen  in  consumption  hospitals.*  My  own 
view  is  that  it  is  a  distinct  pathological  entity  and 
not  a  cutaneous  tuberculosis.t  I  base  my  belief  on 
this  point  not  only  on  the  negative  results  of  micro- 
scopic and  experimental  research,  but  on  positive 
clinical  facts  which,  to  my  mind,  have  more  weight 
than  the  presumptive  evidence  of  hereditary  tendency 
or  poasibility  of  infection,  relied  upon  by  those  who 
hold  the  affection  to  be  of  tuberculous  nature.  Thus 
lupus  erythematosus  never  ulcerates,  whereas  tubor- 
cuJoua  lesions  have  a  strong  tendency,  sooner  or  later, 
to  break  down.  Lupus  erythematosus  spreads  at 
the  edge,  not  by  development  of  nodules  in  the 
coriuin.  The  symmetrical  arrangement  of  the 
patches  in  lupus  erythematosus  is  also  in  favour  of 
their  being  of  non- tuberculous  nature.  Again,  lupus 
erythematosus  nevej  occurs  in  children,  whereas 
lupUB  vulgaiie,  which  is  a  tuberculous  process,  usually 

*  Pot  an  account  of  Brouq's  iitgeuioiu  liypotheaia  tliat  Inptitt 
ervtbeTDittosuB  ia  due  to  VHSO-motor  pantlyaiB  owii^  to  the  ahwirp- 
tiiiii  of  lu«in»  from  old  or  latent  tubaiculous  foui,  i  irfc  Jiw,,.  if 
Ci't.  ami  Gen.  Urin.  SU.,  wil.  liii.,  l*ii  ji.  34.i. 

t  ThU  yiew  is  ttUo  atrongly  aupijorted  ■£¥  Sde,  Gm,  dia  Hopilaiix. 

Out.  13,  isas. 


lia  SEUaOTIC  affections  of  the  SKIX.   [caiR-J 

beginB  before  puberty,  often  in  early  childbi 
Furthei,  while  in  lupus  vulgaris  tuberculous  diei 
of  bonea,  joints,  and  glands  is  a  frequent  GDUcomitaat^ 
this  is  extremely  rare,  if  Jt  ever  occurs,  in  lupus  ery-- 
thematosuB.  I  have  never  seen  such  an  a» 
in  any  of  my  own  cases.  The  worst  case — i.e.  the 
one  in  which  the  diseaae  was  most  extensive  and 
most  prolonged — was  shown  at  the  International 
Medical  CongresM  *  in  London  in  1881 .  The  diaeaae 
had  then  lasted  nine  years,  and  the  patient  died  &ve 
years  later  of  apoplexy.  Almost  the  whole  of  the 
integument  was  dise&sed,  but  there  waa  no  evidence 
of  any  associated  tuberculous  lesion.  Another  point 
is  that  when  the  appearance  of  the  lesions  on  the  faee 
is  not  sufficiently  characteristic  to  justify  a  positive 
opinion  as  to  their  nature,  the  doubt  is  often  cleared' 
up  by  the  presence  of  symmetrical  atrophy  inside  thrf 
concha  and  on  the  lobe  of  the  ear,  or  on  the  scalp — '. 
parts  not  usually  attacked  by  lupus  vulgai' 

In  spite  of  careful  research  by  competent  inveeti-' 
gators,  no  specific  micro-organism  has  been  found 
in  connection  with  lupus  erythema toaus.  When 
acute  inflammation  supervenes,  however,  this  may 
be  due  to  the  invasion  of  the  infected  parte  by  a 
micro-organism  such   as   the   streptococcus   of  eiy- 

Under  the  name  of  lupus  imlyaire  frytMmatti^ 
Leioir  f  described  a  class  of  cases  in  which  luptw 
erythematosus  is  closely  simulated  by  lupus  vulgons: 
The  process  usually  affects  the  face,  and  in  excep- 
tional cases  the  neck  and  trunk  ;  never,  apparentgr,' 
tlie  limbs.  The  lesion  occurs  as  a  patch  of  va^ing* 
size,  sometimes  as  two  or  tliree  patches,  beginning 
generally  online  cheek.     It  is  usually  confined  to  om 

•  "TraiiA.  laterant.  Ued,  Congress,  Loodou,  18SI." 
YOlonja,  p.  98. 

t  Jm™.  if  Mai.  Ciilan.  et  Syph..  May,  1391, 


I 


w 


.]     LUPUS   VULGAJRE  ERYTliJiUATOIDE.        llii 

side,  but  In  some  cases  attacks  the  nose  aud  both 
cheeks  Bymmetricalty,  so  as  to  produce  the  classic 
appearance  oE  the  "  butterfty  "  or  "  bat's-wJng."  The 
appearance  of  the  surface  closely  resembles  that  of 
true  lupus  erythematosus,  but  frequently,  on  stretch- 
ing the  skin  about  the  spreading  edge  of  the  disease, 
smaU  yellowish  nodules  having  the  characters  of 
ordinary  lupus  nodules  can  be  more  or  less  distinctly 
recognised.  The  patches  never  ulcerate,  but  a  ten- 
dency to  cicatrisation  may  be  seen  at  the  edge,  which 
is  never  observed  in  true  lupus  erythematosus.  The 
process  is  extremely  chronic,  and,  in  spite  of  its 
relatively  benign  appearance,  is  very  refractory  to 
treatment.  In  some  cases,  after  a  longer  or  shorter 
period  of  time,  lupus  nodules  may  gradually  invade 
the  whole  surface  of  the  patch  or  a  considerable  part 
of  it.  This  is  what  used  to  be  described  as  the 
"  transformation  "  of  lupus  erythematosus  into  lupus 
vulgaris.*  The  process  is,  however,  in  reality  nothing 
more  than  the  transformation  of  the  difiuse  and  flat 
infiltration  of  lupus  vulgaris  erythema toides  into  a 
nodular  raised  infiltration.  In  two  cases  Leloir  saw 
this  form  of  lupus  vulgaris  extending  from  the  cheek 
to  the  inside  of  the  lip,  and  he  suggested  that  the 
cases  in  which  lupus  erythematosus  was  reported 
to  have  attacked  mucous  membranes  were  really 
examples  of  the  erythematoid  variety  of  lupus  vul- 
garis. It  is  unquestionably  the  fact  that  lupus  ery- 
thematosus may  in  certain  parts— as,  for  instance, 
the  lips — become  very  nodular  and  approximate 
closely  in  appearance  to  lupus  vulgaris.  Sometimes, 
though  rarely,  it  affects  mucous  membrane.  In  the 
case  of  a  man  under  my  care  the  disease  attacked 
the  inside  of  the  lower  lip.  Leloir  supplemented 
the  clinical  evidence  pointing  to  the  true  nature  of 

which  HpjHteutlf  pass  ititu  lupiia  vulgariii. 


71 

imental  .^1 

IS  (four  ^M 
in  and  ^M 
results  ^M 
icilli  in  ^M 
I  varied  ^B 


120    NEVKOTIC  AFFECTIONS  OF  THE  SKIN 

the  affection  which  he  described,  by  experi 
inoculatious  of  diseased  tissue  from  six  cases  (four 
of  lupus  vulgaris  erytliematoidea  of  the  skin  and 
two  of  mucous  membrane) ;  in  all,  positive  resulta 
3  obtained.  He  also  found  tubercle  bacilli  in 
amatl  numbers.  The  microscopic  appearancea  varied 
1  different  cases,  but  as  a  rule  partook  to  a  greatei 
r  less  extent  of  the  characteristic  features  of  both 
affections.  A  point  considered  by  Leloir  to  be  of 
great  importance,  as  justifying  the  classitication 
of  the  disease  with  lupus  vulgaris,  is  the  constant 
presence  of  giant  ceils,  which  are  never  met  with  in 
lupus  erythematosus.  The  hybrid  affection  here 
described  by  Leloir  has  been,  in  all  probability,  the 
aource  of  much  of  the  confusion  that  has  hitherto 
surrounded  the  subject  of  lupus  erythematosus. 

Treatment. — In  the  earher  stages  of  lupus  ery- 
thematosus, if. the  hypertemia  is  active,  evaporating 
lotions  or  cooling  ointments  or  salve  muslins,  calamine 
lotion,  lotio  carbonis  detergens,  and  the  solution  of 
Bubacetate  of  lead,  are  all  useful.  The  best  applies 
tion  of  all  is  ichtkyol  in  the  form  of  a  lotion  or  an  omtj^ 
ment,  or  as  a  zinc  ichthyol  salve-mull  applied  at  night 
after  bathing  the  parte  with  hot  water.  When  hypene^ 
mia  is  less  pronounced,  Hebra's  spiritiui  sajMnis  katimu 
(to  which  oil  of  cade,  ^j  or  y,%}  to  5/,  may  sometimea 
be  added  with  advantage)  should  be  rubbed  on  with 
lint  or  flannel.  By  this  means  the  scales  and  fat^ 
plugs  are  removed.  The  application  may  be  te- 
peited  every  few  days.  Reaordn  (10  per  cent. 
tolloHon)  is  a  useful  remedy,  and  saHcylic  add  (3  ky 
ft  per  cent,  m  collodion)  is  in  some  cases  still  better. 
Pyrogallic  add  used  in  the  manner  recommended  by 
Veiel  frequently  gives  good  results.  He  applies  a  10 
per  cent,  ointment  of  the  acid  for  three  or  four  da3ra 
or  til!  a  brownish  eschar  forms  ;  whi 
detached  the  wound  should  be  dressed  with  iotb/t 


I 

a 

a 

k 

I 


B^-1 


ROSACEA. 


If  cliemical  caustics  fail  to  give  satisfactory  results, 
linear  scarification  with,  a  suitable  inBtrumcnt  (Squire's 
or  Veiel's,  modified  by  Pick),  followed  by  tlie  rubbing 
in  of  iodoform  or  tiie  application  of  a  mercurial  or 
salicylic  acid  plaHter-mull  will  sometimes  effect  a  cure. 
The  procedure  may  be  repeated  as  often  as  required. 
The  thermo- cautery  lightly  applied,  followed  by  the 
application  of  iodoform,  boracic  acid,  or  other  anti- 
seftic  powder,  also  gives  good  results.  The  applica- 
tion of  light  by  Finaen's  method  and  of  X-raya  has 
acted  beneficially  in  several  caaea  under  my  observa- 
tioti,  but  its  results  in  lupus  erythematosus  are  mucli 
less  satisfactory  than  in  lupus  vulgaris.*  Internally, 
general  tonics  should  be  given  if  indicated,  and  any 
unfavourable  constitutional  state  should  be  dealt  witli 
by  appropriate  measure.  Ichthyol  internally  in  the 
form  of  pill  sometimes  seems  to  reduce  the  hyperemia, 
Some  writers  lay  great  stress  on  the  internal  use  of 
arsenic,  but  I  cannot  say  that  I  have  ever  seen  any 
good  eSect  follow  the  administration  of  this  drug. 
Buikley  recommends  pkosphorus  (j^,  io  -^^  gr.  three 
times  a  day).     Quinine  in  lull  doses  is  often  of  real 

Rosacea  is  in  its  simplest  form  nothing  more 
thau  temporary  congestion  of  the  fa(-e  i;auMed  by 
redex  circulatory  disturbance.  At  first  the  flushing 
comes  on  after  eating  or  exposure  to  changes  of  tem- 
perature, or,  in  women,  just  before  the  menstrual 
period  ;  the  condition,  however,  gradually  becomes 
chronic,  the  skin  in  the  middle  third  of  the  face  becom- 
ing permanently  reddened,  the  point  of  maximum 
intensity  being  in  most  cases  the  nose.  Subsequently 
lliere  ia  almost  always  considerable  dilatation  of  the 
superficial  vessels.  After  a  time  hypersecretion  and 
retention  of  the  sebaceous  matter  occur,  foUowed  in 

•Foe  details  of  ouea,  .ee  Jl.'.f.  .^M.  hio».,  Teh.  'Jth,  1901, 


F 


122    NEVROTW  AFFECT  IONS  OF  THE  SKIS,  [ct 

aome  instances  by  inflammation.  The  affected  area 
is  thus  studded  with  pimples  marking  the  obstructed 
ducts.  This  is  the  condition  popularly  ki 
"  grog-blosaoma  "—a  designation  aa  unscientific  as 
it  is  uncharitable,  for,  though  drink  may  be  an  aggra^ 
vating  circumstance,  the  affection  ia  often  seen  ii 
the  mosC  temperate  persons.  The  disease  some- 
times passes  into  a  further  stage,  the 'chronic  inflam- 


1 


matory  process  giving  rise  to  hypertrophic  tbicJcen- 
ing.  with  lobulation  of  the  skin  of  the  nose  (Fig.  2). 
This  is  piirticularly  seen  io  habitual  spirit  drinkers 
who  are  much  exposed  to  the  weather,  cabmen  fur- 
nishing a  large  proportion  of  victims.  The  hyper- 
trophy occasionally  takes  the  form  of  pendulous 
masses. 

Rosacea  is  much  more  common  in  women  than  in 
men,  owing,  doubtless,  to  the  periodical  disturbances 
of  the  circulatory  equilibrium  to  which  they  are 
subject.    Women  who   have   passed   the    "  change 


w 


ROHAOEA. 


123 


of  life  "  show 
men  of  the  ( 
chronic  dyspepsiit, 


less  proclivity  to  the  affection  than 
age.  Over-indulgence  In  alcohol, 
feebleness  of  circulation,  and  ex- 
posure to  sudden  ohangee  of  temperature  may  all 
help  to  cauae  it.  especially  when  two  or  more  of  these 
factors  are  comhined.  The  use  of  cosmetics  coutain- 
ing  irritant  Bubstances  may  alao  play  a  part  in  its 
production. 

Pathologies!  ly  the  condition  is  a  vaso- motor  neuro- 
sis called  into  action  by  reflex  irritation,  and  followed 
by  inflammation  in  and  around  the  sebaceous  glands 
with  permanent  dilatation  of  superficial  blood- vessels, 
and  occasionally  by  overgrowth  of  connective  tissue 
around  them.* 

The  diagnosis  of  rosacea  can  hardly  ever  present 
any  difficulty.  The  conditions  for  which  it  might 
poseibly  be  mistaken  are  lupus  erythematosus,  cer- 
tain tertiary  syphihdes,  and  acne  vulgaris.  From 
lupus  erythematosus  it  is  distinguislied  by  the 
alienee  of  acaliness,  by  the  border,  which  is  not  raised 
and  shows  no  signs  of  active  spreading,  by  the  ab- 
sencp  of  atrophic  scarring  in  the  centre,  and  by  its 
fluctuations  dependent  on  digestive  disorder  and 
otlier  causes.  From  tertiary  syphihdes  it  is  distin- 
guished by  its  symmetry,  by  its  slow  course,  by  the 
absence  of  any  tendency  to  ulceration,  and  of  marks 
or  history  of  previous  lesions.  The  possibility  of 
&  mixture  of  diseases  must,  however,  always  be  borne 
in  mind.  Rosacea  is,  as  a  rule,  sharply  diSerentiated 
from  acne  vulgaris  by  the  age  of  the  patient,  the 
absence  of  comedones,  and  the  redness  of  the  affected 


I         uuseuc 


'he  prognosis  is  generally  favourable  as  regards 


w:  Clinical  ani  Hi»toli>gkiil  Obfier- 
(.  ".  .'.'w*.,  Bd.  xtiTii,  Heft,  ii, 
,  i,f  JMrMil..  vol,  ix..p.  'ilHI,  Jnl)-. 


I 


124    NKUEOTW  AFFECTIOSS  OF  TliJi  SKIN.    [ohap. 

mitigation  of  tlie  condition,  and  in  the  majority  of 
oases  a  complete  cure  can  be  efEected. 

lacea  the  first  object  of  treatment  ia  to 
get  rid  of  possible  aourcea  of  reflex  irritation  by 
correcting  any  functionul  disorder  of  the  stomach, 
liver,  bowels,  ovaries,  etc.,  that  may  exist.  The  diet 
must  be  carefully  regulated,  whatever  causes  flushing 
of  the  face  being  avoided.  Abstinence  from  alco- 
holic Btimulauts  should  be  enjoined,  and  it  would  be 
well  also  if  the  patient  could  be  induced  to  forego  tea 
and  coffee.  Arsenic  is  seldom  of  use.  After  the  re- 
moval of  any  obvious  cause,  the  most  trustworthy 
internal  remedy  Is  ichthyol,  which  often  brings  about 
a  marked  improvement  after  even  a  few  days'  ad- 
ministration. It  regulates  the  bowels,  prevents 
flatulence,  helps  the  digestion,  stops  the  reflex  flush- 
ing, and  steadies  the  circulation.  I  usually  begin  by 
ordering  five  grains  in  capsules,  tabloids,  or  pUts,  to 
be  taken  on  an  empty  stomach  early  in  the  morning 
and  late  at  night.  In  a  few  days  I  increaEe  the  dose 
to  seven  and  a  half,  and  afterwards  to  ten  grains  and 
upwards,  until  the  desired  results  are  obtained.  In 
addition  to  the  internal  administration  of  ichthyol, 
local  treatment  on  the  lines  laid  down  for  acne  vul- 
garis {see  p.  :iSS)  will  be  required  if  there  be  inflamed 
papiUea  and  pustules.  The  varicose  venules  may, 
be  destroyed  by  scariiication,  the  superficial  use  of 
Paquehn's  cautexy,  or.  better  still,  by  electrolysie. 
Hypertrophic  excrescences  should  be  pruned  viik 
the  knife,  and  pendulous  growths  must  be  dealt  with 
by  ordinary  surgical  procedures. 

Pellagra  is  a  troplio-neurotic  affection,  endemic 
in  northern  and  central  Italy,  in  the  northern  part 
of  Spain,  in  Roumania,  and  in  Egypt.*     It  generally 


u  total   pupuUtioji    of   u,339,a5(l  (Doduu  i^ 


^^^Bl]  125  H 

'  commences  in  the  spring  with  malaise,  pains  in  tUe        ^H 

joints,  a  burning  sensation  in  the  back,  ladiating        ^H 
through  the  limba  to  the  hands  and  feet,  and  gastro-     '  ^H 
intestinal  diaturbance.     An  early  symptom  is  spastic 
paresis   of   the   lower   limba.*    The   skin   affection 
consists  of  an  erythematous  eruption,  chiefly  affecting 
^^^  parts  exposed  to  the  sun.     The  skiu  is  swollen  and 
^^^^enee,  and  is  the  seat  of  burning  or  itching  sensa- 
^^^^mona  ;    petechiie  are  frequent,  and  bullte  also  occur, 
^^^^^rliich  on  rupturing  leave  indolent  ulcers.     In  about 
^^^   a  fortnight  from  the  commencement  of  the  attack  the 
erythema  subsides,  and  desquamation  follows,  leaving 
the  underlying  skin  thickened  and  stained  to  the 
I  colour    of   cafe    au    laii    or    sepia.     The    symptoms 

^^HrtiBually  subside  towards  the  end  of  summer,  only  to 
^^^Keappear,  however,  In  the  following  spring.  The 
^^^Kttttacks  thus  recur  regularly  every  year,  the  thickening 
^^^  and  pigmentation  being  increaaed  on  each  occasion 
'  in  tiie  first  four  or  five  years.     Afterwards  the  integu- 

ment undergoes  atrophy,  and  becomes  dry  and 
wiaened  as  in  old  age.  This  is  especially  marked  on 
the  backs  of  the  hands.  The  nails  and  hair  show  no 
change.  Wben  the  patient  has  suffered  from  the 
disease  for  three  or  four  years  he  becomes  weak, 
wastes,  bis  vision  becomes  dimmed,  swallowing  is 
painful,  colliquative  diarrhcea  sets  in,  symptoras  of 
cerebro -spinal  irritation  increase,  and  he  sinks  into 
a  typhoid  condition,  in  which  he  passeB  away.  In- 
sanity is  an  extremely  frequent  complication,  the 
Kiental  disorder  chiefly  showing  itself  in  the  form  (if 
lelancholia,  with    marketi    suicidal  tendency.     Tlie 

B,  Str.  MiJ.  lU  I'llrt,  Septembur  Itt,  1H03).      As  cegaids 
»  BButhrith.  Biit.  Mo<1.  Aivoi^.  Annuiii  Meeting,  ISQfi. 
mmido ;     "  I,e     iiltiTj^irjni    Hnn-toniidii!    ilella.    midoDu 
^Hjielliigtti  e  loro  taiiporto  coi  fatti  cliuid  "  (ffii'inta 

^ di  jVsiiiDdi'o  c  J/crf.    Lrg.,   vols.   iv.    ivi.,    IfiSO-BO). 

^  Tnc»lt;      "Kliniwlie  iind   aiiBtoiniEci^c  StwMea    ulitr    die 
"(Berlin,  18B3;  Fiwher). 


w 


i    yEUROTIC  AFFECTIONS  OF  THE  SKIS,  [oh 


^ 


disease  lasts  on  the  average  five  years ;  in  mild  cases 
patients  may  live  ten  or  fifteen  years.  Poverty,  in- 
sufficient nourishment,  and  insanitary  surroundingB  ' 
are  predisposing  eauaea.  The  immediate  etiological 
factor  is  generally  believed  to  be  the  prolonged  use 
as  food  of  decomposed  or  fermented  maize,  which  has 
a  toxic  eSect  analogous  to  ergotism.  De  Giaxa 
thinks  the  disease  may  be  caused  by  the  use  of  even 
sound  grain  by  imperfectly  nourished  individuals, 
auto -intoxication  being  caused  by  the  formation  of 
toxic  substances  in  the  intestines,  owing  to  modifica- 
tions in  the  substances  of  which  the  grain  is  com- 
posed.* The  disease  is  most  common  between  the 
ages  of  thirty  and  fifty  ;  females  are  more  often 
attacked  than  males,  and  children  are  less  liable  than 
adults.  Pathologically,  pellagra  consists  in  a  toxic 
eflect  on  the  vagus  and  sympathetic  nerves,  giving 
rise  to  hyper»mia  and  inflammatory  processes  in 
the  membranes  of  the  brain,  in  the  liver,  spleen, 
kidneys,  etc.  ;  to  atrophy  of  the  principal  viscera 
and  of  the  skin  ;  and  to  fatty  degeneration  of 
various  organs. 

The  diagnosis  can  hardly  ever  be  doubtful,  the 
disease  being  limited  to  a  particular  class  of  patients 
who  are  expose*!  to  special  influences,  and  presenting 
features  clearly  differentiating  it  from  other  aSec- 
tions.  The  prognosis  ia  very  gloomy,  except  in  very 
slight  cases,  when  the  patient  can  be  rescued  from 
the  influences  which  have  caused  and  continue  to 
aggravate  his  disease. 

In  the' treatment  of  pellagra  the  most  important 
point  ia  prophylaxis.  Stringent  enactments  have 
recently  been  passed  by  the  Italian  Government  for 

*  ConOibiito  Bile  rogniziaui  ijall'  etiologiu  delln.  pcUifm 
("  Annitli  delt'  IsCJtutn  it'  iKiene  Speriinentali:!,"  vol  ii.,  fuo.  I, 
and  «al.  iii.,  late,  I).  Thees  papers  mubodr  the  reRiills  of  H  moat 
oxbnustiTe  inTmtigatiou  iiito  the  etiolngy  of  jieliugru. 


ACRODYNIA.  127 

the  prevention  of  the  sale  of  diaeaaed  maisie,  and  for 
the  suitable  care  of  patients  in  institutions.  When 
the  disease  ie  developed,  treatment  must  be  sympto- 

I  matic,  Ofiwn,  gttinine,  and  calotnd  being  used  ae- 
'"  ^  to  the  indications.  Arsenie  is  said  by  Lom- 
)  to  be  the  moat  efficient  lemedy  ;    it  should  be 

f  tiven  in  small  doses  ( j  to  '2  mmitnt  of  liquor  ar^enicalis 
daily).  Attention,  must  be  paid  to  the  hygienic 
BiuToundings  of  the  patient. 

Acrodynia  is  closely  allied  to  pellagra  and 
ergotism.  The  disease  so  far  has  been  observed 
chiefly  in  France,  where  it  has  several  times  occurred 
epidemically  in  the  army.  The  affection  is  a  form  of 
erythema,  the  eruption  being  preceded  by  gastro- 
intestinal disturbance,  conjunctival  congestion  and 
[sdema  of  the  face,  with  aching  and  numbness  in  the 
limbs,  pricking  and  burning  in  the  palmw  and  soles  ; 
the  sensitiveness  of  the  akin  in  the  latter  situations 
is  at  first  increased,  and  afterwards  abolished.  The 
eruption,  which  consists  of  erythematous  patt^hes 
sometimes  intermingled  with  papules  and  bullie, 
comes  out  chiefly  on  the  hands  and  feet,  sometimes 
extending  over  the  limbs  to  the  tnmk.  It  is  followed 
by  exfoliation  of  the  epidermis,  a  blackish  discolora- 
tion being  left  in  the  affected  parts,  especially  in 
warm  regions,  as  between  the  thighs.  Tn  severe 
eases  wasting  and  paresis  of  the  limbs  are  sometimes 
observed.    The  eruption  is  not,  as  a  rule,    accom- 

,  paoied  by  any  febrile  phenomena,  and  the  disease 
Murcely  ever  proves  fatal,  except  in  elderly  orweakly 
nbjecffi,  who  sometimes  succumb  to  diarrlnpa.  Re- 
rvery  generally  takes  place  in  a  few  weeks.  The 
etiology  of  acrodynia  is  obscure  ;  it  has  been  ascribed 
to  some  toxic  element  in  the  food,  but  of  this  no  proof 
is  forthcoming.  There  are  no  jtosl-morlevt  changes 
(hat  can  be  called  eharaetexistic  of  the  affection. 


CHAPTER   IX. 

AFFECTIONS  OF  TBE  SKIN  DEPENDENT  ON  NERVB 
DISORDER  (condBHcr/). 

Dermatitis  Herpetiformis— Herpes  Gestationis 
— Impethio  Herpetiformis — Cheiropomfho- 
LYX — PEMPHroits — Herpes. 

Dermatitis  herpetiformis,  —  Affections  of   the 

akin,  differing  from  each  other  more  or  less  in  certain 
pftrtioulara,  but  all  characterieed  by  pemphigoid  erup- 
tions, causing  intense  itching  and  burning,  have  be^i 
described  under  various  names  by  different  authors. 
Thus  dermatologists  are  acquainted  with  the  eczeioa 
pruriginosum  and  herpes  circinatus  bulloBUS  of 
Brnsmus  Wilson,  the  hydroa  vacciniforme  of  Bazin, 
the  hydroa  herpetiforrae  of  Tilbury  Fox,  and  the  pem- 
phigus pruriginoaua  of  Hardy.  Though  each  of  these 
aSnctiona,  aa  described  by  the  author  who  named  it, 
haa  features  of  ita  own,  tliey  are  essentially  nothing 
more  than  varieties  of  tlie  extraordinarily  polymor- 
phous disease  to  wliich  Duhring  lias  given  the  name  of 
dermatitis  herpetiformis."  *  The  aSection  has  been 
dolined  by  Unna  as  "  a  chronic  neurosis  of  the  BkiD, 


•  A  BuiniDiirv  lit  Pcofiasor  DnliriuK's  iibfotrnti 
nuoliH  on  tint  aflcetiivn  nil!  Ic  found  in  hi!> 
Mnlirinn,  a  SjtteniHtii' TkniUw  oii  Duuorcs  of  the  Skin,"  put 
it  i  Pliiliulalplilu,  ISim,  I'lie  Hffectiou  apticui^  in  li'ivu  been  firat 
rnoMuiwd  and  wm  olearlj  detcribed  hy  Tiliurv  Foi  (*w  a 
nnAliBmuDa  Uticle  poliUehed  with  umolatinii?  by  Cnlcott  ¥ax, 
in  Amrr.  Aitii,  Vrmiptolag!),  IS80],v:h«ii  dniius' to  iiriori^  id 
this  nuttnr  have  beiu  ovDrlouked  Wh  i      '  '        ~'  ~ 


"  CuUiHWU 


I 


PI 

not 


DERMATITIS  IIEIIPF.TlFOnMIS. 


associated  with  some  yet  unexplained  blood  changes 
not  markedly  interfering  with   the    general   health. 
'  more  or  leas  universal  eruption,  coupled 

with  burning  or  itching  sensations,  and  regularly 
curring  ior  an  iudefinite  period  after  intervals  of  c* 
plete  or  comparative  immnnity.  The  type  is  ery- 
themato- bullous,  which,  however,  may  undergo 
siderable  modification."  (Fig.  3.)  Characteristic  ob- 
jective features  are  the  multiformity  and  herpetiform 
grouping  of  the  lesions.  The  most  marked  subjective 
symptom  is  intense  itching.  This  is  sometimes  re- 
lieved, though  it  is  occasionally  aggravated,  by  the 
appearance  of  the  eruption,  and  in  most  cases  it  is 
subject  to  paroxysmal  exacerbations.  The  symp- 
totnfi  are  frequently  of  such  severity  as  to  rob  the 
patient  of  sleep  and  keep  him  in  a  state  of  constant 
nervous  excitement.  When  the  erythema  ia  spread 
over  an  extensive  area,  great  pain  and  tension  in  the 
skin  are  complained  of. 

Almost  any  part  of  the  cutaneous  surface  may  be 
invaded,  the  limbs  (both  flexor  and  extensor  aspects), 
the  scalp,  the  face,  and  the  trunk  being  all  equally 
liable.  In  the  majority  of  cases  the  limbs,  especially 
the  wrists  and  forearms,  are  the  first  points  of  attack. 
The  lesions,  as  they  subside,  leave  pigmented  areas 
of  greater  or  less  extent,  the  pigmentation  varying 
from  dirty  yellow  to  an  almost  coppery  brown  ;  the 
discoloration  is  often  very  persistent.  The  skin  re- 
mains thickened  and  rough,  and  pitted  and  scarred 
here  and  there  from  the  healing  of  excoriations  under- 
neath the  scabs. 

In  severe  cases  the  disease  is  ushered  in  by  fever 
and  general  constitutional  disturbance,  and  there  is 
often  great  cutaneous  irritation  before  there  is  any 
visible  lesion  of  the  sldn.  This  is  so  marked  a  feature 
insomeeasea  that  the  patient  is  frequently  able  to  fore- 
tell an  impending  relapse  two  or  three  days  beforehand: 


130  NEUROTIC  AFFECTIONS  OF  THE  SKIX.  [chap.  ix. 

The  actual  onset — that  is,  the  appearaace  of  the 
Bkin  eruption — is  often  Budden.  The  characterisJac 
feature  of  the  eruption  is,  as  akeady  aaid,  its  extreme 
multiformity,  erythematous,  papular,  vesicular,  pus- 
tular, and  urticarial  elements  being  mingled  together 
in  every  conceivable  variety  of  size  and  shape,  and  in 
all  stages  of  evolution  ;  or  one  type  may  predominate 
at  one  time  and  another  at  another.  The  earliest, 
and  perhaps  the  most  characteristic,  lesion  is  a  vesi- 
cular eruption  in  which  the  vesicles  are  arranged  in 
herpetiform  groups  on  an  erythematous  base.  In  the 
earlier,  atagea  these  veaiclea  soon  dry  up  and  form 
scabs,  but  at  a  later  period  they  have  a  tendency 
to  run  together  and  form  bullte,  often  of  considerable 
size.  (Fig,  4.)  These  bullse  do  not,  as  a  rule, 
burst  spontaneously.  Their  contents,  which  are  ^t 
first  clear,  gradually  become  opaque,  and  as  the  con- 
tained liquid  thickens  the  bulla  slowly  shrinks,  and, 
if  left  to  itself  finally  shrivels  up  to  a  thick  browa' 
scab.  In  addition  to  the  elementary  lesions  of  vari- 
ous kinds,  the  akin  in  the  affected  parts  ahowB 
excoriation  and  other  results  of  scratching 

The  disease  exhibits  the  most  marked  tendency 
to  recur,  attack  following  attack  at  varying  intervals, 
sometimes  for  many  years. 

Dennatitis  herpetiformis  may  be  said  to  combine  in 
itself  the  characteristics  of  several  different  varieties 
of  skin  affection,  the  herpetic  and  pemphigoid  lypes 
on  the  whole  predominating.  (Fig,  5,)  The  lesions 
need  not  be  described  in  detail.  The  essential  features 
of  the  process  are  :  (1)  The  multiformity  of  the 
eruption — a  multiformity  showing  itaelf  not  only  in 
the  appearance  o!  crops  of  lesions  of  different  types 
in  different  phases  of  the  disease,  but  in  the  co-exist- 
ence of  several  different  types  at  the  same  time. 
(2)  Disorders  of  sensation  of  varying  int«uaity,  bttt 
always   present   in  greater    or  less  degree — itching 


1 

i 


/ 


T.'-; 


QHAP.  IX,]     DERMATITIS   HERPETIFORMIS.  131 

burning,  and  pain.  These  partesthesife  may  precede 
or  accompany  the  eraptiona,  and  may  exist  in  the 
intervals  between  the  successive  crops.  (.'J)  The  pro- 
tracted course  and  constant  tendency  to  exacerba- 
tion and  recurrence.  (4)  The  absence  in  most  cases 
of  any  grave  impairment  oi  the  general  health,  in 
spite  o£  the  physical  suffering  and  mental  anguish 
caused  by  the  disease.  In  some  caseSj  however, 
especially  in  the  later  stages,  the  attacks  are  accom- 
panied by  symptoms  of  blood-poiaoning,  and  death 
has  been  known  to  occur.  I  have  myself  seen  four 
cases  in  which  death  occurred  as  the  direct  result  of 
the  disease.  In  two  of  these  the  fatal  issue  was  due 
to  heart  failure,  and  in  the  others  to  exhaustion  after 
prolonged  attacks.  Pringle  *  has  also  seen  two  cases 
in  which  the  disease  ended  in  death.  In  one  of  these 
the  patient,  who  had  Buffered  from  the  disease  for 
seven  years,  died  of  peritonitis  following  perforation 
of  the  ileum,  which  was  the  seat  of  numerous  ulcers, 
others  of  the  same  kind  being  scattered  about  the 
cEBcum.  These  were  regarded  as  internal  manifesta- 
tions of  the  disease.  Throughout  the  illness  there 
had  been  indications  of  marked  implication  of  the 
alimentary  mucous  membrane  {dysphagia,  vomiting, 
diarrhcea,  and  melsna), 

The  sexes  appear  to  be  equally  liable  to  derma- 
titis herpetifonnis,  and  no  age  is  exempt.  Unna  has 
described  a  variety  of  the  affection  which  he  considers 
peculiar  to  childhood,  and  which  he  therefore  pro- 
posea  to  call  "  hydroa  puerorum."t  The  following 
are,  according  to  him,  its  distinguishing  features  : — 
(1)  It  begins  in  the  first  years  of  life.  ('2)  Continual 
relapses  take  place  during  childhood.  (3)  The  at- 
tacks reach  their  maximum  of  intensity  in  the  hot 

•  Brit.  Jonrn.  Derm..  189S,  p.  130. 

t  CongruB  Inteni.  de  DeniLitDl.  «6  de  Sypb.  teuu  a  Parin  en 
Vm  ;  CuiiiiHr,.Scnam,  Puris,  1880,  p.  IH5. 


133  NEUROTIC  AFFECTIONS  OF  THE  8KIN.  [ciiap.  ix. 

(4)  Multiformity  of  lesion  is  not  so  marked 
-  a.  feature  as  in  ordinary  dermatitiH  herpetiformis,  the 
eruption  almost  exclusively  consisting  of  papular 
erythema,  vesicles,  and  bullte.  (5)  Conversely  to 
what  is  the  rule  in  adults,  itching  is  a  much  lees 
prominent  symptom  than  pain.  (<i)  The  acutenesa  of 
the  attacks  is  in  itself  a  characteristic  feature.  (7) 
The  general  health  is  affected  even  before  the  appear- 
ance of  the  eruption.  (8)  The  attacks  become  pro- 
gressively less  severe  as  the  period  of  puberty  is 
approached.  (9)  The  disease  disappears  or  becomes 
extremely  mild  in  adult  age.  (10)  Boys  are  more 
liable  to  the  disease  than  girL=i.  The  affection  seems 
to  be  identical  with  that  described  by  Bazin  under 
the  name  of  "  hydroa  vacciniforme "  and  by  Mr. 
Hutchinson  under  that  of  "  hydroa  testivale," 

As  to  the  etiology  of  dermatitis  herpetiformis,  all 
that  can  be  said  with  certainty  is  that  the  neurotic 
disposition  is  a  predisposing  cause.  In  the  great 
majority  of  cases  the  outbreak  of  the  disease  is  pre- 
ceded by  a  definite  nervous  shock  or  long- continued 
depressing  influences.  Aa  in  all  other  diseases,  some 
predisposition  is  necessary  before  the  exciting  cause 
can  produce  its  effect ;  in  the  case  of  dermatitis 
herpetiformis  the  susceptibility  of  the  patient  is  pro- 
bably determined  simply  by  loss  of  nerve  force.  Of 
the  sudden  onset  of  the  disease  after  extreme  nervous 
shock  Duhring  rc]at«s  a  striking  example.*  A 
strong,  healthy  man,  aged  thirty-four,  who  had  never 
before  had  any  disease  of  the  akin,  narrowly  escaped 
being  buried  ahve  in  a  quagmire.  Threo  days  later 
the  eruption  appeared  in  the  form  of  small  variously 
shaped  vesicles,  and  he  continued  subject  to  the 
disease  in  a  well-marked  form  for  at  least  four  years. 
Dermatitis  herpetiformis  may  be  mistaken  for 

'  Amtr.  JoiifH,  Mnl,  Hei.,  Jitiiuoj-j-,  1885, 


ST.]    DtiHMATITtS  MERPETIFOHMIS.  133 

any  of  tlie  diaeaaes  whose  characteriBtic  lesion  pre- 
dominatfis  at  any  given  period  of  its  comae.  The 
diag'nosis  must  reat  on  the  following  points  :  (1)  The 
multiformity  of  the  leaiona  ;  and  under  this  head 
must  be  counted  the  scars,  pita,  and  pigmentary 
blotchea  left  by  previous  attacks,  as  well  as  the 
veaicles,  bulloa,  etc.,  actually  present.  (2)  The  intenaity 
of  the  itching,  which,  as  already  said,  often  vexea  the 
patient  when  otherwise  the  diaease  appears  to  be 
quiescent.  (3)  The  frequency  of  relapaes ;  and  (4) 
the  general  refractorineas  of  the  affection  to  treat- 
ment of  every  kind.  The  practitioner  must  he  guided 
by  the  aggregate  of  symptoms  rather  than  by  one  or 
other  feature  which  may  happen  to  be  predominant 
at  a  particular  time. 

Investigations  by  Leredde,  Perrin,  Darier,  and 
others  into  the  changes  occurring  in  the  btood  of 
cases  of  dermatitis  herpetiformis,  pemphigus,  and 
builous  leprosy  have  disciosed  the  fact  that  the 
eoainophile  cells  of  the  blood  are  usually,  if  not 
always,  in  great  excess.  Thus  instead  of  finding  them 
present  in  the  proportion  of  1-4  per  cent,  of  all  leu- 
cocytes, as  in  normal  blood,  they  are  usually  found 
increased  to  from  S  per  cent,  to  20  per  cent,,  and  cases 
have  been  reporteil  with  an  even  higher  percentage 
(60  per  cent,  in  pemphigus).  In  a  case  of  mine,* 
in  which  the  blood  waa  examined  by  Dr.  Whitfield, 
the  eosinophUia  rose  from  4-i)  per  cent,  in  the  blood 
at  the  commencement  of  an  acute  attack  to  12  per 
cent,  of  all  leucocytes  present  when  the  eruption  was 
at  its  height. 

Thia  discovery  led  to  the  examination  of  the  fluid 
obtained  from  the  buliro  and  vesicles  in  various 
diseases,  with  the  result  that  it  was  found  that 
whereas  ia  artificial  blisters  produced  in  the  ordinary 

•  £rit,  Jourii.  itovc,  Jiiue,  1897. 


cKAp.is.}     DERMATITIS   HERPETIFORMIS.  13B 

characteriaed  in  its  earlier  atages  by  a  very  acute 
inflammatioQ  of  the  papillary  layer  of  the  coriiim 
with  formation  of  vesicles  immediately  Ijeneath  the 
ppidermis  and  fclie  migration  of  large  numbers  of 
polynucleax  leucocytes ;  the  epidermia  is  only  pas- 
sively engaged. 

No  treatment  appears  to  be  of  much  avail  in 
curing  or  even  controUing  dermatitis  herpetiformis. 
Alt  that  can  generally  be  done  is  to  relieve  pain  and 
induce  sleep  by  hypodermic  injections  of  morphine 
or  opium  internally,  and  soothe  irritation  by  some 
of  the  means  already  described.  No  spirituous  lotions 
should,  however,  be  employed,  as  they  cause  smarting 
of  the  skin,  which  is  always  raw  and  tender.  The 
rubbing  in  of  vxak  aul'phur  ointment  ia  the  local 
measure  which  has  so  far  given  tbe  best  results  ;  tlia 
inunction  should  be  done  with  some  degree  of  force, 
so  as  to  rupture  the  vesicles  and  bullK.  This  method 
should  be  employed  at  first  over  a  Hmited  area,  so  as 
to  minimise  the  risk  of  setting  up  dermatitis.  The 
application  of  almond  or  carbolic  oil,  or,  better  still, 
olive  oil  cofitbined  witk  Hme-teater,  to  the  whole 
surface  aometimes  gives  relief.  Saliajlic  acid  is  often 
useful  as  a  local  remedy,  Schwimmer  *  obtained  satis- 
lactory  results  with  thiol,  a  solution  {lO'O  to  30'0) 
of  which  was  painted  over  the  aSected  surface  twice 
daily  for  two  or  three  days,  the  skin  being  then  care- 
fully washed  with  pure  water.  Weak  ichthyol  oint- 
ment or  solution  is  of  value  as  a  local  application. 
Of  internal  remedies,  araenio  is  probably  the  most 
efficient,  although  in  many  cases  it  seems  to  have 
little  or  no  effect.  The  dose  of  arsenic  required  is 
smaller  than  that  generally  used  in  pemphigus.  In 
the  early  stages,  when  the  inflammatory  symptoms 
are  very  marked,  imtiihony  given  as  already  directed 

•  r.ra.  khii.  jraehemrhfift,  1S90,  So.  18. 


I3Q  SEUROTtC  AFFECTIOXS  Of  THE  SKIS,  (cttip.  a.. 

may  be  usetol,  but  its  use  should  be  continued  only 
lor  a  sliort  time.  Iron,  phosphorus,  and  nerve  tonic* 
may  do  good  by  maintaining  the  strength  and  bracing 
up  the  nervous  system,  especially  in  the  later  stages 
of  the  disease.  I  have  seen  good  results  in  subduing 
nervous  symptoms    from   the  use  of    phenaceli 

V  in  the  middle  of  the  day,  and  gr.  x-xv  in  the 
evening.  The  mid-day  dose  may  with  advantage  be 
combined  with  citrate  of  caffeine,  gr.  ij.  Phenacetin 
has  proved  beneficial  in  the  hands  oE  Fringle,  who 
has  also  seen  much  diminution  in  the  amount  of- 
itching  from  antipyrin*  Wann  bathing  gives  relief 
in  Rome  cases,  but  in  others  appears  to  aggravate  the 
Bymptoma.  The  diet  should  be  strictly  regulated, 
all  Bubstancea  that  have  any  tendency  to  disagree 
being  carefully  avoided,  and  liquids,  such  as  cosee, 
generous  wines  and  spirits,  which  stimulate  the  heart 
and  cause  an  increased  flow  of  blood  to  the  skin, 
being  absolutely  prohibited.  Disturbing  emotions 
of  all  kinds  are  likely  to  intensify  the  evil,  and  the 
patient  should  expose  himself  as  little  as  possible  to 
vicissitudes  of  temp  era  ture.'f' 

'  Herpes  ^estattonis  is  a  skin  affection,  occui- 
ling  in  association  with  pregnancy,  which  is  charac- 
terised by  multiformity  of  lesion  and  excessive  itching. 
It«  clinical  features  are  practically  identical  with  those 
of  dermatitis  herpetiformis,  the  only  point  of  distinc- 
tion being,  according  to  Brocq,  that  among  the  lesioos 
observed  pustules  are  less  frequent  than  in  the  latter 
affevtion.  The  symptoms  come  on  during  the  last 
six  months  of  gestation,  sometimes  a  few  days  after 
delivery.  The  eruption,  wluch  is  multiform  in 
I    character,  appears  usually  lirst  on  the  limbs,  espe- 

\  •  J)ri:.  J-m-n.  Der-u..  18W),  p.  lai. 

I  t  For  a  diseiHiIoii  ot  the  whole  lubject  ol  danoalitii  ber- 

I  patifunnii  Hnd  other  conditions,  iie  Brtt.  Jimra.  /term,,  1998, 

I  fp,  Vlaai  1  IS;  with  uommeatBb}' Brocq,  itid.,  1899,  p.  2131 


1 


■cbap.  IX.]  HERPES  QESTATIONIS.  137 

cially  the  liaada  aud  aims  ;  sometimeB  the  umbiUuus 
ia  the  point  first  attacked.  The  subjective  pheno- 
mena {itching,  burning,  etc.)  are  constant  and  very 
pronounced.  Sometimes  the  eruption  is  accompanied 
by  slight  febrile  disorder,  but  on  the  whole  the 
afiection  has  little  eSect  on  the  health  beyond  causing 
a  certain  degree  of  fatigue.  When  the  period  of  par- 
turition is  over,  the  disease,  as  a  rule,  disappears 
apontaneously  ;  but  it  has  a  marked  tendency  to 
recur  with  each  successive  pregnancy,  increasing 
each  time  in  severity,  and  to  merge  into  ordinary 
dermatitis  herpetiformis.  A  curious  fact  pointed 
out  by  Brocq  *  is  that  true  dermatitis  herpetifomus 
seems  to  disappear  in  women  suSering  from  it  if  they 
become  pregnant. 

In  regard  to  thf  treatment  of  herpes  gestationis, 
there  is  nothing  to  be  added  to  what  has  been  said 
concerning  dermatitis  herpetilormiB,  except  to  warn 
the  practitioner  to  be  cautious  in  the  use  of  internal 
remedies,  in  view  of  the  patient's  condition. 

Impetigo  herpetiformis.— Under  this  name 
Kaposi  t  described  an  aSection  which,  while  present- 
ing certain  affinities  with  dermatitis  herpetiformiB,  ex- 
liibita  pecuHar  characteristics  sufficiently  well  marked 
to  entitle  it  to  be  classed  as  an  independent  disease. 
It  begins  by  the  development  of  small  pustules  with 
opa<|ue  contents,  which  gradually  assume  a  greenish 
hue.  These  pustules  are  arranged  in  groups  on  an 
inflamed  base,  and  he  very  close  together ;  they 
appear  first  in  the  groin,  on  the  umbilicus,  on  the 
breast  and  in  the  armpit,  other  parts  being  attacked 
at  a  later  stage.  They  dry  up  in  one  or  two  days, 
leaving  a  dirty  brown  crust.  New  pustules  come 
out,  forming  a  double  and  even  a  triple  circle  around 

•  "  Troitement  doa  MuJuiiiei)  de  la  Toqu,"  PoriB,  ISBO.  p.  135, 
i- "Hnludiia  lie  1u  reau,"  Freiicili  tmnsmtiou  by  Besnier  aiid 
DDjbii,  2tid  edition,  Tol.  1,,  p.  799,  Poru,  ISBl. 


138  NEVHOTIC  AFFECTIONS  OF  THE  SKIN,  [en 

the  first  as  a  centre  ;  these,  as  they  dry,  increase  the 
Bize  of  the  central  scab.  In  this  way,  starting  irom  a 
few  isolated  points,  the  disease  may,  by  the  coales- 
cence of  adjacent  foci,  gradually  spread  oveT  ex- 
tensive  areaa.  When  the  scabs  become  detached, 
the  skin  underneath  is  found  to  be  red  and  smooth, 
sometimes  moist,  as  in  eczema,  but  never  ulcerated. 
In  the  course  of  three  or  tour  months  nearly  the  whole 
cutaneous  surface  may  be  invaded. 

The  skin  is  burning  hot,  tense,  and  scabbed  all. 
over,  the  cuirass  of  crusts  being  here  and  there 
cracked  and  excoriated.  The  mucous  membranes 
of  the  tongue,  palate,  velum,  and  the  back  of  the 
pharynx  in  some  cases  present  circumscribed  greyish 
patches.  In  one  case  referred  to  by  Kaposi  groups 
of  pustules  were  found  in  the  cesophageal  folds ; 
in  many  places,  especially  near  the  cardiac  orifice, 
these  had  ulcerated.*  The  eruption  on  the  akin 
IB  accompanied  by  more  or  less  continuous  fever, 
exacerbations  of  which,  with  rigors  and  general  con- 
stitutional disturbance,  usher  in  each  fresh  crop  of 
pustules.  The  disease  lasts  a  few  weeks,  or  at  moBt 
some  months,  and  is  almost  certain  to  prove  fatal.. 
The  cause  of  death  is  by  no  means  clear,  but  in  soi 
at  least  of  the  cases  it  was  due  to  marasmus, 
petigo  herpetiformis  is  very  rare,  and  has  so  far  hardly 
been  observed  anywhere  else  than  in  Vienna.  Nearlj^ 
all  the  patients  have  been  pregnant  women,  and  in 
one  or  two  there  have  been  uterine  complications. 
These  facts  would  seem  to  show  that  the  cause  of  the 
affection  is  often  in  some  way  connected  with  uterine 
disease.  It  would  thus  appear  to  be  a  reflejc  neurosis 
analogous  to  herpes  gestationis,  hysterical  pemphigus, 
etc.  Kaposi  himself  appears  to  be  not  altogether 
disinclined  to  look  upon  it  as  an  infectious  disease.t 


] 


I 
I 


c  upon  it 


+  dp.  dt,  p.  8 


p.  SOI. 


OK*p.  TI.I       IMPETIQO  HERPETIFORMIS.  139 

It  must  be  admitted  that  impetigo  herpetiformis, 
as  described  by  Kaposi,  ia  a.  disease  entirely  distinct 
from  either  dermatitis  herpetiformis  or  herpes  gesta- 
tionis  ;  and  Duhring  himself,  who  formerly  main- 
tained that  they  were  identical,  some  time  ago 
acknowledged  that  Kaposi's  description  of  the  disease 
had  led  him  to  change  his  view  on  that  point.* 
Besnierf  thinks  that  impetigo  herpetiformis  is  not 
so  much  a  definite  pathological  entity  as  a  group  of 
closely  allied  afEections.  The  feature  common  to 
these  is  the  formation  of  vesicles  in  groups,  which 
quickly  become  pustules  and  spread  at  the  circum- 
ference while  healing  in  the  centre.  In  this  way 
neighbouring  lesions  unite  and  thus  cover  large  areas. 
In  their  evolution  the  lesions  assume  at  difierent 
stages  an  eczematous,  ulcerative,  vegetative,  or 
papillomatous  aspect.  He  thinks  it  probable  that 
visceral  changes  are  present  in  fatal  cases.  In  .'<liort, 
Besnier  looks  upon  impetigo  herpetiformis  as  ai 
pxeasion  covering  multiple  affections  of  septictemic 
type,  or  reflex  lesions  leading  to  trophic  changes. 

Impetigo  herpetiformis  is  very  refractory  to  treat- 
ment. All  that  can  be  done  is  to  reheve  the  local 
symptoms  by  continuous  baths  and  cooling  applica^ 
tions,  and  to  support  the  patient's  strength. 

Cheiropompholyx,^    or   dysidroais,  is    charac- 
terised by  an  eruption  consisting  of  vesicles  sy 
metrically  distributed  on  the  extremities.     The  feet 
sometimes  escape,  but  the  hands  are  always  attacked. 
The  affection  begins  with  subjective  sensations 
burning  and  itching,  quickly  followed    by  the  appei 

«  his  latter  to  M.  Brocg,   wliich  was  luod  iit  tJie  Inti 

I  Congress  of  Dermatolbgy  la  Vans  in  18H9;  Conipl 

(.Paiu,  ISDD.  p.  183. 

2  i'reud)  translatiQii  of  Kaposi,  Pima,  ISfll,  vol  i.,  p.  803. 

X  Aa  the  diEeose  usuuUr  nffei^a  the  feet  as  well  an  tho  hnii 

"  Bcruponipholfx  "   would  be  a  more  accurate  designation  tl 

"  oheiropompliolyjt." 


f 


140  NEUROTIC  AFFECTIONS  OF  THE  SKIN.  [cwap.  is. 

aoce  of  numerous  tiny  vesicles  deeply  embedded  in 
the  Bkin,  and  stowing  through  the  epidermis  like 
boiled  sago  grains.  Their  appearance  is  accompanied 
by  increase  of  the  itching.  As  they  become  more  pro- 
minent on  the  surface  they  run  together  and  form 
large  irregular  hulte  containing  clear  fluid.  These 
show  little  tendency  to  burst,  but  become  more  and 
more  distended  for  a  time  ;  and  then,  as  the  contents 
become  opaque  and  tliieken,  they  begin  to  shrink, 
and  finally  form  dense,  dark  brown  crusts.  When 
these  are  thrown  ofl,  the  surface  of  the  akin  under- 
neath is  found  smooth,  red,  dry,  and  exquisitely 
tender.  The  itching  sometimes  ceases  when  the 
bullffi  are  fully  developed,  as  if  some  irritant  substance 
had  been  thereby  eliminated  from  the  skin.  When 
the  bullffi  are  pricked,  the  liquid  which  issues  is  clear, 
and  neutral  or  alkaline  in  reaction.  The  first  tiny 
vesicles  may  usually  be  seen  grouped  around  the 
orifices  of  the  sweat  ducts.  The  eruption  comes  out 
along  the  sides  and  palmar  aspects  of  the  fingers,  and 
in  the  interdigital  spaces.  In  severe  cases  the  whole 
surface  of  the  hands  may  be  involved.  Sometimes 
an  eczematoid  eruption  spreads  up  the  arms  from 
the  hands,  or  may  develop  at  distant  parts,  allying 
the  disease  with  some  form  of  eczema,  with  which 
many  authorities  consider  it  identical.  Its  patho- 
logical anatomy  on  the  whole  rather  support  this 
view,  The  duration  of  the  disease  is  about  a  fort- 
night, but  recurrence  is  almost  certain,  and  may  occur 
at  such  short  intervals  as  to  make  the  disease  ail  but 
continuous.  Repeated  atta(.^ks  at  the  same  parte 
leave  the  ekin  discoloured,  harsh,  thick,  and  dry,  and 
some  time  elapses  before  this  inconvenient  covering, 
which  deadens  sensation  and  hinders  the  movements, 
of  the  fingers,  is  shed. 

The  disease  was  named  "  dysidrosis  "  by  Tilburjr 
Fox,  on  the  supposition  that  the  process  was  pmnuily 


1 


w 


.]  CUEIROPOMPHOIYX.  141 

set  up  by  retention  of  the  sweat  secretion.  Crocker, 
on  the  other  hand,  thinks  that  excessive  sweating  ia 
a  predisposing  condition.  There  can  be  little  doubt 
that  the  disease  is,  in  the  first  instance,  a  vaso-motor 
neurosis,  and  it  is  in  harmony  with  the  notion  ot  its 
nervous  origin  that  it  is  much  more  common  in  women 
than  in  men,  and  that  its  especial  victims  are  young 
women  oi  neurotic  temperament  or  who  have  been 
exposed  to  worry  or  excitement.  So  strongly  marked, 
indeed,  is  the  neurotic  character  of  the  affection, 
that  in  many  cases  the  slightest  unpleasant  emotion 
or  mental  agitation  is  sufficient  to  bring  on  an  attack. 
Among  the  immediate  causes  of  the  disease,  next  to 
nervous  shock,  is  temperature.  The  affection  is  more 
coimnon  in  spring  and  summer  than  in  the  colder 
seasons,  and  hot  weather  has  a  marked  effect  in  deter- 
mining an  attack  or  aggravating  an  already  existing 
one.  Artificial  heat  acts  exactly  in  the  same  way,  and 
exposure  of  the  hands  to  the  fire,  as  in  cooking,  often 
induces  an  attack  in  those  subject  to  the  complaint.* 
Winkelried  Williams  f  has  shown  that  the  anato- 
mical hie-history  of  the  cheiropompholyx  vesicle  is 
as  follows  : — (I)  A  mild  inflammatory  action  in  the 
papillary  layer  of  the  corium  results  in  an  exudation 
of  serum,  which  finds  its  way  between  the.  rete  cells 
and  leads  to  their  compression,  degeneration,  and 
destruction.  (2)  Vesicles  are  thus  formed  which 
receive  fresh  fluid,  and  so  increase  in  size.  (3)  The 
vesicular  contents  dry  up,  fresh  epithelium  forma 
below,  and  the  superficial  togetlier  with  the  dried 
contents  of  the  vesicles  are  thrown  off.  The  ana- 
tomical characters  ot  cheiropompholyx  thus  closely 
resemble  those  of  vesicular  eczema. 

"iHtopiitliDloBj-,"  p.  179,  lia.1  found  a  hacilluB  like 
lia,  but  Blou'ter  in  ull  ei^tlions,  Kliich  he  belieTCS 
b*  pathooenic. 
■itrtf.  Jourii,  Ilerm.,  vol.  iu,,  1891,  p.  303  rl  w/j. 


F 


1+4  XEUROTIC  AFFECT/OXS  OF  THU SmX.  [caxe.  IX.  ' 

children  and  in  elderly  persons,  by  greater  or  less 
febrile  diaorder,  and  the  appearance  of  the  emption 
IS  ac<;ompanie9^Tyltehing  and  burnings    The  bullm 
qiiieklr   apring   up,   ei th«  _on_8mall   ervthcmaton^ 
Pfttcha  or  qn  vnaltered  skin  ;    they  are  fully  deve- 
loped in  a  few  houTB.  and  as  a  mle  they  stand  oat 
on  the  akin  aa  henuBpherical  blebs,  without  any  ii 
flammatory    areola    around    their    base.     They    and 
scattered  about  irregularly,  or  arranged  more  or  lessl 
symmetrically  on  the  limbs,  trunk,  or  lower  part  o" 
the  face.     Sometimes  they  are  set  so  close  togethwa 
as  almost  to  deserve  to  be  called  "  confluent,"  and  isfl 
rare  cases  they  actually  do  run  together.     Occaaioo- 1 
ally  they  are  grouped  around  bullce  of  older  date  so  afl  4 
to  form  circles,  which,  as  they  in  turn  gradually  diB-  I 
appear,  leave  irregular  wavy  linea.     The  contents  ofl 
the  bullffi  are  at  first  clear  and  transparent,  but  they 
soon  become  opaque  ;  the  bullae  then  dry  up,  formii^ 
brownish -yellow  scabs.     If  the  surface  of  skin  covered 
by  these  scabs  is  extensive,  they  give  rise  to  a  disagree- 
able feeling  of  tension,  and  excoriation  may  be  caused 
by  their  premature  separation.     When  the  scabs  faHjB 
dS  naturally,  the  surface  underneath  is  seen  to  Iwl 
covered  with  newly-formed  epidermis,  which  is  at-l 
finit  purple  in  colour,  but  gradually  turns  brown  audi 
remains  pigmented    for   some  weeks.     In   some   ior^ 
stances  the  ulcers  under  the  scabs  become  covered.! 
with    fibrinous   exudation,  and  leave   more   or   leeitfl 
scarring.  I 

Pemphigus  also  sometimes  attacks  mucous  mem-  I 
branes.  I  have  seen  a  case  in  which  the  mouth  and  l 
the  conjunctiva  were  ufected,  the  process  beinaJ 
accompanied  bv  "  easential  shrinking  "  of  the  lattet.V^ 
(Fig.  7.)  I 

*  Str  a  report  of  the  case  by  the  author  ainl  Lcslio  Boborto'l 
[Jlrit.  Jbuiii.  JJniH.,  Ajml,  \m>},  where  a  full  bibliography  at» 
OQUjnnctlviil  pemphigus  a  given.  V 


PEMPHIGUS    VUI/IARIS. 


The  life -history  of  each  bulla  extends  only  over 
a  few  days ;  but  as  auccessive  crops  of  them  coma 
out,  more  frequent  and  abundant  in  proportion  to 
the  severity  of  the  attack,  the  disease  may  last  for 
aeveial  monttia.  In  certain  cases  hiemorrliage  takes 
place  into  the  interior  of  the  bulUe,  the  oontenta  of 
which  are  then  pink,  red,  or  blackish,  according  to 
the  amount  of  blood  effused.  In  other  cases  the 
bullte  may  end  in  sloughing  and  more  or  less  extensive 
gangrene  of  the  surrounding  skin. 
These,  however,  are  not  varieties 
of  the  disease,  but  pathological 
accidents.  Sometimes  the  general 
health  is  little,  it  at  all,  aSccted ; 
but  in  persons  of  feeble  constitu- 
tion the  discomfort  of  the  lesions 
and  the  consequent  insomnia  cause 
depression,  loss  of  strength,  ex- 
haustion, and  even  death.  When 
the  disease  ia  on  the  decline  the 
bullte  no  longer  come  out  in  crops, 
ymt  singly  here  and  there ;   the 

rer  ceases,    sleep  and    appetite 

n,  and  the  healtli  is  rapidlv       Mombrane    o( 

itored.     There  may  be  no  re-       '*'"'*^ 
■ence  after  a  first  attack,  but 

more  often  happens  that  after  some  months,  or 
even  a  year,  the  patient  is  again  attacked,  perhaps 
more  than  once.  The  disease  may  then  definitively 
cease  from  troubling ;  or,  on  the  other  hand,  it  may 
get  so  firm  a  hold  on  the  patient  that  it  cannot  be 
shaken  off,  attacks  following  each  other  at  such  short 
intervals  as  to  make  the  afiection  practically  eou- 
'"  luous.  In  such  cases  the  whole  body  may  be  in- 
roded  by  the  lesions,  to  the  grievous  detriment  of  the 

Ltient's  health,  and  sooner  or  later  to  the  destruc- 
ol  hia  life ;    or  the  process,  though  persistent, 


Fig.  7.— "EasDiitial 
S]irinkiog"of  Coii- 
jmio'tiva  oonuected 
with  Peuiphigiie  of 
Skin   and   Mbcous 


146  NEUROTIC  AFFECTIONS  OF  THE  SKIN. Ictu^.m. 

,  may  be  mild,  the  bullsB,  though  never  altogether 
absent,  being  few  and  tar  between.  These  "  apor- 
adic  "  (if  the  term  may  be  allowed)  bullse  are  apt 
to  select  parts  where  the  circulation  is  sluggish 
{extremities,  noae,  etc.)  for  their  appearance. 

Though,  as  a  rule,  essentially  chronic  in  its  course, 
pemphigus  is  occasionally  so  acute  in  its  manifesta* 
tiona  as  to  warrant  the  term  "  malignant  "  which  has 
been  applied  to  anch  cases.  The  buUse  form  in  enor- 
mous numbers,  crop  following  crop  so  closely  that 
there  is  no  remission  of  the  process,  which  is  accom- 
panied by  high  fever  and  rapid  wasting,  and  ends  in 
death  in  two  or  three  weeks  or  even  a  few  days. 
This  form  of  the  disease  is  usually  seen  in  young 
children,  and  must  not  be  confounded  with  syphilitic 
pemphigus.  Pernet  and  Bulloch  *  have  recorded  a 
number  of  cases  of  acute  pemphigus  which  followed 
wounds  of  the  hands  in  butchers,  and  mostly  ended 
fatally.  A  similar  case  has  been  observed  by  Wil- 
fred Hadley  and  Bulloeh.'f  In  all  these  oases  diplo- 
cocci  were  found  by  Bulloch  in  the  fluid  of  the  bull». 
The  so-called  pemphigits  neonatorum  is  an  affec- 
tion met  with  in  new-bom  infants,  characterised  by 
the  eruption  of  buihe  on  the  thighs,  buttocks,  face, 
and  other  parts,  accompanied  by  greater  or  leas 
constitutional  disturbance.  The  children  are  free 
from  syphilitic  taint,  and  are  often  well  nonriahed, 
but  have  been  exposed  to  septic  infection  from  in- 
sanitary surroundings.  In  some  instances  the  diaeaae 
occurs  in  the  form  of  a  limited  epidemic,  and  a  par- 
ticular midwife  has  occasionally  appeared  to  be  the  * 
means  of  convejHng  the  disease.  The  affection  is 
not,  as  a  rule,  of  any  gravity,  but  occasionally  ib 
assumes  a  mahgnant  type,  the  contents  of  the  bulln 
being  dark  and  fetid,   and  gangrenous  ulceration 


.]  PEMPHIGUS    FOLIAGEUa. 


taking  place,  with  symptoms  of  infection  generalised, 
ending  in  deatli  in  ten  or  twelve  days  (Tilbury  Fox). 

Pemphigus  foliaceus.  —  This  affection  was 
first  described  by  Cazenave,  hy  whose  name  it  is 
sometimes  called.  In  pemphigus  fohnceUH  the  bullae 
are  not  rounded  and  tense  lite  those  of  pemphigus 
vulgaris,  but  flattened  and  flaccid.  They  break 
easily,  and  the  affected  surface  has  a  blistered  appear- 
ance. The  bullte  form  yellowish  crusts,  and  as  the 
disease  spreads  scales  of  considerable  size  nre  formed. 
These,  as  they  become  detached,  leave  red  excoriated 
areas  on  which  new  layers  of  epidermis  are  formed, 
only  to  be  quickly  shed  again  or  brushed  away  mech- 
anically. After  a  period  of  months  or  years  the  whole 
cutaneous  surface  may  be  invaded,  the  skin  readily 
ulcerates  wherever  it  is  subjected  to  any  pressure, 
the  face  becomes  disfigured  by  cicatricial  contraction, 
causing  ectropion,  etc.  The  patient  loses  flesh,  and 
as  the  disease  advances  the  febrile  symptoms  and 
constitutional  disorder  become  intensified  ;  he  cannot 
move  or  lie  down  without  pain,  and  his  condition  is 
one  of  great  misery.  Pemphigus  foliaceus  generally 
ends  in  death.  The  affection  may  begin  and  run  its 
whole  course  as  an  independent  disease,  or  it  may 
follow  long-standing  pemphigus  vulgaris,  when  the 
eruption  lias  become  continuous  and  widely  dis- 
tributed, and  cachexia  has  been  induced. 

Both  in  pemphigus  vulgaris  and  pemphigus  foli- 
aceus the  mucous  membrane  of  the  mouth,  pharynx, 
and  larynx  may  become  the  seat  of  eruption.  If 
bullie  form  on  the  epiglottis  there  may  be  danger  of 
suffocation.  If  the  buliie  on  the  mucous  membraue 
follow  the  same  course  as  they  do  in  pemphigus  foli- 
aceus of  the  skin,  swallowing  becomes  impossible, 
the  voice  is  lost,  and  the  respiration  may  be  em- 

raased.    In  such  circumstances  the  patient  is  in 

mdition  of  the  gravest  danger.    The  lesions  of 


148  NEUROTIC  AFFECTIONS  OF  THE  SKIN.  [chap.  is. 

pemphigus  may  extend  far  into  the  lower  air- passages, 
and  in  the  last  stage  of  pemphigus  foliacoua  the 
trachea  and  bronchi  are  often  invaded. 

Leredde*  considers  pemphigus  foliaceus  as  essen- 
tially a  blood  disease,  the  cutaneous  manifestations 
being  secondary,  both  the  blood  changes  and  the  skin 
lesions  depending  on  an  affection  of  the  bone  marrow 
set  up  by  toxic  bodies  of  one  kind  or  another. 

Pemphigus  vegretans,  a  form  described  by 
Neumann, f  presents  features  so  peculiar  as  almost  to 
entitle  it  to  rank  as  a  distinct  disease.  It^  only  rela- 
tion with  ordinary  pemphigus  is  the  fact  that  the 
eruption  is  at  first  bullous  in  character.  The  initial 
lesions  are  bullae  of  the  size  of  lentils,  which  gradually 
distend  the  epidermis  with  the  colourless  exudation 
wliich  they  contain.  Excoriation  takes  place,  and 
in  four  or  five  days  the  centre  of  the  denuded  snrface 
is  occupied  by  a  pale  white  protuberance  which  grows 
rapidly  in  height  and  width,  so  that  in  a  short  time 
warty  or  granulation-like  escreacences  are  formed. 
These  are  at  first  bounded  by  a  circle  of  excoriation, 
later  by  bullce,  which  form  at  the  circumference. 
The  snrface  of  the  patches  is  uneven,  slightly  raised, 
flesh-coloured,  and  disohaTges  a  thin,  fouI-smelllng 
secretion.  The  discharge,  as  it  dries,  forms  a  thin 
crust,  which  can  easily  be  stripped  off,  when  an  ex- 
crescence, partly  covered  by  a  thin  stratum  of  epi- 
dermis, is  seen.  The  first  pointe  attacked  are  the 
labia  majora  and  minora  ;  next  come  the  mouth  and 
lips  ;  then  the  skin,  axlllte,  hands,  feet,  inner  parte 
of  thighs,  face  (where  the  eruption  joins  that  of  the 
lips  and  mouth).  The  mucous  membrane  becomes  dry 
and  fissured,  and  swallowing  is  so  painful  that  the 

*  jtm.de  Jifnii.tl  lit  Svph.. voi.x.,Ja\j.l»90.  (Ahstrnctedin 
Sril.  Jiiurn.  Derm.,  1S89,  n.40fi.l 

t  Consri>a  Intern,  ie  DenDBtul.  at  i!o  8vph.,  tetiu  k  Paria  to 
I'UW;   Untt><r«-.fi»>ifM,  Piiris,  ISSD,  p.  8t. 


^^f    tJBAX 


s.]  PEMPHIGUS   VEQBTANH. 


patient  does  not  care  to  attompt  it.  On  the  akin 
the  buUse,  instead  of  drying  up  into  Hcabs,  break 
down  and  form  excoriations,  upon  which,  in  part« 
where  the  integument  is  folded  on  itaelf  (armpits, 
-janction  of  thiglis  with  perinjeum),  papillary  excres- 
cencea  sprout  up.  Fresh  crops  of  bullse  continue  to 
come  out,  the  epidermie  strips  ofi  in  large  sheets, 
leaving  the  papillary  layer  exposed,  as  in  a  burn  of 
the  second  degree.  The  diseased  surface  is  dirty, 
wet,  and  warty.  The  secretion  decomposes  rapidly 
and  is  horribly  ofienaive.  Finally,  superficial  gan- 
grene takes  place,  and  the  patient  dies  exhausted 
by  his  auSerings  and  by  want  of  food,  or  of  some 
intercurrent  disease  (nephritis,  cedema  of  the  lungs, 
etc,)  a  few  months  after  the  first  appearance  of  the 
eruption.  The  disease  ia  extremely  rare,  Neumann 
himself  in  1889  had  seen  only  fourteen  cases.  Crocker 
has  met  with  a  typical  example,  which  he  considers 
to  be  the  only  one  observed  in  England,*  though  he 
thinks  some  cases  of  "  a  rare  postulating  disease  of 
tho  skin  and  mucous  membranes,"  allied  to  foot-and- 
jaouth  disease,  reported  by  Hutchinson,  may  have 
been  examples  of  a  mild  variety  of  pemphigus 
T^etans. 

As  to  the  etiologry  of  pemphigus  vidgaris  nothing 

^jU9  known  with  certainty.     New-born  babies  and  young 

'^Idien  are  more  liable  to  it  than  adults.     It  is  not 

ti  that  sex  has  any  influence,  statistics  coUected 

different  observers  giving  contradictory  results. 

is  occasionally  hereditary.     Kaposi  cites  the  case 

a  patient  whose  mother,    sister,   and   maternal 

mcle  had  been  sufferers  ;  several  of  the  man's  own 

children  were  also  subjects  of  the  disease,      I  have 

myself  treated  three  members  of  the  same  family  for 

peonphigua.     The  direct  causation  of  the  disease  is 

■  ••  Trans.  R,  Med.-Chir.  Soo.,"  luii.  (with    bibliograiilij  up 
io  date). 


'   150  NEUROTIC  AFFECTIONS  OF  THE  aKIN.  [ohap.  is. 

doubtless  Bome  tnBtability  or  over- excitability  of  the 
nervous  system.  Chauges  iu  the  peripheral  nerve- 
ends  under  the  bulliB  Iiave  been  iound  in  ft  few  caaee 
of  pemphigus  by  Dfijerine  and  others,  and  Weir- 
Mitchell  has  ahown  that  bullous  eruptions  Bometimes 
follow  injuries  of  the  nejves,  eapeeially  such  as  cause 
neuritis.  In  certain  forms  of  nerve  degeneration 
or  irritation  bulliE  are  apt  to  be  induced  along  the 
course  of  the  affected  nervous  trunks  by  heat,  cold, 
or  slight  injury.  The  pemphigoid  blebs  which  are 
a  frequent  accompaniment  of  leprosy  are  probably 
the  result  of  direct  irritation  of  the  vaso-motor  nerves 
by  the  leprotic  infiltration.  Bullous  eruptions  are  also 
not  uncommonly  associated  with  sclerosis  of  the  pos- 
terior columns  of  the  cord.  It  is  probable  that  pem- 
pliigu."  is,  as  Schwimmer  suggested,  a  tropho- neurosis, 
but  in  the  present  state  of  knowledge  no  conclusive 
proof  of  this  theory  is  obtainable.  Some  confirma- 
tion of  the  view  just  expressed  as  to  the  nervous 
origin  of  pemphigus  is  afforded  by  the  fact  that  it 
is  not  infrequent  in  neurotic  and  hysterical  subjects. 
According  to  Kaposi,  in  women  the  disease  is  occa- 
sionally associated  with  gestation,  the  eruption  shoW' 
ing  itself  in  the  course  of  every  pregnancy  and  dis- 
appearing after  delivery.  In  such  cases,  however, 
it  is  probable  that  the  affection  is  not  true  pemphigus, 
but  the  same  as  that  already  described  under  the 
name  of  "  herpes  gestationis,"  and  therefore  of  the 
nature  of  dermatitis  herpetiformis. 

As  regards  tlie  pathology  of  pempliigus,  1  have 
already  expressed  my  belief  that  the  process  is  tii 
angio-neuiotic  nature.  Tbe  characteristic  bulla  k 
the  result  of  inQammatory  exudation  from  the  veasela 
of  the  papillary  layer.  Crocker  states  that  in  the 
case  of  a  very  large  bulla  which  he  ejiamined  the 
fluid  poured  out  had  stretched  the  lower  rete  cells 
L  bntil  they  were  separated  from  the  coriuin  ;    and  as 


s.]    ^PATHUWay  OF   PEMFMIGOS. 


the  process  contimied  the  Iowpt  layers  were  destroyed 
and  the  upper  compressed  until,  at  the  centre,  the 
roof  was  formed  by  tlie  horny  layer  and  about  the 
upper-two  thirds  of  the  rete,  with  Iiere  and  there  a 
fragmeJit  of  a  sweat  duct  or  hair  follicle  depending. 
At  the  border  the  lower  stretched  cells  of  the  retc 
were  still  present.  The  fibres  of  the  coriura  below 
the  bulla  were  compressed,  and  there  was  free  cell 
infiltration  of  the  upper  layers. 

Tha  liquid  contained  in  pemphigus  bulhe  has  most 
of  the  characters  of  blood  serom;  Even  when  it 
is  clear,  leucocyt«8  may  be  found  in  it ;  and  when 
it  becomea  opaque,  pns- corpuscles  and  red  blood- 
corpuscle  abound  in  it.  It  is,  as  a  rule,  weakly 
alkalino  in  reaction.  The  eosinophile  cells  are  as  a 
rule  present  in  great  excess  in  the  blood  (see  p.  133). 
Micro-organisms  have  been  found  in  it  and  in  the 
urine  of  the  patients  by  Paul  Gibier,  and  in  the  con- 
tents of  the  bullie,  in  the  urine,  and  in  the  blood  by 
Spillmann.  Demme  found  _it  in  the  bullas  and  in  the 
blood  diplococci,  of  which  he  succeeded  in  making 
pure  cultures.  Similar  organisms  have,  as  already 
said,  been  found  by  Bulloch.  Crocker  found  a  few 
micrococci  in  recent  bulhe,  and  under  cultivation  in 
peptonised  gelatine  minute  bacilli  developed.  Alm- 
qiiist*  f»und  a  coccus  slightly  resembling  staphylo- 
coccus in  the  bullm  in  six  cases  of  pemphigus  neona- 
torum. Inoculation  always  produced  typical  pem- 
phigus bullffi  after  a  short  period  of  incubation.  It 
is  obvious,  however,  that,  in  view  of  the  numerous 
micro-organisms  of  the  most  diverse  kinds  which  are 
found  on  the  epidermis  under  normal  conditions,  all 
observations  on  the  bacteriology  of  skin  lesions  must 
be  received  with  greater  caution  than  those  relating 
to  any  other  part  of  the  body.     The  urine  of  patients 

,•  Arc/i.f.  I'lTm.  «.  .syph.,  No,  2,  1P92. 


I 


152  SEUROTW  Al-'FEGTWSS  OF  THE  SKIS.  [caAf.  IS. 

suffering  from  pemphigus  shows  a  diminution  in  the 
normal  amount  of  urea.  Among  the  complications 
of  peinpliiguH  iire  Bright'a  iliHease,  pneumonia,  tuber- 
culosis, and  ulceration  oi  the  intestinal  follicles. 

The  diagnosis  of  pemphigus  vulg'aFis  seldom 

presents  much  difflculty.  The  preaence  of  the  charac- 
teristic buite  and  oi  scabs  and  pigmented  spots  re- 
presenting bulhe  of  eadier  formation,  and  the  absence 
of  pustules,  erythematous  patches,  and  other  lesions, 
taken  together  with  the  history  of  successive  crops 
of  exactly  similar  eruptions,  are  points  which  wUl  in 
most  cases  suffice  to  identify  the  disease.  Pemphigus 
may  sometimes  be  confounded  with  bullous  forma  of 
urticaria  and  erythema.  In  both  theae  conditions, 
however,  there  are  other  lesions  besides  the  bull»; 
moreover,  except  in  pempliigus,  the  bulla  is  mors 
adventitious  than  a  primary  lesion — implanted  on  a 
wheal  (as  in  urticaria),  or  on  a  raised  red  plateau  in 
a  setting  of  vesicles  (as  in  erythema  multiforme),  not 
rising  out  of  healthy  skin^  which  is  the  pathognomic 
feature  of  pemphigus.  From  dermatitis  herpeti- 
formis, agaiu,  pemphigus  is  distinguished  by  the  uni- 
formity of  the  lesion.  Pemphi^s  foliacms  may  be 
mistaken  for  eczema  rubrum  and  pityriasis  rubra, 
and  the  diagnosis  can  sometimes  be  made  only  by 
taking  into  account  the  history  of  the  case  and  hy 
carefidly  watctiing  its  course.  Thus  in  eczema  the 
scales  are  not  so  large  as  in  pemphigus  foliaceus,  noz 
is  the  disease  often  universal.  In  pityriasis  rubza 
there  are  no  bullie,  and  the  surface  is  dry.  Moreover, 
the  scales  are  smaller  and  thinner  than  in  pemphigus 
lohaceua.  In  all  forms  of  pemphigus,  and  especi^y 
in  pemphigus  vegetans,  one  of  the  first  tilings  to  be 
done  is  to  exclude  syphilis.  Neumann  gives  the 
following  three  points  of  distinction :— (1)  In  pem- 
phJgUH  veget«ins  the  excrescences  are  always  sui- 
tonnded  by  a  zone  of  bullte,  while  condylomata  have 


"" 


IX.]  PEMPHIGUS  1  DIAONOSIS,  PROGNOSIS.  153 

an  infiltrated  border,  (3)  In  pemphigus  vegetans 
the  surface  is  excoriated  and  warty  ;  in  condylomata 
it  is  even  and  amooth,  (3)  The  sequence  of  events 
and  concomitant  circumstances  in  the  two  cases,  con- 
dylomata being  almost  invariably  the  consequence 
of  ao  acute  process,  and  being  accompanied  and  fol- 
lowed by  other  signs  of  ayphilia  ;  moreover,  if  left  to 
themselves  they  finally  tend  to  involution.  In  pem- 
phigus foliaceus,  on  the  other  liand,  the  lesions  con- 
tinue to  multiply,  and  the  disease  goes  steadily  from 

In  pemphigus  vulgaris  the  prog'nosis  is,  as  a  rule, 
favourable  as  to  life,  though  recurrence  is  only  too 
likely,  and  it  is  impossible  to  say  how  often  this  may 
take  place.  In  acute  cases  there  is  nearly  always 
a  greater  or  lesser  amount  of  danger,  especially  in 
young  children  or  old  people.  The  longer  the  disease 
lasts  the  less  hopeful  is  the  prospect.  One  element 
of  danger  in  very  chronic  cases  is  that  the  process 
may  pass  into  pemphigus  foliaceus,  which  is  always 
fatal,  though  life  may  be  dragged  on  for  years.  As 
to  pemphigus  vegetans,  Neumann  says  that  ia  no 
disease  is  the  prognosis  so  gloomy  ;  "  A  small  excori- 
ation in  the  axilla,  one  or  two  bulliie  on  the  mucous 
membrane  of  the  lips  are  often  sufficient  grounds 
for  prognosticating  death,  irrevocably  inpending,  in 
a  few  months."  *  Crocker,  however,  thinks  that 
early  treatment  before  the  skin  Is  much  involved 
offers  some  chance  of  recovery. 

In  the  treatment  of  pemphigus  the  chief  reliance 
must  be  placed  on  the  internal  administration  of 
nerve  tonics.  The  sheet  anchor  is  arsenic,  which  is 
more  of  a  specific  in  this  than  In  any  other  skin 
affection.  It  must  not,  however,  be  looked  on  as  an 
lolutely  un&iiling  remedy.    It  should  be  given  in 


I 


154  NEUROTIC  AFFBCTIOfS  OF  THE  SKIN,  [cbai 

tte  form  of  Fowler's  sokition,  begiimmg  with  a  dose 
of  three  drops,  graduaUy  increased  to  five,  seven, 
eight,  aitd  even  ten,  three  limes  a  day.  When  arsenic 
fails,  famine  is  often  beneficial ;  in  other  casee 
opium  is  the  moat  efficient  internal  remedy.  Phos- 
phorus, icMhyal,  and  beUadontia  are  all  occaaionally 
nseful.  The  Ioca,l  lesions  must  be  treated  on  general 
principles,  the  itching  being  relieved  by  one  or  other 
of  the  methods  already  described.  If  the  bullte  are 
very  large  and  tense  they  may  be  pricked  with  a 
sterilised  needle,  and  afterwards  dressed  with  horade 
add  ointment  or  carron  oil;  if  the  skin  around  them 
be  much  inflamed,  cooling  ointments  will  give  relieL 
In  pemphigus  foliaceus  continuous  emollient  alkaline 
or  sulphurated  potassium  baths  ease  pain,  and  often 
prevent  exhaustion  by  enabling  the  patient  to  sleep. 
Kaposi  kept  a  patient  under  this  treatment  with 
great  benefit  for  more  than  four  years,  during  which 
— without  counting  shorter  periods — he  spent  eight 
months  day  and  night  in  the  bath.  Fever  and  other 
constitutional  disturbances  accompanying  the  skin 
affection  must  be  treated  on  general  principles.  A 
leading  indication  in  all  forms  of  pemphigus,  espe- 
cially in  pemphigus  foliaceus,  is  to  support  the 
atrength  by  suitable  food. 

Herpes  may  be  taken  as  the  tj-pe  of  a  skin 
lesion  of  nervous  origin,  inasmuch  as  its  connection 
with  certain  abnormal  conditions  of  the  nerves  supply- 
ing the  aSected  area  can  be  clearly  established.  The 
term  "  herpes,"  in  strictness,  denotes  merely  a  par- 
ticular lesion  which  may  be  an  incidental  pheno- 
menon in  a  variety  of  diseases,  or  may  itself  be  ths ' 
expression  of  a  definit'e  morbid  state,  or,  as  some 
(Erb,  Laudouzy,  Brocq,  Wasiliewski)  believe,  the 
exanthem  of  a  specific  fever. 

The  lesion  itself  is  a  cluster  of  transparent  veeiolee 
varying  in  sine  from  ft  pin's  head  to   a  pea,  and  in 


^K^.m] 


number  from  two  or  three  to  twenty  or  more,  seated 
on  an  erythematous  patch,  and  surrounded  by 
a  narrow  red  zone.  The  eruption  is  almost  always 
preceded  by  a  feeling  of  heat  and  tension,  sometimes 
itching,  in  the  part  about  to  be  attacked.  The  life- 
hiatory  of  the  individual  lesion  comprises  four 
stages  :  (1)  a  slightly  red  spot  appears  on  the  skin  ; 
(2)  soon  serous  effusion  takes  plai;e  under  the  epi- 
dermis, and  vesicles  are  formed ;  (3)  the  vesicles 
become  opaque^ — occasionally  purulent— shrivel  up, 
and  form  yellowish -brown  crusts,  which,  (4)  after 
some  days,  become  detached,  usually  leaving  no  scar, 
but  a  brownish  stain  which  slowly  fades  and  dis- 
appears. These  four  phases  in  the  evolution  of  the 
lesion  are  named  by  Brocq  congestive,  ve^icatmg, 
desiccating,  and  macular.  The  whole  process  occu- 
pies from  a  week  to  a  fortnight.  On  mucous  mem- 
branes the  lesion  runs  a  somewhat  different  course. 
Owing  to  the  macerating  action  of  the  secretions 
the  vesicle  is  quickly  reduced  to  a  whitish  pulp,  which, 
when  the  eruption  is  extensive,  gives  the  parts  the 
appearance  of  being  covered  with  false  membrane. 
When  the  sodden  epithelium  becomes  detached, 
roundish  excoriations  ate  seen  underneath.  Theae 
may  be  scattered  irregularly  about,  or,  intersecting 
each  other,  may  form  largish  ulcers  with  wavy  borders 
Healing,   as  a  rule,  takes  place  without  scarring. 

Two  distinct  types  of  herpes  may  be  recognised  : 
First,  one  which  I  propose  to  call  irritoHve  or  symp- 
tontalK  herpes ;  and  secondly,  a  definite  morbid 
process,  of  which  a  herpetic  eruption  following  certain 
definite  lines  of  distribution  is  the  expression — herpes 
zoater,  or  zona. 

Irritative  herpes  chiefly  affects  the  lace  and 
the  genitft]  organs — hence  the  herpes  facialis,  or 
tabialis,  and  progentlalis  (or,  as  I  prefer,  with  Besnier, 
to  call  it,  genitalis)  of  authors,     The  process  in  both 


F 


136  SEC  ROT  tc  AFFECTIONS  OF  TBE  SKtS.  [otap. 

these  aituadoQiS  U  esseatiaJly  the  same ;    the  only 
diRerence  between  them  is  that  the  legions,  anii  also 
to  some  estent  the  symptoms,  are  modified  l>y  the 
anatomical  relations  and  the  huictions  of  the  p&rt«J 
affected.     In  the  ia<e  the  eruption  most  frequent^ T 
rome»  out  on  the  lip,  especially  the  lower,  and  about  ^ 
the  mouth  ;  but  any  part  of  the  face  below  the  foie~ 
head   may   be  invaded.     Nor  are  the   ronjnncttvn 
and  the  mucous  membrane  of  the  mouth  and  throat 
exempt  from  attack.     The  lesions  pa.'is  through  the 
four  stages  ol  evolution  which  have  already  been 
described.     The  attack  nxually  occnrs  in 
of  some  febrile  disorder — catarrh  of  the  reapii&toi^ 
passages,  pneumonia,  tvphoid  fever,  cerebro-siHiiAl 
meitingitis,    malaria — and    is    generally  ushered  io 
by  a  sensation  of  chill,  oi  even  actual  shiveriw. 
Herpes  facialis  used  to  be  coosidrred  a  sign  of  "  eiisi^ 
in  acute  febrile  diseases,  and  in  the  case  of  pneumonitt 
in  particular  it  was  looked  upon  as  of  good  augniy 
for  the  favourable  issue  of  the  illness.     It  b  now, 
however,  regarded  &s  a  simple  incident  in  the  gnuenl 
murbid  process  without  any  special  signilicance.     It  I 
ia,  in  short,  merely  fympttmaiic  of  feverisbnesa  witfc  * 
afaiverini;.     In  some  persons  herpes  is  produced  by  ' 
local  irritation  ;   hence  the  frequency  with  whicb  tT 
upper  lip  is  the  seat  of  an  eruptjoa  after  an  attack  of 
nasal  catarrh.     In  many  persons  herpes  of  the  tip 
shows  a  marked  tendency  to  recurrence. 

Uerpea  affects  the  genitals  in  both  aexes,  tfaa 
fsTourite  points  of  attack  in  men  being  th«  pn<  J 
puce,  espwiallr  its  internal  surface,  the  sukuB,  ibt' 
gUns,  and  the  meatus ;  and  in  women  the  labia  WtA 
tie  cervix  uteri.  The  symptoms  are  in  propoctioii 
to  the  severit>'  of  the  lesions.  In  men  tii«  empliaa 
is  usually  discrete,  and,  with  the  exception  of  tltft 
burning  and  itching  whkh  it  causes,  but  little  inoaa- 
venience  is  felt  by  the  patient.     If  neglected,  bow- 


1 

I 

4 
I 


I  ever. 


:.]  GENITAL  HERPES. 


ever,  and  especially  if  irritated,  as  by  frequent  coitus 
01  the  application  oi  caustics,  the  ulceration  may 
spread,  and  the  glands  in  the  groin  may  become 
enlarged  and  painful.  In  women  the  eruption  ia  apt 
to  become  confluent,  and  in  some  cases  not  only  the 
vulva,  but  the  perineum,  the  inside  of  the  thighs,  and 
the  mons  veneris,  may  be  invaded.  The  labia  raajoia 
and  minora  and  the  mucous  lining  of  the  vagina 
become  immensely  swollen,  and  covered  with  mace- 
rated epithelium,  which,  as  it  separates,  leaves  exten- 
sive excoriationvs.  There  ia  an  ofiensive  muco- 
purulent discharge,  and  the  pain  on  movement  ia  so 
great  that  the  patient  can  hardly  walk.  The  itching 
and  burning  are  almost  unbearable.  Enlargement 
of  the  inguinal  glands  is  a  frequent  complication. 

Genital  herpes  is  more  common  in  men  than  in 
women.  It  is  sometimes  symptomatic,  occurring  in 
the  course  of  some  febrile  disorder,  such  as  pneu- 
monia ;  but  most  commonly  it  appears  to  be  the 
result  of  local  irritation.  In  men  the  eruption  is 
sometimes  preceded  by  a  gonorrhcea  or  a  venereal 
sore,  and  it  is  apt  to  recur  at  frequent  intervals  after 
Hexual  intercourse  (especially,  according  to  Brocq, 
with  different  women),  the  passage  of  an  instrument 
into  the  urethra,  or  other  local  irritation,  or  after  any 
unusual  fatigue,  or  even  over-eating.  The  tendency 
to  recurrence  may  last  for  years,  but  sometimes,  as 
pointed  out  by  Berkeley  Hill,  ceases  under  the  altera- 
tive influence  of  a  severe  intercurrent  illneas.  In 
women  genital  herpes  is  often  brought  on  by  the  first 
attempts  at  sexual  iutercourse  after  marriage.  It 
may  also  be  the  result  of  irritating  discharges  (leu- 
corrhtca,  gonorrhtea),  or  it  may  be  related  to  the 
menstrual  function. 

On  the  face  the  affection  may  sometimes  be 
mistaken  for  impetigo,  but  the  acuteness  of  its 
course,  it«  limited  distribution,  and  the  fact  that 


188  SEOROTIC  AFFECTIONS  OF  THE  SKIN.  [chap.  a.  1 

it  ia  not  BUto-inoculable,  will  serve  to  distingiuBli 
it.  In  genital  herpes  the  diagnosis  presents  no 
difficulty  if  the  case  is  seen  before  the  charaotBriatic  , 
vesicular  eruption  has  become  obscured  by  th«J 
violence  of  the  inflammatorj'  process.  It  ulcei^  1 
ation  is  extensive,  and  especially  if  there  be  mtielt'^ 
suppuration,  it  may  be  impossible  at  first  to  distin- 
guish genital  herpes  from  soft  sores.  The  latter, 
however,  have  a  fouler  base  and  excavate  more  deeply. 
Time  will  also  help  to  clear  up  the  question,  the 
lesions  of  herpes  disappearing,  as  a  rule,  in  a  fevj 
days,  while  soft  sores  are  much  slower  in  healinfe 
If  positive  proof  is  required,  the  test  of  auto-inoculaiB 
tion  may  be  applied.  From  true  chancre  genital 
herpes  can  usiiatly  be  distinguished  without  difficulty 
by  the  absence  of  induration,  the  multiplicity,  u- 
regular  form,  and  small  size  of  the  ulcers,  and  the 
intense  burning  and  itching  which  they  cause.  It 
is  not  uncommon,  however,  according  to  Fonmier, 
for  a  chancre  to  develop  ia  the  midst  of  a  premonitory 
eruption  of  herpes. 

Herpes  zoster.— Herpes  zoster,  zona,  orshinglea 
is  an  affection  characterised  by  the  eruption  of  oloB^I 
tera   of   vesicles   seated    on   an   erythematous   basoj 
not  along  the  course  of  one  or  more  peripheral  nervesi'] 
as  is  still  often  taught,  but  in  the  region  of  distribiD 
tiou  o(  one  or  more  of  the  posterior  spinal  roots  q 
the  skin.*     The  intercostal  variety  of  herpes  s 
being  by  far  the  most  common,  may  conveniently  ■! 
be  taken  as  a  type  in  describing  the  disease.     TiMl 
appearance  of  the  eruption  is  usually  preceded  l^J 
pain  of  neuralgic  character  and  tendej-neas  over  t" 

*  Hcud,  s«  Uie  n^ult  of  careful  ioveHtiftutiuu  ( "  ')u  DiBturbuQM 
of  Seneatiou,   with  Mpooinl   Reference  to  the  Pain  of  Tisei 
Diseuae;"    JlrBin.   Partn  1    anil  2,  BD3),    foui>d  that  the  U 
occupied  bj  the  eniptioii  of  herpes  zcMur  aoiTesponilcd  with  Ul 


.]  HERPES  ZOSTER.  159 

a  of  distribution  ol  the  nerve  or  nerves  correspond- 
ing  to  the  part  of  the  surface  about  to  be  attacked. 
Sometimes  there  is  also  slight  conBtitutionai  disturb- 
ance. The  eruption  always  first  appears  at  certain 
points  from  which,  in  most  cases,  it  spreads.  How- 
ever extensive  the  area  involved  may  he,  these 
points  are  always  those  where  the  affection  is  at  its 
masimum  inteiiaity  (Head).  As  a  rule,  though  by  no 
means  invariably,  the  neuralgic  paiu  ceases  on  the 
appearance  of  the  eruption,  but  the  lesions  cause  a 
good  deal  of  smarting  and  tension,  and  there  may  be 
severe  pain  owing  to  neuritis  of  the  implicated  nerve. 
Children  seldom  suffer  much  pain  ;  as  a  rule  they 
complain  more  of  itching.  In  old  people,  however, 
pain  is  often  most  persistent  and  severe.  The  erup- 
tion shows  itself  in  the  form  of  erythematous  patches, 
whicfi  can  be  made  to  disappear  on  pressure.  They 
are  more  or  less  oval  in  outline,  with  their  long  axis 
parallel  to  the  underlying  nerve.  They  come  out  in 
crops,  beginning,  as  a  rule,  nearest  the  corresponding 
nerve  centre,  and  are  scattered  at  irregular  intervals 
along  the  track  of  the  nerve  with  which  they  are  in 
relation,  eBpecially  at  the  points  where  its  twigs  pierce 
the  fascia,  or  are  distributed  in  the  skin.  The  number 
of  lesions  varies  from  two  or  three  to  twenty  or  thirty. 
The  full  development  of  the  eruption  generally  occu- 
pies about  a  week.  In  a  short  time  the  surface  of 
the  red  pat^chee  becomes  studded  with  papules,  which 
are  quickly  transformed  into  vesicles.  These  are 
grouped  in  clusters  to  the  amount  of  about  ten,  or 
even  twenty,  on  each  patch.  The  vesicles  are  some- 
times discrete,  sometimes  confluent,  forming  irregular 
bullie ;  but  the  edge  of  the  erythematous  patch  on 
which  they  rest  is  always  visible  as  a  red  zone  around 
the  base  of  each  cluster.  Most  of  the  lesions  go 
tiirough  the  regular  phasea  of  evolution  already 
described ;  but  some  of  them  may  abort,  while  others, 


160  NEUROTIC  AFFECnOSS  nr  THE  SKIN,  [ohap, 

instead  of  dTying  up  in  the  oidinaiy  way,  may  buret 
and  give  issue  to  a  fluid  which  by-and-by  foinw 
yellowish  or  brownish  crusts.  OcoaHionally  hamor-, 
rhage  takes  place  into  the  vesicles,  and  in  such 
little  ulcers  are  apt  to  form  under  tliem.  These  may 
give  rise  to  permanent  scars,  which  are  sometimes 
whiter  than  the  surrounding  slfin,  sometim.eB  pig- 
mented, or  they  may  be  white  in  the  centre  and 
pigmented  at  the  circumference  (Brocq).  It  is  well 
to  make  a  point  of  warning  patients  as  to  tbe  pos- 
sibility of  such  marks  being  left.  In  elderly  or  weakly 
subjects  the  lesions  of  herpes  zoster  sometimes  sa»j 
Bume  a  gangrenous  character.  Enlargement  of 
glands  in  the  neighbourhood  of  the  lesions  is 


1 


The  eruption  ia,  in  the  great  majority  of  caeeg 
unilateral,  the  right  side  being  far  more  often  affecte 
than  the  left.    Sometimes  it  comes  out  on  both  sides 
though  at  different  levels.     In  certain  rare    cases 
however,  the  lesions  form  a  complete  girdle  roua 
the  body.     Occasionally,  whiie  remaining  unilateriJ^  I 
the  lesions  may  overstep  the  middle  line  in  front 
for  one  or  two  inches.     James  Mackenzie  *  has  shown 
that  the  terminal  branches  from  neighbouring  inter- 
costal nerves  frequently  cross  each  other. 

All  the  different  phases  of  herpes  zoster  may  I 
seen  in  the  same  patient  at  one  time.  The  total'] 
duration  of  the  disease  till  the  separation  ol  tliiB| 
scabs  ia  from  a  fortnight  to  three  weeks, 
attack  appears  to  confer  immunity  ;  but  this  rule  VA 
not  absolute,  Kaposi  having  seen  no  fewer  than  elevoft  ■ 
recurrences  in  a  patient  under  Jiis  care.^f" 

Herpes    zoster,    though    most    frequent    on    tbflt  \ 

•  "  Herpes  Zoeter  anil  the  Limb  PleiuatB  of  Nen™ 
of  ralMw/ii  uud  llaHmohsv,  Febninry.  1893,  p.  332  *( 

+  "  MuTadi™  de  In  Pi-nii  " ;  Frrncli  iranslnti™  by  B. 
Doyon,  tome  f , ,  p.  44;<. 


PftAP.  ii;.]  HERPES   ZOSTE/i.  191 

trunk,  does  not  spare  any  part  of  the  body,  though  it 
is  extremely  rare  below  the  knee.  A  case  in  which 
herpes  zoster  linaited  to  the  foot  followed  a  twist  of 
the  ankle  has  been  recorded  by  Esley  and  Wardrop 
Griffith.*  The  process  is  everywhere  the  aame,  but 
on  the  head  and  limbs  the  lesions  are  distributed  in 
more  or  leas  irregnlar  lines,  and  have  not  the  girdle 
character  which  is  seen  on  the  trunk.  On  the  face 
the  eruption  follows  the  ramificationa  of  the  fifth 
nerve,  especially  the  supra-orbital  branch  and  the 
ophthalmic  division.  In  the  former  the  inner  third 
of  the  frontal  region  la  the  favourite  seat  of  the  disease. 
The  lesions  extend  upwards  in  vertical  lines,  or  spread 
out  tanwise  from  the  supra-orbital  foramen  and  ex- 
tend on  to  the  scalp.  In  ophthalmic  zoster,  especi- 
ally when  the  nasal  branch  is  implicated,  pain  around 
the  orbit  and  photophobia  are  prominent  symptoms, 
and  eye  leaiona  (conjunctivitis,  keratitis,  iritia)  are 
usually  caused,  which  in  rare  cases  lead  to  permanent 
mischief  (posterior  synechise,  deformity  of  the  pupil, 
and  even  amblyopia  and  atrophy  of  the  papilla). 
This  variety  of  herpes  zoster  is  also  frequently  fol- 
lowed by  indelible  scars.  Among  other  parts  liable 
to  be  the  seat  of  herpes  zoster  may  be  mentioned  the 
nape  of  the  neck  and  the  occiput,  and  the  skin  supplied 
by  the  various  branches  of  the  superior  cervical 
plexus.  The  eruption  in  this  case  spreads  over  the 
scalp  along  the  branches  of  the  occipital  nerve.  The 
arm,  the  thigh,  the  buttock,  and  the  genitals  are  also 
liable  to  be  attacked ;  in  fact,  it  may  be  said  that 
wherever  there  are  cutaneous  nerves,  there  herpes 
zoster  may  break  out.  The  musculo -spiral  and  sciatic 
nerves  are  especially  prone  to  be  affected.  Zostor  is; 
however,  rare  on  the  forearms  and  legs,  and  all  but 
onknown  on  the  hands  and  feet. 

•  Jfcrf,  CAroi,U-/t,  Match,  !8!)3,  p,  360. 


w 


N 


162  NEUROTIC  AFFECVIO.VS  OF  THB  SKIN.  [chap. 

The  affection  is  common  at  all  ages,  and  there  does 
not  aeem  to  be  any  macked  difierence  in  tlie  relative 
prochvity  of  the  two  sexes.  Nearly  all  authorities 
are  agreed  that  chill  may  be  an  exciting  cause 
zoster,  and  the  epidemics  of  the  disease  that  have 
been  reported  are  probably  to  be  explained  by  the 
influence  of  the  weather.  The  cold  probably  cai 
neuritis,  which  in  turn  gives  rise  to  zoster.  Arsenic, 
which,  according  to  Hutchinson,  sometimes  causea 
herpes  zoster,  no  doubt  acts  in  the  same  way.  The 
SiBsociation  of  the  disease  with  pleurisy,  tuberculosis, 
cancerous  and  other  tumours,  syphilis,  and  various 
inflammatory  lesions,  may  also  be  explained  by 
the  irritation  to  which  the  peripheral  nerves,  or  their 
spinal  roots  or  ganglia,  are  subjected  when  involved 
in  such  processes.  In  short,  whatever  causes  neuritis 
— cold,  injury,  poison,  or  long- continued  irritation- 
may  also  induce  herpes  zoster. 

The  lesion  of  the  nerve  may  be  in  any  part  of  its 
continuity,  from  i\&  origin  in  the  spinal  cord  to 
peripheral  end.  Barenaprung  •  first  demonstrated 
that  in  most  cases  of  herpes  zoster  there  is  interstitial 
neuritis  of  the  posterior  ganglion  and  of  the  trunk  of 
the  nerve  issuing  thereform,  which  is  distributed  to 
the  aSected  area  of  the  skin.  In  some  cases  the 
lesion  is  in  the  posterior  spinal  root  between  the  cord 
and  the  ganglion,  or  in  the  posterior  columns  of  the 
cord.  Dubler  f  found  zoster  associated  with  peri- 
pheral neuritis  without  any  trace  of  central  disease ; 
and  cases  have  been  reported  (Curschmann,  Eieen- 
lohr)  in  which  the  disease  was  apparently  caused  by 
multiple  neuromata  in  the  course  of  the  affected 
nerves  without  any  central  change.     Tlie  lesion  may 

*  ChariU  Annaltii.  Bd.  U.  2 ;  Bd.  i.  I  :  Bd,  xi.  2.  DuiielMen 
•eeniR  to  havu  beau  tlic  lint  to  ubsei've  [iu  IS<)7)  tliikt  iu  «■  eaaa  of 
fnlDroovtAl  zoster  the  corrHsponding  uerve  vcn'  greatly  congested, 

t  Virehow'B  J.rAiF,  May,  1984, 


w 


|dhap.  IX.]  HERPES    ZOSTER.  16a 

due  to  htemorrhage  as  well  as  to  inflammation, 
.erpes  zoster  sometbncB  occurs  in  association  with, 
locomotor  ataxy.  Willmott  Evans  *  holds  that  in  no 
I  inconsiderable  number  of  cases  a  meningitLB  is  the 
starting  point  of  the  herpetic  eruption.  In  his  ex- 
perienee  it  is  rare  in  connection  with  tuberculous 
meningitia,  but  more  frequent  in  the  non-tubercuious 
basal  meningitis  of  children.  It  also  occurs  as  a  con- 
Bequence  of  meningitia  from  extension  of  disease  of 
the  middle  ear.  The  characteristics  of  herpes  zoat*r 
resulting  from  meningitis  are,  according  to  Wilmott 
Evans,  a  tendency  for  the  eruption  to  be  bilateral  and 
to  be  more  persistent  than  usual.  The  fact  that 
meningitic  herpes  is  so  often  bilateral  may,  he  thinks, 
'account  for  the  belief,  so  widespread  among  the 
'lublic,  that  when  the  disease  encircles  the  body  it  is 
fatal.  He  points  out  that  the  herpes  arising  from 
meuingitl')  always  corresponds  to  tlie  distribution  of 
a  nerve  root  and  not  to  the  distribution  of  a  nerve, 
except  when  they  are  practically  identical,  as  in  the 
dorsal  region  of  the  cord. 

Wasiiiewski  +  rejects  the  theory  of  the  nervous 
origin  of  herpes  zoster,  on  the  ground  that  the  clinical 
phenomena  correspond  closely  with  those  of  infec- 
tious fevers.  His  view  is  based  on  274  cases  gathered 
by  collective  investigation  by  the  Medical  Society 
of  Thuringen.  Wasiiiewski  thinks  the  distribution 
of  the  eruption  is  better  explained  by  the  blood 
stream  than  by  nerve  ramification.  He  points  out 
that  in  some  cases  no  nerve  lesions  can  be  found. 
Pfeifler  J  has  attempted  to  prove  that  the  distribu- 
tion of  the  lesioEH  In  herpes  zoster  is  determined  by 

*  £rit.  Jotim.  Dn-Hi.,  liHIO,  p.  83. 

t  "  Herpes  Zoster  nnd  lieaaBQ  Einteilmng  miter  die  Infections- 
I  kiaukheiten  "  Jena,  189'i. 

J  "Die  VerbteitungdEB  Herpes  Zuatsr  langH  dtr  Hautgebiato 
It  Arterien,"  Jeua,  1H89. 


I 


w 


IM  XBL'ROriC  AFFECTIONS  OF  THE  SKIN.  [chap,  vc 

the  ftrterial  supply  ;  but,  as  pointed  out  by  J.  Mac- 
kenzie,* all  the  cases  he  gives  show  clearly  the  dis- 
tribution o(  the  eruption  in  region§  supplied  by 
definite  spinal  nerves. 

The  lesions  of  herpes  zoster  are  produced  by  a 
peculiar  process  of  epttheliBi  defieneration,  which  is 
also  seen  in  the  epithelium  of  the  rcte  In  such  diaeai>e« 
AS  variola,  varicella,  etc.  Tlie  cells  become  rounded, 
lose  their  prickles,  a  vacuole  appears  in  its  centre, 
gradually  becoming  larger,  swelling  the  cell  and 
causing  both  protoplasm  and  nucleus  to  lose  their 
distinctive  staining  reactions  and  to  degenerate.  At 
the  wime  time  considerable  leucocytic  exudation  takes 
place  into  the  papillie,  and  the  leucocytes  ultimately 
escape  into  the  epithelium  between  its  degenerated 
cells.  According  to  Haight,  of  New  York,  the  nervous 
filaments  going  to  the  affected  parts  are  profoundly 
altered.  They  are  swollen,  and  their  neurilemma 
is  full  of  small  nucleated  ceils.  The  connective  tissue 
around  the  nerves  is  infiltrated  with  leucocytes,  and 
the  nerve  tubes  themselves  are  abnormal  in  appear- 
ance. 

Diagnosis.  ^Herpes    zoster  has    to   be   distin- 
guished from  eczema,  erythema  multiforme  and  der- 
matitis  herpetifonois.  and  irritative  herpes  (herpes 
facialis  and  genitalis).     From  eczema  it  can,  as  a 
rule,  easily  be  distinguialied  by  the  fact  that  the 
vesicles  dr>'  up  and  do  not  keep  up  a  cjantinuous 
"  weeping,"   and,  moreover,  are  distributed  in  the 
area  of  a  particular  nervous  supply.     From  erythema 
multiforme,  dermatitis  herpetiformis,  and  irritative 
herpes,  soster  is  clearly  distinguished  by  its  unilateral 
.   character  and  by  the  neuralgic  pain  which  precedes 
I  and  sometimes  accompanies  it.    The  history  is  also 
I  important  diagnostic  point,  zoster,  as  bos  been 

•  lt^.nt.,y.  33U. 


[ 


X.] 


HERPES  ZOSTER. 


(livii 


i*wd,  being  a  disease  which  attacks  a  person  only 
About  the  genitals  it  may  not  be  easy  to  dis- 
tinguish zoster  from  irritative  herpes.  The  presence 
of  pain  o!  a  neuralgic  character  ia,  however,  a  certain 
sign  that  it  ia  the  former  we  have  to  deal  with. 

Both  in  irritative  herpes  and  in  zoster  the  progf- 
HOSis  ia  favourable.  The  disease  runs  a  regular 
course,  and  tends  to  spontaneous  recovery  in  from  a 
fortnight  to  a  month.  If  ulceration  has  been  seveje, 
and  especially  if  gangrene  has  occurred,  the  lesion 
will  take  a  considerable  time  to  heal.  Weakly  people, 
particularly  if  advanced  in  years,  may  be  exhausted  by 
the  severity  of  the  process  and  the  pain  which  accom- 
panies the  eruption  and  may  persist  long  after  its 
disappearance.  In  a  case  of  Boster  of  the  ophthalmic 
division  death  has  been  known  to  occur  as  the  result 
,o!  embolism  of  the  ophthalmic  vein  (Brocq).     Im- 

Irment  of  vision  has  also  been  known  to  follow 
variety  of  aostw.  Genital  herpes  may  recur 
Jain  and  again  if  irritation  is  kept  up  ;  but  patients 
snfiering  from  zoster  may  be  comforted  with  the 
asBuiance  that  it  is  practically  certain  they  will  not 
be  troubled  by  the  disease  again. 

In  irritative  herpes  the  only  treatment  usually 
required  is  the  application  of  soothing  and  anti- 
pruritic lotions  or  ointroenta,  or  protection  of  the 
affected  surface  by  sprinkling  with  powder  {oxide  of 
zinc,  darch,  eubniirate  of  bismuth,  etc.),  or  mualin 
bage.  When  the  genitals  are  the  seat  of  the  eruption 
the  parts  must  be  kept  scrupulouxly  clean,  and  the 
surfaces  should  be  kept  apart  with  a  piece  of  lint 
in  hiiracic  ami  or  calamine  lotion.  Black 
1  particularly  useful  application  in  genital 
If   the  patient  bo   of  gouty  constitution, 

iropriale  medication  will  be  required. 

In  the  treatment  of  herpes  zoster  the  chief  in- 

rtion  ia.tlic  relief  of  pain,  which  is  frequently  acute. 


w. 


166  NEUROTIC  AFFECTIONS  OF  THE  SKIN.  [chap. 

For  this  purpose  menthol  is  often  useful,  but  9«6- 
cutaneous  injerCione  of  morphine  may  sometimes  be 
needful.  It  is  important  to  protect  the  lesions  from 
friction  and  to  keep  the  parts  warm  ;  they  should  be 
dusted  with  a  pralective  ■powder,  such  as  oxide  of 
zinc  and  bismuth,  tnth  the  addition  of  a  smaU  quan- 
tity of  morphia,  if  jiecesaary ;  they  should  then  be 
covered  with  a  thick  layer  of  cotton-wool.  Inter- 
nally, onitpyrin  in  doaes  of  ten  to  fifteen  grains  is 
useful  in  reUeving  the  neuralgic  pain,  and  tonics  such 
as  quinine,  iron,  strychnine,  arsenic,  etc.,  are  gener- 
ally beneficial.  If  the  patient  is  in  a  low  condition 
of  health,  cod-liver  oii  and  feeding  up  are  indicated. 
If  the  pain  is  very  severe,  the  application  of  the  COD- 
I  .tinuoua  current  along  the  course  of  the  nerve  is  often 
I  .tnost  useful.  Division,  stretching,  or  resection  of 
e  has  been  known  to  relieve  the  pain  in  severe 
flld-standing  cases  afiecting  the  supra-orbital  nerve. 


CHAPTER   X. 


JFECriONS  OF  THE  SKIN  DEPENDENT  ON  NERVE 
DIRORDER  (eonduded). 

^RODEItUIA  —  M0RPH<EA  —  LiCHEN  — PoROKEKA- 

T08IS — Parakeratosis  Var  I  EG  AT  A— Pityriasis 
Rubra  Pilaris— Congenital   Ichthyosiform 

ErYTHR  ODER  MIA  —  LeUCODERMIA — RaYNAUD's 

Disease — Dermatitis  Refens — Diabetic  Gan- 
grene— Hysterical  Gangrene — Glossy  Skis 
— Atrophy  of  the  Skin — Charcot's  Bed-soke 
— Trophic  Ulcers  —  Morvan'b  Disease  — 
Syringomyelia — CEdema. 

Sclerodermic  is  a  disease  characterised  by  har- 
dening of  the  akin,  either  diffuse  or  ciicumscribed. 
The  latt«r  condition  is  usually  known  as  morplicea  * 
{p.  170). 

DifEuae  aclerodermia  is  very  rare.  It  occurs  in 
two  forms — as  an  infiltration  and  as  an  atrophy  of 
the  akin.  In  either  case  the  affection  often  follows 
chiU,  and  is  sometimes  ushered  in  by  pains  in  the 
joints.  A  krge  part  or  the  whole  of  the  skin  may  be 
affected  almost  suddenly,  or  the  disease  may  spread 
eo  slowly  that  it  is  some  time  before  it  is  noticed. 
"  pme  part  of  the  upper  half  of  the  body  is,  as  a  rule, 

As  hair  Iwen  ahown  br  Colcutt  Fox,  in  ilu 
eutitled  "Note  ou  (ho  History  ot  Scloroden 
{Itrit.  Jovrn.  Dei-w.,  1892,  p.  101),  what 
lift  si^liiroilorniiB  waa  deaoribec?  lij  WitJaii  ui 
"iohthynNimjonien,"  by  Adilisoii  under  that  of  '■  true  chnloid," 
by  Wilsou  and  othars  under  thnt  of  "  morphtea, "  and  by  GibHrt 
under  that  ai  "  Ifprr  rililige."     Muob  li^ht  has  been  thrown  on 

.rtuto  and  pathnlogy  of  the  condition  by  CroekBr,  who'ic 

iption  of  it  has  --^^-  '---    '-'•— -^  >- — 


u  foliowoii  here. 


Qg  paper 
iigriind  '■ 


i 


I  NEUROTIC  AFFECTIONS  OF  THE  SKIN.  [chap.  3 

first  attacked,  and  the  limit  of  the  disease  is  often 
indicated  by  a  line  of  demarcation  invisible  to  the 
eye,  but  faintly  perceptible  to  the  touch.  The  dis- 
tribution is  always  symmetrical.  The  afiected  akin, 
becomes  rigid,  tense,  and  hard,  like  that  of  a  frosen 
corpse,  but  without  the  coldness,  its  temperature 
being  only  a  degree  or  two  below  normal  (Crocker). 
It  does  not  pit,  nor  can  it  be  pinched  up  ;  the  joints 
which  it  covers  are  immobilised,  as  if  swathed  in  a 
stifiened  bandage  ;  the  features  are  drawn,  and  the 
face  becomes  fixed  into  an  expressionless  mask  ;  the 
chest  walls  are  so  tightly  bound  that  breathing  is 
seriously  liindered.  Sometimes  the  mucous  mem- 
brajie  {mouth,  pharynx,  larynx,  vagina)  is  attacked. 
At  first  sight  the  skin  often  does  not  seem  to  be  much 
altered  in  appearance,  but  it  is  whiter  than  normal, 
and,  on  looking  closely  at  it,  the  natural  lines  are  seen 
to  be  obliterated.  Erythematous  patches,  with 
telangiectases  and  mottling  from  scattered  pigmenta- 
tion of  varying  hue,  are  often  present.  Sensation 
is  usually  unaltered.  The  skin  is  dry,  owing  to 
diminution  or  suppression  of  the  sweat  and  sebaceous 
secretion,  and  itching  is  sometimes  troublesome.  The 
general  health  is  often  not  appreciably  affected,  but 
the  patients  are  extremely  sensitive  to  cold. 

In  the  atrophic  form  the  shrinking  of  the  skin 
is  always  preceded  by  an  edematous  stage,  in  which 
pitting  is  produced  with  some  difficulty,  as  it  the 
finger  were  pressed  into  a  bladder  of  lard  (E.  Wilson). 
After  this  has  lasted  some  time,  the  skin  shrinks  and 
becomes  ivory-white  in  colour.  The  distribution  is 
symmetTical,  aa  in  the  infiltrated  form,  but,  as  a  rule, 
not  so  extensive,  only  the  face  and  upper  limbs  being 
attacked  in  many  cases.  The  skin  is  stretched 
tightly  over  the  bones,  pinching  the  features  like 
those  of  a  corpse,  shrivelling  the  limbs,  fixing  the 
joints,  and  distorting  the  hands.    The  skin  ia  eo 


1 


^^^BoBAF. : 


aCLERODJSRMIA. 


how 


tightly  drawn  over  the  Tinderlying  parts  that  ulceration 
occurs  on  shght  provocation. 

In  the  infiltrated  form  the  tendency  ia  to  gradual 
softening  of  the  skin  and  recovery,  with  occasional 
relapses  from  taking  cold  or  less  obvious  causes.  The 
atrophic  form  in  more  chronic,  the  condition  often 
persisting  for  years,  and  sometiines  ending  in  death 
irom  exhaustion  ;  the  stiffeuing  of  the  skio  may, 
however,  disappear,  but  the  ahrunken  tiaaues  never 
recover  their  normal  state,  and  some  deformity  may 
The  affection  runs  a  more  acute  course  in 
Idren  than  in  adults. 

Sclerodermia  is  not  unfrequently  associated  with 
acute  rheumatism,  and  cardiac  ieaiona  are  sometimes 
present.    Meneau  *  behevea  that  the  disease  may  he 
secondary  to  various  other  proceases — cardiac  cedema, 
varicose  thickening,  scleroses  due  to  traumatic  lesions 
ataxia,  and  elephantiasis.     Sclerodermia 
id  vitiligo  may  co-exist  in  the  same  person,  and  a 
haa  been  reported  by  Haushalter  and  Spillmann  ■(" 
'hich  may  be  a  connecting  lint  between  the  two 
The  disease  is  much  more  common  in  the 
!1emale  sex  than  in  the  male.     No  age  is  exempt.     Of 
its  causation  nothing  is  known,  but  nervous  depres- 
in  and  privation  are  believed  to  be  predisposing 
itors.     It  has  been  suggested  by  Gustav  Singer  J 
myxtedema,  Graves's  disease,  and  sclerodermia 
closely  allied  affections,  all  springing  from  the 
namely,  a  lesion  of  the  thyroid  body, 
ilargement  of  the   pituitary    has   been   found  in 
iation  with  sclerodermia.g     The  anatomical  con- 
are  due  to  obstruction  of  the  circulation — 


f  •  Jniim.  *»  if"/.  Oil.  M  S»ph.,  titMi.  isns. 

\-i  JVbnc  /mil.  *  la  SaiollrUit.  No.  a,  1S03.  Aiiatrftotoci  iu 

hi'H.  Srm.,  18UV,  p.  410. 

JBtrtin.  itiH.  fFoeluwirlir.,  March  18,  ItO.i. 
HOktoen,  Cenlrallil.  f.  ultg.  ralh.,  viu.  IT. 


170   NEUROTIC  AFFECTIONS  OF  THE  SKIN.  [chap.  x. 

arterial,  venous,  and  lymphatic — by  narrowing  of 
the  vessels  consequent  on  the  pressure  of  layers  of 
cells  which  sunound  thorn  tike  a  sheath  ;  in  some 
cases  further  narrowing  has  been  caused  by  concentric 
hypertrophy  of  the  inner  and  middle  coata  of  the 
bIs.  How  this  accumulation  of  cells  ia  caused 
ia  not  known  ;  it  does  not,  however,  appear  to  be  the 
result  of  inflammation.  The  moat  probable  cause 
aclerodermia  ia  defective  innervation,  the  source 
which  muat  be  situated  liigh  up,  not  improbably  in 
ttie  vaao-motor  centre  (Crocker). 

From  what  has  been  said  it  wUl  be  gathered  thai 
the  prognosis  is  much  more  favourable  in  the  infil- 
tiated  than  in  the  atrophic  form. 

The  indications  for  the  tpeatment  of  sclero- 
dermia  are  to  guard  the  patient  against  cold,  to 
improve  nutrition  by  cod-liver  oU,  etc.,  and  to  stimu- 
late the  circulation  in  the  affected  parts  by  massage 
and  galvaniam.  Arsenic  is  sometimes  useful.  Singer 
suggests  thyroid  feeding. 

MorphOBa  is,  anatomically  and  clinicaliy,  closely 
allied  to  the  condition  just  described.  It  occurs  in 
the  form  either  of  patches  or  of  bands,  the  former 
being  more  common  in  adults  and  the  latter  in  chil- 
dren. The  patches,  which  are  generally  level  with  the 
surrounding  skin,  though  sometimes  slightly  de- 
pressed, are  irregular  in  outline  and  white  or  creamy 
in  colour  ;  the  edges  are  streaked  with  small  dilated 
vessels,  making  a  pink  or  violet  border.  They  occur 
most  frequently  on  the  limbs,  especially  the  lower, 
on  the  trunk,  especially  on  the  breasts,  and  on  the 
face ;  they  are  not,  as  a  rule,  symmetrical,  and  in 
their  distribution  they  sometimes  follow  the  course 
of  a  nerve  distribution  in  the  sense  that  herpes  poster 
does. 

The  affected  skin  is  not  adherent  to  the  imder- 
lying  tissues  ;  on  pinching  it  up  it  feels  like  parchment 


I 


MORPH(EA. 


I tio 

K 


itiff  leather  (Crocker).     The  patehes  may  remam 

itionary  for  a  long  time,  or  thoy  may  graduaUy 
'oxteind,  small  atrophic  spots  appearing  in  their 
neighbourhood,  and  in  time  coalescing  with  them. 
The  condition  cause*  no  symptoms  except  itching 
and  suppresBioa  of  sweat  eecretion  in  the  patches. 
It  may  last  for  years,  fresh  patches  forming  while 
some  of  the  older  ones  disappear. 

Bands  usually  cause  grooving  of  the  skin,  owing 
to  their  being  adherent  to  the  underlying  structures  ; 
sometimes  they  form  ridges  on  the  surface.  They 
often  have  the  appearance  of  a  cicatrix. 

Telangiectases,  patches  of  pigmentation  and. 
atrophic  strife,  are  frequently  intermingled  with 
the  lesions  of  both  forms  of  morphoea. 

The  affection  is  more  common  id  females  than  in 
males.  It  may  occur  at  any  age  after  infancy.  The 
neurotic  temperament  and  nervous  depression  from 
any  cause  are  predisposing  factors.  The  determining 
cause  sometimes  appears  to  be  local  irritation,  as  by 
garters,  the  pressure  or  friction  of  clothing,  stays, 
blows,  et«.  The  pathology  is  essentially  the  same  as 
that  of  diffuse  sclerodermia— namely,  local  obstruc- 
tion to  the  blood  supply,  probably  dependent  on 
'  ifective  innervation.  Cases  of  a  mixed  nature  have 
leen  recorded,  a  primary  diffuse  sclerodermia  being 
illowed  by  the  development  of  typical  morphcea 
'patches. 

Morphcea  is  distinguished  from  ieucodermia  by  the 
absence  of  hardness  of  the  integument  in  the  latter. 
Morphosa,  as  a  rule,  tends  to  spontaneous  recovery, 
the  bands  being  more  persistent  than  the  patches. 
Local  treatment  generally  does  more  harm  than  good. 
Brocq,  however,  has  been  successful  with  electrolysis, 
le  improvement  of  the  general  tone  of  the  circula- 
<a  by  massage  is  likely  t-o  assist  the  curative  efforts 

nature. 


1 


172  NEUROTIC  AFFECTIONS  OF  THE  SKIN.  [chap.  x. 

Lichen- — The  term  "lichen"  ia  often  loosely 
used  to  designate  a  number  of  diseases  wliicL  liave 
nothing  in  common  but  the  fact  that  at  some  time  or 
another  the  eruption  has  been  papular  in  character. 
ThuB  lichen  simplex  and  lichen  agrius  are  reall}' 
varieties  or  phases  of  eczema.  Lichen  strophulosus 
is  a  form  of  miharia  occnrring  in  infants.  Lichen 
tropicus,  or  prickly  heat,  is  also  a  form  of  miliaria ; 
and  lichen  urticatus  has  already  been  described  aa 
a  form  of  urticaria  afFecting  childreu.  Accepting 
Hebra'a  restriction  of  "  lichen  "  to  conditions  charac- 
teriaed  by  papulea  of  typical  form,  which  persist  as 
such  throughout  their  whole  course  without  becoming 
transformed  into  vesicles  or  pustules,  I  recognise  only 
one  form  of  hchen — i.e.  lichen  ruber  planus.  The 
affection  termed  by  Kaposi  "  lichen  scrofuloaorum  " 
ia  described  among  tuberculous  diseases. 

Lichen  ruber  planus. —Lichen  planus  was 
first  described  by  Erasmus  Wilson,  and  is  still  ac- 
cepted by  Besnier  and  other  leading  dermatologists  as 
the  type  of  the  group  of  afiectioas  designated  by  the 
name  of  "  lichen."  The  condition  described  by  Hebra 
under  the  name  of  lichen  rubra  ia  identical  with 
Wilson's  lichen  planus,  as  from  personal  observation 
of  the  cases  on  which  both  these  distinguished  men 
based  their  descriptions  1  am  able  to  testity.  I  there- 
fore call  the  disease  lichen  ruber  planus.  Kaposi 
describes  two  forma  of  lichen  ruber,  namely,  lichen 
ruber  planus  and  lichen  ruber  acuminatus.  In  my 
Opinion,  however,  these  names  represent  two  distinct 
diseases,  the  latter  being  the  same  as  Bcvergie's 
disease  (pity rioaia  rubra  [jilaria),  under  which  lieading 
it  is  described  («ee  p.  1M4). 

The  view  that  lichen  rubra  acuminatus  and 
pityriasis  rubra  pilaris  are  identical  receives  strong 
confirmation  from  the  similarity  of  the  procesa 
in    the   two    conditions,    as    shown    bv    the    histo- 


KvMap.  s.]  LICHEN  RUBER  PLANUS.  173 

logical     researches     of     Lukasiewicz  *     and      Max 
Joseph,  t 

Lichen  ruber  planus  is  characterised  by  an  eruption 
of  small,  irregidariy  shaped  papules,  flat  on  the  top 
and  sometimes  lunbilicated.  {Fig.  8.)  The  papules 
are  of  a  violet  or  lilac  tint,  and  they  have  a  little  scale 
in  the  centre  which  at  first  sight,  especially  if  looked 
at  sideways,  makes  them  look  as  if  they  were  vesicat- 
ing. At  first  the  papules  are  irregularly  scattered 
about,  but  they  soon  group  themselves  in  hnes  or 
curves,  the  favourite  situations  being  the  palms  and 
BoleB,  the  flexor  surface  of  the  wrists,  the  popliteal 
apace,  and  the  limbs.  They  do  not,  however,  spare 
the  tnmk  of  the  body,  and  they  are  seen  on  the  mucous 
membrane  of  the  lips  and  tongue.  In  the  palms  of 
the  hands  the  papuies  feel  like  small  corns.  On  the 
trunk  they  genexally  lie  very  close  together,  like  the 
pieces  of  a  mosaic  ;  the  older  papules  in  the  middle 
become  flattened  and  of  a  aepia  colour,  whilst  a  new 
crop  springs  up  around  them,  producing  something 
of  the  effect  of  a  dark  stone  set  in  pearls  (Kaposi). 
f)ccasionalIy  the  lesions  of  lichen  planus  follow 
tlie  distribution  of  a  nerve,  and  appear  in  long 
streaks  (Fig.  9).  Galloway  J  has  reported  a  case 
in  which  tte  eruption  corresponded  to  the  dis- 
tribution of  the  small  sciatic  nerve,  and  Stephen 
Mackenzie  has  observed  it  around  the  body  like 
Koster.  In  course  of  time  large  areas  of  skin  may  be 
invaded,  and  the  integument  then  has  a  uniform  dark 
red  colour  ;  it  is  distinctly  thickened,  and  feels  rough 
to  the  touch.  At  this  stage  the  disease  has  more  or 
less  the  appearance  of  psoriasis,  but  without  the 
general  scaliness  characteristic  of  that  affection.  In 
the  adult  there  are  never  any  veaicle-s  or  pustules 

'  ArchiV.f.  JJaiH.  ii.  Si/p/t,,  Bii.    ixxiv.,  1S%,  p.  163  «(  sjj. 

*  Hid.,  Bd.  raviii,  January,  1897, 

t  Srit.  /oKJti.  Derm.,  tqI.  Viii.,  Nov.,  ISSfi,  p.  136, 


174  NEUROTIC  AFFECTIONS  OF  THE  SKIN.  [oh*p.  X. 

mingled  with  the  papules.  In  children  vesicleB  are 
Bometimea  seen.  On  the  mucous  membmne  of  tha 
cheeks,  tongue,  palate,  and  iipa  the  eruption  shows 


I 


■Liaenr  LiultaD  ruber  ptiuiiu. 


1  itseli  in  the  {orm  of  Chineee- white  patches.  It  has 
tiie  appeaianoe  of  a  streak  of  milk  on  the  mucous 
membrane,   and  it  is  often  confounded   with   the 


caiP.  X.]-  LICHEN   HVBER   PLANUS.  175 

muGouB  patches  of  syphilis.  The  disease  is  essen- 
tially chronic  in  its  course.  The  papules  disappear 
after  a  few  weeks,  leav^ing  in  their  place  stains  vary- 
ing in  hue  from  hght  brown  to  black.  Later,  these 
stains  lose  their  pigmentation  and  become  white  and 
atrophic,  hke  scars.  As  one  crop  of  papules  dis- 
appears others  come  out  in  difterent  places.  The 
disease  sometimes  remains  limited  to  particular  parts 
of  the  body  for  a  year  or  two,  but  it  may  in  course 
ol  time  invade  nearly  the  whole  surface  of  the  skin. 
In  some  cases — especially  on  the  legs  and  in  persona 
with  varicose  veins — lichen  ruber  planus  assumes  a 
hypertrophic  form,  the  patches  being  raised  so  as 
to  form  plateaux  of  considerable  extent  {lichen  hyper- 
Irophicus).  [See  Fig.  10.)  The  afiection  varies  very 
greatly  in  severity  in  different  persons.  Sometimes 
the  subjective  symptoms  are  very  severe  ;  there  is 
intense  itching,  with  restlessness,  insomnia,  and  the 
deepest  mental  distress  or  violent  excitement.  In 
the  later  stages,  when  the  lesions  extend  over  a 
considerable  portion  of  the  body,  the  skin  becomes 
very  tender,  and  great  pain  is  experienced  when  the 
parts  are  pressed.  Occasionally  old-standing  lesions 
take  on  a  warty  character  {lichen  verrucosus).* 

Special  reference  must  be  made  to  an  acute  variety 
of  lichen  ruber  planus,  which  is  characterised  by 
rapidity  of  onset,  intense  severity  of  lesions,  the 
.  extremities  being  swollen  and  tense,  and  the  blue 
or  purple  appearance  being  very  marked.  I  have 
seen  several  examples.  In  a  very  severe  case  under 
my  care  the  patient  was  a  man  aged  thirty-one,  other- 
wise healthy.  Within  a  few  weeks  the  whole  body 
was  covered  with  the  eruption,  the  hands  and  feet 
being  most  severely  affected,  swollen,  blue,  (sdema- 
tous,  and  subsequently  desquamating  in  large  masses 

*  See  papar  (wiOi  iUastcadonB)  hv  Fordyue :  Jwiiti,  Cut.  ami 
0m,  Urin.  Dif.,  vol.  rv.,  Feb.,  1^97,  li,  49. 


170  NEVHOTIC  AFFECTIONS  OF  TUE  SKIN.  [chap.  s. 

as  in  scarlet  fever.  On  the  ttody,  though  the  eruption 
WEiB  most  extensive,  the  characteristic  appearanca 
of  the  individual  papules  was  not  lost. 

Lukasiewicz  *  has  recorded  a  case  in  which  lichen' 
ruber  planus  and  acuminatus  occurred  in  the  same 
patient,  a  man  aged  twenty-six.  The  lesions  charac- 
teristic o!  the  former  affection  predominated  on  the 
face,  neck,  trunk,  scrotum,  and  penis  ;  those  of  the 
latter  on  the  extrenuties.  The  man  was  in  hospital 
nine  months,  and  Lukasiewicz  had  tlie  opportunity 
of  observing  on  the  trunk  during  a  period  of  exacer- 
bation distinct  transitional  forms  of  planus  and 
acuminatus. 

As  regards  the  pfltholog^y  of  lichen, Crocker,  whose 
careful  examinations  have  been  confirmed  by  recent 
investigators,  has  shown  that  the  process  is  in^am- 
matory,  tlie  starting  point  being  generally  a  aweat 
duct  in  the  upper  part  of  the  oorium.  The  in(lam-> 
mation  results  in  thickening  of  the  lete,  with  enlarge^' 
ment  of  the  papillie,  the  papillary  vessels  being  dilated^' 
and  down-growth  of  the  inter-papillary  processes* 
taking  place.  The  hair  follicles  are  seldom  the  seafr 
of  the  disease.  It  is  possible  that  the  process  is  an^o^" 
neurotic,  but  so  far  this  has  not  been  proved. 

The  disease  occura  in  persons  otherwise  perfectly 
healthy.  It  is  neither  contagious  nor  hereditary.  It 
afiecta  men  in  considerably  larger  proportion  t^ua 
women.  'Lhe  majority  of  patients  are  between  twenty 
and  fifty  years  of  age,  and  the  disease  is  very  rare  at 
each  extreme  of  life.t 

Diagnosis. ^Lichen  ruber  planus  has  to  be  distin- 
guished from  psoriasis  punctata,  papular  eczema, 
and  papular  syphilitic  lesions.     From  psoriasia  it  iS' 


•thiff.  DtrtH.  u.  Syph..  BA.  raiv.,  Heft  2,  March,  1890. 

.  roganlB  lichen  iu  eBTljr  life,  the  reader  ia  referrad  to  i 
r  i>y  Colcott  Fox,  "Noloa  ou  Lieheu  Phmua  ill  IiifuiU,' 
/Mfi-n,  Dtrm.,  IBHl,  p.  201, 


K' 


X.]  LICHEN  BUBEB  PLANUS.  177 

differentiated  by  the  fact  that  the  papules  remain 
unaltered  instead  of  spreading  out  into  scaly  patches  ; 
from  eczema  by  the  lact  that  no  vesicles  are  formed  ; 
and  from  syphilis  by  the  dryness  of  the  papnles.  In 
all  doubtful  cases  the  characteristic  primary  papules 
of  lichen  ruber  planus  must  be  looked  for,  General- 
ised  lichen  niber  planus  is  sometimes  difficult  to 
distinguish  from  generalised  psoriasis.  The  pointe  of 
distinction  are  that  in  the  former  there  is  less  scalinees 
and  more  thickening,  and  characteristic  papules  are 
seen  at  the  margin  of  the  patches. 

Lichen  ruber  planus  shows  no  tendency  to  dis- 
appear spontaneouaJy  ;  on  the  contrary,  if  '^ft  to 
itself  it  is  likely  to  spread  over  the  body,  and  i.iay  end 
by  causing  death  from  exhaustion.  The  disease  is 
not  unfrequently  combined  with  the  acuminated  form 
described  by  Kaposi  (pityriasis  rubra  pilaris). 

The  etiology  of  lichen  ruber  planus  is  obscure. 
The  process,  as  already  said,  is  essentially  inflammatory 
in  character;  but,on  the  other  hand,  it  is, in  my  experi- 
ence, not  unfrequently  the  result  of  a  violent  nervous 
shock  or  emotional  disturbance.  One  of  the  worst 
cases  I  have  seen  was  that  of  a  lady  whose  husband 
died  suddenly  in  a  railway  carriage  while  travelling 
with  her  from  the  South.  Besides  the  shock  of  this 
event,  she  was  subjected  to  much  worry  and  anxiety 
by  the  necessity  of  going  through,  without  assistance, 
the  vexatious  formalities  insisted  on  by  officials  in 
such  circumstances.  She  bore  up  well,  however,  till 
after  the  funeral,  when  she  was  suddenly  seized  with 
a  severe  attack  of  lichen  ruber  planus,  in  which  the 
subjective  symptoms  were  of  such  intensity  as  almost 
to  upset  her  reason.  In  other  cases  the  neurotic 
element  ia  very  strongly  marked,  and  I  think  it  not 
improbable  that  this  may  be  a  leading  factor  in  the 
I  causation  of  the  disease.  I  have  therefore  included 
1  ruber  planus  ia  this- group  prtMsionally,  but 


17H  .\'EUROTIO  AFFECTIONS  OF  THE  SKIX.   [ch 

it  must  be  unJeretood  that  the  evidence  of  ite  nervoua 
origin  IB  HO  fiir  entirely  clinical. 

Treatment. — Lichen  ruber  planus  must  be 
treated  on  the  general  lines  already  laid  down  for 
the  treatment  of  skin  affections  of  nerve  disorder. 
ArBenio  is  particularly  valuable  if  given  in  large 
doses  and  continued  for  a  long  time.  Kaposi,  fol- 
lowing Hebra,  looks  upon  tliis  drug  as  a  specific. 
In  the  case  of  children  he  gives  it  iu  the  form  of 
Fowler's  solution,  beginning  with  Itvo  drops  daily  and 
increasing  the  dose  by  very  slow  degrees ;  in  adults  he 
gives  it  in  the  form  of  hypodermic  injections  of 
Fowler's  Bolwtion  or  of  Asiaiic  pills.  The  treatment  ia 
begun  by  the  administration  of  three  pills  a  day,  in- 
creasing  every  jour  or  five  days  by  one  pill,  untU  a  daily 
total  of  eight  to  ten  pills  is  reached.  As  a  rule  no  im- 
provement is  perceptible  before  a  period  of  six  to 
eight  weeks  has  elapsed,  in  which  time  the  patient  will 
have  taken  from  200  to  500  pills.  The  patient  con- 
tinues taking  eight  or  ten  pills  daily  till  the  disease 
has  almost  entirely  disappeared,  when  the  quantity  is 
gradually  reduced  to  six  pills  daily.  This  amount 
the  patient  continues  to  take  for  tliree  or  foui  montha 
after  the  final  disappearance  of  the  eruption.  I 
agree  with  Besnier,  however,  who,  while  admitting 
that  arsenic  often  gives  satisfactory  results  in  hchen, 
says  that  in  some  cases  it  fails,  while  in  others  recovery 
taki-s  place  without  it.  However  free  from  danger 
the  method  may  be  in  experienced  hands,  the  use  ol 
arsenic  in  such  heroic  doses  is  hardly  to  be  recom- 
mended as  a  routine  practice.  In  a  case  under  the 
cam  of  Pringle  *  remarkable  subsidence  of  the  in- 
flamniatary  lesions  occurred  during  the  administra- 
tion of  antipyrin  in  10  grain  doses  thrice  daily,  which 
appeami  to  arrest  all  itching.    In  generalised  lichen 

•  Bnl.  Jcmv.  Dmu,  lOOl,  p.  12, 


1 


X.1  LICHEN  RVBBR  PLANV8.  179 

planus  I  have  found  the  internal  use  of  biniodide  of 
mercury  most  useful.  I  usually  give  it  according 
to  the  following  formula  :  (i.  Liq.  hydrarg.  perchlor. 
57.  ;  polass.  iodid.  </r.  xl.  ;  decoct,  sarsm  co.  %viij. 
Mist :  two  tablespoonfuls  three  times  a  day. 
Locally,  the  remedies  indicated  in  lichen  are  those 
recommended  for  itehing.  Unna  cured  a  series  of 
oases  in  three  weeks,  without  any  internal  treatment 
whatever,  by  means  of  frictions  twice  a  day  with  a 
pomade  composed  of  one  gramme  of  corrosive  subli- 
male,  20  grammes  of  carbolic  acid,  and  600  grammes 
of  simple  oitttment,  the  patient  afterwards  being 
wrapped  up  in  linen  cloths  and  put  to  bed.  Pyru- 
gallic  acid  {five  to  ten  per  cent.)  rubbed  on  the  affected 
parts  is  uselul  in  old-standing  patches.  Merourial 
■jiasters  are  beneficial  when  the  lesions  are  confluent, 
but  if  the  surface  thus  treated  is  extensive,  the  prac- 
titioner must  be  on  the  watch  for  symptoms  of  mej- 
curialism.  In  old  atrophic  patches  the  cautery  may 
be  required.  In  a  case  under  my  care  hypertrophic 
masses  which  microscopically  presented  all  the  ap- 
pearance of  commencing  epithelioma  were  left  in  the 
labium  and  had  to  be  removed. 

Lichen  annularis.  —  Under  tliia  name  fJallo- 
way  •  has  deacriljed  an  affection  the  distinctive  char- 
acters of  which  are  summed  up  by  him  in  the  following 
definition  :  "  A  chronic  infiammato^  disease  of  the 
upper  layers  of  the  cutis,  associate^  with  increase 
in  the  overlying  epithelium,  commencii^  as  a  nodule, 
spreading  peripherally  and  heti.ling  in  the  centre, 
without  suppuration  or  any  rapid  form  of  degenera- 
tion." The  disease  especially  affects  the  dorsal  sur- 
face of  the  phalanges  in  the  neighbourhood  of  the 
joints.  In  t!ie  nature  and  distribution  of  the  in- 
flammatory  infiltration   it    closely  resembles  lichen 

•  Uril.  Jwru.  Dri-m.,  June,  189<I 


180  SEUROTia  AFFECTIONS  OF  THE  SKIN.  [crap.  k. 

ruber  planus,  while  in  its  progress  it  simulates 
certain  other  conilitions  whose  toxsemic  origin  is 
better  defined.  Although  there  are  wide  clinical 
difierences  between  the  twg  diseases,  Galloway 
considers  that  the  histological  characters  of  the  affec- 
tion bring  it  witWn  the  strictest  definition  of  the 
t«rm  "  lichen,"  while  the  ringed  arrangement  of  the 
lesions  is  distinctive.  Lichen  annularis  has  certain 
analogies  with  a  condition  described  by  Crocker  uAder 
the  name  of  erythema  elevatum  diutinum  *  and  with 
lupus  erythematosus.  From  a  study  of  a  nuoiber  of 
cases  recorded  under  various  names  by  Hutchinson, 
Dubreuilh,  and  others,  Galloway  concludes  that 
there  are  certain  chronic  inflammatory  conditions 
of  the  skin  which  produce  lesions  resembling  in 
many  points  those  of  lichen  planus,  and  caused  by 
poisonous  substances  circulating  "in  the  blood,  the 
nature  of  which  is  yet  undetermined.  These  lesions 
present  differences  in  the  amount  of  congestion,  in 
the  appearance  of  the  lesions,  and  in  their  duration. 
They  agree,  however,  in  their  chief  oUnical  features 
and  in  the  histological  cbanges  which  they  produce. 
They  do  not  suppurate.  It  is  possible  that  gout  and  ■ 
rheumatism  are  factors  in  their  causation.  TJcben 
annularis  is  exceedingly  rare,  but  in  addition  to  the' 
case  reported  by  Galloway,  others  have  been  ob- 
served by  Colcott  Fox  in  this  country  and  by  Nevina 
Hyde  in  Chicago. 

Porokeratosis  (Mibelli).  ~  By  this  name 
Mibelli  t  has  designated  an  affection  presenting  a 
certain  resemblance  to  lichen  annularis.  It  is  charac- 
terised by  patches  of  irregular  shape  and  siaa,  bUt- 
rounded  by  a  horny  linear  edge.     Galloway,J  who  1 

*  hadcMe   Uraoki.T   tuiil   CumnlxiU  WilUouu :   SrU.  Jtum.  I 

t  MoHaU.f.prakt.  Dtrui.,  ivii.,  I»tt3. 

•  Jlri(.  Jimra.  Derm.,  \90\.  p.  262. 


:.]  POROKERATOSIS.  181 

recently  showed  a  case  at  the  Derma toiogical  Society 
of  London,  pointed  out  that  the  lestonis  cloaely  re- 
sembled those  seen  in  the  examples  reported  by 
Mibelli,  Ducrez  and  Respighi,  Gilchrist  and  others, 
being  generally  circuhir  in  outline,  with  irregularly 
advancing  and  receding  margins.  "  Its  periphery  ia 
marked  by  a  raised  border  of  loose  horny  epithelium, 
the  summit  of  which  has  given  way  and  allows  a 
crack  to  appear  in  the  greater  part  of  ite  course. 
Within  this  homy  outline  numerous  small  conical  ele- 
vations of  the  horny  layer  are  obvious,  while  the 
greater  part  of  the  enclosed  area  of  skin  is  smooth, 
and  shows  the  normal  fuirowa  of  the  skin  with  very 
alight  alteration."  There  seemed  to  be  no  appreci- 
able thickening  of  the  cutis.  The  disease,  in  Gallo- 
way's opinion,  is  of  a  totally  different  nature  from 
lichen  annularis,  in  which  there  is  marked  infiltration 
of  the  cutis,  with  much  less  disturbance  of  the  homy 
layer  than  in  porokeratosis.  So  far,  however,  very 
little  has  been  found  on  histological  examination  to 
differentiate  the  one  disease  from  the  other,  Gallo- 
way thinks  it  probable  that  some  of  the  cases  de- 
scribed by  foreign  observers  under  the  name  of 
porokeratosis  have  really  been  examples  of  lichen 

Parakeratosis  variegata.  —  This  seems  to 
be  the  most  appropriate  place  for  a  brief  description 
of  a  condition  which  clinically  may  be  classed  among 
lichenoid  eruptions,  though  pathologically  it  is 
distinct.  The  term  "  parakeratoses  "  was  suggested 
by  Unna  *  to  denote  superficial  inflammatory  pro- 
cesses affecting  the  epidermis  and  characterised 
clinically  by  scalineas.  Under  this  general  head  he 
grouped  scaly  forms  of  seljorrhcBa,  pityriasis,  psori- 
aais,   and  other  conditions   in  which  scales  are  a 

*  MoHoli,.  f.  prakt.  lhrm.,'Si\.  s.,  IHW, 


1S3   XEUnOT/C  AFFECTIONH  OF  THE  HKIN.  [caxv.  s. 

marked  objective  feature.  The  addition  of  tlie  quali- 
fication "  variegata  "  was  meant  by  Unna  to  designate 
a  form  of  dermatitis,  chronic  in  course,  with  spon- 
taneooB  remissions,  attacking  the  hand  and  extend- 
ing to  the  extremities,  characterised  by  flat  papules, 
often  surmounted  by  scales,  the  eruption  as  a  whole 
producing  a  "  variegated  "  appearance  owing  to  the 
enclosure  of  areas  of  healthy  skin  in  a  meshwork  of 
disease.  There  is  no  disturbance  of  the  general 
health,  and  no  Bubjeetivo  symptoms  except  a  trifling 
amount  of  itching.  In  the  cases  on  which  Unna's 
original  description  was  founded  the  histologic-al 
examination  showed  that  the  papillary  and  sub- 
papillary  layers  were  alone  affected  and  presented 
dilated  vessels,  ccdema,  cellular  infiltration,  and  a 
few  leucocytes.  Inter -epithelial  and  intra -epithelial 
cedoma  and  thickening  of  the  prickle  layers  were 
present,  but  there  was  no  increase  in  mitosee.  The 
stratum  granulosum  was  present  and  the  homy  layer 
slightly  thickened. 

At  the  meeting  of  the  British  Medical  Aasocia- 
tiun  held  in  Edinbui^h  in  18'Jft  Jamieson*  pre- 
sented three  cases  for  diagnosis,  which  were  regarded 
hy  several  of  those  present  as  examples  of  parakera- 
tosis variegata.  In  one  case  the  essential  lesions 
were  papules  "  which,  clinically  and  microscopically, 
were  identical  with  those  of  lichen  planus";  in 
another  "  the  lesions  were  indeterminately  liche- 
noid " ;  while  the  third  case  was  considered  by 
Jamieson  to  form  a  connecting  link  between  the 
other  two.  Jamieson  classified  the  caaes  as  anoma- 
lous forms  of  lichen  ruber  planus  ;  RadclifTc  Crocker, 
lUid  the  author,  suggested  the  possibility  of  their  being 
mstancee  of  a  premycosic  condition  ;  while  l'nn» 
identified  them  as  excellent  examples  of  parakerata)>l8 

•  Bitl.  Jturn.  lirrm.,  Sepleiubi-r,  ISIW. 


PARAKEliATUSIS   VASimATA. 


variegata.  Boeck  stated  that  he  had.  seen  several 
of  similar  nature,  and  had  described  them  under 
ame  "  dermatitis  variegata."  It  may  be  men- 
tioned that  Crocker  has  suggested  the  name  "  lichen 
variegatua  "  for  the  disease.  In  one  of  Jamieson's 
cases  tumniirs  like  those  of  mycosis  fungoides  ap- 
'  sequently  on  the  face  and  body.  Colcott 
and  J.  M.  H.  Macleod  have  published  a  moet 
itnictive  report  of  a  case  under  their  observation, 
md  have  colleeted  and  analysed  all  the  records  of 
cases  hitherto  pubhshed.*  To  their  article 
reader  is  referred.  The  conclusions  at  which 
ley  arrived  are  summarised  by  themseives  as 
'lows  :  "  Parakeratosis  variegata  attacks  chiefly 
male  sex  ;  the  patienta  are  usually  adults,  and 
generally  in  robust  health  when  attacked.  The 
ical  appearances  and  histological  changes  suggest 
lo-motor  disturbance  as  the  etiological  factor ; 
associated  with  cedema  and  infiltration  of  cells 
tiie  corium  and  secondary  changes  in  the  epi- 
'demuB.  The  initial  lesion  is  a  macule  or  maculo- 
papule  of  smaU  size,  flat  on  the  surface  and  covered 
with  a  fine  adherent  scale  which  may  be  scratched  oft 
without  causing  bleeding.  By  the  coalescence  of  the 
lesions  a  peculiar  retiform  arrangement  results,  in 
which  areas  of  normal  skin  are  enclosed,  and  which, 
combined  with  differences  in  the  coloui  of  the  lesions 
in  the  more  dependent  parts  of  the  body,  produces  a 
marbled  or  variegated  appearance,  which  is  one  of 
the  most  pronounced  characteristics  of  the  dermatitis. 
It  afiecte  the  skin  almost  nniveisally,  except  as  a 
rule  that  of  the  face,  scalp,  palms,  and  soles.  It  is 
subject  to  remissions  and  exacerbations,  but  is 
peculiarly  chronic  in  its  course.  Marked  subjective 
qrmptoms    are   singularly    absent.     It   is    strangely 

•  Brit.  Jour".  Den':,SBiitemhrjt.  lUOl, 


184  SEURUTIC  JFFECTIOXS  OF  TUE  SEIS.  [cHiP.  I. 

resistant  to  local  treatment.  It  consists  histologic- 
ally of  a  superficial  inflammation  affecting  the  sub- 
epidermal layer,  with  dilatation  oi  vesseU,  cEdema, 
,  &nd  infiltration  oi  cells ;  and  an  cedematous  condi- 
I  tion  of  the  epidennis,  with  more  or  less  defect  in  the 
process  of  comification.  It  may  be  regarded  as 
belon^ng  to  a  group  of  superficial  inflammations  of 
the  corium,  with  secondary  changes  in  the  epidermis, 
which  we  have  provisionally  entitled  '  resistant 
maculo-papulai  scaly  erythrodermlas,'  which  might 
include,  besides  thia  variety,  erythrodermie  pity- 
tiasique  en  plaques  dlssemiliees  (Brocq),  pityriasis 
lichenoides  chronica  (Juliuetierg),  dennatitis  psoriasi- 
formis  nodularis  (Jadassolin),  and  the  lichenoid 
psoriasiform  exanthem  (Neisser)." 

Pityriasis  rubra  pilaris  is  an  anomaly  oi 
comification  primarily  affecting  the  hair  follicles,  at 
the  orifices  of  which  charscteristic  papules  form,  and 
secondarily  leading  to  inflammatory  changes  of  the 
dermic  structures.  There  has  been  a  good  d»sal  of 
discussion  as  to  the  relation  of  the  affection  to  lichea 
ruber  acuminatus.  Kaposi  thinks  the  two  condi- 
tions identical,  and  1  agree  with  him.  What  may 
hirly  be  called  a  test  case  was  shown  at  Budapest 
to  some  members  of  the  Congress  o!  Dermatology 
held  at  Vienna  in  1892.  The  patient  was  exhibited 
as  an  illustrative  example  of  Uchen  ruber  acuminatus, 
and  the  affection  was  unhesitatingly  pronounced  to 
be  pityriasis  rubra  pilaris  by  the  B'rench  dermatolo- 
gists present.  Neumann,  however,  still  maintains 
that  Uchen  ruber  acuminatus  and  pityriasis  rubra 
pilaris  are  two  distinct  affections.* 

Neisaeif  holds  that  there  is  a  disease,  difieriag 
from  both  lichen  planus  and  pityriasis  rubra  pilaria, 
for  which  the  name  of  lichen  ruber  acuminatus  may 


^"    ml. 


X.]       PITYRIASIS  RUBE  A   PILARIS. 


'.•onveniently.  be  retained.  Two  casea  were  shown 
■to  illustrate  this  view,  one  being  pityriasis  rubra 
'i,  the  other  hchen  ruber  acuminatus.  The 
main  pointfl  in  the  difierential  diagnosis  are,  accord- 
ing to  Neisser,  the  following  : — Lichen  ruber  acu- 
minatus affecta  the  general  health  very  seriously,  is 
benefited  by  arsenic  t-o  a  very  marked  extent,  and 
shows  usually  more  distinctly  papule  formation 
and  less  hyperkeratosis.  Under  the  microscope  the 
papules  of  this  disease  are  seen  to  be  situated  round 
a  hair  follicle,  and  to  consist  almost  whoUy  of  an  in- 
filtration of  small  cells  in  the  corium.  In  pityriasis 
rubra  pilaris,  on  the  other  hand,  the  disease  causes 
scarcely  any  alteration  of  the  general  health,  is  essen- 
tially chronic  in  nature,  is  quite  uninfluenced  by  the 
administration  of  arsenic,  and  shows  less  marked 
papule  formation  but  great  hyperkeratosis.  Under 
the  microscope  there  was  seen  to  be  very  little  in- 
filtration of  the  corium  and  a  marked  increase  of  the 
epidermis,  Neisser  admits  that  Kaposi  described 
Devergie's  disease  under  the  name  of  lichen  ruber 
acuminatus,  but  thinks  that  this  disease  was  also 
included  in  the  description.  On  the  other  hand,  he 
considers  that  the  French  school  have  fallen  into  the 
same  error,  and  described  two  diseases  under  the  one 
name  of  pityriasis  rubra  pilaris.  Lastly,  the  author 
admits  that  the  initial  lesion  of  lichen  rubra  acu- 
minatus may  also  show  hyperkeratosis,  but  even 
then  the  state  of  health  and  the  action  of  arsenic 
make  a  great  difference.  This  appears  to  coincide 
with  Unna's  licJien  nearoticus.* 

Pit)Tia8is  rubra  pilaris  usually  comes  on,  so  to 
speak,  in  disguise.  Sometimes  it  appears  in  the  form 
of  scaly  patches  resembling  psoriasis  on  the  palms 
and  soles,  sometimes  as  a  dry  eruption,  covered  with 

*  '■  Histopntlioloey,"  p.  :!03. 


I 

I 


18(1   NEUROTIC  AFFECTIONS  OF  THE  SKIN.  [i;hap.  x. 

eczema touB-lookiiig  cruBts,  on  the  aca^  and  face. 
Soon,  however,  the  characteristic  papulea  become 
vifiihle  at  the  orifices  of  the  hair  follicles.  These 
papules  are  small,  red,  hard,  dry,  harsh  to  the  touch, 
and  more  or  leas  conical  in  shape,  each  having  a  single 
atrophied  hair  in  the  centre  surromided  by  a  kind  of 
horny  sheath  which  penetrates  into  the  follicle,  The 
projection  of  these  tiny,  cone-ahaped  papnles  is 
sufficient  to  roughen  the  surface  of  the  integument, 
ao  that  it  feels  like  the  skin  of  a  newly-plucked  fowl 
(Besnier).  The  papules  are  distributed  on  the  limbs, 
especially  where  the  hail  is  most  abundant,  that  is  to 
say,  on  the  backs  of  the  fingers  (particularly  the  first 
and  second  phalanx),  on  the  outer  aspect  of  the  fore- 
arms, on  the  outside  of  the  thighs,  and  on  the  but- 
tocks. They  are  also — though  less  frequently— seen 
about  the  elbows  and  knees.  On  the  trunk  they 
chiefly  aSect  the  waist  and  the  lower  part  of  the 
belly.  They  are  at  first  discrete,  but  as  they  increase 
in  number  they  tend  to  become  confluent,  and  thus 
form  patches.  In  these  patches  the  distinguishing 
characters  of  the  individual  papules  are  lost  ia 
a  pale  yellowish-red  surface,  covered  with  papery 
scales,  or  with  small  adherent  ones  resembling 
micft,  which,  when  situated  in  the  positions  most 
affected  by  psoriasis,  may  closely  simulate  the 
lesions  of  that  disease.  At  the  edge  of  the  patches 
the  characteristic  conical  papules  are  always  to 
be  seen. 

The  three  marked  objective  features  of  pityriasis 
rubra  pilaris  are  :  (1)  the  "  goose-skin  "  appearance 
and  grater-like  feeling  caused  by  the  conical  papules 
at  the  orifices  of  the  hair  follicles  ;  (2)  the  desquama- 
tion ;  (3)  the  redness  of  the  surface.  The  natural 
folds  of  the  affected  parts  of  the  skin  are  always 
exaggerated.  The  eruption  often  spreads  over  a 
HtgQ  part  of  the  body,  and  in  some  cases  becomes 


CHAP,  s,]     pityhiasis  rubra  pilaris.  ist 

imiveraal.  The  lesions  present  certain  difierences  of 
appearance,  according  to  their  situation.  On  the  face 
they  are  often  of  a  aeborrhoeic  type,  a  red  base  being 
covered  with  adherent  crusta  ;  sometimes  they  have 
the  characters  of  pityriasis  rubra.  They  are  always 
dry,  and  there  is  usually  considerable  tension  of  the 
skin,  which  may  give  rise  to  ectropion  of  the  lower 
lid.  On  the  scalp  they  are  generally  of  seborrhieic 
type  ;  the  hair  is  often  matted  together  by  firm 
crusts.  The  nails  become  soft,  greyish  in  colour, 
and  marked  with  longitudinal  yellow  stripes.  On 
the  hands,  however  extensive  the  eruption  may  be, 
small  blackish  cones  can  always  be  seen  around  the 
hair  follicles. 

Beyond  a  trifling  amount  of  itching,  which,  more- 
over, is  by  no  means  a  constant  feature,  tiiere  are  no 
subjective  symptoms  in  pityriasis  rubra  pilaris.  The 
general  health  is  never  affected.  The  onset  of  the 
disease  may  be  preceded  by  great  irritation  in  the 
parts  about  to  be  attacked.  Its  course  is  alow,  and 
subject  to  sudden  remissions  and  exacerbations 
without  obvious  cause.  Even  when  the  affection 
appears  to  be  completely  cured,  relapse  may  occur 
at  any  time, 

The  diagnosis  is  almost  always  easy.  The  charac- 
teristic conical  papule,  with  its  single  hair,  plugging 
the  mouth  of  a  follicle,  is  conclusive  as  to  the  nature 
of  the  disease.  The  best  place  to  look  for  the  lesions 
IB  on  the  backs  of  the  fingers  :  they  can  be  picked  off, 
little  pits  being  left  which  give  the  skin  a  cribriform 
appearance.  The  absence  of  any  attendant  disorder 
of  the  general  health  distiiiguislies  the  affection  from 
other  forms  of  exfoliative  dermatitis.  From  lichen 
ruber  planus  it  is  differentiated  (a)  by  the  absence  of 
itching ;  (6)  by  the  absence  of  impairment  of  nutri- 
tion ;  »nd^(c)  by^its  resistance  to  the  therapeutic 
Action  of  arsenic. 


1 


(190  NEOROTIC  AFFECTIONS  OF  THE  SKIN.  [chap,  x, 
so  far  as  we  know  at  present,  is  an  indepeiident 
disease. 
Leucodermia,  or  vitiligo,  is  somewhat  rare  in 
Great  Britain,  aad  in  Europe  generally  ;  but  it  is 
common  in  the  tropics,  and  especially  in  the  dork 
races.  Its  chatactexistic  feature  is  tlie  formation  in 
different  parte  of  the  body  of  white  patches,  sur- 
rounded by  a  pigmented  border.  The  appearance  is 
as  ii  the  pigment  had  receded  from  the  aSected  area 
and  heaped  itself  up  at  its  circumference.  The 
patches  are  at  fiiat  stpall,  and  more  or  less  rounded 
in  shape.  As  they  spread,  however,  their  outline 
becomes  irregular,  but  the  border  always  remains 
oonve.t.  The  pigmented  zone  surrounding  them 
merges  insensibly  into  the  healthy  skin  around  it. 
The  white  patches  may  be  few  or  many  in  number, 
and  they  may  be  scattered  about  irregularly,  giving 
the  surface  of  the  integument  a  map-like  appearance, 
or  distributed  with  some  approach  to  symmetry,  espe- 
cially on  the  limbs.  The  neck  is  a  common  situation  ; 
but  the  face,  the  scalp,  and  the  trunk,  as  well  as  the 
limbs,  may  be  tlie  seat  of  the  affection.  The  disease 
is  vary  slow  in  its  course,  and  in  some  cases  after 
a  time  It  becomes  stationary.  .  In  other  cases,  again, 
it  spreads  over  the  whole  body,  taking,  however, 
many  years  to  do  so.  The  affected  skin  is  smooth 
and  supple,  and  shows  no  sign  of  scaliness ;  the 
physiological  functions  of  the  skin  are  intact,  and 
sensation  is  unaltered.  Sometimes  slight  itching  may 
precede  the  formation  of  a  patch.  The  hairs  in  the 
affect«d  areas  participate  in  the  loss  of  pigment,  and 
turn  white.  Both  sexes  are  equally  liable  to  the 
disease.  Between  ten  and  thirty  is  the  time  of  life 
when  it  generally  commences. 

There  can  be  little  doubt  that  leucodermia  is 
A  disease  of  neurotic  origin,  and  LeloJr  in  some 
oaaee  found  changes  in  the  nerves  supplying  the 


1 


X.]  LEVCODERMIA  ;   RAYNAUD'S  DISEASE.  191 

whitened  pat«iiea  of  Bkin.  It  also  not  unfrequently 
follows  violent  mental  emotion  or  prolonged  depres- 
sion from  illness  or  anxiety.  Extreme  heat  or  cold 
appears  to  have  some  influence  as  an  exciting  eauae. 

Leucodermia  can  he  distinguished  from  macular 
leprosy  by  the  absence  of  auiesthesia  in  the  white 
patches,  and  from  selejodermia  by  the  absence  of  the 
parchment- like  stiffness  and  thickening  of  the  akin 
characteristic  of  that  condition. 

The  prognosis  of  leucodermia  is  by  no  means 
favourable,  so  far  as  restoration  of  the  pigment  is 
concerned.  The  process,  as  already  said,  sometimes 
comes  spontaneously  to  a  standstill. 

There  is  little  to  be  done  in  the  way  of  treat- 
ment. It  is  impossible  to  restore  the  lost  natural 
colour,  though  the  surrounding  increase  of  pigment 
may  be  modoiied  by  the  apphcation  of  weak  gotto- 
siiK  sublimate  or  peroxide  of  hydrogen. 

Raynaud's  disease,  or  symmetrical  gangrene 
of  the  extremities  (including  in  that  term  the  tip  of 
the  nose  and  the  ears),  is  a  disorder  of  the  peripheral 
circulation,  and  has  three  well-marked  stages : 
Pirst,  spasm  of  arterioles,  with  pallor  and  loss  of  sen- 
sibility in  the  affected  parts  (local  syncope,  "  dead 
fingers  ") ;  secondly,  stagnation  of  the  venous  circu- 
lation, with  consequent  cyanosis  of  the  parts  ;  thirdly, 
superficial  gangrene — the  skin  becoming  black,  the 
epidermis  becoming  covered  with  eschars,  and  being 
raised  here  and  there  into  bulls,  which  dry  up  or 
burst  and  leave  persistent  ulcers.  A  line  of  demarca- 
tion is  formed,  and  in  several  cases  separation  of  the 
affected  part  takes  place.  The  gangrenous  process 
is  at  first  accompanied  by  sharp  pain,  formication, 
and  itching.  In  slighter  cases,  after  the  sloughing 
of  the  superficial  tissues  is  complete,  healing  takes 
place,  the  fingers,  however,  lemaining  thinned,  and 
covered  with  small  white  depressed  cicatrices  of  con- 


I 


1B2  NSUROTIG  AFFECTIONS  OF  THE  SKIN.  [chap.  x. 

aiderable  toughness.     The  procesB  may  be  arrested 
in  any  of  the  three  stages  above  described. 

RajTiaud's  disease  is  almost  invariably  sym- 
metrical, but  the  procesH  may  be  mild  on  one  side  and 
severe  on  the  other.  In  a  case  under  my  own  care  it 
was  asymmetrical.  The  order  of  frequency  with 
which  different  parts  are  attacked  is  as  follows  : — 
Fingers,  toes,  heels,  nose,  and  ears.  Any  part  of  the 
body,  however — limbs,  trunk,  or  face— may  be  at- 
tacked. 

Males  are  rather  more  liable  than  females,  pro- 
bably because  they  are  more  exposed  to  cold  No 
age  is  exempt,  but  children  are  more  often  attacked 
than  adults.  Persona  in  whom  the  circulation  ia 
weak,  and  especially  those  who  are  subject  to  "  dead- 
ness  "  of  the  fingers  or  to  chilblains,  are  especially 
prone  to  Raynaud's  disease.  The  most  favourable 
predisposing  condition  for  ita  development  is  the  com- 
bination oi  a  sluggish  circulation  with  an  unstable 
nervous  system.  .Both  in  Raynaud's  disease  and  in 
chilblains  there  is  an  undue  susceptibility  to  the 
affection,  apart  from  exposure  to  cold  ;  in  chilblains, 
however,  reaction  follows  early,  while  in  Raynaud's 
disease  necrosis  occurs  before  reaction  can  take  place. 
Malaria,  gout,  and  diabetes  are  beheved  to  have  a 
certain  predisposing  influence.  The  most  frequent 
exciting  causes  are  cold  and  an  attack  of  acnte 
disease  (scarlet  fever,  measles,  diphtheria). 

The  prognosis  depends  on  the  severity  and  estent 
of  the  process  and  the  constitutional  state  of  the 
patient.  Death  is  rare  ;  but,  on  the  other  hand,  the 
disease  is  always  likely  to  recur,  and  permanent 
changes  in  the  parte  or  mutilation  may  occur. 

Treatment.— The  most  efficient  remedy  is  gal- 
vanif  m.  The  constant  current  should  be  applied  by 
imnier&ing  the  affected  extremity  in  a  large  basin  of 
salt  water,  one  pole  being  placed  in  the  water  while 


s.] 


RAYNAUD'S  DISEASE. 


net 
^^^^  ore 


the  othei  is  applied  to  the  limb.     If  this  treatment 
employed  Bufficiently  early,  the  progress  of  the 
disease  will  often  he  cut  short,     Massage  is  also  very 
^Saeful,  and  the  internal  administratioa  of  ichtkyol^ 
quinine  may  sometimes  prove  of  service, 
hen  gangrene  has  takcD  place,  the  treatment  must 
conducted  ott  ordinary  surgical  priuuiples. 
Sclerodactylia  or  acronderoiermia,  which  is  gener- 
ly  described  aa  a  form  of  sclerodermia,  may  occur 
association  with  Raynaud's  disease  ;  it  may,  how- 
over,  occur  independently,* 

The  process  appears  to  consist  in  spaam  of  the 
arterioles,  due  to  central  or  peripheral  nervous  dia- 
irder.  The  other  phenomena  are  those  of  ordinary 
ngrene. 
DePmatitis  Pepens,— Under  this  title  Crocker 
described  a  form  of  spreading  dermatitis  occa- 
Bionally  following  injuries.  It  commences  almost 
exohieively  in  the  upper  extremities,  and  is  probably 
neuritic  in  character.  The  general  aspect  of  the 
affected  parts  usually  resembles  that  of  eczema 
.nibrum.  The  condition  might  sometimes  he  mistaken 
*  ir  eczema,  hut  the  oozing  surface  entirely  denuded, 
id  the  sharply  defined  undermined  spreading  edge, 
ore  quite  different  from  anything  seen  in  that  affec- 
tion. The  disease,  though  primarily  the  result  of 
peripheral  neuritis,  is  probably  kept  up  and  aggra- 
vated by  secondary  parasitic  irritation.  This  view 
is  confirmed  by  the  beneScial  effect  of  the  local 
application  of  anti-paraaitio  remedies. 

Erythema    serpens.— Morrant    Bakery    gavo_ 
name   to    an   aifection   which    has  since  been 


an    iutcretting  lUwusaion  of    tbza  aubj^ot   ^'?  Park 
mrmi-^Ly    '^Trophic    DiHOnA«fl  of  tbu  Feet;    su  AiiomaEoua  ai 
Ujmnictricat  CatK  uf  Sclnrodactyliu  withRuyiiaud's  Pheiiomeiiii 
*»f.  /ok™.  Dfrm.,  Pehniary,  lOOl. 
L    t  St.  BartholoiuDw'H  HoBpitol  Ueinrti,  vol  is.,  1873. 


¥■ 


164   NEUROTIC  AFFECTIONS  OF  THE  SKIN.  [chap.  x. 

described  independently  by  Rosenbach  under  the 
designation  of  "'  erysipeloid."  •  It  appears  to  be 
due  to  inocuiation  with  poisonous  matter,  and  is 
seen  most  frequently  in  cooks,  butchers,  and  persons 
who  handle  game,  skins,  etc.  It  shows  iteelf  as  an 
erythematous  eruption  which  starts  from  the  seat  of 
B  small  injury,  doubtless  the  point  of  inoculation, 
generally  on  the  fingers,  especially  about  the  knuckles. 
It  spreads  centrifugal  ly,  clearing  up  in  the  centre  as 
the  edge  advances  :  the  circle  soon  breaks  up,  and 
when  first  seen  the  lesions  generally  present  them- 
selves as  blotches  of  pink  erythematous  rash.  There 
is  no  leucocyte  suppuration,  and  no  involvement  of 
the  lyraphatics  of  the  arm.  The  subjective  symptoms 
consist  of  local  tingling,  burning  or  shooting  pains ; 
there  may  also  be  some  nervous  excitement.  The 
duration  is  from  a  fortnight  to  six  weeks,  the  average 
being  three  weeks.  Rosenbach  believes  that  the 
affection  is  due  to  a  mirro- organ  ism,  supposed  to  be 
B  cladothrix,  which  exists  in  decomposing  animal 
matter.  He  found  a  coccus  associated  with  the 
disease,  the  inoculation  of  pure  cultures  of  which  pro- 
duced a  typical  attack  of  the  disease  within  forty- 
eight  hours. 

Dermatitis  serpens  appears  to  be  quite  distinct 
from  dermatitis  repeus. 

Diabetic  ^an^rene. — in  diabet««  localised  in- 
flammation, ending  in  gangrene,  is  not  unfrequently 
observed  in  the  foot,  especially  in  one  or  other  of  the 
toes.     It  is  not  always  the  distal  end  that  is  attacked. 

I   The  lesion  sometimes  affects  a  circumscribed  area  on 
the  sole,  the  ball  of  the  toes,  oi  the  dorsum.     The  part 

'  Ijecomes  inflamed,  bullie  are  formed,  and  more  or  less 
Axt«neive  sloughing  takes  place.    The  process,  as  a 

I  nile,  affects  only  one  side.     Kaposi  f  has  described  a 

tThaHdliingm  d.  drulrrh  ',\>„/l.rl.afl /.  CA.f-.,  April,  1H87, 
+  Op.oit.,ti.,p.<8!l, 


HYSTERICAL   GANGRENE.  ii>5 

case  of  what  he  calls  "  builo-Herpiginous  diabetic  gan- 
grene," in  which  the  left  leg  was  the  seat  of  an  erup- 
tion of  disaerainated  bullte  on  an  inSamed  base,  with 
Bubsequent  formation  of  eschars.  From  the  affected 
part,  as  from  a  centre,  the  process  extended  ser- 
piginously :  the  lesions  took  several  months  to 
cicatrise,  and  death  occurred  only  after  the  process 
had  invaded  the  tibio-tarsal  joint.  Gangrene  of  the 
penis,  toes,  etc.,  has  ako  been  observed  in  association 
with  diabetes. 

Hysterical  gang-rene.— So-called  "spontane- 
ous "  gangrene  of  the  skin  has  occasionally  been  seen 
in  young  women,  mostly  in  those  presenting  unmifl- 
takabln  signs  of  hysteria  and  aciemia.  The  patient 
suddenly  feels  a  sensation  of  bamiDg  on  some  part 
of  the  skin,  usually  the  cheat  or  the  arms.  On 
examination  a  raised  and  somewhat  red  spot,  varying 
in  size  from  a  shilling  to  a  crown  piece,  is  seen  in  the 
place  where  the  sensation  was  localised.  In  a  few 
hours  the  skin  becomes  bluish-black  or  greenish- 
brown  in  colour,  and  a  leathery  eschar  is  formed 
resembling  that  produced  by  the  application  of  sul- 
phuric acid.  This  separates  in  due  course,  and  its 
place  is  taken  by  a  hypertrophic  cicatrix.  The 
same  process  is  repeated  in  other  parts  at  intervals 
of  a  few  days  or  weeks,  and  this  may  go  on  for  months 
or  even  years,  and  then  finally  stop.  This  descrip- 
tion is  taken  almost  verbatim  from  Kaposi,*  who 
expresses  no  suspicion  of  the  genuineness  of  the  phe- 
nomena. To  me,  however,  the  facts,  as  given  by 
him,  are  strongly  suggestive  of  imposture.  Max 
Joseph  has  recorded  a  case  of  multiple  neurotic  gan- 
grene of  the  skiu-t 

Glossy  skin.— As  the  result  of  injury  to  the  trunk 
of  a  nerve  supplying  a  particular  part  of  the  integu- 


•Op.c 

t  -fiv*. 


:i.,  Jut 


NEVRUTW  AFFECTIONS  OF  THE  SKIS,  [cai 

ment,  a  peculiar  change  is  often  observed  wliioh  ia 
known  as  "  glossy  skin."  The  first  account  oi  this 
condition  was  given  by  Paget  many  years  ago.  After 
injury  to  the  brachial  plexus,  he  noticed  that  the  J 
fingers  assumed  "  a  smooth,  glossy,  tapering  appear- 
ance, almost  void  of  wrinkles,  and  hairless,  pink  or  \ 
ruddy,  or  blotched  as  if  with  permanent  chilblains, 
and  associated  with  this  condition  of  tbe  skin  was 
diatressing  local  pain."  *  A  fuller  account  of  the 
condition  was  given  by  Weir- Mitch  ell,  Morehouse,  and 
Keen  f  from  their  vast  experience  ot  nerve  injuries 
during  the  American  Civil  War.  They  compare  the- 
appearance  of  the  affected  skin  to  that  of  a  highly 
polished  scar.  The  skin  easily  becomes  inflamed, 
excoriated,  and  fissured.  Characteristic  changes  in 
the  nails  are  also  observed.  They  are  curved  botJi 
in  the  longitudinal  and  in  the  transverse  direction, 
and  the  cutis  beneath  their  free  ends  is  sometimes 
thickened.  The  condition,  in  short,  is  one  of  atrophy 
with  degeneration  of  the  skin,  rendering  it  more 
vulnerable  by  injurious  influences  of  all  kinds  owing 
to  impaired  nutrition.  This  is  dependent  on  neuritis 
of  the  trunks  from  which  it  derives  its  nervous  supply, 
and  the  efiect  is  the  same  whether  tbe  nerve  lesion 
is  the  result  of  injury  or  disease.  This  "  glossy  j 
skin  "  is  observed  in  non- tube rcula ted  leprosy,  gout^  ^ 
rheumatism,  etc.,  as  well  as  after  traimiatism. 

The  condition  tends  to  disappear  as  the  nervous  1 
influence  is  restored  either  by  subsidence  of  the  •! 
neuritis  or  by  the  establishment  of  a  collateral  supply. 

Localised  atrophy  of  the  skin  may  be  the  I 
result  of  tropho-neuiosis ;   it  may  take  the  form  of 

*  "Surgical  Fatholasy."  tbirl  cditiou.  Lolidou.  ISTO.  p.  32. 
PugPt'a  rases  were  iiubGiiluDd  in  tba  Mol'nl   T,m--ii  -iml  (ias^t4    ^ 
oflUreh  2eth.  IS64.  ' 

i  "■Gunshot  Bull  othiT  Injuria  uf  Nerves,"  PhiloJelphin, 


X.]  LOGAUSBD  ATUOPHY  OF  THE  SKI2i.    107 

linear  streaks  or  striie,  or  lesa  commonly  of  maculse, 
A  good  example  of  the  formej  has  been  recorded  by 
Ohmann-Dumesni!.*  A  littie  girl,  who  had  been 
severely  burnt  on  the  wrist,  some  years  afterwards 
presented  atrophic  rectilinear  areas  about  three- 
quarteiB  of  an  inch  in  width,  and  varying  from 
three- quarters  to  two  inches  in  length,  on  the  front 
of  the  arm  and  forearm,  apparently  following  or  lying 
directly  over  the  brachial  and  radial  nerves.  The 
areas  were  five  in  nnmber ;  they  were  distinctly 
depressed,  and  the  colour  was  paler  than  that  of  the 
normal  skin,  but  warmth  made  them  redder  than  the 
healthy  integument.  On  pinciiiog  up  the  afiected 
skin  it  waa  felt  to  be  thinner  than  in  other  parts. 
Strise  may  also  be  the  result  of  injury  during  growth, 
pregnancy,  and  other  conditions  in  which  the  skin  is 
subjected  to  stretching. 

Charcot's  bed-sore.  —  A  form  of  localised 
gangrene  of  the  akin  has  been  described  by  Charcot 
under  the  name  of  ''  acute  bed-sore."  Its  character- 
istic feature  is  the  suddenness  of  its  development.  It 
is  generally  associated  with  transverse  myelitis,  some- 
times with  abscess  of  the  brain,  and  is  in  that  case 
situated  on  the  side  of  the  body  opposite  to  that  of 
the  cerebral  lesion. 

Trophic  ulcers.— Trophic  ulcejs  are  the  result 
of  direct  injury  to  nerves,  or  in  some  cases  of  reflex 
irritation.  They  generally  spread  serpiginous ly,  and 
are  preceded  and  accompanied  by  pain  of  neuralgic 
character  referred  to  the  area  of  distribution  of  a 
particular  nerve.  The  ulcers  often  form  under 
vesicles  or  bullw,  and  leave  indehble  depressed  or 
cheloid  scars  (Brocq).  In  some  cases  the  process 
takes  on  a  gangrenous  character. 

Perforating'  ulcer  of  the  foot  is  a  special 

•  Brit.  Jom,>.  Un-~..,  IBttI,  p.  'HG. 


\\)H   NKUHOTW  AFFKCTIONS  OF  THE  SKIN.  [chap.  x. 

form  o(  (.rop)ii<)  ulceration  generally  seen  on  the  foot, 
hut  (HMMiHionally  alHo  on  the  hand.  It  is  the  result 
of  prc^MMun^  or  injury  in  an  extremity  in  which,  owing 
to  poriphoral  or  central  lesion,  the  proper  nervous 
Hupply  iM  intorfonnl  with.  It  occurs  in  locomotor 
nhixy  luul  in  Hvphilis,  leprosy,  etc.,  as  well  as  in 
cMiKtv*  oi  inj\iry  to  the  nerve.  The  most  common 
Hit\intion  o\  the  ulcer  is  at  the  point  of  greatest 
prt»H»\irc.  such  as  the  under  aspect  of  the  metatarso- 
phalangoal  joint  of  the  big  or  little  toe,  or  the  ball  of 
tht^  grtvit  too.  It  is  more  a  sinus  than  an  ulcer,  and 
is  \isua)ly  pjiinKv^^.  The  process  is  generally  very 
clmM\ic.  and  if  the  pressun*  from  walking  is  continued, 
\\\^  fhickon^ni  opidermis  forms  a  kind  of  natural  corn 
shiold  ariMUui  the  opening. 

Lf^prosy.  The  uKvrs  ,^nd  other  lesions  of  the 
skiu  in  non-tuWrvnilHtcii  leprosy,  which  are  all  de|>en- 
dout  on  inrtammatory  losions  of  the  nerves  supplying 
iht^  jitT^.*f?\l  rt*i!Sons,  wi-l  be  described  under  the 
hiMdu^C  of  l.eprvviy  ,0-iipter  XXl.V 

MorVWl'S  disi&ase,— TMs  atfe.tior.  i>  chArio- 
tii>nsi^i   bv    iv4Tv^xvs!^is*   Atto.ks   of   r.eurA*4rI:   TViiTi. 

f.^^C^Ts  V<wi"y  cT.f  CT  r.v:r-  ir\::*:ar>  ::tt;.  i-i 
ywv-tv^kcis  ,'•  :.:,f  yr.A!iA7j?f<  :AVf*>  y'.v.r      A  yf:-:..:jtr 

r» ',v."7i':^s>  vii>  ::ii'  i.p— :i    :  -    '.i.t:  :.ji  ■    V:.-'  :    .  •  ."..i- 


s.]  ACUTE   CIRCUMSCRIBED  CEDEMA.  199 

Jlorvan's  disease  were  examples  ol  leprosy  attenuated 

my    descent    in    an    ancient    population.     Repeated 

latllological  observation  failed  to  give  support  to  tlan 

"potheais,  and  it  has  now  been  conclusively  prnved 

lat  Morvan's  disease  is  a  special  form  of  syringo- 

feyelia,  in  which  trophic  skin  lesions  are  prominent.* 

Syringomyelia.— In    syringomyeUa    the   skin 

Bcotnes  the  seat  of  various  lesions,  such  as  "  glossi- 

hyperkeratinisation,    excessive    secretion    of 

Mreat,  and  whitlows,  leading  to  necrosis  of  the  pha- 

as   in  Morvan's  disease.     There  is  nothing 

pharacteristic  about  the  sldn  lesions  in  syringomyeha, 

Whicli   are  tropho- neurotic   in   origin.     The  disease 

■.itself  belongs  to  tJie  domain  of  neurology,        ^ 

Acute  cipcumseribed  cedema  arising  sud- 
denly and  rapidly  subsiding,  only  to  develop  in 
another  part,  is  a  lesion  of  the  skin  which  is  now 
fairly  famihar  to  dermatologists.  The  onset  is 
usually  preceded  by  slight  general  malaise,  with  some 
gastric  disturbance.  The  process  consists  in  indltra- 
tioii  of  the  skin  and  subcutaneous  tissue,  with  serous 

^exudation.  The  o^dematous  swellings  are  isolated, 
JlfcU  defined,  red  or  reddish  in  colour,  smooth  aud 
g  on  the  surface.     They  vary  in  circumfer- 

'ince  at  the  base  from  a  tive-shiliing  piece  to  the  palm 
of  a  man's  hand  (Brofiq).  They  are  not  the  seat  of 
pain  or  itching,  but  they  sometimes  give  rise  to  a 
slight  feeling  of  tension.  The  ajfectiou  is  sometimes 
associated  with  purpura,!  and  eolic  and  gastro- 
intestinal disturbance  may  be  concomitants  of  the 
flkdn  affection.  More  oft-en,  however,  there  are  no 
general  symptoms.  As  a  rule  they  last  only  a  few 
r  at  most  a  day  or  two.     The  aSection  may, 


200   NEUROTIC  AFFECTIONS  OF  THE  SKIS.  [chap. 

however,  persist  a  considerable  time,  ae  fresh  swellings 
may  continue  to  appear.  Any  part  of  the  body  may 
be  attacked,  but  the  favourite  seats  of  the  swellings 
would  seem,  to  be  the  face  and  the  genitals.  Circum- 
scribed cedema  may  attack  the  mucous  membraneB, 
and  if  the  swellings  develop  in  the  pharynx  or  larynx 
alarming  symptoms  may  ensue. 

The  afiection  is  sometimes  hereditary.     Milroy 
has  traced  it  through  six  generations  of  one  family. 
Among  ninety-seven   individuals,    twenly-two 
the  subjects  of  cedema  ;    in  all  but  two  the  disordej 
was  congenital. 

Acute  circumscribed  cedema  can  only  be  oon' 
founded  with  the  "  giant  "  form  of  urticaria,  but  th« 
itching,  which  is  a  characteristic  feature  of  the  latter 
afiection,  is  absent  in  circumscribed  cedema.  More- 
over, the  swellings  have  not  the  white  centre  which 
is  a  distinguishing  mark  of  urticarial  wheals. 

The  process  is  the  result  of  vaso-motor  disturb- 
ance, the  vessels  actually  implicated  being  those 
passing  from  the  subcutaneous  layer  to  the  corium. 
It  hits  been  suggested  that  the  fundamental  factoi. 
in  the  affection  is  the  development  of  products 
manufactured  in  the  organism  and  circulating  iB 
the  blood.f  These  products,  under  the  operation  (^ 
some  influence,  hereditary  or  acquired,  may  irritate 
the  sympathetic  in  different  parts  of  the  body  and., 
throw  the  regulating  apparatus  of  the  peripheral  cuh 
culation  into  confusion.  Clinically,  acute  circum- 
Bcribed  osdema  presents  certain  analogies  with  othet 
vaso-motor  disorders,  such  as  urticaria  and  exoph- 
thalmic goitre.  Osier  has  shown  that  it  is  related 
to  peliosis  rheumatica  and  erythema  nodosum. 

Acute  circumscribed  o-dema  must  he  treated  on 

•  S.  y.  Med.  Jom;:,  Novemticr  fl,  lfl02. 

t  Joseph   Collins:    Amtr.    J»m.:    Mtd.    Meiiert,    Decelnher,   J 


1 


1 


.  s.]  HYSTERICAL   (EDEMA. 

lines  laid  down  for  urticaria,  oi  which  it  i 


Hysterical  OBdema. — This  is  a  form  of  cedema 
which,  though  noticed  by  Sydenham,  waa  fiUly  de- 
scribed leas  than  twenty-five  years  ago  by  Charcot,  and 
notably  by  Renaut.*  It  is  met  with  in  hysterical 
subjects,  and  is  a  hard  swelling  of  a  violet  colour 
{(Edfime  hleu  des  hygteriques) ;  it  scarcely  pits  even  under 
prolonged  pressure.  The  local  temperature  is  usually 
subnormal,  and  numbness  and  sometimes  pain  of 
greater  or  less  severity  are  complained  of.  The  swel- 
ling, which  is,  as  a  nde,  associated  with  hysterical 
paralysiB  or  contracture,  is  very  persistent ;  but  it  is 
subject  to  extremely  sudden  variations  under  the 
influence  of  emotional  disturbance  or  in  connection 
with  the  menstrual  function.  If  the  redema  reaches 
a  certain  degree  of  intensity  it  may  induce  gangrene 
of  the  akin,  followed  by  deep  and  wide -spreading 
ulceration,  which  may  be  mistaken  for  malignant 
disease.  A  remarkaliie  case  of  an  apparently  miracu- 
lous cure  of  such  a  cancer  is  related  by  Charcot.f 

In  hysterical  n?dema  the  main  part  of  the  treat- 
ment must  be  directed  to  the  restoration  of  the 
system  to  a  condition  of  healthy  etjuiiihrium. 

•  XtdeciM  Mahrne,  Febrimi')-  20,  IS1«I. 


Artificial  eruptions  include  all  skL 
duced  by  the  external  or  internal  action  of  acme 
substance  foreign  to  the  economy.  They  form  natur- 
ally two  great  groups  :^1.  Eruptions  caused  by  the 
direct  contact  of  irritant  substances  with  the  skin 
(dermatitis  venenata).  2.  Eruptions  following  the 
ingestion  of  substances  that  have  a  toxic  efiect  on 
the  system,  manifesting  itself  by  the  production  of 
<iertain  lesions  on  the  skin  (toxic  dermatitis). 

External  Agents, 

The  Jirst  of  these  divisions  includes  all  cntaneoUB 
aSections  produced  by  external  agents.  These  may 
be  of  animal,  vegetable,  or  inorganic  nature.  Among 
the  aoimal  substances  causing  irritation  of  the  akin 
are  :— {a)  parasites  (lice,  fleas,  ete.) ;  (h)  jelly-fish, 
gnats,  wasps,  mosquitoes,  etc.  ;  (c)  irritating  dis- 
charges from  the  body  itself  (in  coryza,  gonorrhcea, 
and  diabetes).  Among  vegetable  irritants  are  : — 
(a)  vegetable  parasites  (achorion  Schonleinii,  micro- 
aporon  furfur,  etc.)  ;  (b)  vegetable  substances  that 
come  iMJciden tally,  or  in  the  way  of  occupatjon,  in 
contact  with  the  human  skin  (rhus  venenata  and 
toxicodendron,  thapsia,  the  common  orange,  arnica, 
etc.).  Among  other  substances  giving  rise  to  akin 
eruptions   by   direct    contact    may   l>e   mentioned 


OHAP.  XL]  INFLUENCE  OF  EXTERNAL  AGENTS.     203 

mustard,  sugar,  soap,  paraffin,  etc.  The  lesions 
cauBed  by  parasites,  whether  of  animal  or  ol 
vegetable  nature,  are  described  in  Chapters  XVI. 
and  XVII. 

The  influence  of  these  various  agents  on  the  akin 
shows  the  greatest  diversity  as  regards  the  nature 
and  severity  of  the  lesions.  Aa  a  general  rule  it  may 
be  stated  that  the  effect  is  proportionate  to  the  length 
of  time  during  which  the  oontact  is  prolonged.  The 
lesions  may  simulate  almost  any  disease  of  the  skin. 
The  erythematous  type  largely  predominates,  but 
frequently  the  eruption  fakes  the  form  of  urticaria 
or  eczema.  The  severity  of  the  process  varies  from  a 
simple  pat«h  of  erythematous  redness,  readily  dis- 
appearing under  preasure,  to  violent  inflammation  of 
the  skin,  presenting  all  the  outward  charact-era  of 
the  formation  of  eschars  and  ending  in  widespread 
ulceration  and  gangrene.  Between  these  limits  every 
degree  of  the  inflammatory  process — papules,  vesicles, 
bnllsB,  wheals,  and  pustules — may  be  seen.  The 
erythema  is  always  followed  by  more  or  less  des- 
quamation ;  the  vesicles,  bullte,  and  pustules  by 
crusts  and  scabs.  As  the  result  of  prolonged  irri- 
tation the  skin  sometimes  becomes  thick,  harsh,  and 
wrinkled,  while  it  is  at  the  same  time  the  seat  of 
a  chronic  eruption  characterised  by  papules  and 
excoriated  vesicles  and  resembling  lichenoid  eczema 
(Brocq). 

Aa  typical  examples  of  the  effect  produced  by 
certain  vegetable  irritants  on  the  skin,  mustard  and 
rhus  may  be  taken.  The  former  produces  redness 
and  vesication  :  in  some  cases  the  process  may  run  on 
to  an  actual  dermatitis  of  erysipelatoid  character, 
and  even  ulceration  may  1)b  produced.  The  lesions 
may  persist  for  several  weeks.  There  are  three 
varieties  of  rhus,  all  oi  which  have  strongly  irritant 
properties,  but  only  certain  persons  are  susceptible 


ARTIFICIAL    EEVFTIONS.  [chap,  s 

to  their  action.*  Those  in  whom  the  idiosyncrasy  I 
" .  very  pronounced  may  be  ailocted  even  by  the  i 
volatile  emanations  from  the  plant.  The  eruption  is 
usually  eczematous  in  character  ;  the  hands,  aimB, 
and  face  may  lie  enonnously  swollen.  Distant  parts 
may  share  in  the  general  eruptive  disorder.  There 
is  always  intense  itching.  Erysipelatoid  inifainina' 
tion  of  the  skin  and  dermatitis  exfoliativa  a 
frequently  observed.  Rhus  vernix  is  much  employed 
in  Japan,  and  to  it  the  so-called  "  lacquer  poisoning  " 
is  due.  Touching  furniture  that  has  been  varnished 
witii  this  substance,  or  even  sleeping  in  a  room  where 
some  of  the  furniture  has  been  so  treated,  often 
Bufiices  to  induce  an  attack  in  those  predisposed  there- 
to. The  effect  on  the  skin  is  violent  dermatitis,  with 
much  swelling  of  the  eyelids  and  face  generally,  and 
with  more  or  less  severe  headache,  dizziness,  and  con- 
stitutional disturbance. 

Trade  eruptions.  — Among    eruptions    caused 
by  the  contact  of  irritant  substances,  many  are  of  tha 
nature  of  diseases  of  occupation.     Thus  persons  who  ( 
often  handle  paraffin,  petroleum,  tar,  bichromate  ol  I 
potash,  sugar,  salt,  Ume,  sulphur,  croton  oil,  etc:, 
all  subject  to  eruptions  of  varying  character  aoA.  I 
severity  directly  due  to  their  occupation.     The  a 
is    true    of    bakers,    paperhangors,    dye 
chemists,  washerwomen,   etc.     The  lesions  in  ( 
case  may  assume  any  of  the  forms  that  have  \ 
mentioned,  but  in  the  majority  the  aSection  more  Ot  ' 
less  closely  simulates  eczema  :    and  in  patients  pn> 
disposed  to  affections  of  the  skin  the  trade  eruption 
not  seldom  develops  into  true  eczema  if  the  irritation 
causing  it  is  sufRcicntl}'  prolonged. 

Rdntg-en  ray  dermatitis.— A    form  of   arti- 


(iiiAP.  XL]  FEJONEr/  ERUPTIONS.  2U5 

ficial  dermatitis  is  set  up  by  prolonged  exposure  to  the 
Rontgen  rays.  A  caae  reported  by  Crocker  has 
akeady  been  referred  to.  A  complete  account  of 
the  subject  has  been  given  by  Gilchrist.* 

Feigned  eruptions.— Artificial  eruptioas  are 
sometimes  produced  by  the  patients  themselves, 
either  to  excite  sympathy  or  to  escape  work.  The 
subjecta  are  mostly  hysterical  girls,  beggars,  prisoners, 
malingerers,  or  iunatics.  Some  of  these  impostors 
become  by  practice  artists  of  sufficient  skill  to  deceive 
the  unwary  practitioner.  The  Bubatancea  used  are 
chiefly  crotou  oil,  nitric  acid,  carbolic  acid,  essence  of 
turpentine,  iodine,  mustard,  thapsia,  cantharides, 
and  urine.  The  points  which  shoidd  give  rise  to 
suspicion  are : — The  situation  of  the  lesion  (breast, 
limbs,  or  otiier  easily  accessible  part,  the  left  side 
being  for  obvious  reasons  much  more  often  chosen 
as  the  seat  of  operation  than  the  right)  ;  the  total 
absence  of  eruption  in  other  situations  ;  the  anoma- 
lous outline  of  the  Itsions,  which  may  be  angular, 
and  may  resemble  nothing  seen  in  disease  ;  the  want 
of  Bymmetry,  or  less  frequently  the  too  perfect 
symmetry,  at  once  suggesting  the  work  of  art  rather 
than  of  nature.  Circumstantial  evidenoe  of  fraud 
is  also  frequently  supplied  by  the  smell  of  the  agent 
with  which  the  lesions  have  been  produced  (e.y.  tur- 
pentine), by  stains  on  the  skin  or  the  clothes  (e.g. 
nitric  acid),  or  by  particles  of  mustard  or  other 
irritant  being  found  on  the  patient. 

The  affections  most  often  simulated  are  erythema, 
ulcerations,  and  cliromidroBis  (caused  by  blacklead, 

.).     Colcott  Fox  and  Sangster  have  reported  cases 

'  rhich  sores  on  the  skin  were  produced  by  per- 


,  p.  n. 


ARTIFICIAL    ERUPTIOf^'S.  [chap.  xi. 

iringiy  rubbing  a  spot  with  the  enda  of  the  fingers 
moistened  with  saliva.* 

In  the  French  army  thapsia  juice  ia  in  great 
favour  witi  malingerers,  on  account  of  the  erysipelaa- 
iike  inflammation  of  the  skin  which  can  be  induced 
by  means  of  it.f  Patients  of  this  kind  will  often 
inflict  a  good  deal  of  pain  on  themselves,  and  will 
snip  out  pieces  of  skin  with  sciseors,  burn  themselves 
with  lighted  matchcR.  etc.,  with  a  fortitude  worthy  of 
a  better  cause. 

Internax.  AiiENTa. 

Among  eruptions  caused  by  internal  agents  are 
included  all  those  produced  by  substanoes  swailowed 
either  as  food  or  as  medicine.  In  the  former  case 
(he  agent  is  generally  a  particular  article  of  diet  in 
regard  to  which  the  patient  exliibita  an  idiosyncaraay. 
The  eruption  which  in  many  persona  follows  the  eating 
of  shell'^h.  especially  mussels,  may  be  taken  as  the 
type  of  this  skin  aSection  ab  ingeslis.  The  prooesB 
has  already  been  described  under  Urticaria  {p.  77), 
and  need  not  be  further  referred  to  here. 

Drug*  eruptions.  —  Drug  eruptions,  properiy 
speaking,  include  those  caused  by  the  external  ss  well 
as  the  internal  use  of  medicinal  substances,  inasmBch 
as  a  drug  applied  to,  and  producing  lesions  in,  iim 
skin  may  also  be  absorbed  into  the  circulation,  so 
that  it  is  difficult  to  separate  the  one  effect  from  tiw 
other.  In  this  province,  as  Brocq  well  says,  indi- 
vidual susceptibility  is  the  most  important  factor; 
it  is  that  which  determines  the  appearance  of  Hm 
eruption  and  the  form  which  it  assumes.  The  erup- 
tions caused  by  drugs  present  a  variety  of  type  that 
delies  all  classification  :  they  may  be  erythematoua, 
uittoarial,  papular,  vesicular,  bullous,  etc.  etc.      A 

■  laimt.  DeGcmlieF  30.  1SS2. 


CHAP.  XL]  DRUG  ERUPTIONS.  207 

particular  patient  generally  reacts  in  the  same  way  to 
the  same  drug.  The  lesions  are  seldom  multiform 
at  a  given  time,  though  almost  every  variety  may 
be  exhibited  in  the  course  of  an  eruption  at  different 
stages. 

As  for  the  mode  in  which  drugs  produee-eniptioiiB, 
various  theories  have  been  advanced.  According  to 
Farquharson,  when  from  any  cause  there  is  dimin- 
ished activity  of  the  kidneys,  which  are  the  natural 
channels  by  which  most  medicinal  substances  are 
eliminated,  the  skin  vicariously  assumes  the  functions 
of  these  organs,  and  the  drug,  in  working  its  way  out- 
wards through  the  cutaneous  glands,  irritates  the 
skin  and  produces  lesions  of  various  kinds.  This 
theory  would  imply  that  before  an  eruption  can  be 
produced  the  drug  must  have  accumulated  to  a  greater 
or  leas  amount  within  the  body.  This,  however,  is 
not  by  any  means  the  rule,  for  the  smallest  dose  of 
a  drug  will  produce  an  eruption  in  some  persons, 
while  in  other  cases  very  large  doses  may  be  taken 
for  a  long  time  continuously  without  producing  any 
effect  whatever  on  the  skin.  But  in  the  case  of  the 
halogens  it  is  probable  that  the  eruptions  which  they 
produce  are  due  to  the  excretion  of  the  drug  by  the 
cutaneous  glands.  Another  theory  is  that  certain 
drugs  have  an  elective  affinity  for  certain  anatomical 
elements,  and  that  in  this  way  some  medicinal  sub- 
stances naturally  gravitate,  as  it  were,  to  the  cutane- 
ous glands.  In  proof  of  this  ia  adduced  the  fact  that 
traces  of  the  drug  are  often  found  in  the  lesions  which 
it  lias  produced.  This,  however,  is  probably  nothing 
more  than  an  accident ;  it  is  certain  that  the  most 
careful  testa  frequently  fail  to  reveal  any  trace  of  the 
drug  in  the  cutaneous  lesions,  while  it  is  readily  found 
in  the  urine. 

Behrend  has  advanced  the  view  that  drug  erup- 
tions, with  the  exception  of  those  caused  by  the 


w 

I 


ARTIFICIAL    EBCPTIOXS. 


[CB 


bromides  and  iodides  and  the  eirthemas  produced 
by  belladonna,  hyoscramua,  stramonium,  and  possibly 
aisenic,  are  due  to  the  presence  in  the  blood  of  some 
foreign  material  generated  by  the  action  of  the  drug 
tbia  material  he  thinks  probably  of  chemical  nature. 
It  is  a  sufficient  refutation  of  this  theory  that  drug 
eruptions  arc  often  confined  to  particular  parts  of 
the  cutaneous  surface,  whereas,  if  tbcy  were  due  to  an 
alteration  in  the  blood,  one  would  expect  to  see  them 
wherever  that  fluid  circulatea.  My  own  view  is  that 
— at  least  in  the  majority  of  cases — the  mechanism 
of  drug  eruptions  is  the  same  as  that  of  the  erythe- 
matous, vesicular,  bullous,  and  pustular  afiecttons 
which  they  simulate — that  ia  to  say,  the  process  is 
angio-neorotic  in  character.  It  has  abeady  been  ex- 
plained that  the  simple  mechaiusm  of  ' 
paralysis,  followed  by  the  phenomena  of 
and  inflammation  in  varying  d^rees,  is  sufficient  to 
account  for  the  production  of  an  ascending  series  of 
lesions,  ranging  from  simple  erythema  up  to  gangrtme 
and  iniLsmuch  as  all  these  various  lesions  are  simu- 
lated by  drug  eruptions,  there  appears  to  be  no  reason 
to  look  farther  for  an  explanation  of  their  mode  tA' 
action.  In  short,  it  may  be  stated  that  drug  emp* 
tions  arise  in  response  to  irritation  of  nerve  endiii|p, 
as  when  medicinal  substances  are  applied  eztemally 
to  the  skm,  or  to  irritation  of  nerve  centres  (■ 
motor),  as  when  drugs  are  taken  internally. 

Morrow  has  pointed  out  that  a  large  proportaoa 
of  the  medicinal  agents  which  determine  emptive 
disturbance  act  specifically  upon  the  nervous  system. 
Prom  this  point  of  view,  the  individual  predispositioa 
or  idios3T)craay,  which  ia  a  necessary  underlying 
condition  for  the  production  of  drug  eruptions,  ia, 
as  has  already  l>een  said  in  a  previous  chapter,  nothing 
but  abnormal  excitability  or  instability  of  the  nervoiu 
eyetem.    Tlus  may  possibly  be  combined  in  the  ol 


1 

"I 


CHAP,  xi.)  DRVa  ERUPTIONS.  •2M 

of  cases  under  consideration  with  undue  suscepti- 
bility of  the  skin  to  irritation.  The  skin,  being  the 
organ  of  tactile  sensation,  is  in  the  most  intimate  con- 
nection with  the  nervous  systcan.  So  close,  indeed, 
in  some  persons  is  the  sympathy  between  the  nerve 
centres  and  the  sldn,  that  the  latter  is,  as  it  were,  a 
mirror  on  which  every  passing  shade  of  nervous  im- 
pression or  mental  emotion  is  reflected.  It  is  not, 
therefore,  to  be  wondered  at  that  it  should  often  re- 
spond sympathetically  to  nervous  disturbance  pro- 
duced by  central  or  peripheral  irritation.  In  the  case 
of  drugs  which  excite  or  irritate  the  nervous  aystem, 
it  may  be  laid  down  as  a  general  rule  that  the  greater 
the  nervous  disturbance,  the  more  severe  will  be  its 
manifestations  on  the  skin.* 

The  diagnosis  of  drug  eruptions  ia  not  always 
easy.  Those  following  the  external  application  of 
irritating  substances  are  usually  limited  to  the  part 
with  which  the  agent  has  been  in  contact ;  more- 
over, in  some  cases  the  lesions  themselves  present 
certain  definite  characters  by  which  they  can  be  recog- 
nised. These  will  be  referred  to  in  connection  with 
the  several  agents.  The  rashes  produced  by  drugs 
taken  internally  often  simulate  those  of  the  specific 
fevers,  or  of  certain  toxtemic  conditions,  so  closely 
that,  if  rise  of  temperature  and  constitutional  dis- 
turbance happen  to  be  associated  with  them,  it  is 
almost  impossible  to  distinguish  them.  Thus,  co- 
pailia  eruption  resefflbles  that_fif,iaeaale3^and  thosel 
oTTjeUadpona  jind.  quinine  that  of  scarlet  te^ei.  AnI 
important  point  ia  the  sudden  occurrence  of  an  erup-i 
tion  during  the  administration  of  a  di'ug  ;   and  if,  on 

*  For  u  Lucid  diocuEBion  of  the  mgde  rrt  action  of  dnigfl  in  pro- 
ducing skin  lesions  tlie  rfwler  is  referred  to  tiio  valniible  papers 
by  H.  O.  Brooke  on  "  Behrend's  XHvisiou  of  Drug  Bodies  into 
Spodflc  nnd  Dynamic  Groupa"  {Bril.  Jouni.  IleriH,.  Oct.,  1890), 
nlid  to  Colcott  Foi'b  "  Coiitrilmtiou  (o  tho  Study  of  Dniff 
BrniitionB"  (iiirf.,  Nov.,  1890). 


I 


ARTIFICIAL.    ERUPTIONS. 


[OHAP.  H, 


diacontuniing  the  use  of  that  drug,  the  eruptioa 
vanishes,  it  may  safely  be  concluded  that  the  two 
stood  to  each  other  in  the  relation  of  cause  and  effect. 
In  addition  to  this,  the  drug  may  be  found  in  the 
urine,  the  saliva,  or  the  sweat.  This,  as  a  rule,  holds 
good  only  when  the  drug  has  been  taken  in  large 
quantities  or  for  a  long  period  of  time.  In  the  case 
of  certain  substances — such  as  turpentine  and  othw 
essential  oils — their  presence  in  the  ui 
obvious  to  the  sense  of  smell ;  in  the  case  of  the  bal- 
samic preparations  the  drug  reveals  itself  by  the  smell, 
of  the  patient's  breath.  Otiiers,  again — such  oq,' 
arsenic  and  nitrate  of  silver — produce  a  characteristios 
discoloration  of  the  skin  which  is  sufficient  of  itself^ 
to  indicate  the  cause.  As  a  general  rule,  it  may  bo 
eaid  tiiat  in  the  case  of  eruptions  appearing  suddenly, 
or  presenting  features  different  from  those  seen  irt 
idiopathic  skin  affections,  the  practitioner  sliouli]. 
always  make  careful  inquiry  as  to  what  medicines 
the  patient  has  been  taking.  It  is  impossible,  within 
the  limits  of  a  small  text-book,  to  deal  exhaustively 
with  aU  the  varied  lesions  that  may  follow  the  use  of 
drugs ;  and,  after  all,  there  are  only  two  drugs  that 
cause  eruptions  of  a  sufQciently  definite  character  to  be 
pathognomonic.  These  are  bromine  and  iodine  and 
their  compounds.  The  skin  legions  to  which  th< 
substances  are  apt  to  give  rise  will  therefore  be  con- 
sidered in  some  detail,  and  a  brief  summary  of 
principal  effects  on  the  skin  that  may  be  produoed 
by  some  of  the  drugs  in  everyday  use — such  as  arsenic, 
copaiba,  mercury,  opium,  belladonna,  and  quinine — 
will  be  given.  The  effects  of  other  drugs  on  the  skii^ 
are  indicated  in  a  tabular  summary  {see  p.  235). 

Bromide  eruptions.— Characteristic  eruptioi 
are  caused  by  the  use  of  bromine  or  its  compounds- 
bromides  of  potassium,  ammonium,  sodium,  etc.  ~' 
primary  lesions  may  be  papules,  vesicles,  wh< 


and  ^ 

leae^l 
oa-^H 

the^ 


■J.]  BROMIDE    ERUPTIONS.  211 

bullffl,  or  erythema touB  patches,  but  by  far  the  most 
common  and  characteristic  lesion  is  a  pap ulo- pustular 
eruption  (bromie  acne)  which  is  said  to  occur  in  about 
75  per  cent,  ol  all  patients  treated  with  bromide  of 
potassium.  Bromie  acne  presents  a  considerable  re- 
semblance to  acne  vulgaris.  Unlike  the  latter,  how- 
ever, the  bromie  lesion  does  not  confine  itself  to  parts 
rich  in  sebaceous  gknda,  and  the  papulo -pustules 
always  develop  without  the  antecedent  existence  of 
comedones  (Morrow).  Bromio  acne  shows  a  marked 
preference  for  hairy  parts  of  the  skin.  The  papules, 
as  a  rule,  precede  the  pustules,  and  they  are  seen 
about  the  forehead  and  nose  and  the  back  of  the 
shoulders,  especially  in  persons  whose  skin  is  thick 
and  greasy.  They  commence  as  small  hyperajmic 
patches  on  an  indurated  base.  Most  of  them  are 
pierced  by  a  hair.  They  may  uadergo  no  change  for 
weeks,  or  they  may  quickly  become  transformed  into 
pustules  of  a  yellowish-white  colour.  Sooner  or  later 
the  contente  escape  and  a  hard  nodule  or  pigmented 
spot  remains.  They  often  give  rise  to  small  rounded 
cicatrices.  This  pustular  eruption  generally  persists 
as  long  as  the  administration  of  the  drug  is  continued, 
and  the  number  of  lesions  increases  as  the  dose  is  aug- 
mented {Veiel).  On  discontinuing  the  drug,  the 
eruption,  as  a  rule,  disappears  in  from  one  to  three 
weeks.  In  women  and  in  children  taking  bromides, 
and  in  infants  nursed  by  mothers  who  are  taking 
them,  the  predominant  type  of  ieeion  caused  by  the 
drug  is  the  "  confluent  acne  "  de8crii>ed  by  Cholmeley. 
This  at  first  resembles  varicella,  the  vesicles,  however, 
running  together  instead  of  drying  up,  and  forming 
.  clusters,  which  continue  to  enlarge  and  finally  sup- 
purate. In  course  of  time,  in  this  way,  flattened 
elevations  are  formed,  covered  with  thick  light-brown 
cniste  and  surrounded  by  a  zone  of  redness.  There 
is  a  tendency  in  these  lesions  to  papillary  hyper- 


212 


ARTIFICIAL    ERUPTIONS. 


trophy,  Bometimes  to  aucli  an  extent  as  to  Bimulato 
condylomata.  The  lega  are  the  chief  seat  of  thiB 
eruption. 

Furunciilar  and  anthracoid  forma  of  bromide  erup- 
tion are  not  imeommon.     The  boils,  which  are  mostly 
of  small  size,  are  commonly  seen  in  the  situations 
generally  affected  by  ordinary  furuncles  (forehead, 
neck,  hairy  parts  of  face),  while  the  anthracoid  swell- 
inga  are  usually  found  on  the  face  and  limbs,  seldom 
on  the  trunk.     The  swellings  are  red  in  colour  and 
well  defined.     The  tops  are  dotted  with  numeroua 
yellow  points  which  give  them  something  of  the  appear- 
ance of  a  carbuncle.     After  a  time  a  scab  is  formed, 
and  involution  takes  place  rapidly  if  the  drug  is  dis- 
continued.    If  it  is  pushed,  however,  ulceration  is 
pretty  sure  to  take  place.     Sometimes  the  bromide 
eruption  assumes  an  ulcerative  character  almost  from 
the  first.     Largo,  irregular  ulcerated  patches  form 
symmetrically    on    the    legs.     The    granulomatous 
tumours  arising  in  such  cases  may  be  mistaken  for 
certain  other    forma  of  tumour.*     The  drug  may  bo 
continued,  to  allay  the  discomfort  from  eruptions  ofrj 
which  it  is  actually  the  cause.     The  ulcerated  surface' 
is  firm,  and  is  composed  of  large  raised  masses  oftett>i 
papillomatous   in   appearance.    Warty   growths 
the  face  have  been  described  as  a  result  of  bromii 
medication    (Veiel).     Though   bullous    elements   ai 
Bometimes  associated  with  other  lesions  due  to  bro*i 
mide,  true  buUce  without  more  or  less  solid  base  wwS 
with  fluid  contents  are  rare  (Colcott  Pox).     The  ajlsr 
pearance  of  bromide  eruptions  is  not,  as  a  rule,  acconf' 
panied   by   fever  or  constitutional  disorder.     Thrff' 
not  uncommonly  develop  on  scar  tissue.     They  oftMii 
eighbourhood  of  the  sebaceous  gland^i 
and  hair  follicles,  bat  are  not  by  any 


•  1 


1.]  BROMIDE    ERUPTION'S.  213 

to  these  sitiiatioiis.  Idiosyncrasy  plays  a  compara- 
tively subordinate  part  in  the  production  of  bromide 
eruptions.  So  constant,  indeed,  is  their  occurrence, 
given  the  necessary  conditions  of  dose  and  persistence 
of  administration,  that  the  changes  in  the  skin  may 
with  propriety  be  classed  among  the  exaggerated 
physiological  efEecta  of  the  drug.  Idiosyncrasy  does, 
however,  come  into  play  in  some  cases  when  very 
small  doses  are  followed  by  the  development  on  the 
skin  of  some  of  the  lesiona  that  have  been  described. 
TSie  drug  in  all  probabihty  produces  its  effect  through 
the  nervous  system,  but  at  present  there  are  not,  so 
far  as  I  am  aware,  any  data  from  which  its  exact 
modus  operandi  can  be  interred. 

The  acneilorm  bromide  eruptions  lesions  are  easily 
distinguished  from  those  of  acne  vulgaris  by  the 
absence  of  comedones,  and  by  their  occurrence  at  any 
period  of  life  and  on  any  part  of  the  body.  The 
anthracoid  swellings  are  differentiated  from  carbuncle 
by  the  absence  of  a  red  border  and  of  brawny  indura- 
tion around.  In  many  cases  the  smell  of  bromine 
in  the  breath  and  it-s  presence  in  the  urine  at  once 
point  to  the  true  origin  of  the  skin  lesions. 

Iodic  eruptions. — Eruptions  produced  by  the 
action  of  iodine  or  its  salts  (iodide  of  potassium,  iodide 
of  ammonium,  iodide  of  sodium,  etc.)  are  erythema- 
tous, papular,  urticarial,  veaicular,  and  sometimes 
bullous  in  type.  The  erythematous  form  is  the  most 
frequent  among  the  earlier  manifestations  of  the  in- 
fluence of  the  drug  on  the  skin.  The  redneas  may  be 
scattered  about  in  small  or  large  patches,  or  pretty 
generally  diffused,  the  favourite  situations  being  the 
chest,  the  face,  and  the  forearms.  At  a  later  period 
papules  and  wheals  may  develop  on  the  erythematous 
ground,  and  on  these  wheals  large  capillary  vessels 
are  frequently  seen.  Vesicles  may  also  develop  on  the 
erythematous  patches.    These  are  usually  discrete, 


^H  214 

^^H  and 

^^H  wliici 

^"  type 


ARTIFICIAL   SBVPTIONS. 


and  are  sometimes  asaociated  with  wheals,  around 
which  a  ring  of  clear  vesiclea  may  iorm.  The  bullous 
type  of  eruption  is  comparatively  rare.  The  bullie  are 
sometimes  mingled  with  vesicles  and  pustules.  They 
may  be  as  large  as  a  pigeon's  egg,  and  if  two  or  three 
coalesce,  as  they  sometimes  do,  enormous  blisters 
may  be  formed. 

The  iodic  eruptions  often  commence  «8  hard 
papules  which  have  the  shot-like  feel  characteristic 
of  the  earliest  stage  of  small-pox  pustules.  As  the 
papules  become  transformed  into  vesicles  they  fre- 
quently show  a  tendency  to  umbilication.  They  are 
for  the  most  part  surrounded  by  an  erythematous 
areola,  and  the  skin  about  them  is  generally  more  oi 
lesa  infiltrated.  The  papulo-pustular  form  is  the  most 
common  and  the  most  characteristic  eruption  caused' 
by  the  iodides.  The  face,  the  upper  part  of  the  chest, 
the  backs  of  the  shoulders,  and  the  arms  are  the  parts 
in  which  it  chJofiy  shows  itself.  This  form  also  begins 
as  shot-hke  papules,  which  become  pustular  either 
at  the  summit  or  throughout  their  whole  depth  as 
they  develop.  These  pustules  dry  up  and  form  crusts, 
which  leave  a  scar  on  becoming  detached.  In  other 
cases  the  papules  develop  into  vesicles  and  even  bulls, 
or  they  may  become  transformed  into  red,  hard 
nodules  deeply  implanted  in  the  tissues  and  disap- 
pearing very  slowly.  From  these  elementary  lesiona 
various  more  complex  forme  of  eruptions — ecthyma- 
tons,  condyloma  told,  moUuacoid,  etc. — may  arise. 
Among  the  other  forms  of  eruption  caused  by  iodides 
there  is  one  of  carbuncular  type  resembling  the  "  con- 
fluent acne  "  already  deatiribed  as  a  frequent  efieot 
of  the  bromides.  The  little  boil-like  nodules  are 
violaceous  in  colour,  with  a  depressed  centre  covered 
irith  a  scab  and  studded  at  the  circumference  with 
numerous  sebaceous-looking  pustules.  Wben  these 
ilbsions  disappear  they  leave  a  brownish  scar.      A  pur- 


:>] 


lODK     hRtrpTlONS. 


puric  eruption  Bometimes  appears  on  the  legs  as  the 
result  of  treatment  with  iodides  (Fournier).  The 
petechiBB  almost  always  come  out  within  a  very  few 
da\8  of  the  bogmmng  of  treatment.  Stephen  Mac- 
kenzie has  reported  a  fatal  case  of  iodic  purpura  in  a 
child  caused  by  a  smgle  do<w  of  two  and  a  half  grains.* 


A  nodular  form  of  iodide  eruption  has  been  described 
(Fig,  II),  Hard,  red,  painful  nodules,  varying  in  size 
from  a  nut  to  an  egg,  come  out  on  the  face,  neck, 
buttocks,  thighs,  and  calves.  The  eruption  closely 
resembles  erythema  nodosum.  Aa  a  rule  the  effect 
of  iodides  on  the  akin  is  restricted  to  one  type  of 
lesion  in  any  given  case,  but  sometimes  the  eruption 
~*|  polymorphous.  Iodide  eruptions  are  often  asso- 
•  nini!.  Jftit,  Xetei,  NoTembor  IT,  1S88. 


ARTIFICIAL    ERUPTIOXS. 


[CB 


^V   216 

r  ciat«d  vith  renal  and  caiyliac  inadequacy,  and,  thongli 

I  usually  of  little  practical  importance,  occasionally  as- 

^^_  same  a  grave  character  and  react  unfavourably  or 
^^K  even  dangerously  on  the  patient's  general  condition. 
^^H  The  eruption  generally  shows  iuelf  within  a  week  of 
^^^P  the  commencement  of  adminiatratioa  of  the  drug,  bat 
^^^  tiie  interval  varies  according  to  dose  and  individual 
susceptibility.  After  it  has  subsided  one  small  doae 
may  suffice  to  bring  it  out  again  in  a  very  fev  hours. 
According  to  some  observers,  the  salts  of  iodine  vary 
somewhat  in  their  power  of  producing  skin  eruptions, 
the  iodide  of  ammonium  being  the  most  and  iodide 
of  sodium  the  least  active  in  this  direction. 

In  the  early  stages  the  papular  form  of  iodic 
eruption  may  simulate  small-pox,  and  the  resemblance 
is  increased  by  the  umbilication  which  occurs  when 
the  papules  develop  into  vesicles.  The  absence  of 
severe  constitutional  symptoms,  however,  and  the 
rapid  disappearance  of  the  eruption  on  discontinuing 
the  drug,  will  quickly  clear  up  any  doubt  that  may 
exist.  lu  some  cases  iodic  eruptions  mav  simulate 
acne  or  varicella,  but  here  again  the  coincidence  of 
the  skin  lesions  with  the  administration  of  the  drug, 
their  aggravation  by  increase  of  the  dose,  and  theii 
disappearance  on  suspending  tlie  treatment,  will  pre- 
vent any  misitppnOicnsiuu  as  to  their  nature. 

Kupial  ami  other  forms  of  iodide  eruption  may  be 
mistaken  tor  syphilitic  lesions,  and,  in  the  words  of  . 
HoiTow,  "  iodide  of  potassium  may  be  continued, 
possibly  iu  iucruasinK  doara,  fur  the  very  conditiaa. 
.  which  It  has  cauawl." 

On  (.■ompnriitg  the  eruntions  caused  by  bromides 
with  those  canned  by  iiMlidcs,  it  will  be  soon  that  tiie 
eesontial  lesion  in  each  is  a  dermalilis  showing  a  ten- 
dency to  localisation  about  the  HelmcT^ius  glands.  In 
each  the  eruption  may  t«bf  the  fonu  of  papulea, 
pustules,  vwiclon,  biillH,  uimIuIm,  and  almost  every 


OHAP.  XT.]  IOD!C  EUVPT10N8.  217 

variety  ol  combination  of  these  elementary  lesions. 
These  often  coalesce,  and  large  swellings  with  crusts, 
warty  excrescences,  and  ulcere  may  result.  The 
bromide  eruptions  are,  as  a  rule,  slower  in  their  de- 
velopment and  ieaa  painful  than  those  caused  by 
the  iodides.  Moreover,  the  latter  are  usually  smaller 
than  the  former,  and  confluence  is  less  frequently 
observed.  In  the  case  of  both  bromide  and  iodide 
eruptions  the  parts  chiefly  affected  are  the  face  and 
limbs,  especially  around  hair  follicles. 

Iodoform. — The  use  of  iodoform  in  surgical 
dressings  sometimes  causes  irritation  of  the  skin. 
This  is  in  the  majority  of  cases  accompanied  by 
greater  or  less  constitutional  disturbance.  The  rash 
is  generally  erythematous  in  character,  papules, 
vesicles,  and  even  bullse  not  unfrequently  developing 
on  the  inflamed  surface.  Sometimes  the  eruption 
rather  approximates  to  the  eczematous  tj^e.  Pur- 
puric lesions  have  in  rare  cases  been  observed  in 
connection  with  the  application  of  iodoform.  In 
cases  where  idiosyncrasy  in  relation  to  the  drug  is 
pronounced,  intense  iteWng,  with  rise  of  temperature 
and  swelling  of  the  hwida,  arms,  and  face,  may  be 
caused  by  simple  contact,  as  in  dresaing  a  wound  with 
an  iodoform  bandage  (Morrow). 

OrthofOrm.  —  Orthoform,  when  apphed  to 
ulcerated  surfaces,  may  also  give  rise  to  eruptions. 
Dubreuilh  *  groups  them  under  two  lieads  :  erythe- 
matous eruptions,  with  or  without  complicating  veai- 
cutation  or  pustulation  ;  and  gangrene.  In  the  latter 
case  the  appearance  is  said  to  resemble  that  of  lupus 
vulgaris  treated  by  pyrogallic  acid. 

Arsenic. —Arsenic,   when  applied  to   the   skin, 
acts  as  an  irritant,  causing  dermatitis ;  used  in  a  con- 
mtrated  form,  and  for  a  long  period,  it  is  a  caustic. 

•  La  Frttif  MidicnU,  No.  40,  1901. 


SIS 


ARTIFICIAL  ERUPTIONS.         [okat.  jl 


The  irritant  effects  are  usually  seen  after  the  use  of 
the  drug  in  lotions  for  the  complexion,  in  dusting 
powders  for  children,  and  in  various  industrial  pro- 
ductfl — notably  artificial  flowers,  green  wall-papers, 
certain  aniline  dyes  (in  stockings,  under-veats,  et«,). 
The  resulting  lesion  is  at  first  erythematous  in 
character,  and  on  this  vesicles  and  pustules  often 
develop ;  and  aometimes,  especially  about  the  scrotum 
and  pudenda,  small,  shallow,  clean-cut  ulcers  may 
result.  When  given  internally,  arsenic  may  cause 
exacerbation  of  acute  inflammatory  disorders  of  the 
skin.  When  no  previous  cutaneous  affection  exists, 
the  internal  administration  of  the  drug  may  cause 
dermatitis,  with  papular,  vesicular,  urticarial,  pete- 
chial, and  pustular  lesions  ;  boils  and  carbuncles  are 
also  sometimes  observed.  A  general  acarlatinifonn 
eruption,  with  inflammation  of  the  conjunctiva  and 
mucous  membrane  of  the  respiratory  passages  {lead- 
ing in  the  nose  not  unfrequently  to  ulceration  and  per- 
foration of  the  septum),  has  sometimes  been  observed. 
A  conunon  elfect  of  arsenic  on  the  skin  is  the  produc- 
tion of  a  peculiar  greyish  or  brownish  discoloration, 
with  desquamation  in  various  parts.  The  prolonged' 
administration  of  the  drug  also  aometimes  gives  rise  to 
general  thickening  of  the  epidcrmia  on  the  palms  and 
soles,*  and  occasionally  to  the  formation  of  small 
corns  ;  if  the  drug  is  persevered  with,  these  corns  may 
assume  an  epitheliomatous  character  (Hutchinson). 
It  is  well  known  that  arsenic,  like  other  drugs  rf 
the  metallic  group,  has  been  given  for  a  long  time  ' 
large  doses,  as  in  chorea,  and  that  in  such  cases 
sometimes  produces   peripheral   neuritis;    this    tuck. 


the  auxt,  in  wbich  kemtuKi*  nS  the  uult 
to  foUow  licLeii  («^  Brooke.  Sril.  Jum;, 
bare  been  of  aiBeiitcBl  origin, 


I  pomble  th&C  k 
a  And  iDlea  baa  (em 
Dtrm.,  1891.  p- 18)  » 


CHAP.  Ki.]  CHLOSAl  ERUPTIONS.  219 

probably  explains  the  occurrence  of  zoeter  and  other 
forma  of  herpes   in  association  with   treatment  by 

On  the  basis  of  facts  observed  in  the  epidemic  of 
arsenical  beer  poisoning  which  occurred  in  the  north 
of  England  and  Midland  counties  in  1900,  Brooke 
and  Leshe  Roberta  f  conclude  that  arsenic  and  the 
other  members  o£  the  nitrogen  group  raust  be  dis- 
tinguished from  all  other  medicaments  by  the  fact  that 
their  action,  whether  therapeutic,  pharmacological, 
or  toxicological,  ia  entirely  dynamic,  and  consiats 
essentially  in  altering  the  ratio  to  the  tissues  of  one 
of  the  most  active  normal  constituents  of  the  body, 
namely,  oxygen. 

Chloral. — Chloral  hydrate  acta  as  an  irritant 
when  apphed  to  the  skin,  and  Hitter  J  thinks  it 
superior  in  some  ways  to  cantharides  as  a  vesicant. 
When  given  internally  it  occasionally  causes  a  diffuse 
erythematous  eruption  on  the  skin ;  thia  generally 
begins  on  the  face,  and  may  spread  to  the  neck  and 
cheat,  and  may  also  affect  the  extremities.  An 
eryalpelatous-looking  flushing  of  the  head  and  face  is 
one  of  the  commonest  forms  of  chloral  rash.  On 
other  parts  of  the  body  the  eruption  sometimes  occurs 
■  in  patches  or  scattered  dusky  red  spots,  giving  the 
skin  a  mottled  appearance  (Morrow).  The  rash  comes 
out  as  a  rule  within  ten  days  of  the  commencement 
of  administration,  is  unattended  with  conatitutional 
disturbance,  and  quickly  fades.  The  taking  of  food 
and  the  drinking  of  tea,  and  eapeeially  of  alcohol,  has 
a  marked  effect  in  intensifying  and  extending  the 
eruption ;  and  even  when  chloral  ia  no  longer  being 
taken,  the  rash  may  for  some  days  come  out  after  each 

•Cf.Meuettu:  "  Les  Dflrnrntil™  Arstnitulea,"   Aim.  ile  Ikmi. 


^ 


220  ARTIFICIAL  ESUPTIONS.         [ohap.  n. 

meal.  In  some  cases  it  is  distinctly  Ecarlatinifoiin 
in  character,  and  may  spread  over  the  entire  auriace 
of  the  skin.  This  condition  is  often  accompanied  ^^ 
by  fever  and  is  followed  by  desquamation.  Papular, 
nrticarial,  vesicular,  and  petechial  eniptions  haV9 
also  been  described  as  occurring  in  connection  with 
the  taking  of  chloral.  The  mucous  membranes  majf 
be  aSected  as  well  as  the  ekiu.  Chloial  rash  bears  a 
close  resemblance  to  that  produced  by  copaiba,  bell^~ 
donna,  and  quinine.  The  characteristic  odoui  of 
copaiba  is,  however,  absent,  while  the  throat  is  not 
effected  as  in  the  case  of  belladonna ;  the  abaence  oi 
mydiiasiB,  which  is  eo  characteristic  an  efiect  of  tha 
latter  drug,  is  another  point  of  distinction.  From 
quinine  eruption  the  ekin  lesions  caused  by  chloral! 
can  be  distinguished  by  the  marked  effect  which  a  full 
meal  or  alcohol  almost  always  has  on  the  latter. 
From  measles  and  scarlatina  chloral  eruption  is  dif- 
ferentiated by  the  absence  of  coryza  and  sore  throat 
respectively. 

Copaiba  and  cubebs.  —  These  drugs  caua© 

eruptions  on  the  skin  tliat  vary  in  character,  thft^ 
erythematous  and  papular  forms,  however,  pra- 
dominating.  The  lesions  are  gencrujly  seen  aroon^' 
the  wrists,  ankles,  and  knees  ;  often  on  the  haad^ 
and  feet,  breast,  aad  abdomen ;  sometimeB  tiiej 
spread  over  the  whole  body.  The  most  character 
iatic  effect  of  copaiba  on  the  skin  is  the  so-callej 
"  balsamic  erythema,"  which  consists  of  amali  discrete 
erythematous  papules,  apparently  seated  at  the 
follicles,  and  sometimes  agminated  into  patehea. 
These  patches  may  also  become  confluent.  Vesicif 
lar,  urticarial,  bullous,  and  petechial  forms  also  ocoW* 
and  the  eruption  may  simulate  erythema  multiformeiL 
The  copaiba  rash  might  possibly,  from  its  appearance 
be  mistaken  for  an  erythematous  syphilide.  or  lor  th(| 
esanthem  of  an  eruptive  fever,  especially  rothel^ 


CHAP.  XL]        BELLADONNA    EBVPTIONS.  221 

when  the  papular  element  predominates.  The  charac- 
teriBtic  violet-like  odour  of  the  drug  will,  in  the 
majority  of  cases,  prevent  such  an  error  ;  but  it  must 
be  remembered  that  the  balsamic  eruption  and  ery- 
thematous ayphilide  occasionally  coexist. 

Belladonna.— The  rash  caused  by  the  use 
(external  or  internal)  of  belladonna  or  atropine  is 
generally  erythematous  in  type  ;  it  is,  as  a  rule, 
diffuse,  and  closely  resembles  the  exantliem  of  scarlet 
fever.  The  face,  neck,  and  trunk  are  the  usual  seats 
of  tlie  eruption,  and  a  stinging  or  pricking  sensation 
in  the  affected  skin  is  commonly  complained  of.  The 
rash  quickly  disappears,  and  is  not  followed  by 
desquamation.  Children  with  fine  skins  are  par- 
ticularly subject  to  eruptions  from  the  use  of  bella- 
donna. In  ophthalmic  practice  the  use  of  atropine 
ia  sometimes  followed  by  severe  dermatitis  resembling 
erysipelas. 

Chlorine. — An  acneiform  eruption  caused  by 
contact  with  chlorine  has  been  noted  by  Henheimer. 
Bettmann  •  has  reported  two  cases  in  powerful  men 
who  had  been  at  work  cleaning  out  the  place  for  the 
manufaoture  of  hydrochloric  acid  in  a  chemical 
factory.     The  disease  was  very  obstinate. 

Formalin.  —  The  use  of  formalin  occasion- 
ally produces  eruptions  on  the  skin.  In  a  case  under 
the  care  of  Dr.  Lewis  G.  Glover,  of  Hampstead,+  a 
young  lady  was  attacked  by  violent  urticaria,  prac- 
tically covering  the  whole  body,  after  using  a  hair 
lotion  containing  formalin  in  bay  mm.  The  face 
was  swollen  so  that  the  features  were  scarcely  recog- 
nisable, and  great  wheals  were  observed  on  the  trunk 
and  extremities.  A  large  amount  of  erythema  was 
also  present,  and  the  discomfort  was  so  great  that 
d^  was  impossible.     No  local  dermatitis  on  the 

•  Iki".  uTil.   Worh.,  July  4,  1901. 
t  B<-il.  /uHCH.  Drrin.,  1901,  p.  164. 


ASTIFICIAL    ERUPTIONS.  [uHiP.  h^ 

Bcalp  was  produced.  An  eczematoid  eruption  on  the 
fingers  ia  sometimes  cauaed  by  handling  aolutiona  of 
the  substance  in  the  preparation  ol  museum  speci- 
mens.* After  putting  cotton-wool  soaked  in  a  weak 
solution  ol  formalin  into  a  hollow  tooth,  Fisher  noted- 
an  urticarial  eruption  on  his  own  body. 

MercilPy. — The  irritation  of  the  skin  caused  by 
the  external  use  of  mercury  varies,  according  to  the, 
stiength  of  the  application  and  the  length  of  time 
contact  is  prolonged,  from  slight  erythema  to  seve» 
dermatitis,  which  may  run  on  to  ulceration  and. 
sloughing.  The  most  common  lesion  is  eiythematouS' 
redness  with  the  formation  of  vesicles,  especially- 
around  the  hair  follicles  ;  these  vesicles  often  develop, 
into  pustules.  Such  eruptions  have  been  very, 
common  since  corrosive  sublimate  became  fashion- 
able among  surgeons  as  an  antiseptic.  Certain  widely: 
advertised  preparations  for  the  removal  of  pimplM. 
and  blotches  from  the  face  contain  corrosive  sub- 
limate, and  serious  effects,  local  and  general,  have 
been  known  to  follow  the  use  of  them.  When  taken' 
internally,  mercury  may  produce  almost  any  kind  of 
skin  lesion,  and  the  effect  of  the  drug  may  simulatfri 
urticaria,  herpes,  impetigo,  or  furuncle  ;  sometimes 
it  produces  extensive  ulceration.  In  the  majority 
of  cases,  however,  the  eruption  is  erythematous  or 
scarlatiniform  in  type ;  desquamation  sometime^ 
follows.  In  certain  cases  violent  eruptions,  resemb* 
ling  pityriasis  rubra,  may  be  produced.  The  skin^' 
lesions  caused  by  the  internal  use  of  mercury  are  no' 
unfrequently,  however,  polymorphic.  The  eruptioi 
is  often  preceded  by  itching  and  dryness  of  the  skin, 
and  in  severe  cases  it  is  ushered  in  by  constitutional 
disorder.  The  symptoms  often  come  on  quite  sud- 
denly, not  unfrequently  after  a  single  dose  of  the  drug. 


CHAP.  XI.]  MEUCURY   AND  OPIUM  ERUPTIONS,    223 

The  malaise  generally  ceases  on  the  appearance  of  the 
eruption. 

The  visceral  and  other  symptoms  of  mercurialism 
(stomatitifl,  etc.)  are  frequent  accompaniments  of 
the  skin  eruption.  The  average  duration  of  the 
latter  is  from  one  to  three  weeks,  but  the  condition 
may  persist  for  six  months  or  more.  The  diagnosis 
is  not  always  easy ;  measles  and  the  other  ex- 
anthematous  fevers  have  to  be  excluded,  and  all  other 
possible  sources  of  drug  eruption  have  also  to  be 
ehminated.  When  the  affection  is  severe  the  prog- 
nosis is  often  serious.  A  case  of  malignant  mercurial 
dermatitis  ending  in  deatli  has  been  recorded  by 
Mari.* 

Opium.  —  The  intolerable  itching  sometimes 
caused  by  opium  was  known  to  Dioscorides  and  other 
ancient  writers,  who  speak  of  it  as  pruritus  o/iii. 
The  eruption  caused  by  it  Is  mostly  scarlatioiform  in 
character  ;  sometimes  it  is  morbilliform,  consisting  of 
small  discrete  spots,  bright  or  dusky  red  in  colour. 
The  face,  neck,  and  Sexor  surfaces  are  the  usual  seate 
of  the  eruption,  the  appearance  of  which  is  generally 
preceded  by  local  heat  and  itching.  The  rash  may 
involve  the  whole  cutaneous  surface,  making  the 
patient  "  as  red  as  a  lobster."  Desquamation  is  the 
rule.  The  rash  quickly  disappears  on  discontinuing 
the  drug ;  but  in  those  susceptible  in  this  way  to  the 
influence  of  opium  an  eruption  is  almost  eertain  to 
follow  the  adiuinistration  of  it  in  any  form.  Similar 
effects  often  result  from  the  internal  or  subcutaneous 
administration  of  morphia.  The  latter  is  also  apt  to 
cause  local  inflammation  and  abscesses  in  the  skin, 
unless  proper  antiseptic  precautions  are  employed ; 
these  conditions  may  lead  to  the  formation  of  very 
obstinate  ulcers. 


w 


ARTIFICIAL   EROFTIOSS. 


Quioine. — QuininQ,  and  all  preparationa  of  cin- 
chona, may  give  rise  to  skin  eruptions.  Externally 
applied,  it  is  not  an  irritant  to  the  healthy  skin,  I 
workers  in  quinine  factories  are  subject  to  emptli 
which  are  no  doubt  due  to  absorption  of  the  drug. 
These  lesions  are  mostly  eczematous  in  character,  and 
generally  come  on  suddenly  ;  the  parts  chiefly  affected 
are  the  bands  and  forearms,  thighs  and  genitals. 
Lichenoid  and  urticarial  eruptions  have  been  seen  to 
follow  the  application  of  ointments  or  solutioos  coa- 
taining  sulphate  of  quinine.  The  hypodermic  use  rf 
the  drag  is  sometimes  followed  by  widespread  exy- 
thema,  abscesses  at  the  sites  of  injection,  and  ulcei 
tion.  When  given  internally  it  causes  skin  lesions  at 
the  most  various  types.  The  crytheniatoua  ioim 
predominates  ;  but  macules,  papules,  vesicles,  bullse^ 
pustules,  wheals,  and  petechia  are  not  uncommon. 
On  analysing  sixty  cases  of  quinine  eruption,  pub*- 
lished  during  a  period  of  ten  years,  Morrow  *  fouod 
that  in  thirty-eight  the  general  character  of  thft. 
eruption  was  erythematous  ("  scarlatinal,"  "  measly," 
etc.) ;  in  twelve  it  was  urticarial,  with  "  iBdema, 
"  puffinesa  of  the  face,"  etc.  ;  in  a  few  cases  it  waa 
papular  and  vesicular  or  petechial.  Bullous  and 
gangrenous  forms  of  quinine  eruption  have  also  been. 
described.  In  diagnosis,  the  chief  source  of  poaaibkj 
confusion  is  the  close  resemblance  of  the  rash  to  thttf 
of  scarlatina  in  many  cases — a  likeness  which  iB  iDitd^r' 
all  the  greater  by  the  fact  that  the  quinine  eruptaoQ 
may  afiect  the  mucous  membrane  of  the  throat  as  well 
as  the  skin.  Usually,  however,  the  quinine  eruption 
is  not  accompanied  by  fever  ;  but  sometimes  there  is 
considerable  constitutional  disturbance.  The  subsid' 
encG  of  the  eruption  on  discontinuing  the  drug  uA' 
the  presence  of  the  latter  in  the  urine  are  the  pol&t9-j 
of  distinction. 


1 

"J 
i| 


H^oau-  xi-l  SUMMARY  OF   DRUO   ESUPTIONS.         *iG 

Salicylic   acid,    salicylate   of  soda.  —  Bx- 

ternoUy  applied,  salicylic  acid  is  more  irritating  than 
carbolic  acid,  even   a  2  per  cent,    solution  causing 
the  appearance  of  irritable  vesiclea  in  the  neighbour- 
hood of  wounds  (Callender).     The  internal  uae  both 
of  aalicylic  acid  and  of  salicylate  of  soda  sometimea 
gives    rise    to    erythematous,    urticarial,    vesicular, 
pemphigoid,  and  petechial  lesions  on  the  skin.*     The 
erythematous  lesions  resemble  those  caused  by  anti- 
pyrin,  chloral,  etc.,  and  their  appearance  is  generally 
accompanied   by   some   febrile   disturbance.     Some- 
times   the    rash    closely    resembles    that    of   scarlet 

throat  and  systemic  disturbance,  it  may  be  difficult 
to  distinguish  the  one  condition  from  tlie  other.     In 
some  cases  the  administration  of  the  drug  is  followed 
by  the  appearance  of  a  morbilliform  rash. 

A  summary  of  the  eruptions  caused  by  other 
drugs  in  common  uae  will  be  found  in  the  table  here 
appended  :^    . 

Exlertvai^  applied  r   Rodneas,  itolling  vesiolea, 

InternaUy    adminuiered:    Vesicular    eruption 
with  formication  and  itching ;  eome- 
timps  puatules  and  lileba. 

^^^ 

InlerimBu  adminiilered  .■  Slate -coloured  oyano- 
bIb. 

SilernnUy  applied  :  Vttrioloid  eruption  :  Bome- 
timea  ecthymntoufl  ulcers  and  exten- 
sive dsatruction  of  tissue. 

InitraaUy  adminintercd  :  Veeiculo-pustular  and 

varioloid    eruption    like    that    pro- 
duced by  Bjrterual  applicatiau. 

^^^^B'&i)  ebepbord:  Jbuiik   Oil.  and  Gni.    Uria.  Sis.,  vol.  xiv.,             H 
^^^Re,  JsQuarr,  1 S96.                                                                                             ■ 

^H     226                    ARTIFICIAL    ERUPTIONS.          [chap.  si.     ■ 

^^^L  Antipyrin 

tdon,     with    pcofiisB    sweating    and 

back.  Bomptimes  on  lirobB,  eapeoially 
flexor   surfaces.     Raah   uBually    de- 
Boribed  aa  "  meaaly." 

OF     greyish-black     discoloratioii     ol 
skin,  Bomewhat  cesembling  Addison's 
diaeaae,  eBpecially  on  face  and  flexiH'     ' 
oBpBcta  of  limbs  (acgyria).     Krythe- 
matoufl  and  papular  eruption  with 
pruritus. 

■  ..„ 

EHermlly  applied :  Erytliemato-veaiuular  erop- 

IrUeTnally  adminUlersd  :  ^ytbema  with  fonni- 
catiou;  diaphoresia. 

^^M  KOuracrf 

ExUrjioBy    applied:     Erytheuifttoua,    Bciema. 
tons,  and  urticariar  oniptiona. 

^^^H     Boraoic  acid 
^^B     Borate  of 
^B       Bodium 

ExteTKoay  ap-plUd  ;  Erythematous  rash  on  faoe, 
trunk,  and  oxtremitiea  (after  wuh- 
ing  out  pleura)  j  impetigo  after  long. 
use  of  borai.      Sometimea  burning 
and  cliarring  of  akin. 

asis  (GowerB). 

^H    CodeoU 

which  may  spread  over  large  WM  j  , 

eruption,  like  "  tar  acne  "  on  haixj  • 
parte  {Sycotiii  cadiqite  of  B8.an). 

^^B     CuuubiB 

Inltnalls  adminiiterrd  :  Papulo-veBipiUar  mip.^ 
tion  on  scalp,  face,  neck,  trunk,  anSl 
limbs.       Only    one    case    on    nMMM|l[ 
(Hyde).     In  poisouing  by  the  drttft 

1.]    SUMMARY    OF   DRUQ   ERUPTIONS.      227 

'Externalti/   applied:    Veaioantj     akin   around 

,  blister    may    become    covered    with 

veBiclea,  which  are  often  couHuent ; 

Mm    I  .niption  .omrfme,  yunnie.  Maim.. 

touB    character,    Hnd    extends    over 

I  whole   body.     In   persons   of  feeble 

i  constitution     ulceration     and     gan- 

I  grene  may  follow  application. 

\ExleTnaUy  applitd  :  Erythema  up  to  complete 
destruction  of  tissues,  accordin<;  to 
strength  of  preparation.  Rash  often 
acoompnnied  by  toxic  effects  (head- 
ache,  vomiting,   oliguria,   and   dark 


1.). 


ExternaUi/  applied :  Hs^ersemia  with  pnmo- 
juioe  discoloralioG  of  skin  ;  erythe- 
matous, papular,  pnatular,  ami 
fnrunculHr  eruption.  Erysipelas- 
like  Bwellhig  of  head  and  face.  Ex. 
foliative  dermatitis. 


ExtentdUy  ap'plied .-  Erythematous,  papular, 
Teaioular,  pustular  eruptions.  Some- 
times secondary  eruptions  appear  on 
distant  parts  (from  absorption  ?). 


BypodermicaU!/  giiva  :    Painful  black  swelling 
at    site    of    puncture,    phlegmonous 

iinllij  iiitiiiininlered :  Vesicular,  pustular, 
[ii?ti?i'liial.  fiiruncular  lesions,  apha- 
ceUiri,  gangrene  '' 
(ergotism). 


Inkmallji  admmitieTed  .-  Acneiform  eruption  on 
face,  breast,  and  neck.  Iodide  o/  iron 
cauHea  i^rythematous,  papular,  urti- 
carial, eczematous  leeiona  (probably 
chiefly  from  iodine  contained  in  it). 

liBod  (acetate  *^e™attff  applied  :    Blackish  or  brownish  dis- 
jjj  coloration, 

wbonate)  ^"'^"wWy  adminislered  :    Erythematous  rash  : 


228                    ARTIFICIAL    ERUPTIOSS.          [chap.  xi.,^| 

Nux  Tomica : 

InitTwMg  odminUlrTed  :  Praritiis  and  formii*. 
tion.     Miliary  or  acarlatiniform  erup- 
tion. 

themat0U9  eruption  on  face. 

I'ix  liquidii 
(tar) 

Externally   appliid :    Erythematoua,   popular, 

ftcne   consiflting   of  bouiIL   hard   red 

Bry  acne  by  biftok  tarry  pointo  ia* 
centre  of  each  papule ;   they  petaU^ 
long  aft«r  tho  applicatiOD,  and  may 
require  three  or  foiir  n-eeka  fw  tbcK, 
complete       involution.      Erytlieni* 

pitoh-plaater. 

rubeoloid,  urticarial  lesiona,                          1 

^H  PodophylUn 

EltemaEy  applied  :  (in  workmen  who  pulvtaiae 
it}  irritant,  eapocially  on  wirotura  and 
genitals. 

producBd    by   bslladonna.    but    lees 
vivid  in  colour;    numbore  of  xmall 
brilliant  petechiic  on   face   (Meiga) ; 
erysipelatoid  infiamiuation. 

B^^"" 

Itilernally  adminislereil :  Diffuse  scariatiniform 
eruption      with      intense      itching ; 
generalised  macular  erythema. 

^H' Sulphur 

ErUnuOlg  applUd  -.   R^li.eas.  papnl™,  painful 
veaicles  (often  conHuont) ;    artifioinl 
eczema.    Papular  and  vesicular  erup- 
tion common  in  those  tating  auiphur 
thtraiiil  liatlis. 

skin;     ecsematoua    eruption,    bfala, 
earbunclFs. 

INOCULATION  RASHES.  22E 

Exlemallji  applied :  Turpetitiue  caiisei  eit^-n. 
sive  redneBB,  veaiclea,  and  infiamma. 
tdry  lesiona.  Very  pprsistent  and 
'ULtractniile, 

Inlcri'nllg  administered  :   Turpentim  may  taust 
erythema   of  wine-red   hui* 
antl  Tipper  part  of  trunk  ;    girofu) 
papula -veainular     eruptii: 
tinJEB  eruption  becooiea 
in  chnracter.      Terebene  may 
bright  red  papular  rash. 


Eruptions  are  occaaionally  caused  by  bitter  at- 
pmd,  calcium  sulphide,  capaicum,  chinoUn,  coDium, 
Blyoscyamua,  ipecacuanha,  cod- liver  oil,  castor  oil, 
phosphorus,  aantonin,  tatmin,  and  veratrum  viride  ; 
but  these  are  so  rare  that  they  are  of  little  practical 
importance.  For  full  information  on  drug  eruptions 
the  reader  is  referred  to  Prince  Morrow's  work  on  the 
subject,  edited  for  the  Sydenham  Society  by  Colcott 
Vox,  who  has  enriched  the  text  with  copious  not«s, 
which  add  greatly  to  the  value  of  the  book.  A  very 
'1  bibliography  of  the  literature  of  the  subject  is 
1  at  the  end. 


Inoculation  Rashes, 


This  seems  to  be  the  most  appropriat*  place  for 
brief  description  of  certain  eniptions  that  follow 
ccination  and  other  inoculations  performed  for  a 
therapeutic  purpose.  At  present  our  eitperience  of 
skin  eruptions  due  to  this  cause — apart  from  vaccina' 
tion — is  very  scanty ;  but  as  the  current  of  thera* 
peutical  opinion  is  setting  strongly  in  the  direction 
of  iajections  of  organic  liquids  (tuberculin,  thyroid 
juice,  antitoxic  serums  of  various  kinds,  testicular 
and  ovarian  extracte,  etc.),  it  will  probably  soon  be 
tsiderably  extended. 
.  Vaccination    eruptions.  —  Prom    the    etio- 


230  ARTIFICIAL   ERUPTIONS.         [chap,  xi. 

logical  standpoint,  I  some  years  ago  suggested  *  the 
division  of  vaccination  eruptions  into  two  principal 
groups  : — 

1.  Eruptions  due  to  pure  vaccine  inoculation. 

2.  Eruptions  due  to  mixed  inoculation — that  is  to 
say,  to  vaccine  together  with  an  additional  virus. 

The  following  classification  of  vaccination  erup- 
tions under  these  two  headings  appears  to  me  to  in- 
clude every  kind  of  eruption  traceable  to  that  source  : 

Group  1. — Eruptions  due  to  pure  vaccine  inoculation  : 

Division  A.  Secondary  local  inoculation  of  vaccine. 

B.  Eruptions  following  within  the  first  three 

days  before  the  development  of  vesicles. 
Urticaria. 

Erythema  multiforme. 
Vesicular  and  bullous  eruptions. 

C.  Eruptions    following    after   development   of 

vesicles  due  to  absorption  of  virus. 

C  Roseola — like  measles. 

1.  ^  Erythema — like  scariet  fever. 
(  Purpura. 

2.  Generalised  vaccinia.     (Fig.  12.) 

D.  Eruptions  appearing  as  sequelae  of  vaccina- 

tion :    eczema,  psoriasis,  urticaria,  etc. 

Group  2. — Eruptions  due  to  mixed  inoculation  : 

Division  A.  Introduced  at  time  of  vaccination. 

Subdivision  a.  Producing  local  skin  disease. 
Contagious  impetigo. 
Erythema. 
Subdivision  b.  Producing  constitutional 

disease. 
Syphilis. 
Leprosy  ? 
Tuberculosis  ? 
B.  Introduced,  not  at  time  of  vaccination,  but 
subsequently,  through  the  wound. 

1.  Erysipelas. 

2.  CelluHtis. 

3.  Furunculosis. 

4.  Gangrene. 

5.  Pyajmia. 

*  Jiritifih  Medical  Juimml,  November  29,  1890,  p.  1229  et  aqq 


CHAP.  XI.]  VACCINATION    RASHES.  231 

There  ia  one  vital  point  of  difierence  between  the 
eruptions  in  these  two  groups  respectively.  Those 
lielotiging  to  Group  1,  depending,  as  they  do  lor  tlie 
moat  part,  on  idiosyncrany,  are  practically  unavoidable. 
On  the  other  hand,  those  in  Group  2  are  preventible 
by  using  only  pure  vaccine  lymph  with  the  strictest 
antiseptic  precautions, 

The  eruptions  belonging  to  Division  A  ot  Group  2 
may  be  local  lesions,  or  manifestations  of  constitu- 
tional disease.  To  the  former  category  belongs  con- 
tagious impetigo,  wliich  can  be  inoculated  with  the 
vaccine  virus,  become  developed  in  the  vesicles,  and 
spread  by  auto- inoculation  to  all  parts  of  the  Blcin. 
Another  local  manifestation  is  a  dermatitis  or  ery- 
thema, which  starts  from  the  areola  and  spreads  over 
a  limited  area,  passing  imperceptibly  into  healthy 
skin.  This  is  often  spoken  of  as  true  erysipelas,  but 
as  it  never  extends  to  other  parts  of  the  skin,  it  is  in 
reality  only  a  local  dermatitis. 

A  peculiar  "  raspberry  excrescence  "  has  been  . 
described  by  American  writers  as  sometimes  appearing 
from  three  to  seven  days  after  vaccination.  It  begins 
as  a  red  elevation  at  the  site  of  inoculation,  but, 
instead  of  advancing  to  the  vesicular  stage,  it  remains 
bard,  dense,  bright  red  in  colour,  and  nodular  in  form, 
looking  not  unlike  a  small  naavus.  It  is  very  persis- 
tent, is  not  foUowed  by  a  scar,  and  does  not  confer 
immunity.* 

As  regards  constitutional  disease,  Hutchinson  has 
proved  that  syphilis  may  be  transmitted  by  vaccijia- 
tion ;  but,  judging  from  the  rarity  of  vaccinal  syphilis 
as  compared  with  the  inherited  form  ot  tlie  disease, 
it  seems  probable  that,  if  pure  lymph  is  used,  syphilis 
cannot  be  transmitted  before  the  eruptive  period. 

*  Welch  ftnd  Schamberff, 
"The  ComphcatiauB  of  Viii 
July  6,  \Wii, 


.1  llTIh'irlAL    EIIVPTIONS. 


That  lepDHj'  miiy  be.  transmitted  by  vaRcination  is  I 
inhoTontly  proltablo  from  the  fact  that  the  dieeaee  it 
inocuhible.  That  it  has  actually  been  so  transmitted  j 
tliurc  K  extremely  little  decisive  evidence  to  show.  J 
I  know  of  only  two  published  cases  of  the  kind  I 
which  will  bear  examination.  Both  of  these  wera  T 
ri'iiiili-il  1i\  n.iuliler,*  I  know  of  no  evidence  that  I 
!■      ■  ■     'i!  ■  -  iiJnsis  has  ever  been  transmitted  by  J 

^  1 Hr.  (Iraham  Little.f  however,  has  re- 

]"'ri''l  I rs  (ibserved  by  hiroBelf  and  three  by  ( 

t'okutt  t'ox,  w  liidi  seem  to  show  thftt  the  transmission  J 
of  lupua  is  at  least  a  possible  accident  of  vaccination.  J 
Fox,  however,  does  not  think  that  any  conclusion  of  I 
scientific  value  can  be  drawn  from  these  cases.  Ths  | 
vaccination  sores  may,  he  suggests,  have  been 
latcd  secondarily,  or  a  previous  tuberculous  centre  1 
may  have  existed  and  an  embolus  found  its  way  to  ] 
thi^  sear. 

Passing   to   Division   B   of  Grouji  2,  true   ery- 
■  RJpulaa    occasionally    occurs.       It    is    distinguiefaed    , 
from  the  local  dermatitis  above  referred  to  by  ita 
characteristic  margin,   swelling  and   tension  of  the  J 
skin,  high  fever  and  general  constitutional  dialiurb-  « 
ance,  and  by  the  rapidity  with  which  it  spresda 
over  the  limbs  and  the  body.    Cellulitis  is  ext^eme^^  j 
rare.     Boils  are  occasionally  seen  after  the  eigfalli,* 
day,  not  only  near  the  pustules,  but  on  other  parts  of   , 
the  body.     Gangrene  has  in  rare  cases  attacked  tllft  " 
vaccine  vesicles,  causing  extensive  sloughing,  and  io  :, 
one  instance  a  general  vaccinia  is  said  to  have  become  ■ 
gangrenous    (Hutchinson).    Pyiemia    is    extreme^  . 
rare;   it  is  caused  by  the  introduction  of  pus  cocci -J 
into  the  wound.  J 

•"UeW  Lepra   iitid  ileron  CoutngioaitHt,"  Moiiatf.heftr  fSe  t 
Srakt.  e.'1-..i..  Fafj,  I,  18SB,  p.  lil.  " 

tlirit.  Jviirn.  Derm,.  Mareh,  1901.  _ 

Far  further  inf ormntioii  on  vuunual  emptiDUB  the  raader  itM 
tetetnd  to  h  pajiBt  ou  the  subject  r«u3  by  me  at  the  uu ""~  "  '^^ 


CBAP.  XL]  ANTITOXIN    ERUPTIONS.  233 

Vaccination  has  also  sometimes  seemed  to  be  the 
determining  factor  in  the  production  of  a  definite 
skin  disease.  I  have  seen  it  followed  by  the  de- 
velopment of  psoriasis,  and  quite  recently  I  showed 
to  the  members  of  the  Dermatological  Society  a 
middle-aged  man  in  whom  vaccination  was  appar- 
ently the  starting  point  of  eruptions  having  the 
character  oi  psoriasis  and  lichen  ruber  planus. 

Tuberculin  eruption.  —  The  injection  of 
tuberculin  sometimes  gives  rise  to  a  difiuae  searla- 
tiniform  or  morbilliform  eruption.  The  lesions  are 
generally  situated  about  the  hair  foUicles,  but  small 
erythematous  patches  are  sometimes  si^attered  about 
the  trunk.  The  eruption,  as  a  rule,  recurs  after  each 
injection.  It  is  in  some  instances  followed  by  slight 
desquamation.  The  new  tuberculin  (TR)  sometimes 
produces  similar  rashes. 

Antitoxins.— Bartl I  reports  a  case  in  wiuch  in- 
jections of  tetanus  antitoxin  (Tizzoni  and  Cattanj) 
as  a  remedy  for  tetanus,  caused  an  urticarial  eruption 
which  lasted  thirty-six  hours.  Erythematous  rashes 
also  frequently  follow  the  injection  of  diphtheria 
and  streptococcus  antitoxins  and  various  therapeutic 
serums.  According -to  Washboum,*  the  rashes  which 
occur  during  the  antitoxin  treatment  of  diphtheria 
are,  as  a  rule,  erythematous  or  urticarial,  occasionally 
scarlatiniform  or  morbilliform ;  in  very  rare  casefl 
purpuric  hflsmorrhagea  into  the  skin  have  been  ob- 
served. The  rash  affects  the  body  generally,  but 
especially  the  extensor  surfaces  of  the  limbs.  It 
comes  out  usually  on  the  eighth  day,  but  it  may 
appear  immediately,  or  as  late  as  the  thirty-first  day. 

tiUi  Bridnli  Medicfti  Associtttiou  iii  IBSO,  anit  to  the  diaciuuDii 
which  followed  it  (JSiii.  jlfeJ,  Jmh-hhI.  Nov.  29,  IseO),  An  «it- 
^tellent  ucixiont  ot  thu  vngoriea,  luiomuiies,  unci  comiilicatioag  of 
^ '      '     "  ■  11  is  gilren  by  Theodore  Aclnnii  iii  Allbutt  a  f'</'lem  of 


ARTIFICIAL    ERUPTIONS. 


I 


BawUngs  *  has  recorded  a  case  of  severe  poisoning 
by  antidiphtheria serum,  in  which  the  feb'rile  condition 
was  accompanied  by  a  blotchy  erythema  around  the 
Bite  of  infection,  which  rapidly  spread  to  the  trunk. 
It  was  markedly  circinate  in  places.  There  was  also 
a  good  deal  of  urticaria,  to  which  the  boy  had  pre- 
viously been  liable.  The  eruption  was  accompanied 
by  intense  itching,  and  by  severe  pains  in  the  limbs, 
without  swelling  oi  joints. 

Treatment. — In  the  majority  of  cases  of  drug 
eruptions  the  only  treatment  required  is  to  discon- 
tinue the  use  of  the  drug  that  causes  the  skin  lesions ; 
eessanle  causd  cessat  efjedtts.     In  some  cases,  however, 
the  artiflcial  eruption  may  be  so  severe  in  itself,  or 
may  be  attended  with  complications  of  such  a  nature, 
that  both  general  and    local  treatment  will  be  re- 
quired.    The  chief  indication  in  most  cases  alter  dis- 
continuance of  the  drug  is  to  stinaulate  the  renal  func- 
tion so  as  to  promote  elimination  by  that  channel. 
Diuretics  should  therefore  be  freely  used,  and  drugs 
Bueh  as  iodide  of  potassium,  the  use  of  which  some- 
times cannot  be  interrupted  without  disadvantage  to 
the  patient,   should  be  given  copiously   diluted  in 
Vichy,  soda  or  barley  wat«r,  milk,  eic.    A  saline  purge 
is  also  generally  useful.     Bromide  eruptions  should  be  i 
treated  with  arsenic,  intexnally  ( iii.w;  to  n^v  of  FowUr'aA 
solution    thrice    daily],   and  by    the    applioataon    oil 
lead  lotion.     If  the  drug  must  be  persevered  withi 
(as  in  the  case  of  epilepsy),  a  drop  or  two  of  Fowlnr'al 
solution  added  to  each  dose  of  the  bromide  will  ofteafl 
prevent  the  skin  affection.     Crocker  suggests  m^^ 
[gr.  V  thrice  daily)  as  an   intestinal  antiseptic.     Tbe-J 
same  hues  of  treatment  should  be  followed  in  the  ci 
of  iodide  eruptions.    The  local  treatment  must  I 
conducted    on    general    principles.     Persona    wl" " 
occupation  brings  them  constantly  in  contact  t 
'  St.  B&rtholomew'a  Hospital  Reports,  Deoetober,  1S98, 


CHAP.  XL]  TRKATifENT   OF   DRUtl   ERUPTIONS.    235 

irritant  substances  must  be  advised  to  change  their 
trade  ;  but  this,  of  course,  is  in  many  cases  out  of  the 
question,  and  the  only  measure  of  precaution  that 
can  be  recommended  is  scrupulous  cleanliness  and 
rare  to  avoid  touching  any  unexposed  part  of  the  skin 
with  hands  or  articles  of  clothing  impregnated  with 
the  ofiending  substanca.  It  should  be  borne  in  mind 
that  «tiraulants  often  appear  to  increase  the  tendency 
to  drug  eruptions  and  to  aggravat-e  them  when  already 
exbtent.  This  is  particularly  the  case  with  cidoral. 
The  complications  of  vaccination  must  be  treated 
on  the  general  principles  applicable  to  skin  eruptions, 
and  by  the  local  remedies  suitable  to  the  special 
lesions  produced.  The  possibihty  of  the  inoculation 
of  constitutional  disease  can  now  be  guarded  against 
with  practical  certainty  by  the  use  of  glyccrinated 
vaccine  lymph,  In  regard  to  other  complications, 
I  endorse  the  following  recommendations*  made  by 
the  lAincet  Special  Commission  : — 

"  We  lire  strongly  of  opiniou  that  many  of  the  bad  results 
obtained  in  vaccination  are  doe  to  tlie  presence  of  one  or  othir 
of  the  following  conditions : — Iin[)eriect  sterilisation  of  the 
akio  and  wiiut  of  proteotion  against  the  invasion  of  the 
weakened  and  abraded  tissnes  by  extraneous  orgauisms.  Wo 
liftve  found  that,  given  a  good  lyiupb,  the  application  of  a 
plentiful  supply  of  soap  and  water,  a-  laaat  to  take  off  hairs 
and  anrface  epithelinm,  ethec  to  [omove  fatty  and  sebneeous 
matter,  alcohol  to  waah.  away  the  ether,  superficial  Taccina- 
tion  (hy  sterilised  instruments),  anil  protection  of  the  vao- 
ciiia1«d  surface  throughout  tlie  whole  course  of  the  local 
manifestation  of  vaccinia,  most  excellent  resulte  may  be 
obtained.  The  best  means  of  protecting  the  local  lesion  is 
the  appHcation  of  several  folds  of  sterile  lint  containing  nl) 
ohemical  disinfectant ;  that  is  held  in  position  by  stripH  of 
adhesive  plaster ;  a  layer  of  boric  lint  may  then  be  placed 
Dutsidfi  tms  dressing,  and  the  whole  may  be  cbauged  as  aoon 
OB  the  slightest  evidence  of  moistening  by  serum  a[^ais  in 
tile  boHc  lint." 

•  Laoett,  April  2S,  19(10,  aud  Jotie  27,  1902. 


CHAPTER   Xn. 


Is  no  subject  witliin  the  province  of  dermatology  h 
the  loose  use  of  a  term  given  rise  to  greater  confusidf, 
than  in  the  description  of  the  various  afFections  of  tU 
skin  which  have,  at  one  time  or  another,  been  groupc 
together  under  the  head  of  "eczema."  Willan  a 
Bateman  restricted  the  name  to  a  process  in  whi<^ 
vesicleB  weie  an  esaential  lesion.  The  meaning  of  the 
term  was  afterwards  expanded,  especially  by  French 
observers,  so  as  to  include  nearly  all  the  skin  lesions 
wliich  were  supposed  to  stand  in  relation  to  a  consti- 
tutional dyscrasia,  such  as  gout,  rheumatism,  or 
"  herpetiam,"  that  pathological  phantom  which  is 
held  accountable  for  such  varied  disturbances.  On 
the  other  hand,  Hebra,  and  after  him  the  Vieniia 
ijchoul,  went  to  the  opposite  extreme,  contending  that 
eczema  is  a  purely  local  disease,  which  can  be  excited 
artiHcIally  by  the  use  ol  external  irritante  ;  that,  in 
fact,  the  process  is  simply  superficial  inflammation 
of  the  skin  dependent  on  some  external  cause.  Hebra, 
it  is  true,  admitted  that  constitutional  conditions 
might  predispose  to  the  affection,  but  so  strongly  did 
he  maintain  the  determining  eaiise  to  be  a  local 
irritation,  that  he  included  itch  in  his  dcfinitioa 
of  eczema,  on  the  ground  that  it  is  an  inflammatory 
process  caused  by  a  local  irritant — that  is  to  say,  the 
acanis  scabiei. 

It  is  clear,  then,  that  in  order  to  avoid  con- 
fusion it  is  necessary  in  the  first  place  to  dediie 
the  sense  in  which  the  term  "  ectema  "  is  to  be  em- 


CHAP,  xn.]         DEFINITION  OF  ECZEMA.  337 

ployed,  and  in  the  second  to  adhere  strictly  to  the 
meaning  thus  attached  to  it.  In  the  present  work 
the  term  "  eczema  "  is  used  as  connoting  a  catarrhal 
inflammation  of  the  akin,  ongintUing  withwit  visible 
external  irriifiiion,  and  chamclervied  in  some  stage  of 
its  evolution  bi/  seroiis  exudation.  By  "  catarrhal  "  all 
that  is  here  meant  ia  that  an  essential  feature  in  the 
process  is  an  exudation  of  serum,  either  on  the  surface 
of  the  inflamed  skin  or  into  its  deeper  parts,  where 
the  horny  layer  prevents  the  fluid  from  escaping. 
\Ithongh  eczema  is  essentially  a  catarrhal  disorder, 
and  the  idea  of  moisture  \s  an  integral  part  of  our 
conception  of  the  disease,  it  does  not  follow  that  dis- 
charge must  always  and  in  all  cases  be  present ;  all 
that  is  implied  is  that  esndation,  either  on  the 
surface  or  into  the  deeper  layers  of  the  skin,  ia,  has  • 
been,  or  will  be  a  prominent  feature  in  any  given 

The  definition  of  eczema  here  given  excludes 
all  forjns  of  inflammation  of  the  skin  caused  by 
chemical  or  mechanical  irritants.  The  artificial 
dermatitis  set  up  by  such  agents  is  identical  anato- 
mically with  the  eczematous  process,  and  gives  rise  to 
lesions  indistinquisliabje  from  those  of  eczema,  but  it 
is  not  eczema.  The  source  of  irritation  is  visible, 
and  can  be  appbed  or  withdrawn  at  will ;  the  lesions 
are  distributed  over  what  may  be  caUed  the  area 
of  eitpoaure,  and  their  severity  is  mostly  proportionate 
to  the  strength  of  the  irritant  or  the  length  of  time 
during  which  it  is  applied.  Moreover,  artificial 
eczema  runs  a  definite  course,  and  the  process  is 
always  under  the  patient's  own  control^to  tlus 
extent  at  least,  that  he  can  at  any  time  interrupt 
the  action  of  the  irritant,  when,  as  a  rule,  the  eruption 
will  at  once  begin  to  subside.  AH  the  phenomena 
can  be  reproduced  on  any  part  of  the  cutaneous 
surface  to  which  the  irritant  is  applied,  and  although, 


ECZEMA. 


^^g        £38 

r  owing  to  stnictural  differences,  the  skin  of  difieient 

I  individuals  varies  greatly  in  vulnerability,  and  the 

^^^       patient's  state  of  health  may  have  some  influence  o 
^^^L      the  severity  or  duration  of  the  process,  the  constita- , 
^^^1      tion  has  nothing  to  do  with  the  development  of  the  I 
^^^P      disease. 

^^^  Eczema,  on  the  other  hand,  arises  to  all  appear-  \ 

r  ance  spontaneously — that  is  to  say,  not  in  response  ti 

any  visible  cause  of  irritation ;  its  distribution  has  no-| 
I  relation  to  exposure  to  the  action  of  ext«mal  irritants ; 

it  is  not  confined  to  one  particular  spot,  nor  even  to 
I  one  region  of  the  body,  but  may  affect  all  in  succession 

or  simultaneously.  Lastly,  it  does  not  run  a  definite - 
course,  but  may  smoulder  on  for  long  periods  of  time, 
breaking  out  into  active  conflagration  at  irregular  i 
■  intervals  without  any  assignable  cause.  It  may  be  | 
added  that,  so  tar  from  being  under  the  control  of  tha  . 
I  patient,  it  too  often  defies  all  the  efforts  of  the  phy- 

I  sician.     It  is  evident,  therefore,  that  there  is  some- 

thing more  in  eczema  than  inffammation  of  the  skin 
due  to  a  local  and  transient  cause  ;    there  is  an  un- 
known quantity  beyond  tiiis — a  patliologieal  x,  wbioh.  J 
may  be  either  some  invisible  source  of  irritation  or-1 
some  constitutional  peculiarity,  or  a  combination  of '^ 
both  these  factors. 

Most  recent  writers  follow  Erasmus  Wilson  *  in 
describing  a  number  of  different  forma  of  ecEema — 
erythematous,  vesicular,  papular,  pustular,  squamous. 
etc.  All  these,  however,  are  but  different  stages  of  J 
the  same  process,  and  there  is  no  advantage  in  con-  | 
sidering  them  separately,  although  the  terms  i 
Bometiraea  of  use  in  practice  to  indicate  the  p 
dominant  type  of  lesion  in  a  given  case  or  at  a  p 
ticular  time.  Eczema  Is  essentially  ,  _ 
affection,  and  there  is  no  particular  lesion  which  o 
be  regarded  as  distinctive  of  the  disease.    Tilbaiy  1 

•  "LBLiiitiMouDernuitoloiij."     (Lonclou,  1871.) 


CHAP.  sn.J  CLINICAL   COURSE.  239 

Fox,*  following  Wilkn,  held  that  in  ail  cases  the 
initial  lesion  is  a  vesicle,  though  this  may  not  unfre- 
quently  be  so  small  or  so  evanescent  as  to  escape 
observation.  Colcott  Fos  adheres  to  the  same 
opinion,  Tliough  the  vesicular  stage  is  not  a  neoes- 
Hary  phase  in  the  evolution  ol  eczema,  it  may  be 
admitted  that  the  vesicle  is  the  most  constant  of  all 
the  primary  lesions  by  which  the  disease  manifests 
itself. 

As  no  two  cases  of  eczema  are  exactly  alike,  and 
as  even  ia  the  same  case  there  may  be  the  utmost 
diversity  not  only  in  the  lesions  but  in  the  symptoms 
which  they  produce  in  difierent  parts  and  at  diSerent 
times,  it  is  impossible  to  give  a  complete  clinical 
picture  of  the  disease  in  all  its  varied  aspects  as  met 
with  ia  practice.  All  that  can  be  attempted  here  is 
an  outUne  sketch,  the  details  of  which  must  be  filled 
in  by  each  practitioner  for  himself  as  his  knowledge 
grows  by  experience.  It  will  add  to  the  clearness  of 
the  following  description  it  it  be  premised  that  by  the 
terms  "  acute  "  and  "  chronic  "  the  author  does  not 
mean  to  indicate  Buddenness  of  onset  or  slowness  of 
course,  but  only  grealer  or  less  intensity  oj  the  in/lam- 
matory  ■process  at  a  given  lime. 

An  attack  of  eczema  is  generally  ushered  in  by 
sensations  of  itching  and  burning  in  some  parts  of  the 
cutaneous  surface.  Soon  the  skin  at  these  spots 
becomes  the  seat  of  an  erythematous  biuah,  on  which 
numerous  tiny  vesicles  speedily  form ;  the  afiected 
part  presents  the  classical  signs  of  inflammation — 
BwelUng,  heat,  redness,  and  tension— the  itching,  as 
a  rule,  becoming  more  troublesome  as  the  lesions 
develop.  The  vesicles  grow  larger  and  often  run 
together,  but  they  soon  burst  or  are  broken  by  the 
patient's  hngers  in  scratching,  and  give  issue  to  a 
clear  fluid  which  stiffens  linen.     The  discharge  does 

•  "SHu  Diseuai*.'-     (Luud™,  ISTa.) 


m 


[« 


not  at  once  dry  up.  as  ie  the  case  in  other  vesicular 
ernpttoos,  but  conQoues  to  exude,  more  fluid  being 
poured  out  ae  veaides  of  more  recent  formation  in 
their  turn  break  and  add  their  contents  to  the  general 
ooze.  In  mild  c&ses  the  inflammation  begins  to 
subside  in  a  few  days  ;  the  redness  fades  and  the 
"  weepmg  "  gradually  ceases,  scales  or  cmet8  beiitg 
formed,  under  which  the  abraded  surface  heals.  As 
a  rule,  however,  the  process  continues,  fresh  crops  of 
vesicles  starting  up  around  the  edge  of  the  older 
patches,  and  new  centres  of  disease  being  formed  as 
the  eruption  breaks  out  in  distant  parts.  In  tlus 
way  eczema  may  in  time  spread  over  nearlv  the 
whole  body. 

Sometimes  papules  are  the  predominant  leaion, 
Bud  the  aSectlon  in  such  a  case  may  simulate  lichen. 
With  the  help  of  a  lens,  however,  a  minut«  vesicle 
can  often  be  seen  on  the  top  of  each  papule.  A 
characteristic  appearance  in  this  so-called  papulat 
ecEema  is  that,  owing  to  the  rupture  of  the  vemclea 
by  scratching,  the  papules  arc  covered  by  a  tiny  dcune 
of  blood-crust.  The  course  and  symptoms  of  the 
ftfiection  are  as  already  described,  except  that  tJie 
itching  is  usually  more  pronounced. 

In  other  cases,  again,  erythematous  lesions  may 
predominate,  espedally  on  the  face.  The  affected 
Burface  is  red  but  not  shiny  ;  it  is  dry,  and  sometimea 
covered  with  small  scales.  These  appearances  may 
gradually  fade  away  or  may  linger  on,  the  prooeaa. 
being  now  almost  quiescent  and  again  starting  and* 
denly  into  activity  for  a  time.  The  epidermis  is  aot-  ] 
to  crack,  and  serous  discharge  oozes  through  we  \ 
broken  integument.  This  is  especially  likely  to  act 
L  on  surfaces  of  skin  which  rub  against  each  otJutr*  j 
L  forming  an  edematous  variety  of  intertrigo. 

"     -  1  varies  considerably  in  intensity  at  diff«r- a 
As  a  rule  the  onset  is  more  or  less  acatej  J 


I 


■aaue.  xiL]  CLINICAL  COURSJi.  :i4l 

the  afFectioD  gradually  passing  Into  a  more  chronic 
stage  as  it  tends  to  recovery.  Both  acute  and 
chronic  forms  may,  however,  co-exist — that  is  to  say, 
while  the  process  is  intense  at  one  point  it  may  be 
quiescent  at  another,  and  every  intermediate  stage 
may  be  exhibited  in  other  parts.  Sometimes  the 
affection  begins  in  a  trivial  chronic  lesion.  Thus  a 
red  scaly  patch  that  may  have  existed  on  the  leg  for 
years  may  suddenly  wake  up  into  activity,  causing 
intense  irritation  and  exhibiting  all  the  phenomena 
o!  acute  eczema.  Again,  in  cases  in  which  an  old- 
standing  eczema  has  subsided,  leaving  only  a  small 
patch  apparently  dying  out,  this  may  at  some  sub- 
sequent time  form  a  focus  for  a  fresh  development  of 
the  disease,  from  which  it  may  spread  over  nearly  the 
whole  body. 

The  worst  forma  of  eczema  are  ordinarily  accom- 
panied by  some  constitutional  disturbance,  not 
amounting  to  fever,  in  the  earher  stages ;  and  the 
same  thing  occurs  at  each  fiesh  exacerbation  of  the 
process.  The  general  health,  however,  is  seldom 
appreciably  affected,  except  when  the  itching  is  so 
intense  as  to  make  sleep  impossible  ;  but  the  attacks 
seldom  follow  each  other  so  closely  as  to  leave  no 
intervals  during  wliich  the  patient  can  make  up 
arrears  of  rest.  So  slight  is  the  effect  of  eczema  on 
the  system  that  in  the  most  intense  form  of  the 
generalised  disease,  when  the  discharge  is  so  profuse 
as  to  glue  the  hair  to  the  pillow  and  the  linen  to  the 
body,  and  wlien  the  itching  is  maddening  and  almost 
continuous,  fresh  outbreaks  occurring  every  few 
hours,  there  may  be  no  rise  of  temperature,  the 
tongue  may  be  quite  clean,  aud  every  function  in 
perfect  working  order ;  in  short,  with  the  exception 
of  nervous  excitement,  there  may  be  absolutely  no 
disorder  of  the  general  health.  The  itching  and  heat 
ate  often  out  of  all  proportion  to  the  visible  c\iM\.^«fc 


w 


a  the  skin,  and  these  aymptflins  ate  usuaily  ii 
to  aa  extreme  degree  at  night,  especially  in  the  ! 
smaller  hours.  I  have  often  seen  strong  men  hterally 
reduced  to  tears  by  the  irritation  and  discomfort 
which  they  experienced  when  there  was  nothing  par- 
ticular to  see  in  the  skin.  Even  persona  of  the 
strongest  wiU  are  unable  to  control  themselves,  , 
scratch  as  if  by  tearing  their  skin  they  could  root  out 
the  cause  of  the  irritation.  They  will  tell  you  that 
they  feel  a  kind  o!  savage  satisfaction  i 
their  skin  till  the  blood  conies,  and,  as  a  matter  of 
fact,  the  pain  of  the  severe  excoriation  caused  by  their 
nails  seems  for  a  time  to  subdue  the  intolerable 
itching,  A  state  of  mental  calm  follows  the  nerve 
storm  caused  by  the  irritation,  and  the  patient  is  a 
to  sleep.  In  severe  cases  mental  excitement  is  often 
very  pronounced,  especially  in  persons  of  neurotic 
temperament. 

In  the  great  majority   of  cases   of  eczema  the 
following  stages  are  more  or  less  directly  recognis- 
able :■ — (1)  An  initial  erylhema,  the  aflected  sutiace   , 
presenting    the    usual    signs    of    inflammation,    and   i 
generally  soon  becoming  studded  with  vesicles ;   (2)  | 
exudatimi  of  a  clear  serous  fluid,  which  stiffens  linen,   i 
the  surface  being  red  and  "  weeping," 
excoriated  by  scratching  ;  (3)  cm«tafion,  the  discharge  i 
"  setting "    into    greyish-yellow    crusts    of    varyi^  J 
thickness,  which,  as  they  become  detached,  i 
ceeded  by  others  as  long  as  the  oozing  continues ; 
(4)  a  dry  stage,  during  which  no  further  formation    | 
of  crusts  takes  place,  and  the  surface  Is  covered  with 
a  thin,  red,  glistening  epidermis,  dotted  with  small    * 
points  of  a  deeper  red  tint ;   (5)  lastly,  desquatnatitM, 
the  new  epidermis  being  shed  in  scales,  which  grada- 
ally  become  smaller  and  thinner  till  nothing  remains 
to  mark  the  site  of  the  lesions  but  a  brownish  stain. 
All  these  stages  are  usually  present  at  once  in  a  giveoi 


II.]  CLINICAL   COURSE.  243    " 

case,  and  this,  combined,  with  the  modifications  <>i 
the  lesions  in  different  circumstances  about  to  be 
described,  together  with  the  accidental  complications 
produced  by  scratching,  and  by  inoculation  of  puft 
cocci  (pustules,  boils),  gives  eczema  the  multiformity 
of  aspect  which  has  been  mentioned  aa  one  of  its  most 
striking  characteristics.  The  process  always  begins 
with  more  oi  less  violent  inSammation — in  other 
words,  there  is  in  all  cases  an  "  acute  "  initial  stage, 
though  sometimes  this  is  so  brief  in  duration  that  the 
disease  might  easily  be  thought  to  have  been  of  the 
"  chronic  "  type  from  the  first.  It  may  run  through 
ail  the  various  phases  that  have  been  described,  or  it 
may  abort  at  any  stage,  without  in  either  case  leaving 
permanent  changes  in  the  part  attacked.  On  the 
other  hand,  it  may  be  indefinitely  prolonged,  though 
in  an  almost  dormant  state,  leading  to  thickening  and 
other  results  of  slow  persistent  inflammation.  Even 
in  the  oldest  of  such  patches,  however,  the  disease 
may  start  into  activity  at  any  time  and  without  any 
visible  provocation.  Eczema  may,  in  fact,  as  regards 
the  vicissitudes  and  the  varying  degrees  of  intensity 
of  the  process,  be  compared  with  inflammation  of  a 
joint.  First  there  is  the  period  of  onset,  the  heat, 
pain,  and  tension  in  the  joint  having  their  analogues 
in  the  heat,  awelhng,  and  itching  of  the  skin  ;  next 
comes  effusion  into  the  joint,  corresponding  to  the 
"  weeping  "  stage  of  eczema  ;  lastly,  absorption  of 
fluid  in  the  one  case  and  drying  up  of  the  discharge 
iu  the  other,  followed  by  more  or  less  complete  restora- 
tion of  the  alntuB  quo  ante.  Again,  there  is  in  the  joint, 
as  in  the  skin,  the  liability  to  sudden  exacerbation  of 
the  inflanimatory  process  even  after  long  quiescence, 
and  the  tendency  to  structural  changes  after  long 
persistence  or  frequently  repeated  attacks. 

There  is  reason  to  believe  that  certain  forma  of 
malignant  disease  may  supervene  on  eczema,    fftft 


eczematoid  leeions  which  precede,  usually  for  a  long 
time,  the  onset  of  myco^  fungoides,  are  really  the 
prodromal  eraptiou  oi  that  affection. 

MODIPYIKO   Ixn-CEJICES.  I 

While  the  eczcmatouB  process  is  always  essentially 
the  same,  ita  manifestations  in  individual  cases  are 
more  or  less  modified  by  fecial  conditions  of  stxnctniQ 
OI  situation  in  the  afiect«d  parts  of  the  skin  and  the 
age  and  sex  of  the  patient.  These  various  factors  ■ 
will  be  con^dered  separately. 

Distribution   imd    regional   peculiarities.  ' 

— There  is  no  part  of  the  skin  which  mav  not  be 
attacked  b?  eczema,  but  there  are  certain  re^ons  fox 
which  it  eshibitfi  a  more  or  less  marked  predilection, 
and  ia  which  it  usually  begins.  These  are  the  flexor 
surfaces  of  joints — the  bends  of  the  elbows,  the  backs.  ' 
of  the  knees,  and  the  groins ;  other  favourite  e 
tions  are  the  groove  behind  the  ears,  the  scalp,  i 
palms  and  tUe  soles,  the  breasts  in  women,  the  lombsr^ 
region,  and  the  back  at  the  level  of  the  lower  anglei 
of  the  scapul*.  On  the  limbs  eczems 
gives  rise  to  considerable  infiltration  and  indnratioii ; 
hence  deep,  painful  cracks  are  apt  to  be  formed  on 
the  fiexor  Gurfaces  when  the  inflamed  skin  is  subject 
to  frequent  movements.  The  eruption  is  generally 
symmetrical. 

On  the  fronts  of  the  Ugg  and  arms,  and  occasionally 
on  the  Hexor  surfaces  of  joints,  the  disease  assnmea  a 
peculiar  form,  which,  from  the  uniform  redness  of  Uw 
part  attacked,  baa  been  dignified  with  a  special  nana 
— ecsema  rubrum.  The  affected  area  is  of  a  brigh^ 
red  colour  and  glistens  with  moisture,  beads  i 
exuded  fluid  standing  on  the  surface  like  dewdrops 
h^nce  the  term  "  madidans,'"  sometimes  ' 
denote  this  form  of  ecxema.     The  discharge  qui 


I 

mea.^H 
on;  ^1 


p.m.]     IIEQTONAL  PSOUUAIilTlES.  245 

driea,  forming  extremely  thin  scabs  like  flaky  pie- 
crust or  goldbeater's  akm ;  these,  when  torn  ofi,  re- 
veal a.  wet,  raw,  tender  eiirface  beneath.  8ometime8, 
especially  in  partu  where  the  skin  ia  more  or  less 
tightly  stretched,  as  on  the  front  of  the  leg  and  the 
forearm,  the  exudation  cannot  force  its  way  to  the 
surface,  and  the  skin  is  dry,  but  very  tense  and  red. 
When  the  inflammation  is  of  a  slight  degree  of  in- 
tensity the  patches  aie  often  covered  with  scurf, 
which  is  easily  detached,  exposing  a  dull  red  surface 
which  is  not  raw  nor  tender.  As  a  rule,  no  constitu- 
tional disturbance  accompanies  eczema  rubrum,  un- 
less a  very  large  area  of  skin  be  involved,  when  the 
condition  approximates  to  pityriasis  rubra. 

On  the  smlp  eczema  is  generally  of  the  seborrhreic 
form.  Another  form  ia,  however,  met  with  which 
seems  to  be  unconnected  with  seborrhcea.  The  scalp 
ia  red  and  covered  with  crusts,  but  the  hair  does  not 
fall  out.  In  children,  and  also  in  adults,  the  afiection 
ia  sometimes  associated  with  pediculi,  and  in  such 
caaes  pustules  are  almost  sure  to  be  produced  by 
inoculation  with  the  patient's  finger- nails. 

About  the  nostrils  eczema  is  often  accompanied 
by  coryza  of  an  irritating  character,  complicated  at 
times  by  painful  boils.  The  disease  may  attack  the 
nasal  fosste,  where  it  may  cause  considerable  cedema. 
Eczema  in  that  situation  sometimes  leads  to  catarrh 
of  the  naso-pharynx  and  so  to  catarrh  of  the  middle 
ear  (Gruber).  The  upper  lip  may  sufier  in  conse- 
quence of  the  nasal  discharge  trickhng  over  it.  The 
special  features  are  great  swelling  and  redness  of  the 
part  of  the  lip  lying  below  the  nostrils,  with  painful 
pimples  about  the  orifices  of  the  hair  folhclea,  and 
almost  unbearable  itching  ;  crusts  form,  and  a  good 
deal  of  tliickening  of  the  lip,  causing  deformity  and 
even  obstruction  of  the  nostrils,  may  be  left.  A  par- 
ticujarly  painful  form  of  eczema  may  attack  both 


«      t . 


REGIONAL   PECULIARITIES.  -lil 

the  affection  in  umnarried  womeu,  and  even  in  men. 
It  begins  in  aeborrliosa  of  the  nipple  and  the  areola, 
and  preflents  the  ordinary  charactera  of  seborrhceic 
ecaemii.  Cracked  nipple  is  a  frequent  result.  The 
affection  is  generally  Byrauietrical.  It  ia  not  to  be 
regarded  as  tiie  first  stage  of  Paget's  disease ;  it  ia 
innocent  in  character,  though  often  extremely  ob- 
stinate. 

On  the  genitals  eczema  is  chiefly  of  the  erythe- 
matous form,  and  it  is  naturally  worst  where  two 
surfaces  of  skin  rub  against  each  other.  The  irrita- 
tion is  excessive,  and  the  temptation  to  scratch  more 
difficult  to  withstand  than  in  almost  any  other  situa- 
tion. The  scrotum  and  penis  sometimes  become 
greatly  swollen,  and  the  diaease  may  spread  over  the 
perinasum,  round  the  anus,  into  the  fold  between  the 
nates,  and  over  the  gluteal  region ;  not  unfrequently 
it  invades  the  whole  of  what  may  be  termed  the 
"  bathing -drawers  area."  In  such  cases  the  patient 
cannot  sit  down  or  walk  without  the  crusts  and  the 
inflamed  skin  beneath  them  giving  way  somewhere. 
In  the  female  the  state  of  things  is  even  worse.  The 
process  is  generally  stirred  up  to  a  violent  degree  of 
intensity  by  the  chafing  of  the  parts  ;  the  swelling 
may  be  enormous,  and  almost  every  variety  of  lesion 
that  can  be  produced  by  acute  inflammation  aggra- 
vated by  scratching  and  urine— ^foul  crusts  and  scabs, 
fissures,  and  disgustingly  ofienaive  discharge — may 
be  present,  while  walking  is  so  painEul  as  to  be  almost 
impossible,  and  the  itching  is  so  distressing  that  life 
becomes  a  burden. 

Eczema  of  the  anus  is  often  associated  with  piles 
or  worms  ;  the  skin  is  thickened,  and  painful  fissures 
ate  frequently  present.  The  itching  is  in  moat  cases 
intense,  and  the  harassing  character  of  the  affection 
s  and  haggard  expression  to  the  coun- 


» 


248  ECZEMA.  [chap.  xn. 

The  utnhUicus  is  sometimes  the  seat  of  an  obstinate 
tiOEemu,  usually  aeborrliwic  in  form.  The  lesions  are 
circular  in  outline,  and  do  not,  as  a  rule,  extend  far 
beyond  the  edges  of  the  umbiUcus. 

Sex. — Although  eceema  spares  neither  sex,  males 
are  perhaps,  on  the  whole,  more  liable  to  be  attacked 
than  females.  In  childhood,  Crocker's  statistica  show 
a  preponderance  of  boys  to  girls  of  five  to  three.* 
In  middle  age,  when  the  burden  of  life  is  heaviest, 
the  greater  proclivity  of  the  male  sex  is  still  more 
marked.  Bulkley  f  gives  an  analysis  of  5,00U  casea  of 
eczema  under  his  own  observation,  which  shows  that 
in  the  period  from  thirty  to  fifty  years  of  age  the 
number  of  male  patients  in  his  private  practice  was 
about  double  that  of  female.  Hebra's  estimate  that 
tile  proportion  of  females  to  males  among  the  subjects 
of  eczema  in  his  clinic  was  as  two  to  one  is  probably 
to  be  explained  by  the  greater  opportunities  women 
have  of  attending  as  out-patieuts  at  a  hospital.  There 
are,  however,  two  periods  of  life  at  which  women  are 
more  liable  to  eczema  than  men,  namely,  between  the 
ages  of  ten  and  twenty,  when  menstruation  is  becom- 
ing established,  and  again  at  the  menopause.^  In 
old  age  the  influence  of  sex  is  lost  in  the  degenerative 
tendencies  common  to  both. 

A^e. — In  children  eczema  is  mostly  of  the 
fleborrhoeic  form,  and  in  a  large  proportion  of  cases  it 
begins  in  the  earliest  years  of  life.  As  a  rule,  the 
starting-point  is  the  scalp.  The  focus  from  which  the 
disease  starte  is  generally  a  patch  of  dried  eebaoeouB 
matter.  Such  a  patch,  dirty  brown  in  colour  and 
consisting  of  greasy  material,  is  often  seen  soon  after 
birth.    From  the  scalp  the  disease  spreads  to  the 


l.-Vcbnuir 


Difeaeeaof  tbu8kiD,"2udeJ.,  IS93.p,  IIS. 
On  the  Hektion  of  Ef  zenis  to  Bisturhnucw  of  t 
Eeprinted  from   tha    Jtmliml  Sam,  Jumu 

,  isai. 

Dmlii-i.  Areh.f.  kl.H.  3I,d.,  Oolober,  ISH 


[L]     ECZEMA  IN  RELATION  TO  AOE.  240 

ears,  the  forehead,  and  the  face,  and  downwards, 
generally  in  the  middle  hne  of  the  body  {front  and 
back),  but  not  sparing  the  limbB.  Vesicles  show  a 
much  greater  tendency  to  become  pustular  than  in 
adults,  forming  on  the  head  moist  yellowish  crusts 
which  glue  the  hair  togetlier,  while  from  underneath 
them  frequently  wells  up  a  sickly- amelJing  sero- 
purulent  discharge.  On  the  face  the  cruste  often 
have  a  dark-green  or  browniah  tint,  and  cover  the 
face,  leaving  the  mouth,  eyes,  and  nose  free,  like  a 
mask  with  an  opening  cut  in  the  centre  (Unna).  On 
the  trunk,  where  the  exudation  is  usually  less  abun- 
dant, thin  scales  are  more  common  than  crusts. 
Itching  is  Bometimea  very  troublesome,  especially 
where  cleanliness  is  neglected  and  the  lesions  caused 
by  the  diseaBe  are  aggravated  by  pediculi.  The  !ym- 
phatic  glands  are  frequently  enlarged,  and  sub- 
cutaneous abscesses,  particularly  in  the  aub-occipital 
region,  are  a  not  uncommon  complication.  In  babes 
at  the  breast  the  natural  folds  and  creases  of  the  skin 
— nates,  thighs,  neck,  etc, — are  often  the  seat  of 
eczematous  lesions  which  are  often  overlooked, mothers 
and  nurses  not  separating  the  parts  properly  for  fear 
of  making  the  child  cry,  Kaposi*  says  that  in  these 
cases  the  dermatitis  sometimes  assumes  a  very  intense 
character,  rapidly  becoming  gangrenous  or  diphthet- 
itio,  a  cure  taking  place  in  the  most  favourable  cases 
with  loss  of  substance  and  cicatrices,  or  death  ensuing 
in  a  few  days  from  convulaiona  and  collapse.  I  can 
only  say  that  no  case  of  this  kind  has  ever  come  under 
my  observation. 

According  to  Brocq.t  the  rapid  disappearance  of  an 
eczematous  eruption  in  a  young  child  may  be  followed 
by  pulmonary  congestions  of  the  most  dangerous  kind. 

"Maladies  de  lu  Feiiu,"  t.  i.,p.  I>'>S.      FrnDoh  troosliitioD 

i,  1831). 

"  Traitement  dcB  Maladies  do  la  Peau,"  p.  169.    (Paris,  IBOU.) 


^^B    250  ECZEMA.  [chaf,  sn.    H 

^^^1  Unna  *  recogniBcs  three  absolutely  distinct  types     ^M 

^^H  of  eczema  of  the  face  in  Infants— nervous,    tuber-      X 

^^V  culouH,  and  sebon'htcic.     The  first  occurs  during  denti-     ^| 

^^^  tion.     It  is  Hymmetrical  in  distribution,  and  usually    ^H 

r  aflecta  tlie  middle  of  the  cheeks,  then  the  forehead,    ^H 

I  nnd  almoBt  at  the  same  time  the  radial  side  of  the  ^H 

^^^  backs   of  both  iiands   and   wrists.     The   itching  is  ^H 

^^^  intense,  and  the  healthier  the  child  is  the  worse  this 

^^^K  symptom  seenas  to  be.     On  the  appearance  of  a  few 

^^^r  teeth  the  eczema  dies  away,  probably  to  come  out 

^^^  again  a  few  days  later.     The  tuberculous  form  is 

"  localised   in    the    neighbourhood   of  the  eyes,  nose, 
mouth,  or  ears,  and  is  often  aEsociat^d  with  scrofulous 

I  rhinitis  and   otorrhcea,    and  swelling  of  lymphatic 

ftlands.     There  is  little  or  no  itching.     I  agree  with    ^H 
Crocker  f  in  regarding  this  as  a  form  of  impetigo    ^H 

'  contagiosa  rather  than  eczema.     The  seborrhccic  form    ^H 

^^_  is  described  at  page  253.                                                      ^H 

^^|l  At  pvbertg  eczema  may  occur  iu  the  seboirhceic  ^H 

^^^B  iorm  just  referred  to.     Beginning  on  the  scalp,  it  ^H 

^^^F  may  spread  to  the  face  and  other  part*!,  apparently  by  ^H 

^^^  local  infection,     It  also  occurs  in  connection  witli  ^H 

I  the  peculiar  dryness  of  the  skin  known  as  xerodermia.   ^H 

I  In  early  life  this  condition  is  scarcely  noticeable,  but  ^H 

^^^  towards  puberty  the  skin  becomes  diy  and  harsh,  and  .^H 

^^^  on  it  eczema  may  develop.    Another  form  of  eczema  ^H 

^^H  which  appears  at  puberty  alternates  with  neuiotio  ^H 

^^^B  conditions,  more  especially  asthma  and  commencing   ^H 

^^H  iheumatoid  arthritis.                                                            ^^ 

^^H  In  middle  life  eczema  presents  little  peouliaxitf    j^^ 

^^H  either  in  the  nature  oi  the  lesions  or  in  their  distribu-    ^| 

^^r  tion.    "  Weeping  "  and  scaly  forms  are,  however,  la    ^| 

I  more  common  than  the  pustular  lesions  that  pre-  ^H 
dominate  in  infantile  eczema.  It  is  at  the  middle  ^M 
term  of  life,  moreover,  that  the  influence  of  constitu-    ^H 

^^H  •  Jou, 

^^H  t-'D 


11.]    ECZEMA  IN  RELATION  TO  AGE. 

tional  conditions,  such  as  gout  or  rheumatiam,  is  most 
likely  to  make  itself  felt.  These  conditions  do  this 
not  ao  much  by  ejceicising  any  direct  effect  on  the 
ecuematous  procesa  as  by  modifyinR  the  general  health 
in  u  way  favourable  to  the  continuance  of  the  skin 
affection.  The  affection  often  comes  on  very  acutely 
after  a  chill.  According  to  Brocq,  it  ia  especially  in 
middle  life  that  alternations  between  eczematous 
lesions  on  the  skin  and  "  visceral  manifeatationa  " 
of  greater  or  less  gravity  (pulmonary,  renal,  intes- 
tinal, cardiac,  cerebral,  etc.)  are  most  likely  to  show 
themselves.*  When  aU  the  lesions  have  disappeared, 
there  oft«n  remains  an  intensely  irritable  state  of  the 
whole  cutaneous  surface.  The  patient  lives  in  con- 
stant dread  of  a  new  attack,  and  this,  combined  with 
the  itching,  may  bring  him  to  the  verge  of  insanity. 
In  women  at  the  change  of  life  eczema    shows  a 

k  jnarked   tendency   to  relapse  in  particular   regions. 
x>rding  to  Jamieson.f  more  than  three -fourths  of 
1  the  scalp  and  ears.     The  extremi- 

_ities  may  also  suffer  to  some  estent,  but  the  trunk 
generally  escapes. 

Elderly  fersons  are  particularly  apt  to  suffer  from 
a  form  of  eczema  which  is  really  an  expression  of 
enfeebled  vitahty  or  the  result  of  degenerative  changes 
in  the  skin.  The  disease  is  generally  chronic  in 
charactw,  with  short  acute  exacerbations.  The  irri- 
tation is  often  very  great,  making  sleep  impossible. 
The  favourite  situation  of  the  disease  in  such  cases 
is  the  lower  part  of  the  leg,  where  it  is  frequently 
associated  with  varicose  veins  and  ulcers.  The  irrita- 
tion of  the  skin  may,  as  pointed  out  by  Kaposi,  set  up 
reflex  irritation  in  the  intestine,  preventing  the  proper 
digestion  of  food.  The  irregularity  of  the  bowels 
reacts  in  turn  on  the  akin,  and  thus  a  vicious  circle  is 


1 


^^^r  BB^  tkarMBbnap  by  bom 
11  ridn  is  onhr  du^Ir  nm^ 


KZMMA. 


^ 


TW 
eowiitiOB  tkaS  d^  an 

~  '  _  by  Boicidie.  In  mildcT  foans  tiw 
ridn  is  onhr  dii^Ij  nm^iened  aad  icd,  tike  eurfaM 
being  wrwmiA  witli  *  tlmi  GEm  «l  scales ;  in  seven 
caaea  thcJcB  oftai  gwt  thkfaaaagol  the  skin,  awom- 
puiied  br  dubn&uig  hdung.  WIicb  tl)«  skin  is  veij 
diy  sod  strapUc,  as  it  nmaDT  is  in  persons  of  ad- 
Tanced  age,  K  is  <^t  to  nack  along  the  tines  of  cleaT- 
age,  canaiiig  great  pain  on  movement.  In  oM  lOKa 
ecxcma  not  nnfreqaentl;y  Bpieads  fiom  an  old,  afanost 
forgoUai  patch,  commonlj  on  tbe  \e%,  inTolving 
wide  areas  and  devdoping  fnsh  ceatiea  in  distant 
part*,  til!  neaiiy  the  whole  soriace  of  the  body  maj  be 
invaded-  The  eiythematons  form  already  mentioned, 
which  attacks  the  face  and  neck,  is  common  in  elderly 

SpEaAL  Forms  of  Eczema, 
The  general  phenomena  of  the  eczematous  process 
having  been  described,  certain  variations  in  the. 
clinical  aspect  and  course  of  the  affection,  dependent 
on  differences  in  its  mode  of  origin,  remain  to  be  con- 
■tdercd.  By  the  terms  of  the  definition  of  eczema 
(pven  at  the  beginning  of  this  chapter,  all  fonos  of 
inflammatioD  of  the  skin  due  to  definite  chemical  or 
mechanical  irritation  are  excluded.  But  even  in 
the  restricted  sense  in  which  it  is  here  used,  ecEcma 
is  still  rather  a  pathological  formula  expressing  tho 
resultfl  of  several  forms  of  morbid  action  than  a 
distinct  disease. 

The  nature  of  eczema  is  one  of  the  vexed  qaea- 
tions  of  dermatology,  and  a  fnll  discussion  of  th« 
question  would  be  out  of  place  in  an  elementary  t«zt>- 


I 


book.     Such  a  diacui 


i  the  les 


necessary  sinoa  I 


I  Jor  all  practical  purposes  it  is  sufficbot  to 

■  two  kinds  of  ecEema,  or,  to  speak  more  precueljr. 


n.]  SEBORHHmiC  ECZEMA.  253 

two  great  groups  of  eczematous  eruptions — thoee 
which  come  out  on  previously  healthy  akin,  and  those 
for  which  the  way  has  been  prepared  by  some  pre- 
exietiag  locai  disorder  of  the  secreting  apparatus  of 
tUe  skin. 

Of  the  latter  category  there  are  three  special  forms, 
according  as  the  source  of  the  niisehief  is  in  the  seba- 
ceous glands  (seborrhcea),  tlie  sweat  glands  (hyperi- 
drosis,  anidrosis),  or  the  hair  follicles  (lolIiculitiB), 

SebOirhCSiC  eczema,  for  our  knowledge  of 
which  we  are  indebted  to  llnna,*  begins,  as  a  rule, 
in  aeborrhiJBa  of  the  scalp,  which  in  some  cases  hae 
existed  since  birth ;  in  rare  instances  the  starting- 
point  may  be  the  margin  of  the  eyelid,  or  a  part 
like  the  asilla,  the  bend  of  the  elbow,  or  the  ciuro- 
Bcrotal  fold,  where  sweat  glands  are  abundant.  In 
connection  with  t!da  point  it  should  be  noted  that, 
according  to  Unna,  what  is  usually  called  "  sebor- 
rhcea "  is  often  a  fatty  liypereecretion  poured  out  not 
from  the  sebaceous  but  from  the  sudoriparous  glands, 
and  should  be  regarded  as  hydrosia  oleosa.  The  affec- 
tion begins  as  a  latent  catarrh  ;  it  first  manifesto  itself 
by  the  agglutination  of  epidermic  scales,  which  are 
thrown  off  in  large  lamellaa.  That  there  is  a  faulty 
distribution  of  the  fat  in  the  skin  is  shown  by  the  fact 
that  the  hair  becomes  abnormally  dry  from  closing 
up  of  the  hair  follicles,  while  the  epidermis  and  ex- 
foliating scales  are  abnormally  fatty.  The  scales  may 
simply  increase  in  quantity,  or  they  may  become 
massed  into  fatty  crusts  between  the  hairs,  which  are 
thus  crushed  out,  leaving  a  bald  patch  on  the  top  of 
the  head  (corona  seborrhwica).  In  other  cases  the 
catarrhal  phenomena  are  more  pronounced  ;  the  skin 
is  red  and  swollen  and  "  weeps  "  profusely  ;  the  fatty 

.    Ditriurs,    December,    1S87 


loputt  Sectjou 
At  Woaliiugtoli 


[lie  papiT  wfiH  ]i  coramniiicatian  to  the  Dermato- 
.f  tliB  Niiitli  liitprmitional   Mi-rlioil  CorigreBs,  hfld 


ECZEMA. 


[chap.  sa. 


^^^K  scales  either  are  not  formed  or  aie  washed  away  by  the 
^^^B  diBcbarge  ;  the  rete  may  be  laid  bare.  Unna  calls 
^^H  these  respectively  the  scaly,  the  crusty,  and  the  moiit 
^^H  forms  of  what  is  generally  termed  "  chronic  eczema 
^^^K  of  the  head."  The  sternal  region  may  also  be  the 
^^^1  seat  of  a  primary  seborrhceic  eczema,  which  is  almost 
^^^B  always  of  the  "  crusty "  form  ;  the  patches 
^^^1  usually  made  up  of  segments  of  circles,  and  present 
^^^^  different  shadings  of  colour,  from  yellow  in  the 
^^^P  centre  to,  bright  red  (after  removal  of  the  scales)  at 
the  outer  edge. 

Eczema  seborrhceicum  spreads  slowly  in  a  peri- 
pheral direction  ;  a  patch  may  remain  almost  sta- 
tionary for  years.  Beginning,  as  already  said,  on 
the  head,  it  extends  over  the  scalp,  thence  to  the  ears, 
the  forehead  and  cheek,  the  neck,  and  down  the  front 
of  the  cheat  and  the  back,  especially  in  the  inter- 
scapular furrow,  into  the  asillse  and  the  bends  of  the 
elbows  and  on  the  hands,  into  the  groin  and  the  cniro- 
scrotal  fold,  over  the  genitals,  behind  the  kuees,  and 
between  the  ti 

Seborrhceic  eczema  is  nothing  more  than  the 
eczematous  process  going  tlirough  the  various  phases 
of  its  evolution  in  a  skin  that  has  long  been  the  seat 
of  seborrhoea.  The  latt#r  prepares  the  ground  for  the  ' 
eczema.  The  discharge  itself  may  posailily  have  sa 
irritant  action  on  the  ekin,  but  the  real  irritant — ^the 
efficient  cause  of  the  lesions — is,  there  is  every  reason 
to  believe,  of  parasitic  nature.  This  affords  an  t 
planation  of  the  suppurative  processes  which  often' 
oomplipate  seborrhfeic  eczema.  Much  discussion  i 
taken  place  regarding  the  micro-organisms,  especiallT' 
the  "  bottle  bacillus  "  of  Unna,  which  are  associated 
with  this  form  of  eczema.  The  question  is  still  no-  ■ 
decided  whether  these  organisms  are  simply  sapro- 
phytic, and  occur  accidentally  on  the  akin,  or  actually 
pathogenic. 


i 


CHAP.  Kn.]  aWEAT   ECZEMA.  255 

Sweat  eczema. — ^Excesaive  secretion  of  sweat, 
without  any  aiteration  in  the  character  of  that  fluid, 
may  alao  prepare  the  way  for  eczema  by  so  modi- 
fying the  condition  of  the  akin  as  to  make  it  prone  to 
become  the  seat  of  the  eczematoua  process  as  already 
defined.  The  most  common  aitnationa  for  the  de- 
velopment of  this  form  of  eczema  are  the  parts  where 
two  opposed  aurfacea  of  akin  rub  against  each  other — 
between  the  nates,  between  the  acrotum  and  the 
thigh,  in  the  axilla,  between  the  toea,  in  the  deep 
folds  under  an  overhanging  breast,  and  in  the  hypo- 
gaatric  region  under  a  prominent  abdomen.  The 
sweat  in  such  parts  is  apt  to  undergo  decomposition, 
and  this  fluid,  mixed  with  slireds  of  macerated  epi- 
thelium and  "  HufE  "  from  the  underclothing,  forms 
a  subBtaace  highly  irritating  to  the  akin.  It  must  be 
understood,  however,  that  hyperidrosis  plus  friction 
can  only  produce  a  dermatitis  similar  to  that  caused 
by  other  chemical  and  mechanical  irritants ;  for  the 
production  of  eczema— i.e.  of  a  train  of  lesions  which 
may  persist  after  removal  of  the  conditions  that  en- 
gendered .them,  and  which  may  be  followed  by  the 
development  of  similar  lesions  in  other  parts  that 
have  not  been  exposed  to  the  same  irritation— a  ter- 
lium  quid  is  required.  This  factor,  which  dermatolo- 
gists of  the  older  school  aaaumed  to  be  gout  or  aome 
equally  convenient  dyacrasia,  will  in  all  probability 
be  shown  to  be  the  action  of  micro-organisms.  Sweat 
eczema  is  almoat  always,  in  the  first  instance  at  least, 
an  intertrigo,  but  is  distinguishable  from  the  erythe- 
mat«ufl  form  of  that  affection  by  the  "weeping" 
of  the  opposed  surfaces  and  the  resulting  crusts.  It 
is  not  necessary,  however,  for  the  development  of 
the  eruption  that  there  should  be  chafing  ;  the  ecze* 
ma,  which  is  one  of  the  signs  of  the  "  crisis  "  of  the 
cold-water  cure,  is  due  to  the  profuse  sweating  that 
ia  the  principal  effect  of  that  method  of  treatment. 


[chap.  XIL 


1266  ECZEMA. 

Eczema  foUiculorum,  which  was  first  de- 
scribed as  a  special  form  of  the  disease  by  the  author, 
begins  iu  inflammation  of  the  hair  follicles.  Each 
inilamed  follicle  stands  out  on  the  akin  as  an  angry- 
looking  red  pimple  ;  the  capillaries  around  are  con- 
gested, and  soon  the  akin  is  involved  in  the  process. 
In  this  way  red  patches  dotted  with  inflamed  follicles 
are  formed,  which  tend  to  spread  by  the  ejcteosion  of 
the  inflammation  from  folhcle  to  follicle.     As  a  patch 

I  spreads  at  the  edge  it  usually  undergoes  resolution 
in  the  centre,  desquamation  takes  place,   and  the 
redness  fades  into  a  yellowiah  stain.     The  itching  is 
often  most  intense.     The  patches  are  generally  mul- 
tiple and  are  scattered  about  the  body,  especially  ob 
the  extensor  surfaces  of  the  arms  and  legs.    The  pre- 
dilection  of   eczema    foUiculorum   for   the   ezteneor 
surfaces  of  the  limbs  is  a  distinctive  feature  as  regards 
distribution,  other  forms  of  eczema  showing  a  prefer- 
ence  for   the   fiesures   of   jointe.     The    afiection  is 
obstinate,  and  recurrence  Is  almost  the  rule.     It  is 
closely  allied  to  sycosis,  and  there  can  be  little  doul)t 
that  it  is  of  parasitic  origin. 
"Nervous  eczema." — Apart  from  the  special 
forms  of  eczema  that  have  been  described,  there  is  m 
large  class  of  cases  in  which  the  disease  springs  up.- 
de  novo  in  skin  that  has  not  been  the  seat  of  eebor- 
ihtea  or  other  preparatory  process.     This  class,  ia 
the    absence    of    any    definite    objective    charooter- 
iatic,  1  propose  to  designate  as  "  nervous  eczema," 
though,  as  will  be  explained  farther  on,  1  include 
under  that  term  many  eczemas  in  which  the  nervoiu 
system  is  not  the  only,  or  the  chief,  etiological  factor 
operation.     That  eczema  may  be  of  purely  nervous 
\  origin  appears  to  be  admitted  by   Unna  himself, 
J  inaemuch   as  he   expressly   states   that  one  of  his 
;  types  of  infantile  eczema  is  caused  by  reflex 
Lirritation  during  dentition,  and  disappears  when  thor 


CK4P.  xiLj  SYMfTOMS.  257 

tooth  has  cut  its  way  tlirough  the  gum,  Eliot  •  has 
applied  the  name  of  "  reflex  nemotic  eczema  "  to  what 
he  considers  to  be  a  defiui.te  type  of  t!:e  disease  which 
lie  has  seen  in  babies  and  young  children.  Barham  f 
has  described  a  "neurotic  eczema"  presenting  ob- 
jective features  sufficient  to  distinguish  it  from  other 
forms  of  the  diflease.  These  are  :  (I)  Grouping  of  the 
lesions  in  circumscribed  patches  sharply  separated 
from  adjoining  lesions  ;  (2)  symmetry  of  the  eruption 
as  a  whole  ;  (3)  preference  for  the  extensor  surfaces  of 
the  extremities  ;  (4)  absence  of  peripheral  spreading 
or  contraction  of  the  separate  patches.  My  own 
experience  leads  me  to  the  conclusion  that  when 
eczema  arises  in  apparently  normal  skin  it  is  always 
nervous  in  origin,  though  the  parasitic  element  often 
comes  into  play  as  a  secondary  factor.  I  cannot  say. 
however,  that  I  have  observed  any  peculiarities  of 
appearance  or  distribution  whereby  a  purely  neurotic 
eczema  could  be  distinguished  from  other  forms  of  the 


Symptoms. — The  objective  phenomena  of  ec- 
zema have  been  described  in  the  preceding  pages,  and 
incidental  mention  has  been  made  of  the  subjective 
symptoms  characterising  the  diflerent  forms  of  the 
disease.  It  may  not  be  amiss,  however,  to  pass  the 
latter  rapidly  in  review  for  purposes  of  comparison. 
The  only  ones  that  need  concern  us  here  are  itching 
and  pain.  These  symptoms,  particularly  the  former, 
vary  greatly  in  intensity  according  to  the  tempera- 
ment of  the  patient  or  the  structure  and  condition  of 
his  skin.  The  lesions  which  in  a  person  of  "  lym- 
phatic "  temperament  cause  only  slight  annojance 
may  in  a  neurotic  or  gouty  subject  give  rise  to  nerve 
storms  of  such  intensity  as  to  banish  him  from  society 
and  almost  wreck  his  reason.     Nor  is  the  intensity  of 


s» 


ECZEMA. 


[CB 


the  itclung  proportionate  to  the  severity  and  extent 
of  the  lesions  ;  it  is  oiten  worse  when  there  is  little  o 
.    nothing  to  Bee,  e.g.  in  the  erythematous  eczema  of 
the  scftip  Roramon  in  old  people.     In  such  cai 
exudation  imprisoned  beneath  the  horny  layer  pro- 
bably presses  on  or  irritates  the  terminal  filaments 
of  the  sensory  nerves  of  the  skin,   and  the  reliel 
given  by   free   scarification  of   the  parts   with  the 
finger-nails  seemH  tg  give  some  confirmation  of  this    . 
view.     It  Dot  unfrequently  happens  that,  owin)^  to 
disturbance  of  innervation,  itching  persists  long  aft«r 
every  trace  of  lesion  has  disappeared.     How  profound 
an  impression   eczema   may    leave  on   the  nervous 
apparatus  of  the  skin  is  shown  by  the  fact  that  ii 
cases  in  which  the  disease  has  lasted  a  long  time  the  \ 
skin  appears  to  be  so  much  under  its  dominion  that  1 
the  slightest  accidental  irritation  is  sufficient  to  bring  I 
on  an  attack.     Pain  is  not  often  severe,  except  when  I 
inflammation  runs  high   and  causes  great  heat  amLj 
tension  of  the  akin  ;    the  pain  generally  subsides  a»1 
soon  as  the  eSusion  finds  its  way  to  the  surface. 
the  neighbourhood  of  parts,  as  the  mouth,  genitals, 
anus,  etc.,  which  cannot  be  kept  at  rest,  the  sHn  be- 
comes thickened  and  tender,  and  the  cracks  caused  by 
movement  are  so  painful  as  to  interfere  with  the  per- 
formance   of    natural    functions.      The    only    other 
subjective    symptoms    caused    by    eczema    are    an 
exaggerated  sensitiveness  to  cold  and  a   feeling  of 
lassitude  or  disinclination  for  work  (Jamieson). 

Complications. — LocaUy,  the  eczematOUB  pronl 
cess  is  often  complicated  by  inflammation  of  1" 
related  lymphatic  vessels  and  glands.  As  the  resuUpl 
of  scratching,  pus  cocci  may  be  inotmlated,  and  wheBA  1 
theae  penetrate  from  the  superficial  to  the  deepflV  I 
layers  of  the  skin  they  cause  the  development  < '  ' 
painful  boils.  Of  itUerwd  complicattous,  the  i 
common  is  dyspepsia.     Gout  is  also  a  frequent  a 


n.]  DIAGNOSIS.  2G9 

comitant.  Both  these  conditions  have  been  aupposed 
to  stand  in  a  causal  relation  to  eczema,  but  to  me 
they  appear  to  be  nothing  more  than  accidental 
complications.  The  case  is  somewhat  different  as 
regards  asthma.  That  affection  is  so  often  asaociatcd 
with  eczema  that,  whenever  a  patient  suffering  from 
the  latter  affection  comes  before  me,  I  am  in  the  habit 
of  asking  if  he  is  subject  to  asthma.  It  will  be  seen 
later  that  I  regard  these  two  affections  as  frequently 
dependent  on  a  common  cause. 

Diagfnosis. — In  a  certain  proportion  of  eases 
of  eczema  the  diagnosis  presents  no  difficulty,  the 
appearance  of  the  leaions,  and  particularly  the 
"  weeping,"  being  sufficient  for  the  identification  of 
the  disease.  Som.etimea,  however,  the  nature  of  the 
affection  may  be  obscured  by  the  very  multiformity 
which  is  one  of  its  characteristic  features.  In  such 
cases  one  must  have  recourse  to  a  process  of  exclusion. 
No  reliance  must  be  placed  on  subjective  symptoms, 
as  they  are  ao  variable  that  they  can  serve  only  as  an 
indejc  of  the  patient's  temperament  and  of  what  may 
be  called  the  temperament  of  his  skin.  All  dis- 
charge, crusts,  or  accumulations  of  scales  should 
first  be  removed,  and  a  careful  examination  should  he 
made  of  every  affected  spot.  However  multiform  the 
lesions  may  be.  one  seldom  fail  f  an  ad  quat  search 
be  made,  to  discover  somew!  th      a  patch 

which  can  be  recognised  as  ecz  mat  u  Th  at  once 
dissipates  any  doubt  as  to  the  n  tur  f  th  disease. 
Secondary  syphilis  and  crythem  m  It  E  m  are  the 
two  conditions  which,  in  the  m  It  f  rm  b  f  their 
leaiona,  most  resemble  eczema.  IF  the  lesions  are 
syphilitic  there  will  be  other  signs  of  the  disease,  while 
erythema  multiforme  can  be  identified  either  by  the 
presence  of  some  tj'ptcal  lesion,  such  as  so-called 
herpes  or  erythema  iris,  or  by  the  preponderance  of 
red  raised  patches  without  scales,  and  especially  with- 


I  wo  ECZEMA. 

out  aay  traoe  of  "'  weeping."  Eryaipelaa 
tludpd  by  the  absence  of  conatitutioDal  symptoms  and 
of  the  characteristic  brawny  induration  and  ridged 
border. 
Of  parasitic  diseases,  the  one  which  most  closely 
resembles  eczema  is  acabies  ;  the  lesions  are  bo  aimilai 
that,  when  the  characteristic  burrows  are  not  visible 
nor  the  iteh-mite  discoverable,  a  mistake  might  easily 
be  made.  The  lesions  of  itch  are,  however,  isolated, 
not  grouped  into  patches  ;    further,   they  lack  the 

L  spreading  edge  characteristic  ot  eczema.  There  are, 
moreover,  difierences  in  the  distribution  of  the  two 
affections — scabies  being  scattered  irregularly  and 
showing  a  marked  predilection  for  the  hands,  especi- 
ally in  the  interdigital  spaces,  the  wrists,  the  inner  side 
of  the  thigh,  the  abdomen,  the  pubes,  and  the  axilla  ; 
while  eczema  is  nearly  always  more  or  less  synunetri- 
cal,  and  mostly  affects  the  head,  the  trunk,  and  the 
flexures  of  joints.  Sycosis  of  the  chin  somedmes 
simulates  eczema  of  that  region  so  closely  that  it  ie 
almost  impossible  to  distinguish  the  one  fiom  the 
other,  except  by  the  fact  that  sycosis  shows  no  ten- 
dency to  spread  beyond  the  area  covered  by  hair. 
Ringworm  of  the  scalp  can  be  identified  by  the  broken 
hairs  which  can  always  be  found  on  careful  aeaidi. 
Tinea  circiuata,  if  it  occurs  as  a  scaly  patch  on  the 
trunk,  can  be  recognised  with  the  help  of  the  micro- 
scope. FavuB  of  the  scalp  is  distinguishable  by  its 
cup-shaped  cnista  and  its  mousy  smeU.  From  herpes 
in  general  eczema  is  distinguished  by  the  eharsctei^ 
istic  "  weeping,"  and  from  zoster  In  particular  by  the 
distribution,  which  does  not  follow  that  of  the  cutuie-  , 
ous  nerves.  Impetigo  contagiosa  may  sometimes  be  I 
mistaken  for  pustular  eczema  ;  in  such  cases  search  \ 
must  be  made  for  definitely  eczematous  lesions  i 
other  parts.  It  la  to  be  noted  also  that  in  impeti^  \ 
oontairioBa  there  is  little  oi  no  inflammatory  areola  < 


IL]  DIAGNOSIS :  ETIOLOGY.  26i 

around  the  cruBts.  Eczema  papula  turn  often  re- 
sembles lichen  ruber  planus  ;  in  the  latter  affection, 
however,  the  papules  are  irregular  in  outline,  and 
neither  discharge  nor  cruat  formation  is  ever  observed. 
Certain  forms  of  dry  seborrhceic  eczema  are  very 
difficult  to  distinguish  from  psoriasis.  Attention  to 
the  following  points  of  difference  will  help  the  prac- 
titioner to  come  to  a  correct  conclusion.  In  the  first 
place,  psoriasis  is  always  dry  ;  moreover,  it  has  a 
typical  distribution,  and  spreads  from  the  elbows  and 
knees.  Eczema,  on  the  other  hand,  in  the  majority 
of  cases,  spreads  downwards  from  the  head.  Further, 
patches  of  psoriasis  have  a  sharply  defined  border,  and 
are  not  so  stationary  as  those  of  eczema.  In  the 
former  the  scales  are  silver  -  white,  in  the  latter 
yellowish,  with  a  distinctive  iatty  and  crumbling 
character  which  is  absent  in  psoriasis.  Lastly,  in 
psoriasis  there  is  no  history  of  previous  seborrhcea. 
The  point  of  diagnosis  from  a  dry  seborrhosic  der- 
matitis so  Irequently  emphasised — namely,  that  on 
removing  the  scales  of  psoriasis,  the  red  or  even  bleed- 
ing tips  of  congested  papillEB  may  be  noticed— is  of 
some  value,  but  may  be  quite  misleading. 

Eczema  of  the  nipple  may  be  distinguished  from 
Paget's  disease  by  the  absence  of  the  parchment-like 
induration  and  retraction  of  the  nipple,  which  are 
characteristic  features  of  the  latter  condition. 

Etiolog^y. — The  causation  of  eczema  has  not  yet 
been  definitively  established  by  scientific  evidence, 
but  it  is  clear  that  for  its  production  two  conditions  at 
least  are  necessary.  These  are  :  first,  a  predisposi- 
tion or  special  irritability  of  the  skin ;  secondly,  an 
exciting  influence  which  brings  this  irritability  into 
action.  The  abnormal  vulnerability  oi  the  skin  may 
depend  on  certain  peculiarities  of  structure,  or  it  may 
he  the  result  of  a  pre-existing  morbid  condition  ;  or, 
again,  it  may  be  connected  with  some  underlying 


ECZEMA.  [C-B4P.  xn. 

coDstitulioiial  state.  The  exciting  influences  may 
act  oa  the  skin  diiGetly  by  setting  up  irritation  and 
so  causing  the  development  of  the  lesions,  or  in- 
directly through  the  nervous  system.  In  many  cases 
both  these  modes  of  attack  are  combined.  Lastly, 
the  eczematous  process,  when  set  in  motion  by  the 
causes  that  have  be-en  referred  to,  may  be  intensified 
and  kept  up  indefinitely  by  secondary  causes,  such  aa 
the  patient's  state  of  health,  his  exposure  to  soorcee 
of  additional  irritation,  etc. 

Aa  regards  peculiarity  of  tissue,  fair-haired  persons 
appear  to  be  somewhat  more  liable  to  eczema  than 
those  of  darker  complexion  (Jamieson).  A  thin,  dry, 
auHimic  skin,  with  deficiency  of  subcutaneous  fat, 
affords  a  very  favourable  soil  for  the  development  of 
the  process.  The  disease  is  not  unfrequently  asso- 
ciated with  xerodermia,  a  congenital  anomaly  charac- 
terised by  abnormal  dryness  of  the  epidermis — in 
fact,  a  mild  form  of  ichthyosis.  Such  anomalies  an 
often  inherited,  and  the  tendency  to  eczema  may  be 
transmitted  with  them ;  in  this  sense  only  is  eczema 
hereditary.  On  the  other  hand,  skins  in  which  the 
sudoriparous  glands  are  over-active  are  especially 
liable  to  "  sweat  eczema."  But  the  condition  of  all 
others  which  makes  the  skin  most  vulnerable  to  attack 
ia  seborrhcea.  I  do  not  go  to  the  length  of  saying 
with  Unna,  "  Treat  the  seborrhcea  of  children,  and 
you  will  not  later  have  eczema  in  adults,"  *  but  I  am 
convinced  that  if  there  were  no  seborrhtea  there  would 
be  much  less  eczema. 

In  the  same  way,  the  ground  may  be  prepared  for 
eczema  by  artificial  dermatitis.  As  has  already  been 
explained,  I  do  not  look  upon  the  eruptions  caused 
by  chemical  or  mechanical  irritants  as  coming  within 
the  category  of  eczema ;  undoubtedly,  however,  such 


CHAP,  sn-l  ETIOLOGY.  263 

lesionB  may  be  the  starting-pointa  of  the  disease. 
Thus  it  is  by  no  means  imcommon  to  see  artificial 
dermatitis  on  a  bricklayer's  liands,  followed  by  the 
development  of  patches  of  true  eczema  on  parts  of 
the  akin  that  have  never  been  in  contact  with  lime  ; 
and  the  eczema  may  persist  and  reproduce  itself  in 
different  spots  when  the  eczematoid  lesions  in  which 
it  took  origin  have  disappeared.  It  is  clear,  thexe- 
fore,  that  in  such  cases  some  other  agency  besides 
the  original  cause  of  irritation  has  come  into  play  ; 
to  the  hme  there  has  been  superadded  an  irritant  of  a 
different  kind,  the  action  of  which  ia  not  temporary 
and  localised,  but  continuous  and  self-multiplying. 
There  can  be  little  doubt  that  this  additional  irritant, 
which  tranatorms  a  simple  seborrhrea  or  dermatitis 
into  an  eczema,  is  the  action  of  micro-organiama. 
As  has  already  been  pointed  out,  the  skin  has  an 
abundant  and  varied  microbic  flora  of  its  own  ;  under 
normal  conditions  these  organisms  do  no  harm,  but 
it  is  easy  to  understand  how  the  lesions  produced 
by  previous  disease  may  make  the  integument  more 
vulnerable  to  their  attacks. 

Unna  •  formerly  taught  that  in  acute  eczema 
the  fluid  in  the  vesicles  contains  a  specific  micro- 
organism, which,  from  its  tendency  to  form  mul- 
berry-like masses,  he  cailcd  "  morococcus."  By 
inoculation  of  cultures  of  this  parasite  he  beheved 
that  he  had  produced  eczema.  He  stated  that  he 
found  the  same  micro-organism  in  the  scales  in 
chronic  cases.  Seborrhceic  eczema  is  beheved  by 
Leredde  "f"  to  be  the  result  of  a  mixed  infection  due  to 
the  association  of  microbes,  such  as  the  fatty  sebor- 
et«., 


•  Sff  Duiia:  "On  the 
Srit.  JoniK.  of  Ilmi... 
"L'Eoifiim,  niuladie  jiurai 

top.  cit.,p.  «. 


eques 


ECZEMA.  [tiHAP.  sn. 

I,  lion,  however,  Unna  haa  made  a  public  recantation  o£ 
lorococcus"  doctrine.*     At  the  fourth  Inter- 
Imational  Congress,  held  in  Paris  in  19(X>,  he  animned 
Fuj)  the  conclusions  to  which  he  had  been  led  by  his 
tmore  recent  researches  in  the  following  propoaitions  : 
Jil.  The  uncertainty  which  exists  concerning  the  patho- 
ngenic  agent  of  eczema  is  due  in  great  measure  to  the 
Bttbsence  of  precise  knowledge  as  to  the  various  forma 
wtA  cocci,  micro-organisms  presenting  the  closest  simi- 
"  iarity  in  appearance,  possessing  widely  different  patho- 
genic   propertiea.     'i.  In    eczema    numerous    micro- 
organisms are  present,  and  among  them  are  eeveral 
which,   when    reinoculated,    reproduce  the    disease, 
which  ia  therefore  contagious  and  in  certain  circum- 
stances may  become  epidemic. 

Dre.  James  Galloway  and  J.  Y.  H.  Eyre,  in  a  com- 
munication presented  to  the  same  Congress,  reported 
the  results  of  bacteriological  examinations  made  by 
them  in  several  cases  of  acute  pap ulo- vesicular 
eczema.  In  early  and  uncomphcated  lesions  they 
found  cocci  producing  whitish  cultures,  all  of  them 
examples  of  the  type  Staphylococcus  pyogenes  albuB, 
and  possesai:^  to  a  greater  or  less  extent  the  patho- 
genic powers  of  that  organism.  They  expressed  the 
opinion  that  in  all  probabihty  there  are  many  factors 
at  work  in  the  production  of  any  attack  of  eczema, 
and,  although  they  do  not  tltink  this  organiain  is  the 
cause  of  the  disease,  they  cannot  help  considering 
that  this  wliite  coccus,  and  other  cocci,  such  as  the 
Staphylococcus  pyogei^es  aureus  and  the  Strepto- 
coccus pyogenes,  which  are  so  often  present,  esp^oially 
in  the  later  stages  of  the  disease,  must  have  very  im- 
portant influences  on  the  development  of  the  malady. 
The  local  infectivity  and  chronicity  of  eczema,  the 
eaae  witli  which  pnrulent  manifestations  occur, 
ahould  be,  in  all  probability,  ascribed  to  the  presence 

M-miUh.f.  prahiTlir  Ihr.:..  Bci.  xxi.,  No.  S. 


CHAF.  xn.]  ETIOWOY.  265 

of  such  bacteria.  Sabouraud,  in  a  communication  to 
the  annual  meeting  of  the  British  Medical  Association 
held  at  Cheltenham  in  IMl,  expreaaed  the  opinion 
that  the  staphylococcus  is  the  cause  of  pustular 
lesions  of  the  skin  in  ecaema  and  other  conditions. 
Neisaer  has  summed  up  his  belief  in  the  formula, 
"  No  eczema  without  micrococci." 

On  the  other  hand,  Reibich  examined  baeterio- 
logically  the  two  to  four  day.q  old  vesicles  of  forty- 
one  cases  of  eczema,  and  found  them  for  the  most  part 
sterile.  Later  in  the  course  of  the  disease  he  found 
Btaphylococci  and  streptococci,  but  wa  nabi  t 
produce  eczema  experimentally  by  inocul  t  w  tl 
these.    Veillon  *  also  examined  the  fresh  1       f 

ordinary  eczema,  and  found  them,  aim    t  w  th     t 
exception,  sterile.     Secondary  infection  w  th    t  ph 
lococci  and  streptococci  is  common,  but  \    II      t 
unable  to  produce  an  eczeraatoua  eruptio    w  th  th 
which  he  isolated.     The  serum  of  a  hora     mm  ni    d 
against  the  staphylococci,  isolated,  exhib  t  d 
fluence  on  the  course  of  the  disease  in  th     h  m 
subject. 

The  parasitic  theory  must  thereto  i  th 
present  be  dismissed  as  "  not  proven,"  th  gl  t 
impossible  to  believe  that  parasites  know  to  p 
definite  pathogenic  properties  can  be  pre  nt  n  h 
numbers  as  they  have  been  proved  to  be  b  mp  tent 
observers  without  having  a  considerable  ffect  n  th 
character  and  severity  of  the  disease.  The  success 
of  treatment  based  on  the  parasitic  theory  is  a  strong 
argument  in  favour  of  its  truth  in  regard  to  a  large 
proportion  of  case^.  On  the  other  hand,  we  know 
that  the  organisms  referred  to  are  harmless  to  a 
healthy  skin.  The  ground  must  therefore  be  pre- 
pared for  their  action.  Neisser.  as  already  said,  holds 
fcthia  is  done  by  external  irritants,     But  how  is 

■  Annul.  •/.  Ihniial.  •I  ili  Si/pli..  No.  a,  ISIMJ. 


fCB 


» 


the  ground  prepared  when  there  are  ao  irritants  t  fl 
The  distinguished  fireslau  professor  gets   over  thiafl 
difficulty  by  giving  the  chief  place  among  "  irritants  "  f 
to  soap  and  water.     Thus,  in  hia  view,  except  a. 
the  "  great  unwashed,"  the  human  skin  is  always  a 
the  mercy  of  this  golden -yellow  staphylococcufi.  Gallol 
way  and  Eyre  include  among  predispoHing  factoTBtT 
1 .  Certain  organic  lesions,  especially  such  a«  pioduul 
circulatory  stasis  in  the  skin  and  consequent  oedei 
and  malnutrition  of  both  cutis  and  epidermis.     2.  T 
seboirhceic  state,  which  permits  the  free  growth  e 
vegetable  parasites,  and  especially  of  certain  bacteria^H 
3.  Certain  conditions  of  imperfect  metabolism,  whioll 
predispose  to  the  onset,  or  at  any  rat-e  the  recurrence 
of  ecaema ;  of  these  the  moat  common  are  those  aaso 
ciated  with  improper  digestion  and  assimilation  t^'l 
food.     Want  of  exercise,  the  impure  atmosphere  i 
cities,  etc.,  aggravate  this  condition  and  increase  t' 
risk  of  recurrent  attacks. 

Galloway  and  Eyre  make  no  mention  of  a  facto 
to  which  1  am  disposed  to  attach  considerable  ini 
portance ;  that  is,  nervous  shock  and  prolonged 
mental  depression.  I  have  so  often  seen  the  diae 
develop  on  skdn  previously  quite  healthy  that  I  c 
not  doubt  that  the  derangement  of  the  nervoU| 
mechanism  brought  about  by  the  Inftuence  i  ' 
mind  on  the  body  has  been  reflected  on  the  ii 
ment,  Bulkley  *gives  some  striking  examples  of  e 
following  worry,  mentaJ  strain,  and  nervous  shoclb 
More  than  one  case  traceable  to  the  "  Black  Friday  *) 
financial  panic  in  Wall  Street  came  under  his  noticq 
According  to  Radouan,  the  siege  of  Paris  by  t 
Germans  and  the  brief  "  reign  of  t«rror  "  of  the  C 
mune  in  I87I  left  their  impress  on  the  skins  of  n 


CHAP,  xn.]  BTIOLOBY.  207 

persons  in  the  fopm  oi  eczema.*  I  have  myself  known 
the  disease  in  its  acutest  form  follow  a  fright.  The 
nervous  depression  caused  by  chill  manifesta  itself 
in  some  persons  as  catarrh  of  the  skin — that  is,  eczema 
— just  aa  in  others  it  shows  itself  as  catarrh  of  the 
respiratory  membrane,  and  in  others  again  as  catarrh 
of  the  intestine.  Thus  a  man  may  go  to  business  in 
the  morning  on  the  top  of  an  omnibus,  being  at  the 
time  to  all  appearance  in  perfect  health  ;  he  may  feel 
that  he  has  "  taken  a  chill,"  and  begin  to  shiver  and 
complain  of  general  mnlaise  ;  on  reaching  home  in 
the  evening,  however,  he  may  lind  that,  instead  of  a 
catarrh  of  his  mucous  membrane,  he  has  developed 
a  well-marked  ecuema.  Reflex  nervous  irritation 
from  the  uterus,  the  stomach,  the  intestine,  etc.,  often 
seems  to  be  the  exciting  cause  of  eczema.  In  some 
women  menstruation  and  pregnancy  are  generally 
accompanied  by  an  attack  of  eczema,  and  the  disease 
is  also  not  uncommonly  one  of  the  indications  of  the 
"  change  of  life."  Eczema  is  sometimes  a  result  of 
the  irritation  caused  by  indigestible  food  in  the 
stomach,  or  by  worms  in  the  intestinal  canal. "f"  The 
origin  of  eczematous  eruptions  beginning  on  the 
cheeks,  eyehds,  etc.,  has  been  traced  to  disturbances 
of  vision,  and  the  skin  lesions  have  ceased  to  appear 
when  the  eye  afiecfcion  has  been  cured.J 

Uuna  has  described  a  special  type  of  eczema  on  the 
face  in  infanta  occurring  in  coimection  with  dentition.  § 
While  not  denying  that  reflex  irritation  from  that 
source  may  give  rise  to  eczema,  I  am  inclined  to  think 


*   "Etrnie  tliiJot.  et  first,   but  I'Eti^n 
1875.     On  the  nerTOiia  ongin  of  BMenia  w 

+  Scareuiio  (quoted  by  Bulklej-,  /or,  HI.) 
wlu^  ecxema  was  due  to  the  presenve  oi 
" "   1  it  dapandad  on  tlia  oiyuria. 
'-r,  ZoB«(,  1S84. 
).  Ciilmi.  imd  6'™.  l',-h<.  Batai^a, 


that  in  tlie  majority  of  cases  the  production  of  the 
Bldn  affection  ia  rather  to  he  explained  by  the  seboi- 
rhtea  which  ia  apt  to  be  set  up  by  tlie  abnormally 
large  amount  of  blood  supplied  to  the  head  in  inianta 
for  the  building  up  of  bone  and  brain.  The  same 
influence  is  more  or  leas  actively  at  work  in  all  grow- 
ing children ;  lience  the  frequency  of  Beborrhcpa  at 
that  time  of  hfe. 

Eczematous  eruptions  may  alao  be  produced  by 
reflex  irritation  ol  peripheral  origin,  aa  in  the  cam 
of  burns,  etc.  ;  or  they  may  be  a  consequence 
of  changes  in  the  nerves  reaulting  from  injury  or 
disease,  or  they  may  be  connected  with  functional 
neurosis.*  Colomiatti  f  found  structural  changes  in 
the  cutaneous  nerves  in  several  cases  of  eczema,  moBt^ 
of  the  papule- squamous  type  ;  and  that  these  changes 
were  in  direct  relation  to  the  process  in  the  skin  he  held 
to  be  proved  by  the  fact  that  in  cases  in  which  the 
akin  leaiona  were  wholly  or  partly  cured  the  nerves  also 
had  in  great  measure  recovered  their  normal  appear- 
ance. These  observations  were  afterwards  confirmed 
by  Leloir.J  Of  the  relationship  between  eczema 
certain  forms  of  functional  neurosis  there  cai 
he  a  better  illuatration  than  the  fact  that  it  is 
quently  associated  with  aathma  ;  so  close,  indeed, 
the  connection  between  the  two  affections,  that  astimiK; 
ia  beheved  by  some  to  be— at  least  in  certain 
simply  eczema  of  the  bronchial  tubes.  It  is  no4 
worthy  that  persons  who  are  the  suhjecl*  of  xi 
(lermia  very  frequently  alao  suffer  from  asthma.  It; 
probable  that  both  the  eczema  and  the  asthma  are  '' 
response  by  the  skin  and  respiratory  mi: 
brane  respectively  to  some  central  or  peripheral  ini) 

*  Eiunples  of  epzonu  folloHTog  thew  different  f 
iluorJun  ure  uitmi  from  TurionsunUiorB  liv  Bitlklor,  liir,  ril, 

*  a.am.  IM.  il.  Mnlallir  rrnn:  r  il.  PtV".  Ift?!'. 
t  Am:  da  litrm.  H  Sgpli.,  ISRti. 


I 


OHAP.  xn,  ]  ETIOLOQ  Y.  20» 

tion  to  which  both  alike  are  exposed.  Cases  have 
been  reported  by  Charcot,  VuJpian,  and  others  in 
which  ecKcma  occurred  in  association  with  disease  of 
tbe  brain  or  spinal  cord,  but  there  is  not  yet  sufficient 
evidence  to  show  whether  the  skin  afiection  in  these 
cases  was  the  result  of  the  nerve  disease  or  an  acci- 
dental coincidence.  Anything,  however,  which  inter- 
feres with  the  proper  nutrition  of  the  akin  lesaens  its 
power  of  resistance  to  injurious  influences,  and  in  this 
way  disease  of  the  central  nervous  system  may  be 
regarded  aa  a  predisposing  cause  of  eczema.  The 
afEection  is  said  by  some  observers  to  be  frequent 
among  the  insane.* 

The  exact  mode  in  which  eczema  is  induced 
by  nerve  disorder  is  still  somewhat  obscure.  Such 
evidence  as  is  available  is  almost  entirely  clinical. 
It  is  certain  that  under  the  influence  of  nerve  shock 
and  nerve  exhaustion  (neurasthenia)  ecsema  ruay 
arise  de  now?  in  a  previously  healthy  skin.  In  such 
circumstances  the  trophic  influence  of  the  nervous 
system  on  the  skin  is,  to  a  greater  or  less  extent, 
impaired;  and,  according  to  Leloirf  and  Bulkley.j 
eczema  may  be  the  result.  In  other  words,  eciema 
is,  in  the  opinion  of  these  dermatologists,  simply  a 
trophoneurosis.  Here  again,  however,  to  my  mind 
something  more  is  required  for  the  development  of  a 
process  so  complex  iu  its  manifestations  as  eczema. 
It  appears  to  me  more  reasonable  to  look  on  the  in- 
hibition of  trophic  influence  as  preparing  the  way  for 
eczema  by  reducing  the  skin  to  a  condition  of  lowejed 
vitaUty  in  wliich  it  is  powerless  to  resist  the  action  of 
micro-  organisms. 

As  regards  reflex  irritation,  the  case  is  somewhat 
diSerent.     It   has   already  been  shown  that  vaso- 

•  Fivre  aud  Nieol,  (juoted  ty  Bulkley,  /w.  ril. 
t  "  Hacherehes  cliuiques  Biir  lea  Affeutious  tutiuites  d'liripuB 
"  Piuis,  18a:!. 


^^^1       motor  disturbance  alone  is  eufficiont  to  produce  all 
^^^H       the  eBsential  lesions  of  the  eczematoua  process.   Even 
^^^H       here,    however,    miciobes   must  often  intervene,   or  _ 
^^H       there  would  be  no  pustules.     While,  therefore, 
^^H       prepared  to  go  the  length  of  maintaining,  with  Unna^fl 
^^H       that  eczema  is  always  parasitir.  I  am  etJIl  less  d' 
^^^B       posed  to  accept  the  view  of  Leloir  and  Bulkley  tha 
^^^1       it  is  never  anything  more  than  a  neurosis.     That  ii 
^^^1       the  majority  of  cases  eczema  is  parasitic  is  proved  bwV 
^^^       the  eSect  of  anti -parasitic  treatment ;  that  there  amS 
I  many  cases  in  which  the  affection  is  of  nervous  o  '_' 

r  is  shown  by  the  fact  that  it  may  be  cured  by  remecUee  1 

I  which  act  on  the  nervous  system.     Moreover,  in  many 

^^^        parasitic  cases  the  neurotic  element  may  be  so  pro-  J 
^^^       nouuced  as  to  furnish  the  leading  indication  for  treat  I 
^^H       ment.     Apart   from    the   condition    of   the    nervotai'V 
^^^P       system,  I  attach  little  importance  to  the  constitutioil^ 
^^^         of  the  patient  as  an  etiological  factor  in  regard  to 
eczema.     The  tendency  to  that  affection  is  sometimeB 
found  associated  with  rheumatism,  and  sufiereia  irom 
gout  are  prone  to  eczema  as  they  are  to  other  forma 
of  catarrh.     There  is  not,  however,  any  form  of  skin 
lesion  known  to  me  which  can  properly  be  c&lled 
"  gouty  eczema  "  ;  in  other  words,  there  is  no  special 
type  of  eczema  that  can  be  recognised  objectively  m  m 
of  gouty  origin.     Brocq  *  describes  an  eaima  e  _ 
•pdatoide  reddivanl  des  artkriliques,  characterised  1; 
the  rapid  occurrence  of  inflammatory  attacks  of  g 
intensity,  almost  always  affecting  the  head  and  fsc«, 
sometimes   the   hands,    genitals,    etc. ;     the   skin.  !•■ 
swollen  and  red  as  in  erysipelas,  and  constitutional 
tlisturbance  is  more  or  less  severe.     Although  gout  is 
go  common  Jn  tireat  Britain,  I  am  not  familiu  with 
a  type  of  skin  affection  answering  to  this  dcscriptioti. 
In  Germany,  where  gout  is  comparatively  rare,  ectenu 
is  just  ax  common  as  it  is  in  England.     But  while  | 

*  Up.  tit.,  pp.  ljl.5J. 


a.]  ETIOLOGY.  271 

denying  that  gout  is  of  itself  sufficient  to  produce 
eczema,  I  am  willing  to  admit  that  the  gouty  djathesis 
or  any  otlier  constitutional  state  characterised  by  a 
tendency  to  sudden  vaso- motor  disturbance  may 
aggravate  the  sldn  affection  to  such  an  extent  as  to 
require  to  be  taken  into  account  in  treatment. 

There  is  no  connection  between  eczema  and  rickets, 
nor  has  malnutrition  any  direct  influence  in  it*  pro- 
duction. The  disease  is  just  as  common  in  the  well- 
nourished  children  of  weU-to-do  people  as  in  those  of 
the  poor,  and  breast-fed  infants  are  no  more  exempt 
from  it  than  those  brought  up  by  hand.  Nor  has 
scrofula  anything  to  do  with  the  production  of  eczema, 
except  iu  as  far  as  proclivity  to  catarrh  is  one  of  the 
notes  of  the  scrofulous  diathesis.  It  is  true  that  many 
children  suffering  from  eczema  are  the  subjects  of 
scrofula,  but,  on  the  other  hand,  there  arc  iar  more 
eezematous  children  than  scrofula  can  account  for. 
It  is  almost  unnecessary  to  say  that,  although  scrofula 
<'-anD0t  produce  eczema,  it  may  have  a  powerful 
modifying  influence  on  the  lesions. 

Eczema  is  not  as  a  rule  contagious,  but  when 
parasitic  it  is  auto-inoculable  ;  in  this  way  it  repro- 
duces itself  in  distant  foci,  while  individual  patches 
continue  to  spread  at  the  edge.  Sometimes  it  appears 
to  be  inoculable  from  one  patient  to  another.  Thus 
the  arms  of  nurses  who  carry  babies  suffering  from 
eczema  of  the  nates  may  become  irritated,  and  eczema 
may  be  induced  by  scratching.* 

To  sum  up  :  eczema  in  a  large  proportion  of  cases 
is  of  parasitic  origin,  but  the  parasites  cannot  produce 
the  lesions  unless  they  And  a  suitable  soil  in  which  to 
proliferate.  In  some  cases  the  skin  is  made  suitable 
lor  this  purpose  by  seborrhoea  or  other  pre-existing 
morbid  condition  ;  iu  others  by  diminished  resistance 
owing  to  loss  of  nerve  control.     In  another  class  of 

•J,L.m(«on,  op.  cit.,1..  2t,i, 


r 


272 


/ECZEMA. 


[chat.  xa!H 

d{  nervong.^B 
3in  one  ovfl 

:,  by  reflei   J 


caaes  the  disease  is  probably  altogether  oi  nervouv, 
origin.     When  once  started  it  spreads  from 
two  centres  by  auto-inoculation  if  parasitic,  ' 
irritation  if  neurotic. 

Patholog^y.^Ecnema  is  esaentiaUy  a  catarrhal 
inflammation  of  the  akin,  and  the  appearances  found 
arc  those  characteristic  of  that  process,  being  more  oi 
lesa  marked  in  proportion  to  its  Beverity,  Mg.  13- 
shows  well  the  microscopical  appearances  presented 
by  a  veaicle.  Colomiatti,  as  already  said,  founl' 
changes  indicative  of  neuritis  in  the  nerves  sup- 
plied to  the  aSected  parts  of  the  skin,  and  in  om 
case  * — that  of  a  patient  suffering  from  acute  uni- 
versal eczema,  who  died  of  pneumonia—"  the  upper 
cervical  ganglia  of  the  sympathetic,  as  also 
cifiliac  ganglia,  were  visibly  hypersemic  to  the 
eye,  and  on  microscopic  section  the  changes  w< 
still  more  evident."  No  conclusion  can,  bowei 
be  drawn  from  a  single  case,  and  it  is  obvioi 
that  the  changes  in  the  sympathetic  ganghi 
described  may  have  been  connected  with  the  ii 
mation  of  the  lung  rather  than  with  the  eczema. 

Wben  eczema  has  lasted  some  time  it  often  giv) 
liiie  to  thickening  and  hardening — sometlmee  all 
wooden  in  consistence.  In  certain 
hypertrophy  may  be  so  great  as  to  simulate  elephant!* 
asis.  In  other  cases  a  persistent  warty  condition  may 
be  induced. 

Prognosis. -^Eiczenia  can  nearly  always  be  cniedi 
by  a  proper  course  of  treatment  perseveringly  puT-j 
sued.     In    many    cases,    however,    the   condition 
extremely  obstinate,  and  recurrence  is  the  rule  latlu 
than  the  exception.     When  the  neurotic  element 
strongly  pronounced  the  prospect  of  cure  is  much  le 
favourable  than  in  cases  of  Beboirhceic  origin,     The>J 
general  health  of  the  patient  must  also  be  token  intO' 
account  in  forming  a  prognosis. 

•  Manicoi :  Giurmik  IlaL  d.  M«!allU   t',-mr.  r  ('.  riK-.  1878. 


4 


■^■^•<'!*'?igf*?^'" 


With  regard  to  treatment,  the  queatioa  that  meets 
UB  on  the  threshold  is  whether  eczema  should  he 
treated  at  all.  There  is  a  popular  notion  that  the 
afEection  is  a  kind  of  safety- valve  which  it  is  dangerous 
to  close  ;  nor  is  this  idea  confined  to  the  laity.  So 
experienced  a  practitioner  as  Brocq  warns  us  against 
interfering  too  actively  with  eczema  in  elderly  persona 
or  in  gouty,  rheumatic,  emphysematous,  and  asth- 
matical  subjects,  or  sufierers  from  chronic  bron- 
chitis, melancholia,  B right's  disease,  dyspepsia,  etc. 
"  By  treating  their  eczema  too  energetically  one  may, 
in  fact,  determine  the  onset  of  pulmonary  or  even 
cerebral  congestions  of  the  gravest  kind."  *  He  has 
reported  a  case  in  which  he  believes  that  "  the  sudden 
auppreasion  of  a  chronic  pruriginous  eczema  of  several 
years'  date  in  a  patient  suffering  from  old  asthma, 
melanchoha,  and  troubled  with  occipital  and  tem- 
poral neuralgia,  was  followed  by  the  appearance  of 
morbid  phenomena  of  cerebral  origin,  of  a  nature  so 
grave  as  even  to  put  the  life  of  the  patient  in  danger — ■ 
phenomena  which  lasted  for  many  months,  and  which 
all  disappeared  completely  as  soon  as  an  '  issue  '  was 
formed  on  the  nape  by  means  of  a  blister  or  the 
cautery,  but  especially  after  the  reappearance  of  the 

f'Traitement  ila  Malaiiicia  de  In  Pcuu,"  Paris,  1S9(1,  ]..  17a. 


[874  ECZEMA.  [o 

pmrigmous  eczema  of  the  genitala."  *     Brocq  ex- 
pressly says  that  eczema  in  certain  "  morbid  deter- 
mina^ons  "  afEectiug  internal  organs  acta  aa  a  deriva-  , 
tive — in  fact,  as  a  kind  of  emimctory.f    A  similar  I 
view  is  strongly  held  with  regard  to  ecuema  in  children  I 
by  Gaucher.^     He  diatinguiBhea  between  seborrhcea,  I 
which  he  says  is  a  local  afEection,  the  cure  of  whioh  I 
caimot  be  followed  by  any  ill  effect,  and  true  eczems  1 
— whether  of  the  oozing  or  papular  (lichenoid)  form— 
which  he  lookfl  upon  as  an  aSection  originating  from  1 
aninternal  "diathetic"  cause.     This  eczema  he  be- 
lieves it  to  be  dangerous  to  cure,  especially  in  the 
case  of  children.     Gaucher  appears  to  regard  ecEeina 
as    a    provision   of   nature    for   the   elimination    of 
'  toxic  principles  "  resulting  from  constitutional  and 
often  hereditary  disorders  of  nutrition.     By  shutting 
up  this  outlet  these  toxic  principles  are  made  to 
accumulate   in   the   internal   organs,    "  with    conse-  I 
quences  more    or    less    rapid    and    more     or    le6B  ■ 
serious,  according  to  the  seat  of  the  metastasis."  T 

In  other  words,  Gaucher  shares  the  superstition   ' 
which    is    so  widely   prevalent  among  the  public 
as   to   the   dangers     of   "  driving  in "    the  cUsease, 
Holding,  as  I  do,  that  in  a  large  proportion  of  cases 
eczema  is  of  parasitic  origin,  and  that  the  constdtutiDii, 
when  involved  at  all,  plays  but  a  secondary  part  in 
the  process,  I  am  utterly  opposed  to  the  laissez-aUer 
principle  in  dealing  with  the  disease.    The  caution  in 
treating  eczema  which  is  so  emphatically  enjoined  oftjj 
na  is  based  on  the  assumption  that  we  have  a  powcfl 
of  controlling  the  process  which  we  are  very  far  fnual 
poBsessing.     EVen  if  the  "  abrupt  soothing  down  oif  l1 


may  folloxr  th 

oft  Chraiie 

toDw.,1889,p.l05.-( 

0,-it 

Jo«<,i. 

Ihrm.,  vol,  1 

,  Nov..  1SH8, 

•??.)■ 

t  Bi-il.  Jdii-H.  Ill-em 

TtqI, 

,.  Not. 

1H8S,  i«  Dw. 

188W.  p,  in. 

J-Cougrfc.  luten.. 
1889,"  p.  m  fl  iqq. 

iIh  D 

nil.  Bt 

da  Sypli.,  lilt 

u  A  Pumea 

□.]  TREATMENT  ;  INTERNAL  REMEDIES.  275 

the  cutaneous  phenomena  "  deprecated  by  Brocq 
were  as  dangeTous  as  he  believes,  the  practitioner  need 
not  be  afraid  to  treat  them,  since  it  is  quite  excep- 
tional for  the  disease  to  be  "  abruptly  soothed  down  " 
by  any  means  at  our  disposal.  In  every  case  that 
cornea  before  me  I  do  my  best  to  subdue  the  process 
and  cure  the  lesions  as  rapidly  and  as  thoroughly  as 
possible,  and  I  can  confidently  state  that  in  the  large 
number  of  cases  of  eczema  which  I  have  treated 
during  the  last  twenty  years  I  have  never  seen  one 
in  which  the  cure  or  abatement  of  the  disease  was 
followed  by  any  ill  effect  whatever.  My  view,  there- 
fore, is  that  the  practitioner  should  endeavour  to 
cure  eczema  whenever  he  meets  with  it ;  the  only 
caution  necessary  is  that  he  should  accurately 
adapt  his  remedies  not  only  to  the  process  but  to 
the  patient. 

The  first  step  towards  successful  treatment  ia  to 
determine  whether  the  disease  is  of  parasitic  or  of 
neurotic  origin^that  ia  to  say,  whether  it  is  to  be 
dealt  with  by  local  or  by  general  remedies.  As 
already  said,  these  two  etiological  elements  are  often 
combined,  and  in  that  case  it  is  important  to  ascertain 
which  of  them  predominates  in  a  given  case. 

Internal  remedies. — In  deahng  with  eczema 
the  beginning  of  therapeutic  wisdom  is  to  clear  one's 
mind  of  the  notion  that  arsenic  or  any  other  drug  is  ■ 
a  specific.  The  practitioner  must  learn  not  to  look 
upon  it  as  a  fised  law  that  internal  remedies  are  to  be 
given  in  every  case.  As  a  general  rule,  indeed,  the 
leas  drugging  the  better.  But  if  internal  remedies 
have  to  be  employed,  they  should  be  given  only  for  a 
definite  purpose  and  in  accordance  with  definite  indi- 
cations. Random  polypharmacy  is  often  hurtful  t« 
the  patient  and  an  obstacle  to  scientific  progress. 
How  can  we  expect  to  gain  any  accurate  knowledge 
of  the  action  of  medicines  if  they  are  used  by  the 


^^M     STO  ECZEMA.  [tmAf 

^^H      half-dozen  at  a  time,  like  charges  of  email  shot  filed  1 
^^H      at  the  disease 

^^^K  For  the  subduing  of  the  inflaiumation  in  so-called  I 

^^^K     "  acute  "  cases  there  is,  in  my  experience,  nothing  ] 
^^^1     equal  to  antimony.     Small  doses  of  the  vinum  ami-  j 
^^^ft     moniale  quickly  relieve  the  arterial  tension  and  thus  ' 
^^^B     reduce  the  local  inflammation.     If  the  patient's 
^^^V     stitution  is  sonnd,  I  generally  begin  by  giving  Vi\X 
^^^B     lo  \i\xiii  of  the  wine,  repeating  the  dose  in  an  hour, 
^^^B     and,  if  necessary,  again  two  hours  later.     The  inteival 
^^H     between  the  administrations  is  gradually  increased, 
^^^B     while  the  amount  is  diminished  till  a  dose  of  n\yj  is  I 
^^B      reached.     This  should  be  given  three  times  in 
^^"       twenty-four  hours  as  long  as  the  acute  symptomB    ' 
F  last.     When  there  is  no  great  arterial  tension,  and 

when  depression  is  a  prominent  symptom,  antimony 
I  should  not  be  given.     On  the  other  hand,  id  all  acute 

inflammatory  conditions  of  the  skin,  iron  only  adds 
fuel  to  the  flame  by  increasing  the  activity  of  blood 
formation.  Arsenic  is  also  contra-indicated  in  Bucb 
circumstances.  Stimulants  must  be  forbidden,  the 
diet  should  be  of  the  simplest  kind,  and  the  bowels  . 
must  be  carefully  regulated.  The  clothing  should  be 
light,  and  it  is  particularly  important  that  the  patient 
when  in  bed  should  not  be  covered  with  heavy 
blankets,  as  the  symptoms  are  always  intensified  &t 
'  night.  Complete  rest,  both  of  mind  and  body,  should 
as  far  as  possible  he  secured.  If  the  area  of  skiii 
involved  is  very  extensive,  the  patient  should  be  kept 
in  bed.  When  nervous  symptoms  are  pronounced, 
appropriate  sedatives  must  be  administered.  In  the 
front  rank  of  these  is  opium,  which  soothes  excit«nieiit, 
allays  irritation,  inducer  sleep,  and  so  restores  the 
exhausted  nervous  energy.  If  need  be,  the  remedy 
ehould  also  be  given  during  the  day  ;  sometimeB  it 
may  be  necessary  to  keep  the  suSerer  almost  o 
tinuously  under  the  influence  of  opium  or  morphia. 


n.]  WCAL    TREATMENT.  277 

In  such  cases  the  conetipating  effect  ol  the  drug 
should  be  counteracted  by  giving  a  mild  aperient, 
such  as  Carlsbad  salts,  Friedrichshall,  or  other  saline 
purgative,  in  the  morning.  If  opium  disagrees, 
chloral,  mlphonal,  or  jjhenacetin  may  be  substituted 
for  it.  If  proBtration  is  a  marked  feature  in  the  case, 
it  will  be  well  to  commence  treatment  by  giving 
quinine  ;  this  remedy  may  often,  with  great  advan- 
tage, be  combined  with  opium.  In  neurotic  eases 
arsenic  sometimes  does  good,  Vmt  my  experience  is 
that  this  drug  can  never  be  relied  on  in  eczema. 
Strychnine,  and  especially  phospkorug,  are  more 
frequently  of  use  in  such  cases,  and  ergot  may  occa- 
sionally prove  serviceable,  probably  by  its  action  on 
the  vaso-motor  apparatus.  In  women,  at  the 
climacteric  period,  and  in  hysterical  subjects,  such 
remedies  as  musk,  mlerian,  etc.,  should  be  used  ;  and 
■in  all  cases,  if  any  definite  aouice  of  peripheral 
irritation  can  be  discovered,  it  should,  if  possible, 
be  removed.  When  the  discharge  is  veiy  profuse, 
quinine  may  usefully  be  combined  with  beilndanna. 
When  the  disease  is  very  rebellious,  fresh  exacerba- 
tions occurring  every  few  days,  Crocker  has  found 
counter- irritation  (by  means  of  blistering  fiuid, 
mustard-leaf,  etc.)  apphed  over  the  vaso-mot«r 
centres  of  the  part  very  useful.*  In  all  cases  the 
patient's  general  health  must  be  attended  to,  com- 
plications, like  dyspepsia,  etc.,  being  dealt  with  as  the 
occasion  arises,  and  constitutional  conditions,  such  as 
rheumatism,  gout,  diabetes,  renal  disease,  rickets,  and 
scrofula,  being  treated  in  accordance  with  the  general 
principles  of  practice. 

Local  treatment. — Although  internal  medica- 
tion may  be  a  useful  adjuvant  in  the  treatment  of 
eczema,  the  practitioner  who,  from  a  mistaken  belief 

"Diseasea   of  the    Skin,"  p.  13<i,   second  odition,    London, 


[oHiP.  Sin. 


ifen  ECZEMA. 

in  tlie  constitutional  nutim*  of  the  disease,  trurta 
entirely  tliereto  will  find  that  he  ia  leaning  on  a  broken 
toed,  Bczemft,  being  in  a  large  proportion  of  cases 
ef  pa^asiti(^  origin,  can  be  cured  only  by  appropifil 
looul  remedies,  and  in  seborrhceic  cases,  when  the 
^fttient's  general  health  ia  sound,  no  other  treatment 
la  required.  It  must,  however,  be  understood  that 
for  local  treatment  to  be  successful  two  conditaona 
must  be  fulfilled.  FixBt,  the  strength  of  the  applica- 
tion employed  must  be  judiciously  tempered  to  the 
inteiuity  of  the  process  which  it  is  intended  to 
combat ;  aeC'Oudly,  the  lesions  must  be  kept  continu- 
ously under  the  influence  of  the  remedy.  The  mere 
I  perfunctory  application,  moruing  and  evening,  at  ft 
ilution  or  an  ointment  can  have  httlc  or  no  effect 
I  checking  the  disease.  The  gxiiding  principle  in 
>eal  treatment  must  he  to  deetioy  the  irritant  while 
tothing  the  inflammatory  reaction  set  up  by  its 
esence. 
A  ueeeeaary  preliminary  to  local  treatment  is  the 
l|«uioval  of  all  crusts  and  scales  that  prevent  the 
I  ttce«6S  of  the  remedy  to  the  seat  of  discAse^ 
I  be  softened  by  means  of  oil  applied  on 
rips  of  lint,  or  weak  solutions  of  bicarbonate  of 
CVusts  are  T«AdUy  loosened  by  keeping  the 
covered  tot  a  few  days  with  thtn  inditirubfaer ; 
I  method  is  espeiL'iaUy  useful  on  the  head  aad 
>e.  When  the  crusts  have  been  gut  rid  of,  ikm 
t  step  is  to  attack  the  disea^  directly,  hi  ths 
I  treatment  of  ocxema  t)irei»  objects  havn  to  Im 
t  m  view.  First,  the  destruction  of  the  pataattes  ; 
,  the  protection  of  the  inHamed  surface  bcnk 
r  »nd  tiwm  poasible  invasion  by  fresli  microbw  ; 
',  the  rvlief  uf  irritation.  As  it  is  oi  the  utaMwfe 
Utce  not  to  a^igravate  the  ■"■*— ""■r*"fT 
s  tiu  unirnbiCLUg  pvaailici^  b^mU  iliT^it 
ed  in  tlie  titst  instance ;   tii»  aBwuglh  oC' 


I 


ip.  sm.]  LOCAL    TREATMENT.  279 

application  should  be  very  moderate  to  begin  with, 
and  may  be  gradually  increased  as  the  symptoms 
subside.  When  there  is  much  discharge  a  weak 
solution  of  horacic  acid  is  particularly  useful  for  the 
washing  ol  the  afiected  part.  The  lotion  should  lie 
dabbed  on  with  a  wet  cloth.  A  towel  should  not  be 
used,  but  the  discharging  area  may  be  dried  by  "means 
of  muslin  bags  containing  starch,  with  a  small 
quantity  of  powdered  boracie  acid.  Sometimes  the 
parts  are  so  sensitive  that  the  patient  cannot  bear 
this  apphcation ;  in  that  case,  flour  mixed  with  a 
little  powdered  boracie  acid  should  be  dredged  over 
the  oozing  surface.  This  procedure  is,  however, 
attended  with  the  disadvantage  that  the  ilour  becomes 
caked  on  the  part,  making  it  stiff  and  painful  to 

During  the  acute  stage  the  parte  should  never  be 
washed  with  water,  and  even  when  the  violence  of 
the  inflammation  has  subsided,  washing  should  not  be 
frequent,  and  friction  with  towels  should  be  carefully 
avoided.  Hard  water  should  on  no  account  be  used ; 
only  rain-water  or  water  that  has  been  boiled  should 
be  allowed  to  come  in  contact  with  the  eczematous 
skin.  It  is  better  not  to  use  soap  of  any  kind,  but 
if  any  must  be  employed,  one  of  the  superfatted 
medicated  class  introduced  by  Unna  should  be 
selected. 

For  the  protection  of  the  inflamed  surface  from 
the  air,  and  for  the  rehef  of  irritation,  greasy  applica- 
tions in  the  form  of  "  creams "  are  most  useful. 
These  should  be  as  emollient  as  possible.  The  follow- 
ing formula  may  serve  as  an  example  : — 

B     Zinoi  oxicli  jvj 

Lanoljni        . .  . .         -  -  3ij 

Ol.  olivtB      . .  . .         . .         . .  5j 

AqiiiK  cftleia  5j 


ECZEMA.  [cH 


Some  amtmenta  have  a  tendency  to  lieat  the  skin, 
while  othera  impart  a  feeling  of  coolness  to  it.  Uniia 
attributes  the  latter  property  to  the  fact  that  in  these 
"  creams  "  a  certain  proportion  of  water  is  combined 
with  the  fatty  base  ;  thia  facilitates  evaporation.* 
A  useful  cooling  salve  consists  of  the  following  in- 
gredients : — 

9    Aq.  roaanim            lO'O 

Ol.  amycdal lO'O 

Cerm  albfp TO 

Cetacei         . .         . .         . .          . .  1  '0 


This  cold  cream  forms  a  good  base  for  varioua 
compound  ointments,  and  may  be  made  the  escipient 
for  different  antiseptic  agents.  For  tlie  continuous 
application  of  parasiticide  agents,  pastes,  salve 
muslins,  sticks,  plaster  muslins,  and  varnishes  may 
be  employed.  A  useful  fasle  may  be  formed  by 
mixing  equal  parts  of  starch  and  zinc  ointment ;  to 
this  any  antiseptic  that  may  be  desired  can  be  added. 
The  following  is  the  formula  of  Lassar's  paste,  which 
I  have  found  valuable  both  by  itself  and  as  a  basis 
for  other  drugs  : — 

B     Addi  galiojliei  . .  . .         . .  10  gra. 

Vseelini  5sa 

Zinci  oxidi  . .  -  -  3ij 

Piilv.  Bmyli  . .  . .         . .  Sij 


Resorcin,  ichthyol,  tar,  etc..  can  be  added  to  this 
I  paste.  Sticks,  as  suggested  by  Brooke  of  HaO' 
cheater,  may  also  be  the  vehicles  of  antiseptic  agente. 
The  base  of  the  stick  is  cocoa  butter,  and  in  this  way 
boracic  acid,  salicylic  acid,  ichthyol,  oside  of  mercury, 
resorcin,  sulphur,  etc.,  may  be  kept  in  contact  with 
diaeased  surfaces.     Both  the  pastes  and  sticks  may  be 

•  .\U,ial,h.j:p.„l.l.  Ilcm.,  Suui;  1881. 


m.] 


LOCAL    TRBATMEiiT. 


281 


KSeeh-tinted  with  Aimei^aQ  redbole,  so  that  they  can 

e  worn  on  the  face  or  hands  without  exciting  notice.* 

Salve  muslins  were  introduced  by  Unna,  and  lorm 

ftn  very  convenient  means  of  keeping  remedial  agents 

lia  cootinuous  contact  with  the  parts  on  which  it  is 

p^_deBiTed  to  act.     These  consist  of  muaUn  spread  with 

&  consistent  layer  of  benzoated  lard  and  wax  ;    vase- 

r  lanolin  may,  if  desired,  be  substituted  for  the 

I  hid.     These  salve  muslins  inay  be  the  vehicles  of 

oarbolic  acid,  white  precipitate,  boracic  acid,  ichthyol, 

salicylic  acid,  sulphur,  resorcin,  etc.  ;    pieces  of  the 

salve  muslin  of  the  size  required  may  be  cut  off  and 

accurately  fitted  to  the  part  to  be  treated.     The  salve 

muslins    may    be    obtained   spread    on    both    sides. 

These  preparations  form  the  moat  convenient  means 

of  treating  eczematous  lesions  in  which  the  discharge 

is  no  longer  profuse.     The  salve  mushns  are  of  use 

in  the  earlier  acute  stages  of  eczema  ;   jdaster  muslins 

are  beet  adapted  for  chronic  patahes  left  behind  when 

the  acute  stage  is  past.     These  plaster  muslins  may 

also  be  the  vehicles  for  every  kind  of  local  remedy. 

Another    equally    convenient    method    of    keeping 

liMmedies  in  contact  with  eczematous  lesions  is  the 

I'ff^cerine    jeily    or    varnish    employed  by   Pick   and 

modified  by  Unna.     The  advantage  of  these  varnishes 

IB  that  they  can  be  apjilied  to  any  part  of  the  body, 

so  as  to  form  a  tight-fitting  and  Ht  the  .same  time 

pliable  covering,  which  can  be  easily  removed  and 

readily  reapplied.     Allan  Jamieson  f  envelops  the 

raw,  denuded,  "  weeping  "  surface  with  a  starch  jelly, 

with  which  is  combined  a  proportion  of  boric  acid. 

In  all  cases,  as  has  already  been  said,  it  is  advis- 
able to  commence  local  treatment  with  very  mild 

ulou 


[c> 


applications.     One  must  ieel  one's  way,  so  to  speak, 
as  it  is  impossible  to  know  beforehand  wliether 
particular  remedy  may  not  cause  irritation.     The 
beat  application  in  seborrhceic  and  all  other  parasitic 
forma  of  ecKema  is  sulphur.     At  first  a  small  quantity 
of  sulpliut,  combined  with  a  aoothing  application, 
such  as  zinc  ointment,  should  be  used.     The  propor- 
tion  of    gr.  X  of   precivilated  sulphur  to  5j  of  zinc 
oijUmenl  is  quite  strong  enough  to  begin  with  ;    the 
amount  of  sulphur  should  be  gradually  increased  i{    ' 
the  application  is  well  borne.     The  ointment  should 
be  spread  on  strips  of  thin  linen,  which  must  be  laid 
evenly  on  the  part  and  fised  with  a  bandage.     If  the 
face  is  the  part  to  be  treated,  it  should  be  covered  with 
a  mask.     Resorcin  may  be  employed  in  the  same  way, 
Both  that  drug  and  Bulphui  have  this  special  advan- 
tage, that  they  not  only  destroy  the  micro-organisma   t 
on  the  surface,  but  cause  rapid  exfoliation  of  the  horny 
layer,  thus  getting  rid  of  the  parasites  in  the  deeper 
parts  of  the  epidermis.      Ichtht/ol  is  useful  in  acute  i 
forms  of  eczema  for  its  sedative  as  well  as  its  micro- 
bicide  properties.     In   a   large  number  of  cases  &    ■ 
solution  of  ichthyol  painted  over  the  inflamed  area, 
or  in  an  ointment,  wiU  allay  irritation,  catise  contrac- 
tion of  the  cutaneous  blood-vessels,  and  so  check   , 
the  discharge  besides  destroying  parasites.     In  seboi- 
rhoeic  eczema  ichthyol  is  best  apphed  in  the  form  of  f 
the  varnish  recommended  by  Unna,  the  composition  | 
of  which  is  as  follows  :     ^  Ic/uhyol  40  parts,  starch  . 
40  'parts,  albumen  1  to  li  part,  water  to  100  parts; 
or  the  albumen  may  be  omitted  and  the  proportion   | 
of  the  other  ingredients  modified   as    follows :     "^ 
Ichthyol  2.5  parts,  carbolic  acid  2J  jiarls,  starch  50 
jMxrls,  water  22i  parts. 

Patches  of  chronic  eczema  may  be  the  results  of 
the  acute  form  or  the  remains  of  seborrhoeio  aSec- 
tion.    In  th«  Uttei  case  they  should  be  treated  with 


?.  xm,] 


LOCAL  TRRATMEHT. 


Btroag  applications  ol  Bulphui  aad  other  antiBeptwa 
spread  on  iincn,  or,  better  atill,  in  the  form  of  the 
piaster  muslins  already  referred  to.  Chronic  eczetna- 
tous  patches  of  non-aeborrhceic  origin  arc  often  the 
seat  of  violent  itching  ;  this  can  geneially  be  relieved 
by  applications  of  carbolic  acid  with  a  sponge  or  on  a 

■piece  of  rag.     The  following  ia  a  Ufieful  formula  : — 
P         9    Aoidi  oarbolk'i  -.51 

I                 Glyoerini          . ,         . .         . .         . .     5i 
L  Aq ad  5?iij 

M. 
I  A  wash  of  tar,  in  the  form  of  liquw  carbonts 
telergens,  and  a  weak  solution  of  nitrate  of  silver  in 
9p.  ath.  nit.  {gr.  xx  to  ^j),  are  also  useful  for  the  same 
purpose.  For  the  resolution  of  the  patches  a  plaster 
muslin  of  i/dlow  oxide  of  mercury,  with  or  without 
resorcin,  is  a  serviceable  application.  One  of  the 
best  remedies  for  chronic  patches  is  chri/aarobirt ;  but 
the  patient  must  be  warned  that  the  apphcation  some-" 
times  causes  redness  and  pain,  and  stains  linen  and 
clothes.  It  may  be  applied  as  an  ointment  made 
with  lanolin  and  oil  in  the  strength  of  gr.  x — },j  to  3/, 
or  in  the  form  of  a  plaster  muslin.  For  the  removal 
of  the  secondary  thickenings  which  are  frequently  left 
after  long-standing  eczematous  lesions  massage  is 
often  extremely  useful.  For  the  varicose  veins  which 
almost  invariably  accompany  eczema  of  the  legs 
Martin's  bandage  or  elastic  stockings  should  be  worn. 
Certain  modiflcations  of  local  treatment  are 
necessary  according  to  the  part  that  is  the  seat  of 
disease.  Thus  between  opposing  surfaces,  as  between 
the  scrotum  and  the  thigh,  behind  the  ears,  etc., 
there  should  be  placed  long  narrow  bags  made  of  thin 
cambric  or  muslin,  and  partially  filled  with  starch- 
fowder,  ■powdered  boracic  acid,  or  a  mixture  of  pow- 
dered tola  (87  -parts),  powdered  starch  (10  parts),  and 
aaiicylic  acid  {3  porta)  ;   the  parts  are  thus  dried  and 


t^ 


[chap.  xm. 


i 


kept  in  an  antiseptic  state.  In  seborrhreic  eczema 
of  the  scalp  and  other  hairy  parts  tlie  liair  should  be 
cut  short,  and  after  softening  and  removal  at  the 
crusts,  very  weak  sulphur  oinlToent  spread  on  strips 
ot  lint  should  be  applied  and  fixed  in  position  with 
&  cap  or  bandage.  About  the  ears,  and  on  the  vulva, 
in  both  of  which  situations  the  swelling  is  often  very 
great,  astringent  and  cooling  lotions,  such  as  lactate 
of  lead  and  calamine  lotion,  give  great  relief.  On 
the  face,  as  already  said,  the  local  applications  should, 
in  the  case  of  children,  be  kept  in  position  by  a  mask. 
When  extensive  areas  of  skin  are  involved,  as  on  the 
amiB  or  legs,  swathing  the  parts  in  strips  of  linen 
soaked  in  calamine  liniment  generally  relieves  the 
irritation  ;  but  when  the  inflammatory  process  begins 
to  subside  antise'ptics  must  be  kept  continuously 
applied  in  one  or  other  of  the  ways  that  have  been 
mentioned. 

Treatment  requires  t-o  be  adapted  to  the  pecuhar 
teatures  of  the  disease  manifested  at  certain  periods 
of  age.  In  infancy,  when  it  generally  starts  from  a 
focus  of  seborrhcea  on  the  scalp,  this  should  be  treated 
by  the  gentle  use  of  soap  and  water.  Over-scrubbing 
should  be  avoided,  and  the  soap  should  be  super- 
fatted. If  there  is  any  tendency  to  irritability  of  the 
aoalp,  the  child  should  not  wear  a  cap  in  the  house, 
and  ite  head  should  not  be  too  warmly  covered  out  of 
doors.  A  child's  hands  should  never  be  tied  to  pre- 
vent scratching.  The  best  local  application  is  a  very 
weak  swipAwf  ointment — 5  grains  of  precipitated  ttd- 
phur  to  1  az.  of  benzoated  lard.  The  xerodermia  which 
occurs  at  pubexty  should  be  treated  by  soaking  the 
dry  hard  parts  with  a  mixture  of  one  part  of  glycer- 
ine to  five  of  viater.  For  eczema  at  the  menopause 
there  is,  in  my  experience,  no  remedy  like  ichthyol 
given  internaUy  in  doses  of  2J  grains  after  each  meal 
ftt  first,  and  gradually  increased  up  to  lU  grains.     In 


OHAP.  xni.]  DIET.  286 

the  eczema  of  old  age,  when  the  irritation  is  severe, 
the  only  drug  that  does  any  good  is  opium,  and  it 
should  be  given  freely. 

The  }neChoda  of  general  and  local  treatment  that 
have  been  deacribed  have  often  to  be  supplemented 
by  other  measures  which,  though  not  in  themselves 
curative,  are  naeful  adjuvatUs.  The  chief  of  these 
are  diet,  clothing,  hydrotherapy,  and  climate. 

As  regards  diet,  the  practitioner  must,  in  the  first 
place,  clear  his  mind  of  the  superstition  as  to  this 
matter  which  is  so  strongly  implanted  in  the  mind, 
not  only  of  the  public,  but  of  a  section  of  the  medical 
profession,  especially  those  of  the  older  school.  Their 
ideas  on  the  influence  of  diet  in  eczema  are  founded 
on  the  belief  that  every  skin  eruption  requires  to  he 
treated  constitutionally.  This  notion,  as  has  been 
seen,  is  entirely  erroneous,  and  I  cannot  help  suspect- 
ing that  it  has  arisen  at  least  partly  in  consequence 
of  t!ie  ignorance  which  prevailed  till  lately  as  to  the 
action  and  proper  method  of  using  local  remedies. 
The  excessive  "  lowering  "  diet,  on  which  so  much 
stress  is  still  laid  by  some,  is  not  only  unnecessary, 
but  positively  contra -indicated,  except  when  the 
inflammation  is  extremely  intense.  Alcohol,  how- 
ever, should  be  prohibited,  as  it  aggravates  the 
symptoms. 

In  parasitic  cases  dietetic  treatment  is  utterly 
useless,  and  a  recognition  of  this  truth  will  save 
patients  a  good  deal  of  needless  privation,  t  might 
quote,  in  proof  of  what  has  just  been  said,  numerous 
cases  in  which  patients  have  been  most  carefully 
dieted  for  long  periods  without  their  eczema  being 
in  the  slightest  degree  benefited  ;  whereas  on  remov- 
ing all  restrictions  of  diet,  and  treating  the  affection 
by  local  remedies,  a  cure  has  speedily  followed.  It  is 
only  in  acute  forms  of  eczema  that  beer  and  other 
stimulants  need  be  forbidden.     There  is  no  need  to 


ECZEMA.  [OKAP.  Mu. 

cut  oS  either  tea  or  cofiee  imleBa  these  beverages 
be  definitely  contra- indicated  hy  flatulence,  palpita- 
tion, gastric  acidity,  or  insomnia.  Sugar  may  be 
allowed,  except  In  the  case  of  patients  of  gouty  con- 
stitution, or  when  contra -indicated  by  glycosuria. 

The  clothing*,  as  already  said,  should  be  as  light 
as  is  conaiatent  with  proper  protection  from  cold. 
Too  much  clothing  diminishes  the  activity  of  the 
eebaceoua  glanda,  and  thereby  makes  the  skin  dry, 
and  to  some  extent  predisposes  it  to  eczema.  Only 
silk,  iine  linen,  or  soft  wool  should  be  worn  next  the 
skin. 

Hydrotherapy  has  little  direct  effect  on  eczema, 
though  by  its  alterative  action  on  the  system  it 
may  indirectly  modify  the  affection  of  the  skin. 
Sulphur  waters — notably  those  of  Harrogate,  Strath- 
peffer,  Luchon,  Aix-les- Bains,  and  Schniznach — often 
have  a  markedly  beneficial  effect  in  cases  of  obstinate 
eczema.  "Indifferent"  waters,  like  those  of  Bath, 
are  often  useful.  Bromoiodide  waters  are  of  use 
only  in  very  chronic  conditions.  The  arsenical  waters 
of  La  Bourboule  and  Levico  are  also  of  service  in 
similar  circumstances.  Aperient  waters,  like  those 
of  Carlsbad,  are  of  use  in  the  case  of  gouty  patients 
on  account  of  their  constitutional  effect.  In  my 
experience  the  alkaline  waters  of  Vichy  have  not 
proved  of  service  in  eczema. 

Sea-bathing  should  never  be  indulged  in  while 

eruptions  are  present  on  the  skin.     I  have,  however, 

known  patients  subject  to  periodical  outbreaks  of 

eczema  lose  their  proclivity  to  the  disease  as  the  result 

of  a  course  of  sea-bathing. 

L         With  regard  to  the  influence  of  climate  in  the 

I  treatment  of  eczema,  all  that  need  be  said  is  that, 

I  the  disease  being  catarrhal,  climat«B  favourable  to 

I"  the  production  of  catarrh  of  any  kind  should  as  far 

\  M  possible  be  avoided. 


aiL]     DANGER    OF    OVER-TREATMENT.        287 

The  eczematoua  proceeM  in  the  skin  has  been  com- 
pared to  inflammation  of  a  joipt.  The  same  analogy 
holds  good  with  regard  to  the  treatment  o£  these  two 
conditions  respectively.  The  first  indication  in  deal- 
ing with  an  inflamed  joint  is  to  keep  it  at  rest ;  the 
next  to  subdue  the  intensity  of  the  process  and  bring 
about  resolution  or  quiescence  ;  lastly,  the  product* 
of  inflammation  rauat,  if  possible,  be  got  rid  of,  so 
that  the  joint  shall  recover  its  natural  suppleness. 
In  eczema  the  same  object*  have  to  be  aimed  at,  with 
the  further  indication  that  the  parasites  which  find  the 
lesions  a  favourable  ground  for  their  multiplication 
have  to  be  destroyed  or  rendered  inert. 

To  sum  up  :  The  fundamental  principles  which 
should  guide  the  practitioner  in  the  treatment  of 
eczema  are  to  soothe  when  the  inflammatory  process 
is  acute,  to  stimulate  wLen  it  is  chronic,  and  in  either 
case  to  keep  the  parta  under  the  continuous  influence 
of  antiseptics  and  parasiticides  of  a  strength  carefully 
regulated  in  accordance  with  the  intensity  of  the 
disease  and  the  tolerance  of  the  patient's  skin. 

A  word  of  caution  may  be  added  aa  to  danger  of 
over-treating  eczema.  When  the  disease  ia  quiescent 
or  in  active  retrogression,  a  masterly  inactivity  will 
be  found  the  beat  policy.  In  all  cases  the  greatest 
vigilance  must  be  exerciaed  in  tlie  adaptation  of  the 
strength  of  the  remedies  to  the  disease.  I  have  aeen 
many  cases  in  which  the  condition  has  been  aggravated 
by  injudicious  use  of  baths  and  stimulating  treat- 


CHAPTER    XIV. 


Psoriasis  is  an  affectiou  of   the  skin  characteriaed 
by  flat  dry  patches  of  vary_iiig_extent,  covered  with 
wliite,  silver-grey,  or  aaliSitas:Iike  scales.     There  is 
no  exudation,  and  conseqneritly  ^Eere  are  no  crusta  ; 
the  degree  of  scaiiness  varies  from  a  thin  film  to  a 
dense,  heaped-up  mass.     Qn  removing  the  scales — - 
which  are,  as  a  rule,  tolerably  adherent — a  smooth, 
shining  hyperaemic  surlace  is  exposed,  dotted  here   j 
an3  there  with  deep  red  spots.     This  surface,  which  | 
is  the  base  of  the  lesion,  though  red,  is  not  raw, 
and  the  tint  varies  from  bright  red  in  recent  patches  I 
to  a  duller  tint  in  those  of  older  formation.     Th«  J 
bright  red  spots,  which  can  always  be  seen  with  the  [ 
help  of  a  lens,  are  the  tops  of  the  hyperasmic  papills  ;  I 
these   bleed  very   readily    on  being   touched.     The  ] 
typical  lesion — or  what  may  be  termed  the  patho- 
logical unit — of  psoriasis  is  a  scaly  patch,  rounded 
or  irregular  in  shape,  with  a  sharply  defined  border    j 
standing  out  slightly  but  distinctly  on  the  surface  i 
of  the  skin,  with  a  hypertemic  base  underlying  the  j 
covering  of  scales.     When  the   disease  is  spreading  ] 
the  patch  ia  surrounded  by  a  narrow  zone  of  lednc 
but  this  is  wanting   when  the   process  is  inactive  1 

,  (Fig.  14).  The  scales  are  of  a  dirty  white  colour  on 
the  surface,  but  on  scraping  away  the  uppermost 
layers,    those   underneath  have    the   appearance  of  ] 

I  frosted  silver. 

The  eruption  first   shows  itself  in  the  form  of 


290  PSORIASIS.  [cHiP.  siy. 

Sooner  or  later  the  patches  undergo  involution. 
They  first  begin  to  fade  in  the  centre,  leaving  rings 
with  a  gradually  narrowing  border  ;  as  the  border 
itself  in  turn  disappears  at  difEerent  points,  segments 
of  varying  length  remain,  which,  with  similar  relice 
of  other  patches,  form  wavy  lines,  festoons,  and 
sometim.ea  tracery  of  the  most  fantastic  pattern.  On 
the  trunk  it  not  unfrequently  happens  that  as  invo- 
lution goes  on  at  the  centre,  the  patch  continues 
to  spread  at  the  edge ;  the  spectacle  is  thus  pre- 
sented of  a  circle  steadily  increasing  in  diameter, 
the  circumference  being  formed  by  a  border  which, 
while  constantly  advancing,  never  gains  in  width. 
To  this  condition  the  term  "  lepra  "  was  formerly 
applied,  but,  apart  from  the  possible  confusion  with 
the  more  formidable  disease  designated  by  that  name, 
there  is  no  advantage  in  using  a  special  term  to  denote 
what  is  merely  an  accidental  and  evanescent  appear- 
ance,. 

The'  lesions  of  psoriasis  disappear  completely, 
leaving  behind  only  some  redness,  which  soon  dies 
away.  In  cases  in  which  the  process  has  persisted 
for  a  long  time,  a  deep  brown  stain  often  remains  ; 
pigmentation  is  particularly  likely  to  occur  when 
arsenic  h^  been  freely  used  in  the  treatment.  In 
rare  instances  superficial  atrophy  may  mark  the  sit« 
of  the  patches. 

Psoriasis  is  nearly  always  symmetrical  in  its 
distribution.  It  particularly  afiecte  parts  where  the 
skin  is  thick  and  frequently  stretched,  and  where  it 
is  exposed  to  friction  by  the  clothes,  etc.  Its  favourite 
and  almost  invariable  starting-points  are  the  tips  of 
the  elbows  and  the  fronts  of  the  knees ;  it  shows  a 
special  predilection  for  the  extensor  surfaces  of  the 
limbs.  Next  to  these  comes  the  hairy  scalp ;  then 
the  trunk,  especially  on  its  dorsal  aspect.  The  face 
is  rarely  attacked,  except  in  young  people  and  in  in- 


CHAP.  XIV.]  WGAL  MODIFICATIONS  OF  LESIONS.   201 

veterate  eases  ;  the  palma  of  tlie  hands  and  soles  ot 
the  feet  stil!  more  seldom.  As  regards  the  proportion 
of  cases  in  which  these  various  parts  are  severally 
or  jointly  invaded,  some  idea  may  be  gained  from, 
the  following  statistics  given  by  Nielsen.*  In  a 
series  of  8<i2  cases  of  psoriasis  the  trunk,  the  ex- 
tremities, and  the  head  were  all  afEected  in  489  ;  the 
trunk  and  extremities  in  197  ;  the  extremities  alone 
in  IVi  ;  the  extremities  and  the  head  in  -^3  ;  the  head 
alone  in  5  ;  the  trunk  and  the  head  in  i  ;  the  trunk 
alone  in  1.  These  figures  may  be  taken  as  repre- 
senting the  area  of  territory  invaded  by  the  disease 
when  it  is  of  sufficient  severity  to  induce  the  patient 
to  seek  medical  advice ;  doubtless,  however,  there 
are  very  many  cases  that  never  come  under  treatment, 
and  in  a  considerable  proportion  of  these  the  disease 
is  probably  confined  to  tiie  extremities  and  the  scalp. 

The  lesions  of  psoriasis  axe  mote  or  less  modified 
in  appearance  by  the  anatomical  structure  or  other 
peculiarities  of  the  regions  which  are  the  seat  of 
them.  On  the  scalp  they  are  generally  met  with  as 
scurfy  patches,  yellowish  or  even  brownish  in  colour, 
the  red  ground  of  the  hyperwmic  base  showing  here 
and  there,  especially  about  the  margin  of  the  hair  ; 
it  often  extends  on  to  the  forehead,  wliich  it  seems  to 
bind  with  a  narrow  circlet.  Sometimes  the  scales 
are  piled  on  the  scalp  in  thick,  firm  masses  like  dry 
mortar,  in  which  the  hair  is  embedded.  The  disease 
does  not  usually  interfere  with  the  growth  of  the  hair  ; 
it  is  only  in  cases  of  exceptional  severity  that  It 
causes  baldness.  Psoriasis  seldom  attacks  the  hairy 
parts  of  the  face. 

On  the  scrotum  the  skin  is  often  red,  swollen, 
indurated,  and  fissured,  a  thin  secretion  sometimes 

•"KUnischa  und  uetioIogiBoliu  UutereucliiuigeQii1>er  Paariosis" 
^>id,r-AhdraeK-  aaa  Moimtn/i. /.  pmU.  Dcymnlolf^u;  Bri.  sv., 
Nus.  T  auil  S. 


^F^ 


PSORIASIS. 


oozing  from  tlie  cracks.  On  the  palms  and  eolea  the 
scales  are  usually  heaped  up  icto  thick  massea,  which 
preservp  the  characteristic  sharply -defined  border  ; 
the  lesions  in  these  situations  show  little  dispositiun. 
to  crack.  On  the  nails  the  disease  is  sometimes 
situated  in  the  matrix,  in  which  case  the  nail  becomes 
dull  and  transversely  ■furrowed.  As  the  scales  are 
more  and  more  heaped  up  underneath  it,  the  nail 
splits  and  is  pushed  out  of  its  bed.  In  other  canes 
psoriasis  of  the  nails  shows  itself  as  a  discoloration 
about  the  free  border  ;  this  gradually  extends  down- 
wards to  the  root,  the  nail  becomes  thickened,  but 
there  is  no  soreness  of  the  matrix.  Other  modifica- 
tions of  the  appearances  characteristic  of  psoriasis  may 
be  produced  by  causes  of  various  kinds.  Thus,  pre- 
vious treatment  may  have  removed  the  scalinees, 
or  the  same  result,  together  with  other  lesions,  may  be 
produced  by  scratching.  It  is  to  be  noted  also  that 
when  the  process  is  very  acute  in  character  the  scales 
are  often  shed  very  rapidly,  and  there  may  be  nothing 
to  be  seen  but  a  red,  inflamed  surface. 

Thesubjectivesymptomsof  psoriasis  are  seldom 
very  pronounced.  lU'hing  is  neither  bo  constant  not 
80  prominent  a  feature  as  it  is  in  eczema ;  indeed,  in 
many  cases  there  is  little  or  no  irritation.  No  rale 
can,  however,  be  laid  down  on  this  point,  as  patients 
vary  greatly  in  their  sensitiveness  to  itching ;  alt 
that  "can  be  said  definitely  is  that  in  the  acute  forms 
of  psoriasis  itching  is  generally  more  marked  than 
in  cases  of  the  ordinary  type.  In  the  more  chronic 
forms,  especially  in  patches  about  the  elbows  and 
knees,  the  itching  is  so  often  entirely  absent  that 
the  disease  may  exist  for  a  long  time  without  thtt 
patient's  being  aware  of  it.  There  is  seldom  any  paitt 
in  chronic  cases,  except  when  the  skin  is  fissured  ;  &a^ 
is  especially  apt  to  occur  over  tlie  "  bathing-drawi 
area,"  where  the  sldn  sometimes  cracks  every  time  t 


Y.]       SYMPTOMS  AND  COURSE.  2ft3 

patient  sits  down.  In  very  acute  cases  the  akin  may 
be  the  seat  of  pain  from  tensioa  with  heat  and  tender- 
ness. In  a  certain  proportion  of  cases  o£  paoriaaia 
there  are,  according  to  aome  French  writera — notably 
Bourdillon  *  and  Besnier  "f" — paina  about  the  joints 
reaetabling  those  of  rheumatoid  arthritis.  Besnier 
givea  the  proportion  of  cases  in  which  this  complica- 
tion occurs  in  his  experience  as  .5  per  cent.  In  the 
first  editioa  of  this  book  it  was  stated  that  the  author 
had  not  aeen  any  chnical  evidence  of  a  relationship 
"letween  psoriasia  and  rheumatoid  arthritis.  Further 
^perienct'  makes  it  necessary  for  me  to  correct  that 
tatement.  In  the  last  few  years  I  have  seen  several 
Bs  in  which  joint  affection  existed  concurrently 
ii  psoriasis.  Inatanaes  of  the  like  associatioo  have 
jen  reported  by  Duckworth  and  Stephen  Mackennie. 
;  the  association  is  not  common,  however,  is 
efficiently  proved  by  the  experience  of  Brooke.J  who 
tates  that  in  some  hundreds  of  cases  of  psoriasis 
9  has  hardly  met  with  a  single  one  in  which  joint 
toaeaae  existed,  although  he  has  been  on  the  look-out 

course  of  the  disease  ia  essentially  chronic, 
int  it  is  subject  to  sudden  exacerbations,  during  which 
spreads  over  large  arests.  These  exacerbations 
les  appear  to  be  due  to  the  influence  of  a 
utioular  diet,  change  of  climate,  or  mental  shock ; 
I  other  cases  they  cannot  be  attributed  to  any 
lofinite  cause.  It  ia  impossible  to  predict  when 
•  in  what  circumstances  such  an  outburst  may 
some  patients  are  attacked  regularly  once  or 
I  year,  others  at  longer  or  shorter  intervals. 
Xhe  disease  if  left  to  itself  may  last  for  months  or 

oriasia  tt  ArthropathiBa. "     Thisc  de  Pans,  ISBS. 
|-  French   lruu«latiuu   nf   Kupo^'s   "  Mulaiiius  de  la  Pcuu," 
id  «d.,  Tol.  L,  p.  5S3  fl  iim. 
t  AUbatt'g  "  Syatem  of  Medidne,"  viiu,  p.  67L. 


r 


PSOniASIS.  [CHAP,  s 


even  years,  with  intermissioas  of  variable  duration, 
during  which  it  may  entirely  disappear.  More  fre- 
quently, however,  patches  remain  on  the  elbows  and 
kneea  in  a  state  of  inactivity  until  a  fresh  exacer- 
bation occurs.  Although  a  very  large  part  of  the 
cutaneous  surface  may  be  attacked,  psoriasis  is 
never  absolutely  universal.  However  completely 
psoriafiia  may  disappear,  recurrence  ia  merely  a 
((uestjon  oi  time.  C'heloid,  warts,  and  even  car- 
cinoma may  develop  on  the  site  of  the  lesions,  or 
the  disease  may  become  transformed  into  pityriasis 
rubra.  The  afiection  has  generally  little  or  no  efiect 
on  the  general  health  ;  indeed,  Hebra  considered 
that  a  certain  standard  of  health  is  necessary  for 
its  development,  and  in  fact  patient*  have  generally 
a  robust  appearance,  their  complexion  heing  par- 
ticularly clear  and  ruddy.  In  further  confirmation 
of  this  it  is  to  be  remarked  that  if  the  general  health 
ia  in  any  degree  impaired  the  psoriasis  tends  pro- 
portionately to  subside.  Thus,  during  a  severe 
.attack  of  fever  the  patches  often  fade,  breaking  out 

U  again,  however,  as  convalescence  is  eatablished. 

■  Psoriasis  in  its  clinical  manifestations  follows 
Certain  types,  which  may  be  briefly  summarised  as 
follows  :  There  ts  a  simple,  uncomplicated  psoriasia 
with  occasional  outbursts  of  activity  seen  in  young 
persons,  without  any  sign  of  impaired  health  ;  thwe 
is  an  acute,  rapidly  spreading  form,  associated  with 
headache,  asthma,  and  other  nervous  symptoms ; 
there  is  the  form  which  occurs  in  connection  with 
osteo- arthritis,  associated  with  severe  conetitutional 
disturbance ;  there  is  a  psoriasis  which  tends  to 
become  transformed  into  pityriasis  rubra.  Lastly, 
there  is  a  simple  but  atypical  form  which  resembles 
seborrhcea. 

As    regards  etiology,  we  are  reluctantly    com- 
peiled  to  agree  with  Brooke's  admission  that  "  not- 


f.XFf., 


ETIOLOGY. 


withatandmg  researches  in  every  direction — social, 
statistical,  chemical,  microscopical,  and  bacteriolog- 
ical— the  cause  of  psoriasis  is  still  imknown."*  The 
disease  is  not  common  in  early  iniancy,  and  it  rarely 
begins  after  the  age  oi  fifty  ;  it  is,  on  the  whole, 
more  cogimoiL  iu.  JB.ljtii  than  in  later  adult  hfe. 
Statistics  seem  to  show  that  men  are  somewhat 
more  subject  to  it  than  women.  Neither  rant  in 
life  nor  occupation  has  any  influence  in  the  pro- 
duction of  the  disease.  It  is  to  a  certain  extant 
hereditary,  and  Brocqf  says  that  it  is  not  uncommon 
to  pee  gout  or  some  form  of  neurosis  replaced  by 
psoriasis  In  one  member  of  a  family  subject  to  the 
former  complaints.  Some  dennatologiBts  hold  that 
gout  is.aa  irnpprtant  factor  in  a  certain  proportion 
of  cases,  and  one  even  hears  of  "  gouty  psoriasis  " 
as  a  special  form  of  the  disease.  To  me  there  appears 
to  be  no  evidence  to  support  this  hypothesis.  Season 
seems  to  have  a  certain  influence,  not  so  much  in 
causing  the  disease  as  in  increasing  its  intensity  ; 
thus  the  subjects  of  psoriasis  are,  as  a  rule,  more 
liable  to  exacerbations  in  the  spring  and  the  autu^m 
than  at  other  seasons  ;  recent  cases,  however,  are 
often  worse  in  the  winter  than  at  any  other  time. 
Polotebnoff  has  endeavoured  to  show  that  psoriasis 
is  a  neurosis  of  the  sldn  ;  from  an  analysis  of  67 
cases  he  affirms  that  headache  or  other  nervous 
disorder  is  present  either  in  the  patient  himself  or 
in  other  members  of  his  family  in  a  large  majority 
of  cases. t  It  is  certain  that  psoriasis  often  follows 
nervous  shock,  mental  emotion,  or  depressing  in- 
,  such  as  insufficient  nourishment,  and  in 
a  child-birth  or  suckhng.  The  neuropathic 
',  however,  rests  on  a  very  slight  foundation 

■Op.e 


+  0p.  ml.,  p.  702. 

:^  ErgOiisungihtft  d,  Moaalnh. 


V.7  PATHOLOGY.  20T 

tially  inflammatory,  others  a  hyperplasia  of  the  rete, 
others  again  a  parakeratosis  or  anomaly  of  cornifica- 
tion.  An  important  contribution  to  our  knowledge 
of  the  nature  of  psoriasis  has  recently  been  made  by 
W.  J.  Mimro,*  whose  researches  were  carried  out  in 
Sabouraud's  laboratory.  As  the  result  of  the  ex- 
amination of  l,r)00  sections  of  psoriasis  furnished  by 
six  necropsies  of  nascent  lesions  in  difierent  patients 
before  any  treatment  had  been  employed,  and  ol  the 
study  of  many  hundreds  of  psoriatic  scales,  recent  and 
old,  he  came  to  the  conclusion  that  the  primary  lesion 
is  a  tiny  "  dry  "  abscess  at  the  surface  of  the  homy 
layer.  Immediately  after  the  first  stage  two  phe- 
nomena supervene— first,  hypertrophy  of  the  epi- 
dermic homy  layer ;  secondly,  the  formation  around 
the  primary  lesion  of  a  number  of  similar  ones. 
Munro  defines  the  squama  of  psoriasis  as  a  multitude 
nl  little  dried  abscesses  included  between  sheets  of 
esfojiated  homy  epidermis.  He  failed  to  find  any 
mTPTn-nrgflffJBi^  j"  t-h"  IfRinr"  He  denies  that 
psoriasis  is  "  a  vice  of  formation  of  the  homy  epi- 
dermis," and  he  holds  that  the  hyperkeratosis  is 
secondary  to  the  primary  lesion.  Among  the  other 
histological  changes  noted  in  psoriasis  is  the  conges- 
tion of  the  vessels  in  the  papillte  ;  the  cells  of  the 
rete  Malpighii  undergo  rapid  multiplication  and  are 
at  the  same  time  much  swollen  (Fig.  15).  The  stratum 
granulosum  never  forms  ;  do  granules  of  keratohyalin 
are  formed.  The  swollen  cells  of  the  rete  pass  on. 
therefore,  into  an  imperfectly  comified  epithelium, 
forming  the  distinctive  scale  of  tlie  disease.  Blood- 
cells  frequently  exude  from  the  swollen  papillary 
vessels,  and  become  mingled  with  the  rapidly  dividing 
cells  and  overlying  desquamating  masses  of  cells.  It 
has  been  shown  by  Robinson  of  New  York  and  by 
3cker  that  overgrowth  downwards  of  the  inter- 
*  Bi-il.  JeiifH.  DeriH.,  IBOO,  p.  6S  il  vi-\. 


^^H    and 


PSORIASIS.  [CHAP.  HV. 

papillary  conea  of  the  rete  takes  place,  with  cedema 
and  exudation  of  leucocytes  in  the  papillary  layer. 
The  epidermic  horny  layer  and  the  papillary  layer 
are  immensely  hyportrophied  ;  tlie  stratum  lucidnm 
disappears  ;  no  eleidin  is  to  be  Been,  and  the  oomifica- 
tion  of  the  epidermic  cells  either  takes  place  not  at 
all,  or  very  imperfectly.  According  to  Audry,* 
the  absence  of  eleidin,  together  with  the  defective 
comification  of  the  epidermic  cells,  is  the  essential 
pathological  feature  of  psoriasis.  The  characteristic 
silvery  appearance  of  the  scales  is  due  to  the  entrance 
of  air  within  and  between  them.  The  overgrowth 
downwards  that  has  been  referred  to  gives  rise  to  an 
appearance  which,  on  microscopic  examination, 
somewhat  resembles  that  of  epithelioma ;  and  in 
fact,  as  haa  been  stated,  psoriasis  occasionally  under- 
goes a  malignant  transformation. 

Tlie  diag'nosis  of  psoriasis  in  well-marked  cases 
presents  no  difficulty.  The  patches  with  sharply  ■ 
defined  border,  covered  with  imbricated  silvery 
scales ;  the  bright-red  points  on  a  hyperasmio 
surface,  bleeding  easily  when  touched,  which  are  ex- 
posed by  removal  of  the  scales  ;  the  absence  of  exuda- 
tion at  any  period  ;  the  symmetrical  distribution  of 
the  lesions  and  their  predilection  for  the  extensor 
surfaces  of  limbs,  together  with  the  unimpaired  health 
and  robust  appearance  of  the  patient,  make  up  a 
clinical  picture  which  can  hardly  be  misinterpreted. 
In  doubtful  cases  the  fact  of  the  eruption  having 
first  appeared  on  the  elbows  and  knees  is  alrooet 
conclusive;  but  if  this  element  in  the  history  be 
wanting,  it  is  sometimes  impossible  to  be  sure  of 
the  nature  of  the  disease.  The  afiections  that  are 
most  Ukely  to  be  confounded  with  psoriasis  are 
eczema,  lichen  ruber  planus,  lupus  erythematosus, 
pityriasis  rubra,  and  syphilis,  secondarj-  and  tertiary. 
•  Jn«.  <&  Dtrm.  it  dt  Syph.,  No.  4,  Aiffil,  18S3. 


oiup.  xn-.]  DIAGNOSIS.  299 

Eczema  is  distinguished  from  psoriasia  (a)  by 
its  distribution — it  prefers  the  flexures  of  joints  ; 
(h)  by  the  initial  lesion— it  generally  begins  in  veaiclee 
grouped  on  an  inflamed  base  ;  (c)  by  the  serous  dis- 
charge which  is  its  cbaiacterisfcic  feature  ;  (d)  by  the 
ill'defined  margin  of  the  patches,  diseased  fading 
insensibly  into  healthy  akin  ;  (e)  by  the  cruste,  which 
are  as  characteristic  of  eczema  as  scales  are  of 
psoriasis.  Less  distinctive,  but  atill  important, 
features  of  eczema  as  compared  with  psoriasis  are 
itching,  which  is  at  once  more  violent  and  more 
constant  in  the  former  than  in  the  latter,  and  the 
muddy  complexion,  which  often  forms  a  marked 
contrast  to  the  ruddy  cheek  of  the  subject  of  paoriaais. 
On  the  scalp,  aeborrhceic  eczema  almost  always  covers 
the  whole  surface,  and  often  spreads  on  to  the  face 
and  behind  the  ears  to  the  neck  ;  psoriasis,  on  the 
other  hand,  generally  occurs  in  patches  and  ends 
abruptly  at,  or  very  slightly  beyond,  the  margin  of 
the  hair.  Another  point  of  difference  is  that  while 
seborrhceic  eczema,  as  a  rule,  spreads  downwards 
from  the  head,  psoriasis  almost  invariably  spreads 
upwards  from  its  favourite  situations.  In  cettain 
very  chronic  forms  of  eczema,  when  there  arc  only  a 
few  scattered  patches  with  no  history  of  an  eruption 
on  the  elbows,  or  knees,  or  of  "  weeping,"  the  diagnosis 
may  be  all  but  impossible.  Even  in  such  cases,  how- 
ever, the  inteJiaity  of  the  redneiss,  if  the  affected 
surface"  be  at  the  same  time  dry,  may  be  some  guide. 
As  in  eczema,  any  marked  degree  of  hypersemia  is 
pretty  sure  to  be  accompanied  by  exudation.  It 
may  be  well  also  to  recall  here  that  \ij  gentle  scratch- 
mg  the  characteristic  scales  of  psoriasis  can  ofttn 
be  brought  into  view  when  previously  invisible. 

Lichen  ruber  planus  is  not  likely  to  be  confounded 
with  psoriasis,  except  in  the  papular  stage,  when  it 
sometimes  presents  an  appearance  resemblio.^  t\>.«.^ 


fO»  PSORIASIS.  [cur.  xir. 

dMoritiad  M  MoriMM  gmtatA.  The  fonner  Is,  how- 
«v«,  diftinfiiulieil  from  the  Inttei  (a)  by  ite  prefei^noe 
lor  Ida  flexor  HpecU  of  tli<t  wriato  and  knees ;  (d) 
by  it*  ubiiriuitnruitif!  aliining  Mnootb  papules  and  the 
•ItNitriM!  ol  kciiIm  ;  (c)  by  the  bluish-red  tint  of  its 
grfrtirul  KN  iJontr(mt<Ml  with  the  bright  red  of  paoriaBiB  ; 
{d)  by  it*  mode  of  nxtcniiioQ,  a  licbea  patch  being 
liirMiK'l  by  t.lin  iig^rr)(»tiun  of  many  papules,  while 
[laiiriitNiM  HpreiLdH  ub  the  edge,  In  doubtful  cases 
uurefiil  Nimrdb  itliiiuld  bii  uiude  over  the  whole  body 
for  Ihn  tyjiioiil  Iohioiu  of  either  disease ;  a  single 
flhurimtifrliillc  patt^h  will  settle  the  question. 

l.iipun  urythematoHUH  usually  afiects  the  cheeks, 
K  pnrt  iiitiittrully  Mpiirml  by  pHoriaaia.  In  the  former, 
tnoi'Kiivnr,  Nimlo*  are  not  abundant;  the  edge  of  the 
(iitti'b  In  innru  rikimMl  tliuu  in  psoriasis,  and  the  plugs 
lit  llin  urilli<t>«  o(  tlie  sobacyoua  ducta  form  a  very 
ili*tlli('tivi>  fi'utuTK.  Further,  there  may  be  scarring 
Iti  lb«  p«lii|i  »nd  wtropliy  of  the  etirs. 

TityriaMo  nibro  is  ditfen-ntiated  from  psoiuau 
(•i)b,v  iu  rapid  dpvfhipincut ;  {J!')by  thp  fart  that  it  is 
■klnuMt  nlwttys  kiiuvnrsal.  psoriasis  hardly  ever  being 
IH>  i  (r)  by  it»  tliiu.  wMfcT-likp  wwlw.  throng  wliich 
Ut»  rMWttw)  «kin  shown  distiiMtlr. 

Aa  lv(p»^)a  ayp^Uides.  the  onlr  tnistwoithy  iii«*m 

«t  dtoiiyptM'fcipg  t^on  tnn  pMMwn  Ik*  in  tb« 

'  kuiloty,  m  tkw  MMUittaMww  piwHK*  of  vtbcr  Immo* 

<  »l  akitt.  iiUiuU.  wmI  mikc«tt»  Mmbcaae,  mad  in  cob- 

WMuMst  «-wkN>.via.    $>'phibs  tm»  twea  i«>t)y  olM 

WMWkj^BK*  iiihN>  buu,  »M  bMM  M  by  It  !■•»  fn«a  ei 
»VBtAiA  oaih  few  bwia^  aaaV 

'.'  .  ••** 


I 


caAP.  XIV,]  TREATMENT.  301 

disappear  for  a  time.  Recnirence,  however,  alter  a 
longer  or  shorter  period  of  complete  or  comparative 
freedom  from  the  m.aiiile stations  of  the  dlsoaae,  is  the 
rule. 

Treatment. — Psoriasis  must  be  treated  hygien- 
ically,  constitutionally,  and  locally.  Attention  must 
be  paid  to  tlie  clothing  so  as  to  avoid  irritation  of 
the  skin,  interference  with  perspiration,  and  chilling 
of  the  surface.  Bulkley  *  has  repeatedly  seen  such 
chilling  followed  by  an  outburst  of  the  disease  in  a 
previously  healthy  person,  and  also  by  returns  of  the 
eruption.  A  warm  and  equable  climate  has  often  a 
most  "beneficial  effect  on  psoriasis  ;  and  Schutz  f  has 
reported  two  very  severe  cases  of  generalised  psoria- 
sis in  which  spontaneous  cure  always  took  place  on 
the  patients  exchanging  thfir  ordinarv  place  of  resi- 
dence for  a  higher  altitude 

As  a  genera!  rule,  no  internal  medication  should 
be  employed,  except  in  response  to  a  definite  indica- 
tion. Of  intBrnal  remedies,  argenie  is  on  the  whole 
the  most  effective  in  the  majority  of  cases  ;  it  is  not, 
however,  well  borne  by  ail  persons,  nor  by  the  same 
person  at  differeat  times.  It  is  contra-indicated  when 
hyperemia  is  very  marked  ;  in  such  cases  it  only  does 
harm,  intensifying  the  process,  aggravating  the 
itching,  and  actually  causing  extension  of  the  disease. 
In  chronic  cases,  however,  arsenic  is  often  un- 
doubtedly of  the  greatest  service.  It  may  be  given 
in  the  form  of  Fowler's  solution,  freely  diluted, 
beginning  with  a  dose  of  three  to  four  minima  thrice 
daily  after  meals,  gradually  increased  up  to  ten,  if 
no  signs  of  intolerance  manifest  themselves.  Kaposi 
gives  arsenic  in  the  form  of  Asiatic  pills,  each  con- 

*  "  CliiiicMl  Studj  and  Aunly^iin  of  Oue  Thousand  Cnses  of 
PBOUMUI."  Reprinted  irom  the  M,i,,,hufl  Mcduvl  Joiinwl, 
SaptHinhBrin,  iSgl,  p,  14. 

t  Areh.f.  Perm.  it.  .^p*..  xwv.,  1802. 


FM2 


PSORIASIS 


'  taining  J  grain  of  arsenious  acid.  He  begins  with  one 
pill  thrice  daily,  gradually  iacreasing  the  aumbei  to 
ten  or  twelve  in  the  day,  and  continuing  the  adminiii- 
tration,  if  necessary,  for  several  months.  If,  after 
I  500  or  600  pills  have  been  taken,  no  decided  improve- 
'  ment  is  observable,  he  considers  that  the  drug  has 
failed.  It  need  hardly  be  added  that  during  the 
administration  of  arsenic  the  efiect  should  be  carefully- 
watched  ;  gastric  or  intestinal  irritation  should  be 
subdued  by  opium.  Aa  already  said,  when  arsenic 
has  been  freely  given,  and  especially  if  its  administra- 


IHie  subjective  aymptoms  are  very  pronounced,  I 
find  atUimony  most  useful.  I  give  it  in  the  form  of 
vinum  anftmonude  \i\v  to  n^x,  thrice  daily.  Phos- 
phorus is  also  useful  under  similar  conditions. 
Crocker  finds  salicylate  of  sodium  of  great  value, 
especially  in  the  period  of  active  development  and  in 
hypercemic  cases ;  it  is  useful  in  all  forms,  except 
perhaps  in  old  chronic  patches.  If  the  drug  causes 
dyspepsia,  of  course  it  must  not  be  continued,*  If 
symptoms  of  nervous  disorder  be  present,  nerve 
sedatives,  such  as  bromide  of  potassium,  bromide  of 
sodium,  hydrobromate  of  quinine,  etc..  may  be 
useful ;  these  and  similar  drugs  are  recommended  as 

I  *  ilni.  .low-,.,  ierm,,  July,  IH!)6. 


OKAP.  XIV.]  TREATMENT.  303 

part  ol  the  regular  treatmeEt  of  paoriaaia  by  those  who 
hold  that  the  disease  is  a  neurosis.  Redcliffe  Crocker 
haa  found  salicin  very  valuable  in  acute  and  subacute 
cases  oE  psoriasis  ;  *  he  begins  with  15  grains  a  day. 
In  chronic  casea  he  haa  not  iound  the  djug  of  much 
use.  8ea*batfcing  m  often  markedly  beneficial, 
doubtleas  from  ita  tonic  action  on  the  general  syatem. 
I  have  seen  caaes  that  have  proved  refractory  to  all 
other  treatment  quickly  get  well  after  a  course  of 
aea-bathing.  Of  the  treatment  of  psoriasis  by  large 
doses  of  iodide  of  potassium,  as  recommended  by 
Haslund,  I  cannot  speak  from  personal  obaervation. 
Whatever  good  effect  it  may  have  ia  probably  to  be 
attributed  to  the  lowering  effect  of  the  drug  on  the 
general  health,  which,  as  already  aaid,  ia  often  accom- 
panied by  a  correaponding  aubsidence  of  the  disease. 
Feeding  with  extract  of  thyroid  gland,  which  was,  on 
its  first  introdnction,  vaunted  aa  almost  a  apecific, 
has  not  answered  the  expectations  which  were  formed 
of  it ;  it  aometimes  does  good,  but  more  often  perhaps 
doea  harm.  Even  when  it  is  useful,  the  beneficial 
effects  are  not  permanent.  My  own  experience  in 
this  matter  is  confirmed  by  that  of  many  other  derma- 


1e  casea  of  paoriaaia  associated  with  rheumatoid 
arthritis,  arsenic  is  useful.  I  give  it  in  Fowler's 
solution,  in  the  doses  already  stated.  In  caaes  of  this 
nature  I  have  seen  results  which  can  only  be  described 
as  marvellous  follow  the  use  of  an  eschisively  meat 
diet  washed  down  by  copious  draughts  of  hot  water. 
As  to  the  mode  of  action  of  this  treatment,  T  can  only 
suggest  that  the  simplicity  of  the  diet  promotes  the 
functional  efficiency  of  the  digestive  apparatus,  while 
the  large  quantity  of  water  increases  the  action  of 

AduhbJ  HuDtiiig  oi  thu  British  Heilicul  Aeaodutiau,  101)2,  Bril. 
jWrtJ.  Journ.,  October  V,,  1902. 


^^m  802 

^^H  taint 

^B  pill! 

^^  tenc 

p  tratii 


psoRusia 


taining  J  grain  of  arsenious  acid.  He  begins  witli  one 
pill  thrice  daily,  gradually  increasing  the  number  to 
ten  or  twelve  in  the  day,  and  continuing  the  adminis- 
tration, iE  neceBsary,  for  several  months.  If,  after 
500  or  600  pills  have  been  taken,  no  decided  improve- 
ment is  observable,  he  coneidera  that  the  drug  has 
failed.  It  need  hardly  be  added  that  during  the 
administration  of  arsenic  the  efieut  should  be  carefully 
watched  ;  gastric  or  intestinal  irritation  should  be 
subdued  by  opium.  Ae  already  said,  when  arsenic 
has  been  freely  given,  and  especially  if  its  administra- 
tion has  been  long^ continued.  deHii  hrnmn  ni^n.™.*- 


1 


J ,.,1.  ojiupuuiiiB   lire  very  pronounce 

find  antimony  most  useful.     I  give  it  in  the  form  of  , 
vinum   mUimottiale    li|_<[i  Co  n\x,  thrice  daily.       Pho»- 
phorua    is    also    useful    under    similar     conditions. 
Crocker  finds  salicyUUt   of  sodium  of    great  value, 
especially  in  the  period  of  active  development  and  in   i 
hypertemic  cases  ;    it  is  useful  in  all  forma,  except 
perhaps  in  old  chronic  patches.     If  the  drug  causes 
dyspepsia,  of  course  it  must  not  be  continued.*     11 
symptoms    of    nervous   disorder   be   present,    nerv« 
sedatives,  such  as  bromide  of  potassium,  bromide  of 
sodium,    hydrobrotnate    of    quinine,    etc.,    may 
useful ;  these  and  similar  drugs  are  recommended  amA 
•  am.  Journ.  JMra.,  July,  1896. 


CHAP.  XIV.]  TREATMENT.  303 

part  of  the  regular  treatment  of  pBoriaeis  by  those  who 
hold  that  the  disease  is  a  neurosis.  EodelifEe  Crocker 
has  found  salioin  very  valuable  in  acute  and  subacute 
cases  of  psoriasis  ;  •  he  begins  with  15  grains  a  day. 
In  chronic  oases  he  has  not  found  the  drug  of  much 
use.  Sea-bathing  is  often  markedly  beneficial, 
doubtless  from  its  tonic  action  on  the  general  system. 
I  have  seen  cases  that  have  proved  refractory  to  all 
other  treatment  quickly  get  well  after  a  course  of 
sea-bathing.  Of  the  treatment  of  psoriasis  by  large 
doses  of  iodide  oj  potassium,  aa  recommended  by 
Hasluiid,  I  cannot  speak  from  personal  observation. 
Whatever  good  effect  it  may  have  is  probably  to  be 
attributed  to  the  lowering  efiect  of  the  drug  on  the 
general  health,  which,  as  already  said,  is  often  accom- 
panied by  a  corresponding  subsidence  of  the  disease. 
Feeding  with  exiract  of  thyroid  gland,  which  was,  on 
its  first  introduction,  vaunted  as  almost  a  specific, 
has  not  answered  the  expectatiooa  which  were  formed 
of  it ;  it  sometimes  does  good,  but  more  often  perhaps 
does  harm.  Even  when  it  is  useful,  the  beneficial 
effects  are  not  permanent.  My  own  experience  in 
this  matter  is  confirmed  by  that  of  many  otlier  derma- 
tologists. 

In  cases  of  psoriasis  associated  with  rheumatoid 
arthritis,  arsenic  is  useful.  I  give  it  in  Fowler's 
solution,  in  the  doses  already  stated.  In  cases  of  this 
nature  I  have  seen  results  which  can  only  be  described 
as  marvellous  follow  the  use  of  an  exclusively  meat 
diet  washed  down  by  copious  draughts  of  hot  water. 
As  to  the  mode  of  action  of  this  treatment,  I  can  only 
suggest  that  the  simplicity  of  the  diet  promotes  the 
functional  nf&ciency  of  the  digestive  apparatus,  while 
the  large  quantity  of  water  increases  the  action  of 

•  Src  report  of  a  discusaion  ou  the  tTBa,tnieQt  of  paoriuaii  ut  the 
nnuil  Mootiue  of  the  Britisli  MoiiicJil  A Bsocintinu,  1902,  Br^r. 
■lA  Jovrii.,  October  3S,  19112. 


304  PSOEIASIS.  [cBAF.  sitt: 

the  kidneys  and  bowels,  and  so  brings  about  a  com* 
plete  elimination  ol  waste  products. 

Passing  next  to  the  local  treatment,  the  fiisfe 
tiling  to  be  done  is  to  remove  all  scales,  so  that 
remedies  may  be  applied  directly  to  the  affected  partk 
For  this  purpose  the  free  application  of  hot  watee 
and  soft  soap,  more  or  less  prolonged  immersion  la 
tepid  water  or  an  alkaline  bath,  or  inunction  witli^ 
oil  or  vaaelini>,  will  be  necessary,  in  order  to  soften 
and  loosen  the  scales.  Each  patch  must  be  dealt  Vi 
separately,  and  the  process  of  clearing  the  surf 
must  be  thoroughly  carried  out.  A  useful  practic^; 
rule  is  that  small  patches  should  be  dealt  with  1^, 
strong  applications,  while  large  areas  require  oarein' 
handling.  A  solution  of  salici/lic  acid  in  spirit,  «_ 
the  strength  of  6  per  cent.,  well  rubbed  in,  will  b^ 
found  effectual  in  removing  the  scales  in  old  patches^ 
When  the  scales  have  been  entirely  got  rid  of,  tli^ 
next  step  is  to  attack  the  seat  of  disease  with  anfr 
parasitic  remedies.  Although,  as  already  stated,  tiii9> 
theory  that  psoriasis  is  of  parasitic  origin  rest*  on  4 
very  slender  foundation,  rt  is  a  clinical  fact  that 
substances  which  have  the  property  of  checking  ttw> 
development  of  microbes  are  more  useful  than  any. 
other  applications.  The  particular  remedy  required. 
in  any  given  case  must  be  judged  of  by  the  degree  of 
intensity  of  the  process.  As  a  general  rule,  it  may  be 
laid  down  that,  as  in  eczema,  soothing  applicationt 
are  indicated  in  acute  and  stimulating  remedies  i^ 
chronic  forms.  If  hyperemia  is  very  marked,  UkS 
surface  should  be  covered  with  strips  of  linen  steepej- 
in  calamine  lotion^  or  smeared  with  olive  oil  or  cold 
cream.  Alkaline  baths  (five  or  six  ounces  of  bicai^ 
bonate  of  soda  in  thirty  gallons  of  water  at  a  ten)' 
perature  of  about  100"  F.)  often  give  great  relief.  In 
less  acute  conditions  mildly  stimulating  remedies 
should     be     employed.        Mercurial     ointments     oi 


CHAP,  xrv.]  TREATMENT.  305 

moderate  strength  will  be  found  eerviceable,  but 
they  ehould  be  applied  only  to  a  limited  Burface  at 
a  time.  Tar  may  be  applied  in  the  form  of  cade  oil 
or  credine  ointment,  or  liquor  carbonis  deiergens 
{v\_xx  to  3]  of  water).  Resorcin  (x-xx  gr.  to  3/  of 
lard)  is  a  very  useful  application. 

The  moat  rapidly  acting  and  most  efficient  of  all 
local  apphcations,  however,  is  chrysarobin.  It  m.ay 
be  uaed  in  the  form  of  an  oitihnent  l</r,  a^v-'^j  to 
5;).  Uniortunately,  there  are  several  diaadvantageB 
attending  the  use  of  this  substanee  which  con- 
siderably linut  its  practical  usefulness.  If  employed 
without  proper  precautions,  it  dyes  the  skin,  the 
bail,  and  the  nails  bright  yellow  ;  it  discolours 
linen  in  the  same  way,  and  the  stain  is  not 
removed  by  waslilng,  but  is  changed  to  purplish 
brown.  A  more  serious  drawback  is  the  irritating 
eflect  of  the  drug  on  the  healthy  skin  adjoining  the 
diseased  area ;  it  may  set  up  erythema  of  an  acutely 
inflammatory  form,  with  itching,  swelling,  etc.  For 
this  reason  it  is  chiefly  suitable  for  the  limbs  and  parts 
of  the  tmnk  away  from  the  neck  and  genitals  ;  it 
must  never  be  used  on  the  face  or  head.  In  some 
cases  chrysarobin  may  in  this  way  determine  the 
transformation  of  psoriasis  into  pityriasis  rubra.  The 
drawbacks  attending  the  use  of  this  powerful  agent 
may  be  avoided  by  combining  it  with  trautnalicin, 
as  suggested  by  Auspltz.  This  is  made  bg  dissolving 
5)  of  fare  guttapercha  in  51  of  chloroform;  to  this 
5;  of  (jiri/sarobin  is  added.  This  preparation  is,  after 
the  removal  of  the  scales,  painted  over  the  affected 
surface,  where  it  forms  a  thin  varnish,  which  should 
be  renewed  every  two  or  three  days,  Clirysarobin 
should  never  be  used  in  cases  in  which  marked 
1  is  present.  It  may  here  be  pointed  out 
y  Waiter  G.  Smith  *  baa  shown  by  experiment 


PSORIASIS. 


[OB 


that  chryaophanic  acid  is  not  an  efticient  substitnl 
for  chrysarobin  in  the  treatment  of  psoriasis.  Pyi 
gallic  acid,  used  in  the  form  of  on  ointment  (gr. 
to  gr.  XXX  to  ^y),  is  also  often  uaeful,  but  it  must  be 
applied  only  to  a  limited  area  at  a  time,  as  toxic 
effects  m.ay  be  produced  by  ite  absorption.  Achille 
Brenda  •  records  two  cases  in  which  patients  sufiering 
from  pBoiiaeis  had  succeeded  in  causing  the  disappear- 
ance of  patches  by  the  application  of  cauHtics,  Th«i 
agent  used  In  one  case  was  nitric  acid,  in  the  othi 
a  solution  of  corrosive  aubU'mate  in  akohol  (I'S) 
Bienda  treated  cases  of  his  own  with  nitrate  of  BJlvt 
and  acetic  acid  applied  on  cotton  wool.  The  treal 
ment  seemed  to  be  successful,  but  in  one  or  two  caaw 
the  nitrate  of  silver  was  followed  by  a  cheloid  condi- 
tion of  the  Bcar.  The  same  author  reports  a  case  in 
which  massage  of  the  akin  carried  out  every  day  for 
a  month  cured  a  case  which  had  resisted  other 
remedies; 

Sulphur  baths  are  often  beneficial  in  chronil 
oases;  The  first,  and  perhaps  the  chief, 
is  the  softening  and  removal  of  the  scales, 
practitioner  must  then  judge  by  the  amount 
hyperfemia  present  whether  weak  or  strong  lo 
applications  are  required  ;  if  the  latter  are  thought 
be  indicated,  they  must  at  first  be  used  well  dilute 
The  action  of  sulphur  baths  on  psoriasis  is  no  doul 
mainly  mechanical  by  removing  the  scales,  but  it 
possible  also  that  some  further  therapeutic  eSect 
produced  by  the  parasiticide  action  of  the  aulphi 
The  sulphur  waters  of  Harrogate,  Strathpefier,  & 
Liichon  are  especially  indicated  in  cases  of  chioi 
psoriasis.  The  waters  of  Aix-les- Bains,  La  Bon 
boule.  and  Royat  are  also  sometimes  beneficial,  bol 
applied  externally  and  taken  internally,  owing  to  tl 
aisenic  which  they  contain.     Even  the  "indifil"""' 


be       I 

tie 

Ue 

i 

a-     1 


CHAP.  XIV.]  TREATMENT.  307 

waters  of  Bath  and  Buxton  often  succeed  when  others 
have  failed.  It  is  important  to  bear  in  mind  that  in 
chronic  cases  the  patient  must  be  urged  to  persevere 
in  the  treatment,  no  matter  what  drug  is  used.  The 
best  security  against  relapse  is  the  completest  possible 
removal  of  every  vestige  of  the  disease. 

In  the  type  of  psoriasis  in  which  there  is  a  ten- 
dency to  the  development  of  pityriasis  rubra,  chry- 
sarobin  and  all  other  local  stimulating  applications 
should  be  at  once  discontinued.  The  patient  should, 
if  necessary,  be  kept  in  bed,  and  his  strength  sup- 
ported  by  nourishing  food  and  cod-liver  oil.  ^ 


CHAPTER   XV. 

PITYRIASIS. 

The  term  "pityriasis"  indicates  not  a  disease,  but  a 
symptom.  It  has  been  used  to  denote  a  variety  of 
conditions,  differing  widely  in  their  origin,  couise, 
and  tenuinatiDD,  but  having  one  objective  feature  in 
common,  namely,  branny  desquamation.  The  scales 
are  small,  easily  detached,  and  not  heaped  up  in  layers, 
as  is  the  case  in  psoriasis.  PUyriasis  simplex,  whether 
on  the  head,  the  face,  or  the  trunk,  is  now  recognised 
to  be  identical  with  dry  seborrhcea  (p.  505) ;  pHif- 
riam  versicolor  is  a  parasitic  disease  as  tinea 
versicolor  (p,  370)  ;  pityriasis  rubra,  pityriasis 
nibra  pilaris,  and  pityriasis  rosea  are  inflammatory 
proceaaea  in  which  more  or  lesa  abundant  exfoliation 
of  the  epithelium  is  an  essential  element.  Pityriasis 
rubra  and  pityriasis  rubra  pilaris  constitute  a  class 
for  which  the  general  appellation  of  "  exfoliative 
dermatitis  "  would  be  appropriate.  In  thiH  category 
should  probably  be  placed  those  cases  in  which  the 
epidermis  is  periodically  "  cast,"  wholly  or  in  part, 
like  a  serpent's  slough.  The  moat  remarkable  instance 
with  which  I  am  acquainted  is  that  reported  by 
Sligh.*  The  patient,  a  man  aged  thirty-six,  is  said 
to  have  been  taken  ill  with  almost  unfailing  regularly 
every  year  since  infancy.  He  complains  of  "  bone 
ache,  weakness,  nervousness,  and  inability  to  eat " ; 
his  temperature  rises  (101°  F.),  and  he  vomits. 
"  Within  a  few  days  he  has  shed  his  akin  from  the 
[  entire  surface  of  his  body,  including  the 

*  Internal.  Mnl.  Jlaff.,  June,  18P3. 


T.]  PITYRIASIS    RUBRA.  309 

toe  nails.  The  new  skm  is  as  soft  and  tender  as  a 
new-hom  babe's,"  but  rapidly  becomes  sound,  and 
in  four  or  five  days  the  man  can  resume  work. 

The  affection  already  referred  to  under  the  name 
of  desquamative  acarlatlniform  erythema  is  a  form  of 
exfoliative  dermatitis  ;  cUmcally,  however,  it  is  more 
closely  allied  to  simple  inflammation  of  the  akin  than 
to  the  more  formidable  diseases  that  are  about  to  be 
described. 

Pityriasis  rubra. — Pityriasis  rubra  is  an  in- 
flammatory affection  of  the  skin  characterised  by 
universal  redness  of  the  surface  without  infiltration 
or  thickening,  but  accompanied  by  profuse  desquama- 
tion. This  varies  in  its  character  in  different  parts  of 
the  body  ;  for  example,  it  is  branny  on  the  head,  on 
the  trunk  it  consists  of  larger  flakes,  while  from  the 
hands  and  feet  the  epithehum  is  shed  in  huge  scales. 
The  disease  used  to  be  considered  an  affection  sui 
generis  till  Buchanan  Baxter  *  showed  that  while  it 
may  occur  as  an  independent  disease,  it  often  follows 
other  skin  affections. 

The  onset  of  pityriasis  rubra  is  usually  more  or 
less  sudden,  and  is  accompanied  by  some  malaise, 
though  not  of  a  very  marked  character.  The  eruption 
is  symmetrical  in  distribution,  and  may  select  any  part 
of  the  skin  for  its  point  of  attack  ;  most  frequently, 
however,  it  begins  on  the  limbs  and  chest.  Red 
patches  appear,  which  spread  rapidly  at  the  edge,  and 
coalesce  with  other  patches  so  as  to  involve  the  whole 
surface  of  the  skin  bterally  from  head  to  foot.  The 
affected  skin  is  uniformly  bright  scarlet  in  hue,  but 
quickly  becomes  covered  with  thin  wafer-like  scales 
which  overlap  each  other  like  slates  on  a  roof,  but  are 
never  fused  together  into  crusts.  There  is  very 
seldom  any  discharge  on  the  surface  of  the  skin,  and 
1  exudation  does  take  place  the  fluid  is  thin  and 

•  Bril.  Med.  Joum,,lS19. 


PITYRIASIS.  toHAP.  xy. 

watery,  like  sweat  (of  which,  indeed,  it  chiefly  coa- 
its),  and  does  aot  stiffen  linen.  The  scales  are 
easily  detached,  and  when  they  separate  the  akin 
underneath  ia  seen  to  he  intensely  red.  Although 
there  may  be  considerable  tension,  there  are  usually 
no  fissures.  Theie  is,  as  a  rule,  no  itching ;  this, 
however,  depends  on  the  temperament  of  the  patient, 
and  in  some  cases  itching  is  very  pronounced.  Over 
the  whole  surface  of  the  skin  an  unpleasant  feeling  of 
stifiness,  heat,  and  tenderness  ia  often  experienced. 
In  my  experience  a  peculiar  feature  of  the  disease  is 
fjfchat,  in  spite  of  the  great  redness  and  desquamation,. 
Ifiiere  is  no  thickening  of  the  skin ;  on  the  contrary, 
there  is  slight  but  distinct  thinning  of  the  integu- 
ment, as  can  be  felt  on  pinching  it  between  the 
fingers.  The  disease  usually  spreads  with  great 
rapidity,  the  whole  body  being  invaded  in  a  few  days ; 
sometimes,  however,  it  remains  confined  to  certain 
regions,  and  never  becomes  universal. 

Pityriasis  rubra  may  develop  as  an  entirely  inde- 
pendent affection,  or,  as  already  said,  it  may  be  a 
sequel  of  some  other  disease  of  tlie  skin ;  in  other 
words,  esfoUative  dermatitis  may  be  either  primary 
or  secondary.*  In  the  primary  form  the  eruption 
flrst  appears  as  a  vivid  red  blush,  which  spreads  so 
rapidly  that  it  becomes  universal  in  a  few  hours. 
There  is  no  infiltration  or  thickening  of  the  aldii. 
Desquamation  is  most  abundant,  the  whole  skin  seem- 
ing to  be  shed  in  some  cases.  The  affection  is  ex- 
tremely rare  ;  I  have  seen  only  three  or  four  caaea. 
The  secondary  form  may  start  from  erythema  multi- 
forme, especially  when  the  lesions— such  as  erythema 

•  In  a  Mrriei  of  tweii^-aiiB  caMa  publithed  by  8t«pheu  ICM- 
kencio  (Bnl.  J<miii.  jJerm,,  July,  18S0)  eleveu  were  primwc 
uni]  teii  aecnlidaty  in  origin.  Hy  own  experience,  howoVDr,  it 
th«t  Uie  liiEtec  it  fat  more  frmuent  thnn  Uie  former.  Siv  aiio 
tiaUoway,  Brit.  Joum.  Aivh,,  1838,  p.  448. 


IV.]  PlTYRlASlti    RUBRA.  311 

iris — are  definite  and  charaeteristic.  Gradually  one 
sees  the  erythematous  elements  subside  or  disappear, 
their  places  being  taken  by  patches  of  reduesB, 
which  spread  over  the  whole  body  and  assume  the 
aspect  of  pityriasis  rubra,  as  described  above.  Again, 
one  meets  with  cases  presenting  all  the  characters  of 
typical  eczema,  with  large  discharging  surfaces  and 
other  distinctive  lesions,  in  which  a  sudden  change 
comes  over  the  face  of  the  disease,  the  whole  skin 
becoming  crimson  sometimes  in  a  single  night,  and 
all  the  eczcmatous  appearances  fading  away,  or  being 
swallowed  up  in  pityriasis  rubra.  Psoriasis,  again, 
with  its  characteristic  lesions  in  typical  positions, 
may  suddenly  lose  all  its  distinctive  features  and 
become  transformed  into  pityriasis  rubra.  Lichen 
ruber  planus  and  dermatitis  herpetiformis  may  im- 
dergo  a  precisely  similar  metamorphosis.  Examples 
of  all  these  transformations  have  come  under  my  own 
notice.  The  event  is  probably  more  frequent  aft-er 
psoriasis  than  any  other  affection.  Sometimes  the 
transformation  is  attended  with  considerable  con- 
stitutional diBt\irbance,  but  this  is  by  no  means  in- 
variable. However  it  may  begin,  pityriasis  rubra 
varies  in  duration  and  intensity,  sometimes  not  affect- 
ing the  general  health  to  any  appreciable  extent,  and 
passing  away  in  a  few  days  or  weeks ;  sometimes 
lasting  for  years,  and  leudiug  to  death  from  exhaustion 
or  some  intercurrent  disease.  In  the  cases  in  which 
recovery  takes  place  relapse  is  frequent.  On  the  other 
hand,  cases  in  which  the  disease  has  lasted  for  many 
years  may  take  a  sudden  tarn  for  the  better  and  end  in 
recovery ;  the  patient  is,  however,  always  liable  to 
subsequent  attacks.  In  primary  pityriasis  rubra  the 
health  is  not,  as  a  rule,  affected  so  early  as  in  the 
secondary  form  of  the  affection.  The  disease  is  rare 
in  children,  but  it  is  much  more  severe  and  fatal  in 
them  than  in  adulte,    It  may  be  remarked.  t^aX.  'tXv& 


312 


PITYRIASIS. 


[ciUP  sv.  ^H 

in  cases  of  H 

;  new-born  ^^ 

:  Prague,*  ^| 

.ave   never  ^| 

isciiptions,  ^1 


mental  faculties  are  sometimes  disordered  in  cases  of 
pityriasis  rubra. 

A  special  form  of  the  disease  affecting  new-born 
infants  litis  been  described  by  Ritter  of  Prague, 
Kaposi,  and  other  observers ;  but  I  have  never 
myself  seen  a  ease  answering  to  their  descriptions, 
nor,  so  far  as  I  know,  has  any  such  case  been  reported 
in  England.  The  aflection  begins  within  the  first 
fortnight — seldom  beyond  the  first  month — of  infancy. 
The  lesions  are  those  of  pityriasis  rubra,  sometimes 
with  the  flaccid  bullae  of  pemphigus  foliaceus  with 
crusts  and  small  fissures  about  the  comers  of  the 
mouth,  the  openings  of  the  nostrils,  the  commissvireB 
of  tlie  eyelids,  and  the  anus.  There  is  no  constitu- 
tional disturbance,  but  in  one-half  of  the  cases  the 
child  dies  of  marasmuB.  What  appears  to  be 
B  contagious  form  of  pityriasis  rubra  has  beeo 
described  by  Savill.f  I6.'i  cases  having  occurred  in 
the  Paddington  Poor-Law  Infirmary  between  July 
and  October,  1891.  The  eruption  appeared  in  the 
form  of  a  thickly-set  papular  rash,  with  genial  con- 
gestion and  thickening  of  the  skin.  Vesicles  occb- 
aionaJly  formed.  Independent  patches  formed  in 
different  parts  of  the  body,  and  in  some  cases  the 
whole  akin  became  crimson,  inflamed,  and  painful. 
A  sickening  odour  was  perceptible.  The  epidermis 
was  soon  shed  in  small  dry  scales,  or  in  large  sheets, 
from  the  hands  and  feet.  There  was  great  constitu- 
tional disturbance,  and  thirty  of  the  sufEerers  diedi 
from  increasing  weakness  and  coma.  The  diseaaft] 
tan  a  more  or  less  definite  course,  lasting  from 
to  eight  weeks,  The  affection  was  clearly  contagioi 
though  its  epidemic  prevalence  is  difBcult  to  aocoonl 
for.  Similar  outbreaks  on  a  smaller  scale  have  bi 
recorded. 

./.  Derm.  u.  Huph..  187B,  Heft  1. 
1.  iJ^rtJi.,  Feb,  nod  Maroli,  199!!, 


V]  ETIOWOY  OF  PITYRIASIS  RUBRA.    313 

The  etiologry  of  pityiiasia  rubra  is  very  obscure. 
The  primary  form  often  follows  a  chill,  but  in  many 
cases  no  cause  can  be  discovereil.  The  male  sex 
shows  a  Bomewbat  greater  proclivity  than  the  female, 
and  the  disease  is  more  common  in  middle  life  than  at 
any  otber  period,  though  no  age  is  exempt.  In  the 
secondary  form  the  cause  of  the  transformation  is 
unknown.  In  some  eases  it  appears  to  follow  an 
injury  to  the  akin.  Thus,  I  have  known  pityriaaia 
rubra  develop  suddenly  after  a  burn,  and  spread  over 
the  whole  body  in  a  single  night.  In  other  caaea  it 
Beems  to  be  the  result  of  tbe  remedies  used  in  the 
treatment  of  the  pre-existing  skin  affection.  In  a 
healthy  girl  under  my  own  care  for  chronic  eczema, 
treatment  with  chryaophanic  acid  was  followed  by 
dilfuse  redness  of  the  akin,  which  gradually  assumed 
ail  the  characters  of  pityriasis  rubra.  She  has  now 
been  under  treatment  for  nearly  two  years,  and  at  one 
time  her  health  was  almost  completely  broken  down  ; 
but  she  is  now  recovering.  Pityriasis  rubra  has  also 
been  known  to  loUow  the  use  of  mercury  and  other 
drugs.  Crocker  •  maintains  that  there  is  a  close 
relationship  between  rheumatism  (especially  tiie  acute 
form)  ani^  gout  and  pityrlasiH  rubra,  such  an  associa- 
tion having  existed  in  eleven  out  of  eighteen  i;a3(;s 
which  he  had  the  opportunity  of  observing. 
Jadassohn  "f"  has  found  tuberculosis  (enlargement  of 
the  superficial  lymphatic  glands,  and  occasionally 
tubercle  of  the  internal  organs)  aasociated  with  pity- 
riasis rubra  in  a  certain  proportion  of  cases.  Even 
if  it  be  admitted,  however,  that  rheumatism  and 
tuberculosis  may  be  predisposing  causes,  we  are  still 
in  the  dark  as  to  the  factors  which  determine  the 
onset  of  the  disease.     It  i,s  possible  that  the  absorp- 

Congria  Ihtemat.   do   Daim.   et  de  Sjph.,   tenu  i  Puria 
11889  :  Caiaplri-R-iidm,  Porui,  IHSO,  ii.  6B. 
"^   '  'A./  J>.™.,No.  6,  1891,  audSoH,  \,-l,i'a6.'i,\«31. 


PITYSIASIS. 


^^^K  tion  of  poiaonous  producta  from  tlie  previously 
^^^K  existing  skin  lesions  might  explain  the  development 
^^H^  oi  secondary  exfoliative  dermatiti't,  but  I  am  more 
I  inclined  to  believe  that  it  will  be  found  to  be  a  result 

of  parasitic  invasion.     Such  evidence  as  we  have  c 
I  this  point,  however,  is  scanty  and  doubtful.     Bisien 

Russell*  found  a  diplococcus  in  the  serum  and  the 
blood  and  also  in  the  skin  in  some  of  Savill's  cases. 
Petrini  do  Galatz,  however,  failed  to  find  micro- 
organisms either  ia  the  scales  or  in  the  blood. ■]■ 
I  The  prOg'nosis  depends  chiefly  on  the  extent  to 

I  which  the  internal  organs,  especially  the  kidneys,  are 

I  diseased.     The  presence  of  albuminuria  adds  much  to 

^^^  the  gravity  of  the  outlook.  In  a  considerable  pro- 
^^L  portion  of  cases  pityriasis  lubra  proves  fatal,  especially 
^^^&  'in  chOdren ;  and,  however  mild  the  symptoms  may 
^^^r  be,  it  ia  never  safe,  even  if  the  patient  appear  to  be 
^^^  on  the  way  to  recovery,  to  predict  a  favourable 
r  tfirmination,  as  at  any  moment  a  turn  for  the  worse 

I  may  occur.     Even  after  complete  recovery  relapse 

[  may  take  place.     In  my  own  experience  a  fatal  result 

has  occurred  much  more  frequently  in  cases  occurring 
secondarily  to  a  pre-existent  skin  affection. 

Pathologically,  the  procesa  is  one  of  inflammation 

of  the  skin,  at  first  superficial,  later  extending  through 

I  the  whole  depth  of  the  integument.     The  changes 

found  on  microscopic  examination  are  simply  those 

I  characteristic  of  chronic   inflammation,   varying  in 

degree  according  to  the  length  of  time  the  process  has 

lasted.     They  are  present  in  all  the  layers  of  the 

integument.     According  to  Petrini  de  Galats,;]:  the 

essential  lesion  ia  in  the  papillse.     Besides  hyperplasia 

I  tA  cells,  there  is  in  the  earlier  stages  of  the  process  » 

•  Jlril.  J'«ir-i.  I>fi-m.,  April,  !892. 
t  ConsT^  InteniBt.   de   Cerm.   et  de  Sjiih., 
I  CD  1889 1  Cumj/ira-RrtulMi,  Parii,  I81HI,  p,  iH 
J  Lot  cit.,  p-  fil. 


OHAP.xv.]  PITYRIASIS    RUBRA.  316 

proliferation  of  round  cells  in  the  interior  of  the 
papillse,  around  the  vessels  and  in  their  walls.  A 
similar  proliEeiation  is  seen  along  the  vessels  of  the 
cutis.  This  leads  to  sclerosis  of  the  papOlte,  and 
especialljr  of  their  veeseU,  and  in  time  to  sclerosis  and 
obliteration  of  the  whole  vascular  apparatus  of  the 
skin,  with  granular  and  fatty  degeneration  of  the 
neighbouring  tisanes.  The  jtlands  undergo  atrophy, 
the  sebaceous  glands  apparently  becoming  trans- 
formed into  fat.  The  redjieas  of  the  aldn  is  due  to  the 
stasis  of  the  blood  In  the  vessels,  and  the  ceaseless 
shedding  of  the  cuticle  is  an  indication  of  the  degree 
to  which  the  nutrition  of  the  skin  is  impaired. 

As  regards  diagnosis,  pityriasis  rubra  is  distin- 
guished from  other  afEections  of  the  skin  by  {])  the 
vivid  redness  of  the  eruption,  (2)  its  rapidity  of  diffu- 
sion, (.3)  its  universality,  (i)  the  constant  and  profuse 
desquamation,  and  the  characteristic  papery  scales 
and  sbeete  of  epidermis,  and  (5)  its  tendency  to  cause 
serious  impairment  of  health  and  even  death.  Prom 
psoriasis  it  is  distinguished  by  its  rapid  spread, 
and  the  involvement  of  the  whole  area  of  the  skin. 
Lichen  ruber  planus  is  seldom  universal,  and  does  not 
spread  so  rapidly  ;  moreover,  it  begins  in  character- 
istic papules.  From  eczema  pityriasis  rubra  ia 
differentiated  by  the  absence  of  exudation  and  crusts. 
From  pemphigus  foliaceus,  which  it  sometimes  re- 
sembles in  other  respects,  it  can  be  discriminated  by 
the  absence  of  the  loose  bulls?  and  foul-smelling 
discharge  characteristic  of  that  affection.  Moreover, 
the  genera!  symptoms  are  more  severe  in  pemphigus 
foliaceus  than  in  pityriasis  rubra,  and  the  disease  is 
less  amenable  to  treatment. 

In  the  treatment  of  pityriasis  rubra  the  first  thing 
to  be  done,  if  the  disease  is  consecurive  on  some 
other  cutaneous  affection,  is  to  discontinue  the  use  of 
chrysarobin  or  whatever  other  drug  may  seem  to  he 


PITYRIASIS.  \Ci 


^H!  SIB 

^^H  thp  determining  cause  of  the  attack.  Every  effort 
^^H  must  be  used  to  keep  the  patient's  health  up  to  the 
^^^^  highest  standard.  Over-drugging  is  likely  to  do  great 
^^^1  harm.  The  digestion  and  bowels  must,  of  coarse, 
^^^H  be  carefully  attended  to  ;  nervouH  excitement  muet 
^^^P  as  far  aa  possible  be  Bubdued  by  appropriate  remedies. 
^^^  If  the  symptoms  are  acute,  antimony,  administered 
r  in  the  manner  already  described,  will  be  found  useful. 

I  In  cases  of  a  chronic  type  arsenic  may  do  good,  but  it 

»  should  never  be  given  if  the  inflammation  is  at  all 
intense.  When  the  patient  sufiers  from  sleeplessness, 
and  the  urine  is  normal,  the  administration  of  opium 
is  often  of  great  use.  Stimulants  should  be  forbidden, 
unless  definitely  indicated  by  weakness  of  the  heart's 
action.  The  strength  must  be  maintained  by  nutri- 
tious food,  and  the  least  appearance  of  wasting 
ahoidd  be  the  signal  for  cod-hver  oil.  Sufferers  from 
pitjriasis  rubra  are  always  unduly  sensitive  to  cold, 
and,  indeed,  a  chill  is  very  likely  to  aggravate  the 
symptoms  during  the  course  of  the  disease,  or  to  bring 

Eon  a  relapse  during  convalescence  or  after  recovery. 
It  is  of  the  greatest  importance,  therefore,  that  ex- 
posure to  cold  should  be  most  carefully  avoided.  In 
severe  cases  the  patient  should  be  kept  in  bed  ;  even 
in  apparently  slight  cases  he  should  stay  indoors. 
Locally,  the  indications  ore  to  soothe  irritation, 
disinfect  the  skin,  and  keep  the  affected  parte  warm. 
Tepid  bran  or  alkaline  baths  are  usually  comfoTtin({; 
In  cases  in  which  the  kidneys  are  sound.  I  have  seen 
great  benefit  from  the  use  of  prolonged  mucilaginoiu 
or  demulcent  baths.  Patients  are  often  able-  to 
sleep  in  these  baths  when  they  cannot  do  so  in  thai 
beds.  Tarry  -preparaivrnt  are  especially  usefid.  The 
liquor  carbonis  delergena  freely  diluted  with  water, 
or  very  weak  creoline.  or  oil  of  cade  ointment,  may  bft 
applied.  Carboliaed  oil  (\  in  20)  is  often  benefidiil,- 
but  in  using  antiseptic  applications  care  must  b«i 


i 


ORiP.  XV.]   PITYRIASIS   RUBRA    AND  ROSEA. 

taten  lest  iiritation  be  caused.  Stephen  Mackenzie 
has  got  the  best  results  from  watery  a  "  ' 
ed  from  oilj-  applications.  His  favourite  i__ 
tion  is  a  lotion  ol  glycerine  of  svhacetate  of  lead  51, 
glycerine  51,  water  to  a  pint.  He  swathes  the  patient 
from  head  to  foot  in  a  suit  of  lint  and  a  mask  soaked 
in  this  lotion.  The  patient  is  kept  between  blankets 
during  the  treatment,  which  is  continued  till  all  red- 
ness has  disappeared.  Then  greasy  applications, 
such  as  simple  vaseline,  are  substituted  for  the  lotion. 
Mercurial  preparations  should  not  be  employed,  aa 
they  are  likely  to  aggravate  the  disease.  For  pro- 
tective purposes  the  skin  may  be  freely  dusted  with 
starch  and  oxide  of  zinc  powder,  and  then  covered 
with  cotton-wooi,  or  it  may  be  wrapped  in  bandages 
steeped  in  calamine  liniment. 

In  the  case  of  infants  special  precautions  must  be 
taken  against  cold.  The  skin  should  be  smeared 
with  fatty  substances  and  covered  with  cotton-wool 
till  the  epidermis  has  been  reproduced.  Special 
attention  should  also  be  paid  to  the  nouiiahment  of 
the  patient.* 

Pityriasis  rosea. —Pityriasis  rosea,  for  the 
differentiation  of  which  as  a  substantive  disease  we 
are  indebted  to  Gibert,^  is  an  inflammatory  affection, 
the  essential  lesion  of  which  ia  a  pink  rash,  very 
slightly  raised,  and  thiiJy  covered  with  small  scales. 
The  eruption  appears  first  as  a  single  patch  situated 
on  the  trunk,  the  neck,  or  the  aim.f  It  is  oval  or 
circular  in  shape.    Its  edges  are  bright  red  in  colour, 

•  For  an  iuatrnctiTB  diaouaaion  of  the  whole  eubject  of  ei- 
foliatJVG  dermatitiE,  in  which  Walter  ti.  Smith,  Stepfaea  Moc- 
keiaie,  Bedtliffa  Croc*er,  F,  J,  Payne,  Colcott  Poi,  J.  O.  Priiiglii, 
GaUoway,  «iiit  others  took  ruirt,  ter  BiiC.  Juuiii.  Dtrni.,  Dec, 
1898,  j>,  IS-  -■(  »f/>,. 

t  "  TraiW  Pratiquo  lieB  Maladiea  do  la  Peau  el  (ie  la  Syphilis," 


PITYRIASIS. 


^^^f  318 

^^^V  Bomewhat  raised,   and  covered  with  floe  adheieut 

^^^1  scales  ;  the  centre  is  of  a  duller  led-biownish  tint,  and 

^^^H  slightly  depressed.     The  patch  gpieads  at  the  edge, 

^^^H  fading  in  the  centre  as  it  does  30.     In  a  week  or  bo 

^^^H  this  hejald  pati:h  is  followed  by  the  appearance  of  & 

^^^P  number  of  small  bright  red  spote,  which  soon  grow 

^^^  into  patches.     These  are  of  two  types  :    one  small, 

r  irregular  in  size,  with  an  indistinct  border  and  a  scaly 
wrinkled  surface  ;    the  other  larger,  rounded  in  onb» 

[  line,  with  a  well-defined  border  like  the  herald  patch, 
and  standing  out  among  the  other  pat«hes  like 
medallions  (Brocq).  Lesions  of  the  former  variety 
are  soraetimca  termed  maadate,  while  those  of  the 

^^_  latter  are  known  as  cirinniUe.     Both  forms  usually 

^^^L  coexist,  the  circinate  lesions  being  'scattered  among 

^^^1  the  others,  which  are  more  numerous.     As  the  cii- 

^^^r  cinate  patches  spread  at  the  edge  the  centre  under-. 

■  goes  involution,  and  rings,  red  and  scaly  at  the  circum- 

r  (erence  and  fawn  coloured  in  the  middle,  are  formed. 

I  In  course  of  time  the  circle  is  broken  by  partial 

^^^  disappearance  of  the  border,  and  segments  remain, 

^^^L  which,  meeting  similar  relics  of  other  patches,  form 

^^^1  wavy  hnes    partly    enclosing    fawn  coloured    areas. 

^^^1  As  the  eruption  fades  at  one  spot  it  comes  out  at 

^^^1  another,  and  at  a  given  moment  all  stages  of  the 

^^^B  process  may  coexist.     Itcliing  is  not  generally  trouble- 

^^H  Bome,  but,  owing    to    individual  differences  in  the 

^^^1  irritability  of  the  skin,  this  rule  is  subject  to  numerom 

^^^B  exceptions.     The  eruption  usually  first  shows  itaeU 

^^^1  on  the  belly,  but  it  may  begin  on  the  chest,  the  fooc^, 

^^^1  or  the  arm.     It  spreads  rapidly,  so  as  often  to  cover 

^^^1  tile  trunk,  the  face,  and  the  limbs  in  two  or  thtee 

^^^V  weeks.     It  is  generally  thickest  on  the  buttocks  and. 

^^H  abdomen,  and  it  seldom  extends  below  the  elbow  or 

^^^H  the  knee.     I  have,  however,  seen  It  in  a  corn-like 

^^^B  form  on  both  palms  in  a  xerodermic  patient.     Occa* 

^^^K  eionally  it  is  universal.     The  appearance  of  the  erup- 


sv.]  PITYRIASIS    ROSEA.  319 

tion  is  sometimeB  preceded  or  accompanied  by  slight 
conatitutional  diatiirbance.  'j'he  process  terminateB 
in  spontaneous  resolution  within  a  period  varying 
from  a  fortnight  to  two  montlia. 

Of  the  etiology  of  pityriasis  rosea  little  can  be 
said.  It  may  occur  at  any  age,  but  is  moat  common 
in  the  youcg,  being  aenerally  seen  in  persona  between 
fifteen  and  thirty-five  years  of  age.  According  to 
Brocq ,•  it  is  more  common  in  the  female  than  in  the 
male  sex.  It  is  said  by  some  to  be  more  common  in 
spring  than  at  any  other  season  ;  of  filty-six  cases 
obKerved  by  Moingeard.f  fifty-tliiee  occurred  in  the 
period  between  April  and  June,  Jacquet  says  it 
sfaowsaprelerence  for  the  subjects  of  dilated  stomach, 
and  Brocq  believes  it  to  be  relatively  common  in 
those  Huflering  from  syphilis,  especially  in  the  early 
stage.  There  is  some  evidence  that  it  is  contagious. 
It  Las  been  thought  to  be  due  to  a  specific  fungus,  the 
microspormt  anomit'on  (Vidal) ;  but  the  very  existence 
of  such  an  organism  Iscke  confirmation,  and  in  any 
case  itfi  presence  on  the  epidermis  would  be  no  proof 
that  it  had  any  causal  connection  with  the  disease. 

The  diagnosis  is  as  a  role  easy,  owing  to  the 
well-marked  objective  features  of  the  affection.  The 
eharacteriatic  single  patch  which  I  have  called  the 
"  herald,"  the  pale  red  tint,  shght  scaliness,  and  want 
of  elevation  of  the  patches,  the  mingling  of  maculate 
and  circinate  varieties  of  lesion,  and  their  sponta- 
neous involution,  make  up  a  distinct  clinical  entity 
which  can  hardly  be  mistaken  for  anything  else.  From 
psOriaais,  pityriasis  rosea  is  differentiated  by  (a)  ifa 
slight  scaliuess ;  (!i)  the  absence  of  the  characteristic 
hyperaamic  spots  on  the  red  surface  underneath  the 
scales ;  (c)  by  its  showing  no  preference  for  the  sltua- 

*  Brocq;   "La   Pratique  Dcrmiiloloeique."   vol,  iii..  p.  803. 
Quoted  by  Brotq.     tip.  at. 


■■3B0 


PtTYRUaiS. 


[CSAP.  XT. 


tions  most  liable  to  be  attacked  b^  psoiiaflis.  From 
syphilitie  lesions  resembling  it  more  or  less  closely 
in  appearance  it  can  be  distinguished  by  the  absence 
of  a  liistory  of  infection  and  of  other  concomitant 
Bigna  of  vcDereal  disease.  From  aebotrhcea  corporis 
it  is  difierentiated  by  (a)  the  absence  of  the  Qhai- 
acteriittic  initial  papules ;  {h]  by  its  distribution, 
aebonhcea  corporis  affecting  almost  esclusivoly  the 
middle  of  the  chest  and  back,  and  always  avoiding 
the  limbs ;  and  (c)  by  the  fact  that  it  disappears 
spontaneously  in  a  tew  weeks,  while  seborrhoea  cor- 
poris, if  untreated,  will  last  lor  years.  From  tinea 
circinats,  pityriasis  rosea  is  distinguishable  (a)  by 
the  large  number  and  wide  distribution  of  the  lesions  ; 
and  (6)  by  the  absence  of  the  tricophyton,  which  is  , 
the  cause  of  the  former. 

The  prOiTDOSis  of  pityriasis  rosea  is  always 
favourable,  spontaneous  resolution,  as  already  stated, 
taking  place  in  a  tew  weeks. 

fn  the  way  of  treEtment,  all  that  is  required  is 
to  soothe  any  irritation  that  may  exist.  For  this  pur- 
pose lit]uor  fids  carbonis,  or  any  of  the  anti- 
pruritic remedies  already  mentioned,  may  be  em- 
ployed. If  the  eruption  is  very  extensive,  a  tepid 
bran  or  alkahne  bath  will  be  useful.  No  internal 
medication  is  necessary, 


CHAPTER    XVI, 


LOCAL    INWULABLE    DLSEASES. 


This  group  of  skin  afEections  includeB  a  number  of 
widely  differont  conditions  which  have  this  one 
feature  in  common,  that  the  oxcitihg  cause  of  the 
disease  ia  implanted  in  the  integument  from  without, 
and  there  under  favourable  conditions  reproduces 
itself  and  pyes  rise  to  local  lesions  without  causing 
ayatemic  infection.  The  agents  which  excite  the 
disease  are  ol  parasitic  nature — that  is  t-o  say,  they  are 
organisms  that  live  at  the  expense  of  their  involuntary 
host.  They  may  conveniently  be  divided  into  (n) 
animal  parasites,  {b)  vegetable  parasites,  and  (r) 
other  micro-organisma.  In  some  of  the  aflections 
described  in  the  present  chapter  the  exciting  cause 
of  disease  is  inocuiable  into  the  epidermis,  in  others 
into  the  true  skin.  The  former  will  be  dealt  with 
first. 

I. — Anim.1l  Pauasites. 
A  formidable  list  of  the  animal  parasites  that 
infest  the  human  akin  is  given  by  Gebor  ;  •  of  tliese, 
only  the  more  common  need  be  mentioned  here.  He 
divides  the  parasites  into  three  classes:  (1)  those 
(called  by  him  "  stationary  ")  whose  habitat  is  almost 
exclusively  the  human  skin — including  the  Sarcoptes 
scabiei  hominis  or  itch-mite,  the  pediculus  or  common 
io'uae  in  its  three  varieties,  (o)  head,  (6)  body  (or  more 
properly,  clothes),  and  (o)  pubic  or  crab-iouse  ;  Pulex 
"Titans  or  common  Bea  ;  Demodex  or  Acarua  folliou- 

■  ZiamSK'ii's  "  Handbook  of  Skia  Diwiviea." 


F 


LOCAL   INOCULABLE   DISEASES,     [ohap- j 

loriim  hominis  (Fig.  Ifi,  o).  (2)  Temporary  or  occ&-  I 
sional  parasites,  which  may  be  present  either  (a)  in  a  I 
illy  mature  or  (6)  in  a  larval  condition.  Among  i 
the  former  may  be  mentioned  Cimex  lectvdarius  or  I 
bed  bug ;  Dermanyssus  aviom  or  bird-mite  ;  tabanidsB  I 
or  house-flies,  etc.  ;  among  the  latter,  ceatodea,  auch  as  1 
Cyaticercua  cellnlosss  and  echinococcus  or  bladder-  ' 
worm ;  tfewatodes,  such  aa  Diatoma  hepatici 
iiver-iluke ;  nematodes,  such  aa  Filaria  medinensis  | 
(Fig.  16,  o),  Filaria  sanguinis  hominis  (Fig.  16,  h), 
Oxyurifl  vermicularis ;  and  various  flies  (tMiscidce)  I 
such  as  Musca  domestics,  cadaverina,  vomitaria,  etc. 
(3)  Accidental  parasites,  of  which  the  moat  familiar  J 
is  Leptus  autumnaha  or  harvest  bug. 

Scabies  la  an  a^ection  produced  by  the  j 
of  the  acarus  or  aarcoptea  acabiei  in  the  epider 
gives  riae  to  lesions  of  an  inflammatory  nature,  caused  I 
by  the  irritation  of  the  parasite,  together  with  otbetBfl 
due  to  scratching.     The  female  is  the  exciting  agent  1 
in  the  initiation  of  the  proceas,  the  function  of  th&l 
male  being  limited  to  the  impregnation  of  his  mate.  i 
When  this  has  been  accomplished  the  female  penc  I 
trates  into  the  deeper  layers  of  the  epidermia,  where  J 
she  depoaits  her  ova.     She  first  passes  downwards  I 
through  the  horny  layer,  and  then  hv  a  wii^ling'4 
movement  puahes  her  way  below  the  homy  layer.  I 
In  this  manner  she  makes  a  tortuous  burrow,  ^e  I 
direction  of  which  ia  indicated  on  the  aurface  by  %  ] 
rough  line  formed  by  the  upheaval  of  the  homy  layer.  i 
At  the  point  where  she  first  enters  the  epidermis  then 
ia  usually  a  vesicle  which  marks  the  situation  of  tho  I 
mouth  of  the  burrow.     The  average  length  of  the  . 
burrow    is    from  one-eighth  to  half  an  inch,  but  ib 
may  be  a  good  deal  longer.     At  difierent  stages  in  tttV' 
excavation  of  the  burrow  the  acarus  deposits  an  Dvnm, 
and  also  excremental- matter.     The  acarus  is  always 
found  at  the  blind  end  of  the  burrow.     She  Uvea  as  a    ' 


.  r  ttO(kiiit,  •lelaiT).    D,  pEdicalna 

eorporla  ireuialf-),  x  fiO  (Kiichtwntintfrt.  P,  FedfoolDH  pnblif,  x  B5 
(JCiiiilUiiiiuiiln).  K,  I>edibUlu>  dDpiUa  (tuHle),  x  36  (,SMl'miiMlir\ 
a,  HlariB  medinaiiBla,  liair natural  bUb,  vrttli  tuvB  (n),  it  »«!a»ii*«v 
H,  Fitaita  lADHtilulH  lioiuinis,  ■  250  (tewis^  -,  'sVi.^i  dsmto  l,n.1  CiWk**- 


r 


324         LOCAL   ISOCLLABLE    DISEASES,     [cuir.  svi^ 

rule  about  two  months,  iluring  which  she  deposits 
some  tiity  ova,  then  dies.  The  ova  are  hateheid  ia  a 
week  to  a  fortnight,  the  oldest,  which  are,  of  coiirae, , 
the  most  superficial,  coming  first  to  the  surface,  aide^ 
by  the  natural  exfoliation  of  the  older  epidermis. 

The  burrows  that  have  been  described  are  tfa(^ 
characteristic  lesdons  of  scabies,  and  the 
common  situations  for  them  are  the  parts  whei 
the  skin  is  least  thick,  namely,  the  webs  betweea.1 
the  fingers  and  toes  (especially  in  infants),  tlie  fronts^ 
of  the  wrists,  inside  the  umbilicus,  the  penis  and 
other  parts  of  the  genitals,  the  breasts  in  women  ; 
occasionally,  though  rarely  except  in  very  uncleanly 
people,  they  may  be  seen  in  other  par(s,  bat  the 
head  and  face  are  never  attacked  except  in  chQdrot  ■ 
in  arms,  where,  for  obvious  reasons,  these  parte  ara  | 
much  exposed  to  contagion.  The  burrows  can 
generally  be  found  without  difficulty  in  persons  who 
are  not  too  particular  in  their  ablutions,  the  rough 
line  marking  the  track  being  bla(.^kei)ed  by  dirt; 
in  other  cases  the  little  vesicle  at  the  entrance  will 
indicate  their  position.  In  cleanly  people  they  an  ^ 
often  by  no  means  easy  to  find,  the  line  inarkin;|(1 
their  course  being  ill  defined.  There  are  also  oertBia'f 
periods  in  the  disease  when  burrows  are  not  present, 
namely,  at  the  very  beginning,  when  the  acarus  has 
only  just  penetrated  the  epidermis  and  has  had  no 
time  to  burrow,  and  later,  when  the  burrows  have 
been  laid  open  and  destroyed  by  scratching  or 
treatment. 

The  secondary  lesions  arc  the  results  of  i 
iiiatory  reaction,  intensified  by  scratching  and  c 
plicated  by  inoculation  with  pus  cocci.     The  eniptu 
is  fir§t  vesicular  ;  later,  pustules  and  sometimes  b 
tooonie  developed.     The  diatinctive  feature  of  1 
lesions  is  that  they  am  not  grouped  as  i 
which  they  otherwise  often  resemble,  but  are  it 


D 

ll 

^1 


I^P^OSAP.  ) 


OOAP.  XT1.1  SCABIES.  325 

and  irregularly  Bcattered  about.  The,  marks  of 
scratching  are  seen  in  all  parts  of  the  body  which  tau 
easily  be  got  at  by  the  patient's  fingers.  In  men  they 
are  chiefly  seen  on  the  front  of  the  body,  from  the 
nipple  to  the  kneea ;  posteriorly  they  are  almost 
esclusively  on  the  buttocks.  In  women  and  children 
they  are  also  visible  on  the  lower  part  of  the  hack. 
The  eruption  is  usually  most  marked  in  parts  sub- 
jected to  friction,  and  over  the  ischial  tuberosities 
in  those  whose  occupation  makes  it  necessary  for 
them  to  sit  long  on  hard  seats.  The  eruption  of 
Bc^ttbies,  therefore,  presents  a  very  pronounced 
multiformity  of  aspect.  Burrows,  vesicles,  bullte, 
pustules  are  mingled  in  the  most  irregular  manner 
with  the  marks  of  linger-naiJs  and  the  results  of 
secondary  inoculations  in  the  form  of  ecthymatous 
or  impetiginous  eruptions  in  various  stages  of  de- 
velopment, and  destruction  by  scratcliing  (ruptured 
vesicles  and  bullie,  pustules  laid  open  and  discharging 
or  covered  with  scabs,  hemorrhagic  points,  etc.). 
The  secondary  lesions  are  sometimes  so  severe  as  to 
disguise  the  real  nature  of  the  affection.  Tht^  as 
rare  in  England,  but  is  frequent  in  Norway  and  some 
other  places. 

The  most  marked  subjective  symptom  is  itching, 
which  is  usually  extremely  troublesome,  especially 
at  night.  As  in  other  conditions,  however,  it  varies 
in  degree  according  to  the  temperament  of  the 
patient,  some  persons  being  the  subjects  of  itch  for 
weeks  or  montlis  without  being  conscious  of  any 
particular  irritation  of  the  skin,  others  being  driven 
almost  frantic  by  it  from  the  first.  Irritation  is  not 
unfrequently  felt  in  places  distant  from  the  seat  of 
the  disease  :  thus,  having  once  inoculated  myself 
Bsperimentally  on  the  arm,  I  felt  bttle  or  no  itching 
( ttA  the  site  of  inoculation,  but  after  a  time  I  became 
^are  of  intense  itching  at  the  back  of  the  shoulder. 


LOCAL   INOCULABLE    DIBEAflLS.    [ohap.  xvi. 

This  reflex  irritation  may  give  rise  to  a  aympathetic 
eruption  in  distftnt  parts,  aa  is  observed  in  urticaria ; 
ftnd  when  the  characteristic  burrows  are  not  readily 
discoverable,  this  may  be  very  misleading.  When 
the  burrows  have  been  destroyed,  the  itching  and  the 
other  symptoms  usually  subside ;  sometimes,  how- 
ever, the  lesions  may  persist  for  &  long  time,  and  in. 
persons  with  an  exceptionally  irritable  skin  may  be 
the  starting-point  of  eczema  and  other  troubles. 

The  disease  is  communicated  by  contact,  but  it  is 
probable  that  this  must  be  intimate  and  prolonged 
to  take  efiect.  Want  of  cleanliness  is  a  predisposing 
cause,  but  persons  of  all  kinds  are  liable  to  attack. 

The  pathology  of  scabies  is  that  of  urticarial 
dermatitis,  with  the  usual  secondary  lesions  caused 
by  scratching  and  inoculation  with  inflammatory  pro- 
ducts. The  acarus,  which  is  the  cause  of  the  disease, 
belongs  to  the  tracheal  order  of  the  Arachnidffi.  The 
female  (Fig.  16,  b),  which  can  jost  be  seen  with  th© 
naked  eye,  has  a  white  roundish  body  with  eight 
conical  legs  :  to  each  of  the  forelegs  is  attached  a 
Bmcker,  to  each  of  the  hinder  ones  a  bristle.  She 
burrows  into  the  epidermis  with  her  head,  the  back 
part  of  the  body  being  tilted  upwards.  The  male 
<Fig.  l(i,  a)  is  about  two-thirds  the  size  of  the  female. 

In  a  well-marked  case  of  scabies  the  diagnosis, 
is  easy,  the  characteristic  burrows  between  the  fingers 
and  on  the  wrists  being  conclusive.     As  already  said, 
the  mouth  of  the  burrow  is  usually  marked  by  a 
vesicle,  and  in  searching  for  the  parasite  the  larthet . 
end  of  the  passage  away  from  the  vesicle  must  bo 
songht  for.     The  following  is  the  method  of  pio-  J 
cedure  most  likely  to  be  succeBsful.     A  pin  is  lud'il 
on  tile  surface  of  the  epidermis,  not  point  downward;  F 
but  on  the  flat ;    it  should  then  be  pushed  into  HiA  | 
epidermis,  at  the  end  nf  the  burrow  away  from  tb*  , 
L  veaole,  with  a  rotatory  movement,  great  care  bui^_ 


I.]  SCABIES.  327 

taken  not  to  draw  blood.  U  the  acatua  is  alive  it  will 
cling  to  the  end  of  the  pin,  where  it  can  be  seen  as  a 
minute  pearly  object.  It  can  then  be  mounted  in 
glycerine  and  examined  micro acopically.  When  no 
bnrrows  are  to  be  seen,  the  diagnoaia  must  chiefly 
rest  on  the  distribution,  and  especially  on  the  irregu- 
larity of  the  lesions.  A  pustular  eruption  on  the 
handa  should  always  excite  suspicion ;  the  distribu- 
tion of  the  marks  of  acratching  is  a  further  guide  to 
the  nature  of  the  affection,  and  any  hiatory  of  a 
similar  afiection  in  tlie  same  house  is  an  important 
link  in  the  evidence. 

The  progTlOSis  is  always  good  as  regarda  re- 
covery, if  proper  treatment  is  submitted  to  ;  but,  as 
already  said  abi  may  in  certain  persons  be  tbe 
starting-point  of   om    oth     affection  of  the  sldn. 

The  points  t  b  a  m  d  at  in  the  treatment  of 
scabies  are  (1)  the  I  ak  ng  up  of  the  burrows  ; 
(2)  the  destn  ti  n  f  th  parasites  ;  (3)  the  relief 
of  the  subject  vmj  t  m  and  {4)  the  prevention 
or  cure  of  sec  nda  1  n  auaed  by  pus  cocci,  etc. 
The  quickness  of  the  cure  depends  on  the  thoroughness 
ol  the  treatment.  The  patient  should  be  stripped,  and 
the  affected  parts  soaked  with  hot  water  and  vigor- 
ously scrubbed  with  soft  soap ;  this  will  remove  the 
superficial  layers  of  the  epidermia,  and  lay  open 
the  burrows.  The  next  step  is  the  application  of 
parasiticide  agents  in  the  form  of  a  thickish  ointment, 
or,  better  still,  a  paste,  which  should  be  thoroughly 
rubbed  in  and  plastered  over  the  affected  parts,  so  as  to 
fill  every  nook  and  cranny  of  the  burrows.  The  usual 
application  ia  simple  fivfykur  ointment  (^ss  to  5j); 
the  sulphur  ointment  of  the  Pharmacopceia  is  un- 
necessarily strong,  and  should  always  be  diluted. 
The  application  should  be  renewed  every  few  hours 
for  two  or  three  days,  the  patient  meanwhile  wearing 
old    under-garmenta.     The     treatment     should    be 


[.OCAL    INtWVLAIiLE    DISEASES     [cam 

brought  to  a  close  with  a  cleansing  bath.  An  essential  \ 
point  18  the  disinfection  of  the  patient's  clothee  by  I 
boiling  or  fumigation  with  sulphur.  I 

At  the  St.  Louis  Hospital,  in  Paris,  the  favourite  j 
remedy  is  an  ointmevi  consisting  of  potass,  carbonat  | 
5j,  svl'pk.  svbUtn.  5ij,  m  an  ounce  and  a  half  of  lard,  i 
Soft  soap  is  first  rubbed  in  for  half  an  hour,  then  the  ' 
patient  remains  in  a  hot  bath  for  half  an  hour  ;  the 
ointment  is  next  thoroughly  rubbed  In,  the  patient 
resumes  his  clothes  without  washing  ofi  the  ointment, 
and  is  usually  cured.  Another  very  effective  oint-  3 
ment  is  composed  of  sublimed  sulphur,  oil  of  cade,  f 
aa  j^tj,  prepared  chalk  ^ijss,  soft  soap  and  laTd,4 
aa  3].  When  time  is  a  matter  of  vital  importuicel 
the  first  and  second  indications  in  the  treatment  of  1 
scabies  may  be  fulfilled  by  one  remedy — namely,  the! 
application  of  Vlemittgkx'i  lotion,  which  consists  of  J 
quicUitne  5ij,  sitlphur  ^iv,  and  water  Jxx.  Thea 
ingredients  should  be  boiled  in  an  iron  vessel,  sitda 
stirred  with  a  wooden  spatula  to  perfect  union.  The] 
quicklime  causes  exfoliation  of  the  epidermis,  andl 
gives  the  sulphur  free  access  to  the  burrows.  IiledJ-V 
cated  soaps — such  ae  the  sulphur  preeipiiaU  soap,  101 
per  cent.,  prepared  according  to  Buzzi's  directions  * — I 
are  also  useful,  For  infants  and  persons  witii  a1 
delicate  skin,  stavesacre,  or  weak  balsam  of  PertfM 
oiiittneni.  is  very  useful. 

A  word  of  caution  may  be  added  as  to  the  way  J 
in  which  the  mechanical  and  parasiticide  applitw  J 
tions  are  made.  Vigour  must  not  he  pushed  to  the  J 
length  of  violence,  nor  is  it  necessary  to  stir  i 
acute  inflammation  of  the  aldu  in  order  to  k 
the  parasites.  On  the  other  hand,  the  mere  smee 
ing  on  of  a  little  sulphur  ointment  is  of  no  lu 
For  the  relief  of  the  subjective  symptoms  sootMng  1 
sppUcations,  such  as  calamine  lotion,  alkaline  1h 

■gan:,iM9>hefl  <1 :  Ufi'i'ili.  f.  /-,tU(.  Ilrrm.,  1891. 


J  PEDICULOSIS.  32!) 

etc.,  and  antipruritic  remedies,  such  as  carbolic  or 
menthol  soap,  or  any  oi  the  remedies  recommended 
for  pruriginous  coTiditione,  should  be  employed.  Thft 
patient  should  he  warned  that  itching  sensations  may 
continue  for  some  time  after  the  disease  is  cured. 
Secondary  inflammatory  or  suppurative  lesions  should 
he  treated  by  antiseptic  applications,  such  as  boracic 
acid  lotion  or  Uquor  carbonis  detergens. 

In  some  cases  the  secondaTy  lesions  in  scabies  are 
of  such  a  degree  of  severity  that  the  application  of 
the  ordinary  parasiticide  substances  is  out  of  the 
qiiestiou.  In  these  cases  the  practitioner  must  first 
endeavour  to  subdue  the  inflammatory  symptoms, 
and  then  cautiously  feel  his  way  towards  the  radical 
treatment  of  the  disease  by  the  graduated  use  of 
parasiticides,  the  effect  of  which  should  be  carefully 
watched, 

Pfldlculosis  is  the  presence  of  lice  on  the  head, 
about  the  body,  and  among  the  pubic  hairs.  The 
parasites  infesting  these  several  locahties  differ  some- 
what in  size  and  form.  The  body-louse  is  the  longest, 
the  crab  the  widest,  the  head-louse  being  midway 
between  the  other  two  in  both  dimensiouB.  The  head- 
louse  {Fig.  Hi,  f)  has  a  triangular  head,  and  varies  in 
colour  according  to  that  of  the  skin  which  it  feeds  on, 
being  grey  with  black  margins  on  the  European, 
yellowish- brown  on  the  Chinaman,  white  on  the 
Eskimo,  and  black  on  the  negro.  The  female  ia 
larger  and  more  numerous  than  the  male  ;  each  one 
lays  from  fifty  to  sixty  eggs,  so  that  multiphcation  is 
very  rapid.  The  body-louse  (Fig.  lli,  d),  besides  being, 
larger  than  the  head-louse,  has  a  more  oval  head  and 
more  developed  legs,  and  is  more  active  ;  it  is  dirty- 
*  white  in  colour,  with  black  margins.  The  crab-louse 
(Fig.  IG,  e)  is  broader  and  flatter  than  either  of  the 
otliera  ;  it  is  yellowish -brown  in  colour,  and  han  a 
rounded  head  with  five  prominent  anteimic  ;    the 


330         WGAL   INOGULABLE    DISEASES,     [okap. 

lemftle  lays  from  ten  to  fifteen  eggs,  which  hatch  ou^.l 
in  a  week,  the  young  being  sexually  mature  in  a  fort-.il 
night.  Pediculi  deposit  their  ova  on  the  hsira,  om 
ovum  or  nit  being  usually  attaciied  to  a  single  hairil 
occasionally  there  are  several.  They  are  attached  to-fl 
the  side  of  the  hair  liy  a  glutinous  material  whicli  | 
binds  them  so  firmly  that  they  can  be  separated  frontJ 
the  hair  only  by  dissolving  the  rement  with  acetla^ 
acid. 

All  three  species   of  lice  cause  similar  leeions^ifl 
modified  by  peculiarities  of  situation.    The  primaiyfl 
lesion  is  a  wound  inflicted  by  the  parasite  in  feeding  -^ 
possibly  also  a  minute  quantity  of  some  poisonoM^ 
secretion  is  inoculated  at  the  same  time.     The  process  " 
of  feeding  is  effected  by  the  insertion  into  the  opening 
o(  a  sweat  duct  of  a  membranous  tube  through  which 
the  blood  is  sucked  up.     When  the  louse  has  satisfied 
its  appetite  it  estracts  the  sucker,   and  the  blooAB 
welling  up'in  the  duct  forms  a  minute  red  speck  c 
tho  surface.     This  hcemorrhagic  speck,  which  can  I 
seen  but  cannot  be  felt,  is,  as  was  first  pointed  ontb^ 
Tilbury  Fox,  the  characteristic  lesion  of  pediculoei^f 
and  its  presence  is  conclusive  evidence  of  the  natuNtJ 
of  the  aSection.     There  are  no  other  lesions  on  t 
skin   beyond   such   as   are   caused  by    scratcM 
erythematous  red  lines  parallel  to  each  otjiar  i 
marking  the  track  of  the  finger-nails,  1 
excoriations,    wheals,    and    impetiginous    pnatn 
When   the   top   of   a   congested  papilla   has 
scratched  off,  a  tiny  blood-crust  is  often  left ;  thte  ii 
-  common  in  all  conditions*  that  are  accompanied  t 
scratching,  and  is  distinguished  from  the  htemonha^ 
speck  characteristic  of  pediculosis  by  the  fact  that-^ 
can  be  felt  as  well  as  seen.     Persistent  s 
may  result  in  the  production  of  a  peculiar  leatti^ 
thickening  of  the  skin  with  pigmentation— the  t 
called  "  vagabond's  skin."     Among  the  rarer  eyU^M 


CHAP.  s\T.]  PEDICULOSIS  331 

toms  of  pediculosis  may  be  mentioned  pyrexia, 
which  is  believed  by  Jamieson  *  to  arise  reflesly 
from  cutaneous  irritation ;  Payne, t  however,  looks 
upon  it  as  the  result  of  a  kind  of  poisoning. 

The  pediculus  capitis  i»  common  in  ctuidren 
whose  heads  are  neglected,  though  it  frequently 
attacks  cleanly  children  and  adults.  It  chiefly  affects 
the  occipital  region,  where  the  hair  is  thickest,  and 
it  gives  rise  to  itching  all  over  the  scalp.  In  the 
healthy  the  Hnratching  only  causes  eKcotiation,  but  in 
ill-nourished  children  a  suppurative  process  is  pretty 
Fiire  to  supervene  from  inoculation  by  pus  oocci. 
Sometimes  the  occipital  and  other  msighbouring 
glands  become  enlarged  and  inflamed,  and  abscesaes 
may  form.  In  very  dirty  persons  a  peailiar  condition 
known  as  ^ica  poionica,  is  produced  by  the  matting 
together  of  the  hair  with  pus,  nits,  scales  and  scabs, 
and  miscellaneous  filth. 

It  is  hardly  neceeaary  to  say  that  pediculi  never 
originate  by  spontaneous  generation,  as  many  un- 
scientific persons  believe,  but  are  always  communi- 
cated by  one  host  to  another,  either  by  direct  contact, 
or  by  the  medium  of  brushes,  towels,  etc. 

When  itching  of  the  scali)  is  complained  of.  and 
especially  if  impetigo  contagiosa  be  present,  and  there 
are  enlarged  glands  in  the  neck,' the  occipital  region 
shoulii  be  carefully  explored  for  nit?.  Impeiigo  con- 
tagioRa  alone,  however,  la  not  enough  to  found  a 
diagnosis  of  lice  upon,  as  there  are  many  other  con- 
ditions with  which  that  affection  is  associated. 

The  treatment  is  to  destroy  the  parasites  and 

•  Bril.  Jmmi.  Tir.ui.,  vol.  i.,  l8H8.Sn,  p.  321  ■•{  iim.  A 
case  ia  cited  iu  which  u  healthy  lad.  aged  uineleeu.  was  on  two 
diitiiiel  occaaions  admitted  into  tho  Edinburgh  Rojal  luftrniary 
with  a  very  high  temperatnce  (lUC'S^  on  out!  occusi^ju,  lOli-4'  ou 
tliB  other),  which  immediately  tell  t  ...  -       . 


WCAL    INOCULABLE    DISEASES,     foi 


I 


induce  liealing  of  the  xecondary  leRions  by  ineBiu> 
antiseptic  remedies.  K  the  patient  is  a  child,  the ' 
should  be  cut  short  and  tohite  ■pTeci-pitaie  otntmeaC 
applied.  In  women  the  hair  need  not  be  sacrificed ; 
the  lice  can  be  killed  by  thoroughly  smearing  the  Boslp 
with  the  eame  preparation.  The  most  difficult  part 
of  the  treatment  is  to  get  rid  of  nits.  For  thw, 
purpose  the  hair  should  be  thoroughly  wetted  wil 
acetic  add.  which  dissolves  the  glutinous  materivl'l 
fixing  the  ovum  to  the  hair,  and  then  cnrefiilly  combed 
out.  Tlie  process  should  be  repeated  as  often  as  may 
be  necessary.  A  mixture  of  ether  jj  aiui  oleaie  of 
mercuTy  {Jii  per  cent.)  3]  is  an  effective  applicadon 
lor  the  destruction  of  pedicull  and  their  ova,  or  thia. 
hair  may  be  soaked  with  petroleum.  The  en 
should  then  be  detached  by  softening  with  carl 
Used  oil,  and  the  impetigo  contagiosa  treated  vil 
weak  mercurial  or  strong  boracjc  acid  lotions. 

Pediculus  corporis  inhabits  the  clothes  rski 
than  the  skin.     The  patient,   who  is  generally 
elderly  person   in  low   condition  and  regardli 
cleanUnesa,  complains  of  irritation,  especially  a1 
the  shoulders,  on  the  back,  and  on  the  extensor 
faces  of  the  limbs,  but  not  on  the  hands  or  ieet^ 
When  the  clotliing  is  removed  there  is  generally  lil 
or  nothing  to  be  seen  beyond  the  results  of  scratchiMJ 
^namely,  long  Unea  torn  by  the  finBer-nalla,  wiw] 
here  and  there  wheals,  but  as  a  rule  no  veuolea 
other  definite  lesions.     On  examination  with  a  li 
the  characteristic  heemorrhagic  specks  ca 
out.     No  pediculi  will  br  found  on  the  skin,  bnt 
t^earching  the  clothes,  particularly  the  folds  of 
under-linen,  they  will  usually  be  discovered,  unless, 
as  often  happens,  the  patient  has  taken  the  precaution 
to  change  his  clothes  before  presenting  himself  for 
inspection.     A  favourite  hunting-ground  of  the  ' 
louse  is  the  shirt-collar  on  its  internal  aspect. 


1 

mm 


oiiAr.  XV1.J  PEhlCVLOSlS.  333 

partial  is  the  parasite  to  this  part  that  signs  of  severe 
scratching  about  the  back  of  the  netk  and  th<; 
shoulders  in  an  elderly  person  of  doubtful  cleanliness 
are  almoat  conclusive  evidence  of  the  presence  of  lice. 
It  ia  in  tramps  and  other  persons  infested  with  body- 
lice  that  the  "  vagabond's  skin  "  already  mentioned 
is  moat  frequently  seen. 

The  diagnosis  rests,  in  the  abMence  ol  viwible 
parasiteh,  on  the  presence  of  the  characteristic 
htemorrhagic  specks  on  the  neck  and  shoulders. 
Prom  scabies  the  affection  ia  distinguished  by  there 
beii^  no  lesions  on  the  hands  or  wrista. 

The  tpeatment  is  to  kill  the  parasites  by  thorough 
disinfection  of  the  clothes  which  are  their  habitat. 
For  this  purpose  the  most  effectual  method  is  baking 
in  a  diainfectiog  oven  at  a  temperature  of  212°  or 
more.  The  patient  himself  may  with  advantjige 
take  alkaline  or  ordinary  hot  baths,  and  the  free  use 
of  some  medicated  antiseptic  soap  will  be  a  most 
useful  adjunct. 

Pediculus  pubis  chiefly  lives  among  the  pubic 
bairK,  but  occasionally  extends  its  depredations  to 
the  abdomen,  thorax,  axillae,  and  occasionally  even 
to  the  eyelashes,  whiskers,  and  beard.  The  only  sub- 
jective symptom  is  itching.  Papules  (the  tops  of 
which  are  generally  scratched  off)  are  the  usual 
lesions,  but  sometimes  more  or  less  severe  eczematous 
inflammation  is  induced.  A  characteristic  lesion 
produced  by  crab-lice,  according  to  Mourson  and 
Duguet,  is  a  pecuUar  steel-grey  pigmentation  which 
appears  in  sp()t6  about  the  aize  of  tlie  finger-nail 
(ftVKidte  cceruletFi.  The  colour  of  these  blue  spots 
corresponds  with  that  of  a  pigment  contained  in  the 
thorax  of  the  parasite,  and  is  thought  ta  be  inserted 
by  it  through  its  sucker  into  the  epidermic  tissues. 
The  Btaia"  fade  when  the  fjediculi  have  been  destroyed. 

The    parasite    ia    usually    communicated    during 


aedy 


334         LOOAf.    INOCVLAHLE    DISEASES.     [imii.-snM 

sexual  intercourse  ;  sometimes  also  by  clothes,  etc 
The  mout  cleanly  people  are  liable  to  be  afieotpd  if 
tliey  put  themaelvea  in  the  way  of  becoming  the  boats' 
of  the  hce. 

Itching  in  the  pubic  region  »}hould  always 
suspicion  of  the  presence  ol  crab-lice.     The  diagnos 
is  made  by  actual  inspection  and  discovery  of  tl 
ofEending  agent. 

The  treatment  should  be  on  the  same  lines 
that  recommended  for  pediculi  capitis,  but  the  pubift 
hair  alionld  not  be  cut.  White  precipitate  ointment 
is  an  excellent  remedy.  Oleale  of  mercury  (5  -per 
cent.)  ;^vj,  miher.  snip,  ^i^,  kills  the  pediculi  and 
destroys  the  nits.  After  the  parasiticide  remedy 
has  done  its  work  some  calamine  or  other  sootl  ' 
lotion  should  be  apphed. 

Miscellaneous  parasites. — Among  the  oth< 
parasites  which  ordinarily  infest  the  human  skin  are 
the  common  flea,  the  common  bed  bug,  and  the  har- 
vest bug.  In  tropical  climates  the  chigoe  or  jigger 
is  a  source  of  considerable  annoyance,  and  the 
guinea-worm  is  often  a  cause  of  much  suffering  ttod' 
serious  or  even  fatal  disease. 

The  flea  makes  a  characteristic  lesion, 
of  a  small  red  spot  with  a  central  point  of  darki 
hue.     Older  spots  become  petechial,  and  sometimi 
in  patientii  sufiering  from  fever  may  be  miatt^t 
for  the  esanthem  of  typhoidor  measles,  or  for  purpi 
Tiie  marks  on  the  linfn  and  the  presence  of  roc      __ 
spots  will  enable  the  observer  to  come  to  a  oomcltj 
conclusion. 

The  bug  produces  a  wheal  with  a  whitish  centiSi 
and  a  central  punctum  resembling  that  made  by  tha 
flea.  Great  irritation  and  hyporffimia  are  usually 
caused  by  bugs,  which  excite  artiJicial  congestion  by 
injecting  an  irritant  substance  »o  us  to  increaas 
the    supply    of    blood    avaUable    for    sucking,     Thfl 


w. 


I.]     MISCELLANEOUS   PAHASITF.S. 


initation  may  be  removed  by  the  application  oi  lineu 
soaked  in  eau  de  Cologne,  toUel  vinegar,  or  Itad  lotion. 

The  bites  and  stings  oi  goals,  moxjuilofs.  and 
other  similar  peata  raise  wheala  usually  acuompanied 
by  exceaeive  itching.  The  remedies  recommended 
fo  ■  bug  bites  will  be  equally  useful  ior  these. 

The  harvest  bug  is  active  In  July  and  August 
amongst  those  who  work  in  the  fields.  It  produces 
bright  red  papules  and  wheals,  generally  on  the  ankles 
and  legs,  but  often  on  other  parte  of  the  body.  The 
itching  is  very  troublesome,  and  scratching  may 
cause  secondary  lesions  of  the  usual  kind.  The  treat- 
ment consists  in  the  application  of  paraaiticidea  such 
as  naphlhol  or  weai  meratriat  oitUmenl. 

The  chigoe  {Pvlex  penetrans)  is  found  in  tropical 
countries.  The  animal  boras  into  the  skin,  and  there 
gives  rise  to  suppuration  and  ulceration. 

The  guinea-worm  or  Dracunculus  medinensiB  (Fig. 
Ki,  g)  is  a  parasite  which  in  tropical  countries  is  sup- 
posed to  gain  admiasion  to  the  body  through  the 
m.ediuin  of  water  by  drinking.  I  have  seen  only  one 
case.  The  patient  was  a  lady  who  had  recently 
returned  from  India,  the  only  symptom  being  one 
large  bulla  on  the  instep.  I  was  able  to  prove  the 
diagnosis  and  efiect  a  cure  by  opening  the  bulla  and 
winding  out  the  worm  on  a  match,  a  process  which 
took  twelve  daya.  The  parasite  has  been  more  fre- 
quently observed  in  England  oi  late  yeara.  An 
interesting  case  has  been  reported  by  Patrick  Manson 
and  Boyd.*  For  a  fidl  account  of  the  worm  and  the 
symptoms  produced  by  it  the  reader  is  referred  to 
C'obbold's  book  on  "  Parasites." 

Craw-craw  is  a  disease  that  occurs  on  the  West 
Coast  of  Africa  ;  it  appears  to  be  caused  by  a  filarial 
ot^amsm. 
H  jScAi'nocotciw  hydatid,  embryos  of  the  Diploma  hepa- 


336         LOCAL   INOCULABLE   DISEASES,     [chap.  xvi. 

ticum,  and  ova  of  Bilharzia  hcematobia  have  also  been 
found  in  rare  instances  in  the  human  skin,  and 
Cysticercus  celluloscB  cutis  is  sometimes  present  in  the 
subcutaneous  tissue. 

Eruptions  are  sometimes  caused  by  the  infection 
of  the  skin  by  larvcB  of  certain  members  of  the 
Arachnida,  and  dipterous  larvse.* 

*  For  fuller  iuformation  ou  these  eruptions  wv?  Dr.  Robert 
Lee  (Clin.  Sor.  TratiK.,  vols.  viii.  aud  xvii.),  Larva  migrans 
(Crocker),  a  review  {lirit.  Journ.  Derm.,  vol.  viii.,  p.  145); 
Dr.  P.  Abraham,  Remarks  on  Cutaneous  Myriasis  due  to 
CEstridian  Larvae  {lYans.  Dcrmht.  Soc.  Orrat  Brit,  and  Ireland^ 
vol.  iii.,  p.  62:  Brit.  Journ.  Derm.,  vol.  ix.,  p.  37)  ;  and  Dr.  C. 
V.  Samson,  Himmelstjerna  [Arch.  f.  Dvrmat.  /^  >Syph.,  Bd.  xiii., 
p.  367). 


1 1. ^Ve  GET  ABLE    PARASITES, 

This  group  includes  all  the  affectiona  oi  tho  skin  in 
which  the  process  is  set  up  by  the  growth  of  a  fungus 
in  the  epidermis.  The  fungi  are  the  Triehophyta 
and  Microaporon  Audouini  (causing  ringworm) ;  the 
Achorion  Schoenleinii  (causing  favus) ;  the  Micro- 
sporon  furfur  (causing  tinea  versicolor) ;  tho  Micro- 
sporon  minutisstmum  {causing  erythrasma) ;  the 
Actinomyces  or  ray  fungus  (causing  aetinomycosis) ; 
the  Tinea  imbricata  (causing  Tokelau  ringworm) ;  the 
Chionyph'J  Carteri,  one  of  the  actinomycea  (causing 
mycetoma)  ;  and  an  unnamed  fungus,  which  ia 
beheved  to  cause  pinta,  a  disease  tndemic  in  some 
parts  of  South  America. 

RingwOPm  may  attack  the  hair,  the  skin,  the 
mucous  membrane,  or  the  nails.  On  the  skin  the 
process  is  everywhere  esBenlnally  the  same,  consisting 
in  the  immediate  infiaramatory  reaction  excited  by 
the  growth  of  the  fungus,  to  which  the  results  of 
secondary  inoculation  with  pus  cocci  are  generally 
superadded.  The  appearance  and  evolution  of  the 
lesions  are,  however,  so  much  modified  by  the  struc- 
tural peculiarities  of  the  parte  on  which  they  are 
situated  that  cUnically  two  distinct  varieties  are 
recognised,  according  as  the  disease  affects  hairy  or 
hairless  parts.  Ringworm  of  the  hairy  parts  is 
naturally  subdivided  into  ringworm  of  the  scalp 
(tinea  tonsurans)  and  ringworm  of  the  beerd  (tinao. 


LOCAL   INOCULABLE   DISEASES,     [ohap.  a 

barbie,  tinea  sycosis).  A  rare  farm  of  ringworm,! 
tinea,  palpebralis,  which  attacks  the  eyebrow,  belongftj 
strictly  Bpealdiig,  to  this  category,  but  is  generallyfl 

ised  with  the  following  group.  Ringworm  of  thai 
hairless  parte  comprises  ringworm  of  the  body  {tineal 
circinata),  ringworm  of  the  naUa  (ouychomycosiB),.  r 
and  ringworm  of  the  raucous  membrane  (mouth,.! 
vulva).  In  addition  to  these,  there  is  a  special  fona'l 
of  ringworm,  occurring  mostly  in  tropical  cliBoatea,,] 
which  attaclcs  the  inguinal,  perineal,  and  gluteal] 
*  regions ;  this  generally  goes  by  the  name  of  eczenm4 
marginatum,  but  would  be  more  appropriately  calledj 
tinea  margins ta. 

That  a  cryptogamic   fungus  is  associated  with  J 
ringworm  was  shown  by  Gruby,*  of  Paris,  in  1843,J 
and  independently  by  Malmsten.t  of  Stockholm,  i 
18-14.     The  latter  named  the   fungus  tjichophytoR.J 
tonsurans. 

Till  recently  dwrm otologists  believed  that  aA\ 
forms  of  ringworm  were  caused  by  one  and  the 
fungus.  In  1891  it  was  suggested  by  FurthmaiiB.-J 
and  Neebe  J  that  more  than  one  speties  of  paiasit».f 
might  be  concerned  in  the  production  of  the  diac&se.jT 
Soon  afterwcrds  the  doctrine  of  the  plurality  of  the  I 
ringworm  fungi  was  definitely  formulated  by  I 
Sabouraud,§  whoso  researches  have  thrown  an  alto-, 
gether  new  light  on  the  subject.  Only  a  brief  sum- 
mary of  the  main  points  in  his  teaching  can  be  given  .| 
here. 

Careful  naked-eye  inspection  of  a  lar^e  numbw  ol  J 
[  untreaUd   cases   of  ringworm   shows,   accordii^  to! 


•  Cam/itfii-Sctidai   ile  PA'adimif  dti 


.   Farin,   1S43, 


+  Xlllrr't  AirA..  1848. 

I  MmaM.f.  BiaR  Jir,iH,.  isai,  Xo.  II. 

iAno.  tif  nrrmtlil-vii',  Nov.,  ISffi;  "  Les  TrifhunlirtSM  J 
f  "Bnttmnoi,"  Pariv,  1804 ;  luteniatiuutLl  (.'ouurcss  ni  DennntolciBT,  j 
L  Xendon,  ISW.  ■ 


[.]  RINGWORM.  339 

Sabouraud,  that  tliey  are  divLuble  into  thiee  classes  : 
(1)  One,  in  which  the  hairs  for  two  or  three 
millimetreB  beyond  the  level  of  the  skin  are  covered 
with  a  scaly  sheath,  which  looks  like  a  prolongation 
of  the  epidermic  lining  of  the  follicle  ;  the  affected 
patch  is  strewn  with  greyish  scales.  (2)  A  second, 
in  which  the  hairs  are  broken  oS  short  and  present 
no  trace  of  a  aheath,  while  the  affected  patch  ia 
free  from  scales.  (3)  A  third,  in  wliich  not  only 
the  hair  but  the  epid«nnis  is  affected.  The  hiiir 
has  a  sheath,  but  this  does  not  extend  bpyond  the 
buried  part,  and  thus  is  seen  only  on  the  epilated 
hairs  ;  the  epideimia  ia  the  seat  of  inflammatory 
and  suppurative  lisions  (impetigo,  folliculitis,  kerion). 
In  the  first  of  these  s^roups,  on  microscopic  exami- 
nation, the  scaly  sheath  is  seen  to  be  formed  of  very 
small  spores  irregularly  scattered  like  the  stones  in 
a  mosaic  ;  the  parasite  lies  arotmt!  the  hair.  In  the 
second  group  the  fungus  lies  altogether  within  the 
hair,  the  spores  are  considerably  larger  than  those  in 
the  first  group,  and  they  are  arranged  in  regular 
chains.  In  the  third  group  the  deeper  portion  of  the 
hair  is  seen  to  consist  of  spores,  also'  relatively  large 
and  arranged  in  regular  chains ;  but  the  fungus  lies 
outside  the  hair,  between  the  dermic  portion  of  the 
shaft  and  the  wall  of  the  follicle.  To  the  small-spoied 
fungus  Sabouraud  give's  the  name  of  Microsporon 
Audouini,  while  the  other  two  he  calls  Trichophyton 
megftlosporon,  endotlirix  or  ectothrix,  according  as 
the  fungus  lies  inside  or  ontaide  the  hair  The  results 
of  cultivation  on  various  media  are  held  by  Sabouraud 
to  prove  that  human  ringworms  which  used  to  be 
looked  upon  as  one  disease  caused  by  one  specific 
fungus,  the  trichophyton,  are  separable  into  two 
distinct  pathological  entities  :  one  caused  by  a  small- 
spored  parasite,  the  Microsporon  Audouini ;  the  otlipr 
by  a  large-spored  fungus,  the  trichophyton ;    and 


340        WCAL   INOCULABLE    DISEASES,     [cbaf. 

further,  that  true  trichophvtosis  may  be  caused  by  a  I 
great  number  of  difierent  speciea  of  the  same  parasite 
femily.     Indeed,  according  to  Sabouraud,  it  is  rare  I 
to  find  the  same  specieB  of  trichophyton  in  any  two  I 
kses.  r 

The  clinical  application  of  Sabouraud's  doctrine  i 
may  be  summed  up  in  the  following  propositions  :   (1 )  I 
The  small-spored  fungus  (Microsporon  Audoniui)  is  | 
the  cause  of  the  forms  of  ringworm  which  are  refrac- 
tory t«  treatment ;  (2)  the  forms  of  ringworm  caused 
by  the  Trichophyton  megalosporon  endothrix  do  not, 
as  a  rule,  exceed  one  year  in  duration  ;   (3)  those  dua 
to    the    Trichophyton    megalosporon    ect-othrix    ; 
benign,  and  can  be  cured  in  two  or  three  months.    The 
small -spored    fungus    attacks    children    only,   and, 
according  to  Sabouraud's  estimate,  is?  the  cause  of  1 
from  60  to  65  per  cent,  cf  all  cases  of  ringworm  of  the  J 
^calp  met  with  in  France.     Large-spored  or  tiicho- 
phytic  ringworm  also  attacks  children,  but  it  does   | 
not  Epare  adolescents  nor  even  adults  ;   in  the  latter, 
however,  it  is  confined  to  the  skin  and  nails,  whereas  I 
in  children  the  scalp  is  invaded,  as  well  as  other  parts 
of  the  integument.     Both  varieties  of  trichophytosis  I 
may  be  seen  anywhtre  on  the  body  except  on  the  J 
chin,  which  is  strictly  preserved  for  the  "  ectothrix" 
variety. 

As  regards  the  origin  of  the  fungus,  Saboursud  i 
has  satisfied  tiimself  that  certain  species  of  tiicho- 
phyta  of  the  "  ectflthrix  "  typo  are  transmitted  tO  | 
human  beings  from  animals — horse,  cat,   dog,   etc. 
—on  which  the  parasite  finds  a  soil  suitable  lot  its  \ 
growth. 

Bodin  *  has  found  on  the  horse  n  parasite  very  | 
closely  allied  to  the  small-spored  fnngus  called  by  1 
Sabouraud     "  Microsporon     Audouini.''       This 


CHAP.  xvn.l  HINOWORM  FV}fBl.  341 

inocnlablfl  in  man,  and  Bodin  thinks  it  possible 
that  it  may  cause  ringworm  of  the  human  scalp. 

As  regards  tha  trichophytes,  Bodin  agrees  with 
Sabourand  that  the  characteristic  of  thosa  of  animal 
origin  is  that  they  are  situated  outside  the  hair  (ecto- 
thrix) ;  on  the  other  hand,  in  human  triuhophytosea 
the  parasite  is  exclusively  endothrix,  and  never 
invades  the  follicle.  The  word  "  ectothrix,"  how- 
ever, merely  denotes  that  the  parasite  is  situated  in 
the  follicle  outside  the  hair,  but  does  not  mean  that 
parasitic  elements  do  not  at  the  same  time  hnd  their 
way  into  its  substance.  The  special  character  of  all 
triohophytea  of  animal  origin  is  to  be  "  endo- 
ectothris  "  in  situation,  and  to  have  irregular  spores. 
The  chnical  characteristic  of  human  trichophytoses 
of  equine  origin  is  that  they  cause  a  deep  lesion  in 
the  form  of  suppurating  folliculitis,  rapid  in  evolution, 
and  tending  to  cause  scara. 

Sabouraud'a  doctrine  has  been  accepted  in  Great 
Britain  by  Jamieson,*  Adamaon.f  and,  with  certain 
difierences  on  minor  points,  by  Colcott  Pox  and 
Blaxall.t 

At  the  International  Congress  of  Dermatology, 
held  in  London,  the  iast-named  investigators  stated 
that  the  results  of  a  clinical,  microscopic,  and  cultural 
examination  made  by  them  of  more  than  iOO  con- 
secutive eases  of  ringworm  of  the  scalp  and  beard, 
and  of  herpes  circinatus  of  the  skin,  agreed  generally 
with  those  of  the  French  investigator.  In  London 
the  Microsporon  Audouini,  in  their  experience,  caused 
from  80  to  HO  per  cent,  of  all  ringworms  ;  the  tricho- 
phyton endothrix  scarcely  4  per  cent.  ;  while  the 
"  ectothrix  "  or  "  endo-ect«thrix  "  was  responsible 
for  the  rest,     Trichophytosis  of  the  beard  seemed  to 

•  BrU.  M-d.  Joiirii.,  Aug.  20,  ISOa,  p.  470- 
t  Sril.  Jomn.  Dei-iH..  July  and  Aug.  1,  lSU.i. 
JIW.,  July,  18B6. 


k 


S42      LOCAL  tmCOLABLE   DISEASES.    [oE*5.  KVJi. 

telong  to  the  "  ectothrix  "  group.  The  great  majority 
of  ringworms  of  the  skin  (herpes  circinafcus)  asso- 
ciated with  tinea  tonsurans  depend,  according  to 
th'm,  on  trictiophytes. 

As  regards  the  microscopical  characters  of  the 
cultures,  Fox  and  Bias  all  cannot  subscribe  to 
Sabouraud's  classilicatiou  of  the  endothrix  and  ecto- 
thrix fungi  as  members  of  the  hotrytis  family  or 
sporotricha,  because  of  their  tendency  to  form 
irregular  masses  of  spores  ("  grape  formation  "),  and 
of  the  microspora  as  an  independent  family.  They 
consider  that  the  microspora  and  the  trichophyta  all 
belong  to  the  same  family,  and  that  their  fructifica- 
tion is  developed  on  a  similar  plan. 

On  the  other  hand,  Leslie  Roberts  *  does  not 
accept  Sabouraud's  view  that  tinea  tonsurans  is  s 
definite  disease  of  two  types  produced  by  distinct 
classes  of  fungi.  The  essential  bond  between  all 
trichophytic  fungi  ia,  he  holds,  their  keratolytic  action, 
He  rejects  the  anatomical,  and  atill  more  the  cultural, 
teat.  He  sums  up  his  conclusions  as  follows  :  That 
there  exists  in  the  lowest  orders  of  plants,  destitute 
of  chlorophyll,  an  extensive  and  natural  group  of 
fungi  whose  distinguishing  feature  ia  then-  ability 
to  digest  homy  tissues,  probably  by  means  of  ft 
ferment ;  that  this  keratolytic  group  includes  favns 
(achorion),  the  various  Vinds  of  trichophytons,  and 
some  aspergilli,  and  probably  many  oUiers  not  yet 
identified ;  that  there  are  at  least  two  natural  dis- 
tinctions  observable  in  the  purely  trichophytic  funp  . 
— namely,  a  kind  that  digests  both  the  cuticle  and 
the  cortical  substance  of  the  hair,  and  a  variety  that  , 
digests  the  cortical  substance  first,  leaving  the  cuticle 
unaffected  or  attacking  it  at  a  later  period. 

I  have  made  some  independent  observations  on 


IL] 


RISOWORM    FUNal. 


tthe  aubje^t.  the  resulta  of  which  were  comnmnicated 
to  the  International  Congress  of  Dermatology  held  in 
London  in  189G,  and  are  more  fully  set  forth  in  a 
monograph,*    They  are  founded  on  the  examination 
of  hairs  from  12fi  consecutive  caees  of  ringworm  met 
with  in  private  and  in  hospital  practice,  and  taken  just 
as  they  came,  without' selection.     In  the  esamination 
I  found  staining — which  has  been  too  muoh  neglected 
by  workers  in  this  field — a  great  help.     Tiip  following 
are  the  eseentiai  points  in  a  method  which  I  described 
some  time  ago  i" ;    A  suspected  hair  is  first  steeped 
I  for  one  or  two  minutes  in  a  mixture  of  a  5  per  cent, 
Ijllcohohc  solution  of  violet  gentian  and  anilin  water 
I  {ten  parts  of  the  former  to  thirty  of  the  latter) ;  next 
•  dried  with  blotting-paper;  then  treated  for  one  or  two 
minutes  with  pure  iodine  and  iodide  of  potassium 
'a  water ;  dried  ag?in ;  treated  once  more  with  anilin 

■  oil  and  pure  iodine;    then  cleared  with  anilin  oil, 

■  washed  in  xylol,  and  mounted  in  Canada  balsam. 
iTurther  experience  led  to  certain  modifications,  and 
■.ill  the  preparation  of  the  specimeus  from  which  a 
Biwries  of  micro -photographs  shown  at  the  Iiondon 
■Congress  of    Dermatology  was  made  the  following 

s  the  method  adopted.     The  hair  was  first  washed 

ether  for  some  seconds,  in  order  to  get  rid  of  the 

superfluous  fatty  material.     It  was  then  placed,  for 

staining  purposes,  in  a  solution  of  gentian  violet  (5 

per  cent,  in  70  per  cent,  of  alcohol).     The  small- 

"Tored  fungus  stains  very  quickly,  not  more  than  five 

ainutes,  aa  a  rule,  being  required.     The  large-spored 

Mrasite  takes  much  longer  to  stain  ;    it  must  be  left 

r  about  an  hour  in  the  solution,   which  should, 

'er,  be  heated  over  a  spirit  lamp  for  five  minutea 

in  this  way  the  alcohol  is  driven  off,  the 


fra 


i',  Aug.,  IMBo,  p.  136. 


344        LOCAL   INOCULABim   DISJSA 

keratin  is  diesolved,  and  the  fungua  I 
the  Imit  is  deeply  etained.  The  pti 
can  be  stained  red  by  treating  then 
same  way,  but  with  the  subatitutionf 
solution  of  fuchsin  in  water,  with  a  I 
a  2  pel  cent,  solution  oi  caibol-fnchi 
better  than  the  violet  stain  for  photogT 

When  the  hair  is  taken  out  of  the  sf 
it  should  be  steeped  in  iodine  i 
stain;  next  it  is  decolorised  by  beingl 
oil  or  a  mixture  of  two  to  four  drops  ■ 
anihn  for  ten  to  fifteen  minutes  ;  the/ 
pure  anilin  and  kept  in  it  for  some  sel 
ia  washed  in  xylol,  and,  lastly, 
balsam.     It  will  be  observed  that  the| 
has  no  place  in  this  method, 
destroys  the  mycelium  and  swells  tm 
hence  the  use  of  this  agent  produce! 
are  not  merely  unsatisfactory,   but  j 
leading. 

By  the  method  here    described  I  ] 
myself  that  Sabouraud's  doctrine  is 
pointa,  and  not  proven  in  others. 
of  my  conclusions  can  he  given  1 
the   reader    must   consult    the   monof 
referred  to. 

Geographical    Distribution.  - 

cases  which  supplied  the  material  for  my  p 
in  no  fewer  than  lit)  the  small-spored  1 
found ;  in  the  remainder  the  paraaite  ^ 
lai^e-spored  variety.  This  gives  a  prop( 
per  cent,  of  small-spored  ringworm, 
closely  agrees  with  Fox  and  Blasall's  estii 
to  90  per  cent.  These  figures  are  much  h 
those  of  Sabouraud,  who  finds  that  the  « 
fungus  is  accountable  for  from  60  to  65  pei^ 
all  caaes  of  ringworm  met  with  in  Franc! 


'>.y  ' 


PLATE    I. 

Fig.  1.— Small-spoked  Ringworm  (Hair). 
Fig.  2. — Large-spored  Ringworm  (Hair). 
Fig.  3.— Fungus    op    Favus,    Achorion    Schoenleinii 

(Hair). 
Fig.  4.— Scutulum  op  Favus,  showing  Fungus. 
Fig.  5. — Tinea  Circinata,  Large-spored  Ringworm. 
Fig.  6.— -Tinea  Imbricata  (Manson). 

Fig.   7.— MiCROSPORON   FURFUR,    FUNGUS  OF  TiNEA  VERSI- 
COLOR. 

Fig.  8.— MiCROSPORON  minutissimum,  Fungus  op  Eryth- 

RASMA. 


To  face  p.  345 


RINOWOliM  FUNGI.  345 

fungus  is  not,  however,  met  with  in  all  parte  of 
France,  for  Dubrenilh  and  Frfiche  iailed  to  find  it  in 
Bordeaiix.  Mibelli  has  met  with  it  only  once  among 
the  numerous  cases  of  ringworm  that  have  come 
before  hina  in  Italy.  Neither  Ducrey  of  Piea  nor 
Reale  of  Naples  has  ever  seen  it  in  Italy.  Fergnani 
of  Barcelona  has  met  with  it  in  Spain  ;  he  does  not 
state  how  frequently.  The  parasite  also  appears  to 
be  rare  in  Germany.  Possibly  the  greater  prevalence 
of  the  small-apored  fungus  in  England  may  exphiin 
the  fact  as  to  which  British  dermatologists  are  agreed, 
that  ringworm  ia  more  refractory  to  treatment  there 
than  it  appears  to  be  in  some  other  countries. 

There  is  a  similar  diversity  in  the  geographical 
distribution  of  the  trichophyton.  Sabouraud  suggests 
that  each  species  has  a  sphere  of  influence  peculiar  to 
itself  ;  hence  workers  in  a  given  country  are  not  war- 
ranted in  rejecting  the  results  of  workers  in  other 
countries  merely  because  they  do  not  agree  with 
their  own. 

The   Small-spoFed  Parasite.  —  The    special 

characteristic  of  the  small-spored  parasite  (Plata  I., 
Fig.  1)  ia  the  absence  of  any  particular  arrangement 
of  the  spores.  They  are  dotted  about  irregularly, 
sometimes  in  small  numbers  ;  everj-where,  however, 
the  individual  elements  are  separate  from  one  another, 
without  visible  bond  of  union.  Interwoven  with 
them  is  a  felting  of  mycelium,  irregularly  pointed, 
curved,  and  branching.  The  fungus  lies  around  the 
hair,  forming  the  greyish  sheath  described  by 
Sabouraud.  It  eata  away  the  hair,  fraying  the  edges, 
working  its  way  into  the  interior  of  the  shaft,  and- 
growing  downwards  towards  the  root.  In  time  the 
hair  breaks  some  way  from  the  follicular  orifice  ;  the 
parasitic  aheath  becomes  disintegrated,  forming  a 
patch  of  aah-coloured  scales  on  the  epidermis. 

The  Lapge-spored  Parasite.— The  distinctive, 


34«       LOCAL  ISOCCLABLE   DISEASES.    [coit.VntM 

fcatnres  of  the  lai^-spored  fungus  (Plate  L,  Fig.  2), 
apart  fTom  its  greater  size,  are  that  it  attacks  the  root 
first  and  grows  upwards,  and  that  the  spores  are 
arranged  in  regular  chains,  intenningled  with  short, 
regularly  jointed  mycelium.  The  hairs  are  broken 
off  short,  and  there  is  no  visible  sheath  ;  the  spores 
lie  around  the  hair,  sometimes  outside,  sometimes 
iniHide,  sometimes  both  inside  and  outside.  I  do  not 
look  upon  the  situation  of  the  parasite  as  having  any 
special  diagnostic  significance,  and  Sabouraud'e 
division  of  the  large-spored  fungus  into  two  gre&t 
classes  —  "  endothrix  "  and  "  ectothrix  "  —  appears 
to  me  to  be  based  on  a  mere  accident  of  position, 
possibly  dependent  on  the  degree  ol  invasion, '  ■ 

Size  of  the  Spores. — As  regards  the  size  of  th«fl 
spores,  the  difference  between  the  so-called  "  small '*'B 
and  "  large  "  varieties  is  not  very  great.  Dr.  Gallo-fl 
way,  who  made  careful  measurements  of  the  parasitic ■ 
elements  in  my  preparations,  reports  that  in  ftS 
specimen  labelled  "  small  "  the  mean  of  ten  measure-  ■ 
ments  of  detached  spores  was  .3'6  micro -millimetres,  fl 
the  extremes  being  2  to  4  /j.  The  transverse  diameter  fl 
of  the  mycelium  ranged  between  2-!j  and  4-5  micro-  fl 
millimetrea,  giving  an  average  of  about  4  fi.  In  afl 
specimen  labelled  *'  large  "  the  mean  of  ten  measnie^H 
mi^nts  of  detached  spores  was  4'8  miero-mtllimetie«.| 
(from  -1  to  G  ^i).  The  diameter  of  the  mycelium  W4B  I 
nbout  5  micro- millimetres,  but  varied  from  3  to  G  (i.  I 
It  seems  fair,  therefore,  to  conclude  that  the  Ait~  H 
fervntiiil  fvAture  between  the  two  varieties  is  not  I 
so  much  the  sise  of  the  spores  as  their  arrangement  fl 
and  their  mode  of  growth  on  the  hair.  H 

Cultures.—!  have  made  cultures  of  both  varietjes  fl 
((iniA)l-!ipon-d  and  lnrge-s|'K>red)  of  fungus,  naiiig  ■ 
8ii1>oUTaud's  medium,  agar  malt<ise.  On  the  wbolfl  fl 
tho  diflvnitors  brtweeai  the  two  cultures  are  not  ■ 
great.    The  principfti  ia  th«  colour.    The  predonuna^  ^k 


n.]  RINGWORM    FVNOh  347 

ing  tone  in  the  small- spored  ia  white,  which,  together 
with  the  powdery  Buiface,  gives  it  a.  snowy  appearance. 
In  the  large-spored  culture  it  is  reddish-brown.  Each 
of  the  two  classes  presented  exactly  the  same  appear- 
ance in  all  the  specimenB  examined,  whether  they 
came  from  the  same  case  oi  not.  Nor  was  I  able  to 
detect  any  difference  between  the  individuals  of  the 
large-spored  group.  Community  of  contagion  may 
be  safely  excluded.  It  would  appear,  therefore,  that 
Sabouraud'a  statement  that  hardly  any  two  cases  of 
trichophytic  ringworm  present  the  same  species  of 
trichophyton  is,  to  say  the  least,  too  absolute. 

The  Fung-i  In  Relation  to  Clinical  Facts. 
^The  conclusion  at  which  I  have  arrived,  as  the 
result  of  my  own  observations  and  researches,  is  that 
there  are  but  two  varieties  of  ringworm  parasite — 
the  small-spored  and  large-spoied — which  concern  the 
clinician.  These  present  sufficient  differences  in  their 
microscopic  appearances,  in  their  mode  of  growth, 
and  in  their  pathological  effects,  to  entitle  them  to 
recognition  as  distinct  in  breed.  Whether  they 
belong  to  different  botanical  families  is  a  question  of 
little  interest  to  us  as  clinicians. 

Sabouraud's  teaching  that  the  small-spored  fungus 
is  confined  to  the  scalp  is,  I  venture  to  think,  errone- 
ous ;  I  have  found  it  in  a  patch  of  tinea  circinata  on 
a  child  affected  with  tinea  tonsurans.  Another  point 
insisted  on  by  Sabouraud,  that  there  is  never  any 
mixing  ol  breeds  of  parasites  in  the  same  case,  is 
contradicted  by  my  own  experience,  for  I  have  seen  a 
case  of  ringworm  on  the  head  and  neck  in  a  child,  in 
which  the  fungus  on  the  scalp  showed  al!  the  charac- 
teristics of  the  smaU-spored,  and  that  on  the  neck  all 
those  of  the  large-spored,  variety.  Again,  whereas 
Sabouraud  holds  that  kerion  and  all  other  suppurative 
lesions  are  caused  by  a  large-spored  trichophyton 
derived  from  the  horse,  in  every  caae  of  kerion  which. 


343       LOCAL   INOCVLABLE   DISEASES,    [ohap.  rvir.| 

ave  examined  I  have  found  a  fuagus  similar  to  the 
small-spored  parasite. 

Relations  of  Certain  Forms  of  Ringworai 

to  FaVUS. — My  observations  have  led  nie  to  thft.' 
conclusion  that  many  forms  of  tinea  tonsurans  whicl) 
were  formerly  believed  to  be  caused  by  a  trichophyton' 
are  really  varieties  of  favua.  I  am  glad  to  find  that 
this  conclusion — at  which  I  had  arrived  by  micro- 
scopic Bs  well  aa  by  clinical  observation — is  indepeU' 
dently  confirmed  by  Bodin,  and  more  recently  by 
Sabouraud. 

Bodin'fi  researches  have  convinced  him  that  thero 
are  fungi  which  produce  in  man  and  in  animals  a 
disease  indiatinguisliable  from  trichophytosis,  but 
which  mycologically  are  more  allied  to  the  parasite 
of  favuB  than  to  trichophyton.  On  the  other  hand, 
favuB  fungi,  which  produce  the  characteristic  Bcutula, 
also  produce  circiuate  lesions  {javua  herfeticut). 
While,  therefore,  he  does  not  deny  the  individualily 
of  the  two  groups — trichophytosis  and  favus — he 
thinks  it  impossible  at  present  to  draw  a  hard  and 
fast  line  of  demarcation  between  the  two. 

Sabrazts  and  Breugues  *  have  published  a  case  (A 
sycosis  barbte  in  which  the  parasite  was  both  micro- 
aoopically  and  culturally  indistinguishable  from  the 
trichophyton  of  the  horse,  but  when  inoculated  on 
mice  gave  rise  to  typical  favus  scutula.  The  original 
case  was  clinically  quite  typical  of  trichophytlc 
aycosis.  These  observers  therefore  conclude  that 
the  hard  and  fast  line  between  the  trichophyton  and 
achorion  must  be  broken  down. 

Summary  of  Etiology.  —  To  sum  up  th?' 
etiology  of  ringworm  : — 

There  are  at  least  two,  probably  three,  possiblf 

more,  distinct  species  of  fungi  which  produce  tm! 

disease  in  different  cases.     One  of  these  is 

•  Semaine  Midieab,  M&y  i,  1S93,  p.  203, 


I 


a.]  BINQWOBM   FUSGl.  349 

spored  fimgua — Microsporon  Audouini — ^ which  attacks 
fihiefly  the  scalp,  and  almost  exclusively  in  children. 
Another  is  a  large-spored  iimgus,  which  attacks  the 
body  (tinea  circinata),  the  beard  region  (sycosis),  the 
naila  (onychomycosis),  and  occasionally  the  scalp. 

The  botanical  character  of  the  ringworm  fungi  is 
uncertain.  Sabouraud  classes  the  large-spored  fungus, 
to  which  alone  he  allows  the  name  oE  trichophyton 
among  the  Sporotricha,  a  species  of  the  genna  Mucedo 
the  Microsporon  Audouini  is  as  yet  unattached 
Colcott  Fox  believes  that  the  microspora  and  tncho 
phyta  all  belong  to  the  same  family. 

The  origin  of  the  fungi  is  also  nncertnm  Sabou 
raud  thinks  it  probable  that  the  trichoph>ta  or  some 
of  them,  may  exist  independently  as  saprophytes,  and 
this  suggests  the  possibility  of  direct  contagion  from 
mouldy  vegetable  substances.  Some  trichophytes 
are  believed  to  be  of  animal  origin,  more  particularly 
the  horse  and  the  cat.  The  small-spored  fungus  is 
likewise  believed  to  be  occasionally  derived  from  the 
horse,  cat,  or  dog. 

Ringworm  is  transmitted  by  direct  contagion  from 
one  human  being  to  another,  or  from  an  animal  to  a 
human  being ;  possibly,  sometimes,  by  inoculation 
with  a  vegetable  moidd  in  its  natural  or  saprophytic 
state,  It  is  also  transmitted  by  indirect  contagion, 
by  infected  brushes,  caps,  etc.  Age  is  an  important 
etiological  factor  in  the  case  of  scalp  ringworm  pro- 
duced by  the  emall-spored  fungus,  the  affection  being 
almost  peculiar  to  childhood.  There  seems  to  be  no 
limit  of  age  in  the  case  of  body  ringworm.  Both 
sexea  are  about  equally  liable  to  the  disease. 

Tinea  tonsurans,  or  ringworm  of  the  scaip, 
is  a  disease  almost  peculiar  to  childhood,  being  only 
exceptionally  seen  in  the  adult.  Liability  to  attack 
continues  up  to  puberty,  but  the  great  majority  of 
cases  occur  in  children  in  the  second  half  of  the  first 


350       LOCAL   INOCULABLE  DISEASES,    [chap.  xvn.  J 

decade  of  life.  There  is  practically  no  difiereuee  in  tha  | 
two  sexes  in  respect  ot  liability,  the  slightly  g 
preponderance  of  boys  in  most  collections  of  statistios  3 
being  explained  by  greater  exposure  to  contagion  in  1 
the  rough  familiarity  of  school  lite.  The  incubatioa.1 
period,  though  variable  within  considerable  limita,  ■ 
may  for  practical  purposes  be  reckoned  aa  under  La 
fortnight. 

Bingworm  of  the  scalp  is  seldom,  if  ever,  seen  ia.'I 
its  first  beginning.     Some  localised  scuifinesa  or  loaftfl 
of  hair  is  discoveied  accidentally,  or  in  consequence  ■ 
of  the  child  scratching  at  the  afFccted  place.     The  I 
initial  lesion  is  often  a  amaU  red  papule,   whioIiW 
develops  about  the  orifice  of  a  hair  folhcle  ;    soma- 1 
times  it  is  nothing  more  than  a  minute  scaly  spot.  I 
The  papule  spreads  peripherally,  becomes  scal_ 
the  surface,  and  in  a  short  time  grows  into  a  patch  1 
round  oj  oval  in  outline,  and  slightly  raised  beyond  I 
the  level  of  the  surrounding  akin.    Other  f' 
patches  are  formed  in  the  same   way  from  otJm(fl 
centres  of  infection.     The  patches  vary  in  i ' 
a  threepenny-pi ede  to  a  florin,  but  they  are  often  sal 
large  as  a  tive-shilhng  piece,  and  sometimes  they  a 
several  inches  in  diameter,  equalUng  in  area  a  cleTicaLifl 
tonsure  [hence  the  name  lonsurans).     Generally  there  f 
are  one  or  two  small  satellite  spots  in  the  neighbour- 
hood of  a  patch.     The  patch,  as  a  rule,  stands  out 
against  the  healthy  skin  more  or  less  sharply  by 
difference  of  colour  as  well  as  by  scallness.     The  hue 
varies  from  a  ditty  grey  or  alaty  blue  to  reddish 
brown ;    in  fair  subjects  it  is  generally  yellowish. 
The  typical  patch  of  small-spore  ringworm  ia  round, 
but  it  may  be  oval  or  irregular  in  shape,  and  the  i 
running  together  of  neighbouring  patches  may  g' 
rise  to  areas  of  thickened  desquamating  integumeiltll 
with   winding  contours.     The   typical  patch   has  bI 
sharply  defined  margin,  but  sometimes  around  wlut  J 


CHAP.  XVII.]        MNQWORM :    CLINICAL.  351 

may  be  calted  &  central  clearance  there  is  an  under- 
growth of  diseased  hairs  spreading  out  more  and 
more  luxuriantly  towards  tlie  belt  of  healthy  hair 
which  marks  the  limit  of  the  disease.  The  typical 
patch  is  often  gii-t  about  by  a  narrow  zone  of  erythe- 
matous redness ;  very  rarely  the  edge  of  the  ring  ia 
marked  out  by  tiny  vesicles.  A  typical  patch  ia 
studded  with  dry,  withered  stumps  of  broken  hairs, 
which  stand  out  on  its  surface  like  the  stubble  on  a 
mown  field.  The  hair-atumps  may  be  seen  to  have 
lost  their  natural  gloss  ;  they  are  thickened,  and  have 
a  whitened,  frosted  appearance,  produced  by  the 
parasitic  sheath  (see  p.  339)  which  surrounds  them. 
Each  stump  sticks  out  of  what  may  be  caUed  a 
miniature  mole-hJll  or  cone-like  elevation  thrown  up 
around  the  hair  by  the  massing  of  epithelial  debris, 
caused  by  the  burrowing  of  the  fungus  in  the  follicle. 
These  tiny  projections  of  the  aurface  produce  an 
appearance  like  "  goose-skin."  The  individual  hairs 
lose  their  elasticity,  and  are  twisted  and  crumpled  so 
as  to  have  the  appearance  of  corn-stalks  beaten  down 
by  wind  and  rain.  They  are  also  loosened,  so  that 
they  can  be  pulled  out  without  pain. 

The  thickening  of  the  hair  is  due  to  infiltration 
with  fungus.  Under  the  invasion  of  the  parasite  it 
becomes  so  brittle  that  it  is  broken  to  pieces  by  the 
epilating  forceps,  however  gently  handled,  and  ia 
crushed  with  the  greatest  ease  between  the  slide  and 
the  cover-glass. 

Instead  of  stumps,  the  surface  is  sometimea 
studded  with  small  black  pointa,  which  plug  the 
mouths  of  the  follicles  ;  these  are  hairs  which  have 
broken  off  at  the  level  of  the  skin.  The  hair,  how- 
ever, aoon  grows  to  an  extent  sufficient  to  show  itself 
for  what  it  is.  Microscopic  examination  of  the  hairs, 
after  washing  in  liquor  potasste,  shows  the  fungus  on 
the  outside  of  the  hair  (Mitrosporon  Audouini)  in 


ri«  t'.  ..r--..-  of  r:.h  k-f.-i  '^■■-^{^ 
witli    viiAii.-s  '-.,Nt.,iir-.     Tt..r 
iliurijly  il-rtiiii"!  iii^rihii,  but  :• 


■""••TO., 


"'""foiu 


«/ftr^ 


'  "  antral  d^  — -     ^ 

■eased  Jui,r'"»«<»  li-.  - 

"«  •boo,  I '"•  *«=»,    ^S^J 


""J-  be  0.,,   , 


I  *  ""Mob  lit.  '..""ons  of  ti   "" 


LOCAL   INOCULABLIi    DISEASES,     [oilip.  x 

the  form  of  spores,   arranged  in  the  fashion  of  a- 
mosaic,  surrounding  tho  shaft  like  the  bark  of  a  tree 
and  inside  the  hair  in  the  form  of  threads  of  mycelia 
branched,  curved,  and  irregularly  jointed. 

When  the  vegetation  of  the  fungua  is  luxuriant, 
spores  are  in  swarms  and  the  myceha  in  thick  massesj 
and  the  hair  can  he  seen  to  be  split  and  frayed  at  thft 
edges.  The  small-spored  fungus,  as  stated  elsewhera, 
is  accountable  for  some  90  per  cent,  of  the  casee  of' 
scalp  ringworm  met  with  in  London.  The  large- 
spored  trichophyton  causes  a  small  proportion  of  tli» 
cases,  and  the  affection  is,  as  a  rule,  much  milder  than 
that  produced  by  the  microsporon.  The  stumps  of 
hairs  attacked  by  the  large-spored  fungus  have  ni' 
white  sheath,  and  commonly  break  ofi  on  a  level  with' 
tho  skin.  With  the  microscope  the  spores  are  seen  t* 
"  e  arranged  in  chains,  and  the  mycelium  is  short  and* 
regularly  jointed. 

The  form  just  described  is,  on  the  whole,  the  mo»it 
common  ;  but  the  affection  presents  an  almost  infuut» 
variety  of  clinical  appearances.     There  may  be 
discoloration  ■   there  mav  even  be  no  scaliness  ;  th 
may  be  no  distmct  patch     but  there  is  always  soi 
where  the  characteristic  broken  hair.     There  is  oSbe^ 
for  a  time,  merely  a  thinnmg  of  the  hair  in  one 
more  places,  hairs  of  a  natural  length  being  mixed 
constderable  number  with   the  stumps.     GenerallT^ 
however,  the  fungus  sooner  or  later  lays  hold  of  tllOB^ 
resisting  hairs,  and  the  classical  stubbly  patch  is  tba 

Ringworm  sometimes  occurs,  not  in  patches,  btitm 
isolated  foci,  thickened  stumps,  perhaps  intermingled 
with  black  dots,  being  scattered  over  the  whole  bck^ 
(ifisseminated  ringworm,  Aldersmith).  The  akin  '" 
generally  healthy  in  appearance.  Another  anomak 
form  is  balii  rinifu'orm  (Liveing),  or  tinea  decalvail 
(Tilbury  Fox).    The  hair  falls  out  in  places,  leaving 


r.J  RISaWORM:   LESIONS. 


smooth  bare  spot  of  greater  or  leas  extent,  This 
may  occur  in  a  spot  to  all  appearance  previouaiy  un- 
affected ;  more  frequently  it  occurs  in  an  ordinary 
patch  of  ringworm.  Other  patches  generally  become 
bald  in  iike  fashion,  and  an  appearance  eimilar  tii 
alopecia  areata  ia  produced.  Crocker  holds  that  the 
common  form  of  alopecia  areata  and  "  bald  ring- 
worm" are  synonymous  terms. 

As  a  rule,  the  only  lesiona  of  the  akin  caused  by 
the  ringworm  fungus  are  a  little  swelling  and  ery- 
thema at  the  outset,  and  not  unfrequeutly  sligtit 
eseoriation  caused  by  scratching.  Inflammatory 
comphcations— vesicular,  eczematoid,  or  impetiginous 
— are  often  set  up  by  over-active  treatment,  but 
Bometimes  occur  Lndependentiy.  Suppurative  pro- 
cesses may  be  induced  by  secondary  infection  with  pus 
cocci,  or  by  the  action  of  certain  large-spored  fungi, 
believed  to  be  almost  exclusively  of  animal  origin, 
which  are,  as  Sabouraud  haa  shown,  pyogenic.  The 
most  common  complication  is  impetigo,  characterised 
by  the  appearance  here  and  there  on  the  scalp  of 
isolated  pustules,  which  on  drying  form  scabs,  [f  the 
impetiginous  process  is  not  speecUly  stopped,  it  Ls  apt 
to  Bpr^d  over  the  scalp. 

The  most  severe  complication  is  kerion.  In  this 
amdition  the  skin  is  raised  iato  a  dome-like  surface, 
which  may  be  of  conaiderable  extent ;  the  surface  is 
angry-looking,  smooth,  and  moist,  and  is  thickly 
dotted  with  small  holes,  from  some  of  which  therp 
projects  a  loose  stump  of  hair,  while  othen  are  filled 
with  a  plug  of  mucopurulent  matter,  and  irthern, 
a^in,  are  empty  and  gaping.  The  holca  arc  dilal«d 
foUiele«,  and  when  a  lai^e  proportion  of  them  are 
|4iigged  in  the  manner  just  described  the  appearance 
ii  very  like  that  of  a  carbuncle.  The  swelling  is 
tendec  and  feels  boggy,  but  does  not  dutinctlf 
floctoate.     Incision  gives  issue  to  UttW  or  no'^^noA. 


304       LOCAL   INOCULABLK    DISEASES,     [ohap.  xvn.| 

The  suppurative  process  is,  in  fact,  localised  in  the 
follicles,  at  the  bottom  of  each  of  which  there  is 
little  abscess.  The  pus  loosens  the  hairs,  and  they 
finally  thrbwn  ofi,  the  way  being  thus  opened  for  the-j 
escape  ot  a  thick,  viscid  pus.  Sloughing  never  occurs, 
but  in  rare  cases  a  subcutaneous  abscess  may  foim, 
After  the  swelling  disappears  the  site  of  it  remi ' 
for  some  time  red  and  bare,  and  it  may  be  long  before  ft] 
new  growth  of  hair  takes  place.  In  some  rare  caaea  tbe 
necrotic  process  is  so  intense  as  to  destroy  the  loota' 
of  the  hairs,  and  thus  cause  permanent  baldness  owl 
-  the  affected  area,  Kcrion  is  seldom  seen  in  adulf 
except  in  the  beard.  A  special  texture  of  skin  appeani 
to  be  needed  for  its  development  at  any  age,  for  caseA^ 
are  sometimes  met  with  in  which  the  use  of  thei 
strongest  itrltants  fails  to  induce  it. 

The  only  subjective  symptom  in  uncomplicated 
ringworm  of  the  scalp  is  itching,  and  even  this  is 
often  absent.  Even  in  strumous  and  ill-nourished 
children  the  affection  causes  no  disturbance  of  the 
general  health.  The  course  is  sometimes  very  rapi^ 
especially  in  very  young  children.  Dark  hair 
less  easy  prej  to  the  fungus  than  fair  hair,  and 
hiiif  resists  more  than  fine  hair.  A  patch  of  considar- 
able  size  oftea  takes  several  weeks,  it  may  be  months, 
to  form.  By  continued  spreadine  ^nd  confluence  of 
patches,  the  whole  scalp  may  in  time  be  laid  waste, 
its  surface  being  covered  by  a  thick  layer  of  d^, 
epidermic  scales.  On  long-standing  patches 
may  be  seen  at  the  same  time  thickened  stumpe 
soft,  downy,  new  hair,  at  first  in  small  amount,  bl 
increasing  as  growth  proceeds  till  a  fresh  crop  of 
has  taken  the  place  of  that  blighted  by  the  ringwoi 
However  long  the  disease  may  last,  it  usually 
in  cure — at  puberty,  if  not  before.  I  have,  howei 
seen  a  few  cases  in  which  the  disease  '  ' 
childhood  to  beyond  the  age  of  twenty-iive.    Vt 


rapid, 

IT  IS^jM 

ooaroM^H 
Qsidor^^H 


II.]         RIXOWOE^:   JtESULTS.  aSS 

manent  baldness  sometimes  resulte  from  the  injurious 
application  of  iiritantB,  such  as  croton  oil,  and  small 
bare  spots  are  sometimea  left  owing  to  destruction 
of  hair  roots  by  kerion.  Bald  spots  are  also  occasion- 
ally left  in  cases  in  which  there  has  been  neither 
artificial  irritation  nor  suppuration. 

In  an  ordinary  case  of  ringworm,  when  the  fungus 
has  worked  its  way  to  the  bottom  of  the  follicle  there 
ia  little  or  no  further  reaction,  and  a  dry,  scurfy 
condition  of  the  aSected  surface  results.  The  disease 
then  enters  on  an  excessively  tedious  phase.  In 
consequence  of  the  thickening  around  the  neck  of  the 
follicle,  which  is  the  result  of  the  inflammatory  process 
set  up  by  the  irritation  of  the  parasite  or  by  excessive 
treatment,  the  sac  is  converted  into  what  may  be 
called  a  bottle  with  a  narrow  neck ;  tlius  the  fungus 
is  imprisoned  in  the  follicle,  and  remedial  agents  are 
prevented  from  gaining  access  thereto.  Disseminated 
ringworm  is  usually  extremely  obstinate,  mainly, 
perhaps,  because  it  is  easily  overlooked.  I  have 
known  a  boy  sufferinf;  from  this  form  of  the  disease 
to  he  a  source  of  contagion  in  a  school  for  many  terms 
without  suspicion  attacliing  to  him. 

Kerion  naturaUy  tends  to  the  cure  of  ringworm, 
the  diseased  hairs  being  cast  oft  and  the  multiplica- 
tion of  the  pus  cocci  having  the  effect  of  choking  the 
growth  of  the  fungus. 

Apart  from  the  nature  of  the  soil,  age  greatly 
mitigates  the  disease.  .Other  things  being  equal, 
ringworm  of  the  scalp  in  a  child  of  fourteen  is  usually 
much  milder  than  in  a  child  of  ten.  The  constitu- 
tional state  appears  to  have  no  influence  either  on  the 
severity  or  the  duration  of  the  affection.  Some  of  the 
moat  persistent  cases  that  have  come  under  my 
notice  have  been  in  perfectly  healthy  children. 

The  question  of  inununity  is  not  altogether  deter- 
mined.    Children  of  ten  have  what  appeal  to  be 


356       LOCAL    INOCULABLE    DISEASES,     [dhat.  x 

second  attacks   of  ringworm,   but  such   cases 
probably  for  the  most  part  instances  of  relapse  rath^ 
than  recurrence. 

Tinea  circinata.    {Plate  L,  Fig.  5.)— On  ham  ' 

is  parts  ringworm,  after  an  indefinite  period  oi  ii 
bation — the  leugth  of  which  depends  on  the  thickneas 
of  the  epidermis — begins  as  a  small  red  spot,  slightly 
raised,  and  having  a  well-defined  border.  This  spot 
gradually  spreads  at  the  edge,  its  surface  meanwhfle 
becoming  more  or  less  scaly.  As  it  extends  peri- 
pherally the  redness  disappears  in  the  centre,  leaTinj  J 
a  slightly  discoloured  branny  area,  which  forms  tMB 
inside  of  a  red  ring.  The  circle  gradually  ealarge«I 
Uke  the  fairy  rings  of  the  mushroom,  without  &vyM 
widening  of  its  edge,  and  it  may  expand  so  as  t^l 
enclose  a  considerable  area.  There  may  be  only  oqbI 
such  ring,  but  more  frequently  there  are  several,  ondfl 
in  that  case  those  adjoining  each  other  may  run  to^l 
^ether  and  form  festooned  patterns.  There  is  geoer-V 
jlly  no  tendency  to  symmetrical  arrangement  07-1 
grouping  of  the  rings  ;  occasionally,  however,  two  o^S 
more  rings  are  placed  concentrically.  The  ]esioiiM 
are  often  situated  on  the  face,  neck,  hands,  or  othan 
exposed  surface.  Not  unfrequentlj  involution  docwfl 
not  take  place  in  the  centre  as  the  edge  advances,  atidll 
the  lesions  take  the  form  of  patches  instead  of  ringSyil 
These  patches  have  a  clearly  defined  border,  but  they,  I 
are  not  always  circular  or  ovat  in  outline.  Thai 
process  is  usually  accompbnied  by  inflammstioil,  1 
the  intensity  of  which  varies  according  to  the  idio-  1 
syncrasy  of  the  skin.  The  ring  or  patch  oiten  J 
becomes  the  seat  of  papular  or  vesicular  etnptifHl^ 
and  pustules  may  develop  as  the  result  of  the  inoenl^J 
tion  of  pus  cocci  and  other  micro-organiBms.  OccA^fl 
sionally  the  neighbouring  lymphatic  glands  u4a 
slightly  enlarged.  1 

In  the  pubic,  perineal,  and  axillary  regions  the  1 


I*AP.  XVII.]  TINEA    GIRCINATA.  357 

growth  oi  the  fungus  is  stimulated  by  the  warmth  and 
moisture,  and  both  the  primary  and  the  secondary 
lesions  are  oi  a  more  intensely  inflammatory  character 
than  in  other  eituations.  The  affection- — which  is 
often  termed  eczema  maTginalum,  but  would  be  more 
properly  called  "  tinea  marginata  " — may  spread  over 
the  lower  part  of  the  belly,  the  buttocks,  and  in  the 
fold  of  tiie  nates.  It  is  seen  in  its  highest  stage  of 
development  in  hot  climates.  Mookhtar,*  of  Con- 
stantinople, has  described  a  variety  of  ringworm 
which  occurs  on  the  palms  and  soles,  where  in  the 
early  stage  it  simulates  sweat- eczema,  and  in  the 
later  stages  a  palmar  aypbilide. 

The  pathology  of  ringworm  represents  the  results 
of  the  growth  of  the  fungus  in  the  epidermis — 
namely,  deatructiou  of  the  hair,  and  an  inflammatory 
process  set  up  by  the  irritation  of  the  fungus,  compli- 
cated in  many  cases  by  lesions  consequent  on  the 
inoculation  of  purulent  material. 

The  diagnosis  of  tinea  circinata  seldom  presents 
much  difiicuity,  the  lesions  having  a  characteristic 
appearance,  The  presence  of  the  fungus  is  conclu- 
sive, but  it  must  be  admitted  that  its  discovery  is 
not  always  easy  even  to  an  expert.  It  is  far  other- 
wise as  regards  ringworm  of  tbe  scalp,  where  in  many 
cases  the  secondary  lesions  mask  the  real  disease  so 
completely  that  doubt  can  be  set  at  rest  only  by 
microscopic  esamination.  In  an  ordinary  case  care- 
ful examination  of  the  diseased  patches  will  seldom 
fail  to  reveal  the  characteristic  broken  twisted  hairs. 
In  very  chronic  cases,  when  the  scalp  is  dry  and  scaly, 
the  disease  may  be  mistaken  for  seborrhoea,  eczema, 
or  psoriasis.  In  seborrhcea,  however,  the  acaliness 
is  not  in  patches.  Although  eczema  may  be  simulated 
by  an  irritated  condition  of  the  scalp,  resulting  either 
from  scratching  or  from  irritant  applications,  circum- 


^^B      360      LOCAL  ISOCULABLE   DISEASES,    [chap.  xtii.| 

^^^K  and  dehydrate  the  tiesues.  It  may  here  lie  pointed  I 
^^H  out  that  as  water  ia  one  of  the  Bubstancea  requiied  hy  I 
^^V  the  fungus  for  it«  nutrition,  parts  that  are  tlie  seat  of  I 
P  ringworm  should  never  be  washed  with  that  fiuid; 

the  disease  ia  always  spread  by  this  procedure.     The  J 
L  'application  of  mild  antiseptic  washes  is,   however, 

^^H       permissible.     A  good  lotion  for  the  purpose  is  saliafiia  | 
^^H     acid  dissolved  in  chloroform  or  dher  {grs.  v.  to  xz,  a^M 
^^H      3?)>'    t^liis  dissolves  the  fat,  dehydrates,  loosens  th«1 
^^^^    hairs,  and  directly  attacks  the  fungus.     By  the  use  o]  f 
^^^B    salicylic  acid  in  this  form,  if  applied  aufliciently  early, 
^^^H     before  the  fungus  has  had  time  to  reach  the  deeper 
^^^p     part  of  the  follicle,  a  rapid  cure  may  be  efiected.     It 
^^~       is  an  essential  condition  of  success,  however,  that  no   i 
'  fatty  substances  sliould  be  used. 

These  remedies,  however,  penetrate  only  a  short  •! 
distance  into  the  epidermis.     In  a  chronic  case  morB<  I 
powerful  remedies  are  required,  in  order  to  set  upS 
a  curative  dermatitis.     In  such  circumstances  cA^-T 
sarobin    ia    the     most    effective    agent.     Unna    basij 
pointed  out  that  the  scalp  does  not  react  stronglf  V 
to  the  drug.     Duhring*  also  speaks  very  highly  ixE-l 
chrysarobin.    He  used  it  in  twenty-nine  cases,  in  only  j 
seven  of  which  was  any  irritation  of  the  scalp  com- 
plained of.     He  applied  it  in  the  form  of  an  ointment 
containing  from  fifteen  grains  to  two  drachnfia  of 
ehryaarobin  to  the  ounce,  the  strength  in  common  use 
being  one  drachm  to  the  ounce.     A  small  quantity  of 
the  ointment  was  well  rubbed  in  with  a  bit  of  clotli  or 
a  mop.     An  explanation  of  the  enormous  number  oi  I 
remedies  found  useful  in  chronic  ringworm  is  to  be  I 
Jound  in  the  fact  that  whatever  excites  InflammatMa  J 
IB  BO  far  beneficial.    This  is  the  mode  of  actiiraoif 
Coster's  ■paste,  slront/  sulphur  and  mercurial  otntotM 
oteate  of  copper,  carbolic  acid,  etc.,  all  of  which  s 
aseful. 

•  Jm„:  Jwi>,  lifMc'l.  Sri.,  Feb.,  lum. 


vn.]  TINEA   SYCOSIS.  361 

Lastly,  in  some  cases  a  inbre  destructive  itiflam- 
matinn,  producing  &  condition  resembling  kerion,  is 
required,  the  object  being  to  excite  an  inflammatory 
procesB  and  perhaps  local  necrosis,  whereby  the 
fungus,  as  well  aa  the  afiected  tissues,  shall  be  involved 
in  the  destruction.  Aldersmith  uses  CTiAon  oil  for 
this  purpose.  Besnier  goes  so  iar  as  to  say  that  ring- 
worm can  be  cured  only  by  inflammation,  as  there 
is,  in  his  opinion,  no  remedy  that  can  destroy  the 
fungus.  Vidul's  *  treatment  is  baaed  on  the  tact 
that  the  fungus,  being  aerobic,  can  be  destroyed  by 
deprivation  of  air.  The  hair  having  been  cut  cloBp, 
the  head  is  rubbed  with  essence  of  turpentine  and  the 
affected  parts  painted  with  tii|uture  of  iodine.  The 
head  is  then  smeared  with  vaseline,  either  pure  or 
containing  boracic  acid  or  iodine  {1  per  cent.),  and 
covered  with  a  caoutchouc  cap  or  a  guttapercha  leaf 
kept  closely  applied  to  the  scalp  with  a  bandagr.  The 
dressing  is  renewed  morning  and  night,  and  the  parts 
are  washed  with  soap  and  water  and  carefully  dried. 
Vidal  is  satisfied  with  the  results  of  this  treatment. 

In  schools  special  precautions  are  required  to 
prevent  the  spread  of  ringworm.  When  a  case  is 
discovered,  the  patient  should  at  once  be  isolated, 
and  a  careful  examination  of  each  child  should  be 
made  day  by  day.  It  would  be  well,  as  I  pointed  out 
in  a  paper  read  before  the  Congress  of  Hygiens  and 
Demography,  if  special  schools  were  established  for 
children  suffering  irom  ringworm,  ae  has  been  done  in 
Rome,  Paris,  and  certain  towns  of  Belgium. 

Tinea  sycosis,  or  tinea  barbEe,  is  foUicidar  in- 
flammation of  the  chin  and  other  hairy  parts  of 
the  face,  in  which  the  ringworm  fungus  is  the  irri- 
tant. The  initial  lesion  is  a  red  scaly  spot,  which 
Boon  enlarges,  sometimes  undergoing  involution  in 


362       LOCAL   ISOCULABLE    DISEASES.     [ck*p.  xvn. 

the  centre,  and  forming  a  ring  ;  in  other  cases  retain- 
ing the  character  of  a  patcli,  with  a.  defined  moTglii 
and  scaly  surface.  An  other  similar  lesions  develop, 
they  often  become  confluent.  Pustules,  each  of  which 
Ib  traversed  by  a  hair,  form  both  on  the  surface  of  the 
patches  and  on  the  intervening  skin.  The  eruption 
is  accompanied  by  considerable  itching.  A  more 
severe  form  of  the  aff'K!tion,  corresponding  to  keiion 
of  the  scalp,  is  sometimes  met  with  ;  the  inflammatory 
process  is  more  intense,  and  spreads  rapidly  ;  tbera 
is  brawny  infiltration  of  the  skin  of  the  chin  and  aides 
of  the  face,  the  surface  of  which  is  thrown  up  herfr 
and  there  into  irregular  lumps,  and  is  thickly  studded 
with  hair-pierced  piistulos.  Tlie  hair  is  loosened,  but ' 
as  a  role  not  damaged,  except  in  very  obstinate  cases.. 
The  suppurative  process  mav,  however,  be  sufBciently'' 
severe  to  destroy  the  follicles,  leaving  permanent 
scars,  on  which  no  hair  can  grow.  The  affection  may 
persist  indefinitely. 

Tinea  sycosis  is  caused  by  the  large-spored  tricho- 
phji^n,  and  is  communicated  by  contact  with  in- 
fected persona— especially  cliildren — or  animals.  The 
shaving  brushes  and  other  instruments  used  by 
barbers  are  very  often  the  medium  of  conveying  the 
disease.  This  form  of  ringworm  is  naturally  almost  - 
confined  to  the  male  sex,  and  it  is  most  conunoa  itt' 
young  adults. 

Pathologically,  the  afiection  is  a  folliculitis  and 

?!rifolliculiti3,  generally  running  on  to  suppuration. 
he  process  begins  in  the  interior  of  the  follicle,  and 
spreads  outwards,  loosening  the  hair-shaft  from  the 
wall  of  the  follicle. 

The  diagnosis  has  to  be  made  from  sycosis  and 
from  ecKematous  foUiculitis.  In  the  former  case  an 
appeal  must  often  be  made  to  the  microscope  i 
clinically,  the  tri chop hy tic  disease  spreads  mors 
npidly,  and  causes  more  lumpl^^e^^of  th«  aSxaX 


1 


a.]    RINGWORM   OF   THE   NAILS. 


The  eczematous  condition  is  distinguished 
/  the  fact  that  serous  discharge  is,  or  has  been,  a 
»tuTe  in  the  process  ;  moreover,  there  is  little  or  no 
weening  of  the  hairs,  and  the  affection  is  not  confined 
D  the  hairy  parts. 

The  prognosis  is  good  as  regards  ultimate  cure, 
if  the  patient  will  persevere  with  suitable  treatment. 
The  treatment  should  he  conducted  on  the  aame 
_  meral  principles  as  that  of  ringworm  of  the  scalp. 
Epilation  must  be  carried  out  piecemeal.  This  will 
give  exit  to  the  pus  ;  incision  is  never  required. 
Parasiticides  must  then  be  applied,  their  nature  and 
strength  being  carefully  adapted  to  the  condition  of 
the  affected  parts  and  the  susceptibility  of  the 
patient's  skin.  OhTysarobin,  in  the  form  of  an  oint- 
ment {grs.  X  to  y,ss  of  tkedrug  to  5/  of  lanolin  or  lard), 
i»  the  most  efficient  apphcation.  Sulphur,  or  oleate 
fif  Gojyper,  is  useful  in  the  milder  forms  of  the  affection, 
I  The  case  must  he  kept  under  observation  for  a  long 
time  after  apparent  cure.  For  the  prevention  of  the 
disease  it  might  he  well  to  follow  the  example  of 
certain  legislative  authorities  in  Germany,  France,  and 
in  some  of  the  United  States  of  America,  which  have 
made  it  compulsory  on  all  barbers  and  hair-dressers 
to  disinfect  their  instruments  thoroughly  every  time 
they  are  used. 

HingWOPm  of  the  Nails.— The  nails  may  be 
attacked  by  the  trichophyton,  either  in  association 
with  ringworm  on  some  other  part  of  the  body  or 
independently,  especially  in  nurses  who  have  to  look 
after  children  suffering  from  the  disease.  Inflamma- 
tion of  the  matrix  is  set  up,  and  the-  nail  becomes 
thickened,  lustreless,  uneven,  and  brittle.  The  treat- 
ment is  to  scrape  the  nail  thoroughly,  and  apply 
chrysarobin  or  some,  other  parasiticide.  The  treilt- 
tnent  used  by  Harrison,  of  Bristol,  for  ringworm  of  the , 
scalp  is  particularly  useful  for  the  disease  aa  it  a-SsKAs. 


364       LOCAL    fXOCi'LABLE    DISEASES,     [chat.  xvn. 

the  nails.  He  uses  two  solutiDna,  No.  1  compoBed 
of  liquor  -potassa!  and  diitiUed  water,  dii.  f,M,  and 
iodide  of  jxHassium  5m;  and  No.  2,  consisting,  of 
hydr.  -perchlor.  gn.  4,  sptV.  vini  reel,  and  distilled 
water,  «d  5M.  The  nail  having  been  scraped.  No.  1 
is  applied  on  lint  under  oiled  akin  for  fifteen  minutes  ; 
then  No.  '2  is  immediately  applied  in  the  same  way, 
and  kept  on  for  twenty-four  houra.  The  nail  is  then 
again  scraped,  and  the  applications  are  repeated  as 
often  as  may  be  necessary;  H.  Fournier  *  recom- 
mends the  removal  of  the  whole  of  the  aSected  parts 
by  scraping,  scratching,  or  evulsion,  and  by  the 
action  of  various  local  remedies  tiuch  as  creosote, 
acetic  acid,  benzine,  corrosive  suUitnate  (2  per  cent, 
in  alcohol  or  chloroform),  tnerourial  plaster,  resorcin 
'  or  tinolure  of  iodine.  The  two  last  named,  combined 
with  previous  maceration  of  the  nail  by  mean»  of 
iudiarubber  coverings,  are  those  which  Fournier  has 
found  most  successful. 

Tinea  imbricata  (Tokelau  ringworm)  is  an 
affection  confined  to  the  tropics.  I  have  no  personal 
knowledge  of  this  disease,  and  the  following  account 
is  mainly  condensed  from  an  article  by  Patrick 
Manson.f  The  disease  is  caused  by  a  vegetable 
parasite  resembling  in  some  respects  the  ordinary  tri- 
chophyton, but  differing  from  it  slightly  in  some 
points,  especially  in  the  great  abundance  in  which  it 
is  present  (Plate  1.,  Fig,  (i).  The  fungus  may  attack 
any  part  of  the  body,  but  generally  spares  the  scalp, 
and  as  a  rule  avoids  hairy  parts.  The  characteristic 
lesion  is  a  patoh  consisting  of  concentric  rings  of 

•  JoHiH.  ,ht  lam.  Cut.  tl  Syuh..  Aiiril,  1B8S. 

t  Jlri!.    Jam-'.,     lifio.,   1802,   p.   .1,     An    eicallont  da 

tkiQ  of  the  diacase  is  atao  ^reu  tn  Gupp;  In  hiii  work,  ' 

Solomon  IiUutdn  and  tbeir  luhalnMuts,"  1887.  8^'  alio  LniteJ 
{itoualih./,  prakl.  Drrm.,  I8B2,  Nu.  4).  TLu  parawle  has  baeiilS 
BBrefuIlT  studied  by  Bonnnt)',   "  I*  Tokelau  et  eon  PBra«ite'"\J 


n.]  FAVU8.  305 

scales  about  J  inch  apart  {Fig.  17).  They  spread  at 
the  edge,  not  only  centrifugally,  but  towards  the 
centre,  bo  as  to  cover  the  spaces  between  the  rings 
and  the  central  area,  thus  converting  the  whole  into 
a  circular  patch  resembling  watered  silk.  The  scales 
are  like  pieces  of  tissue  pupet :  thej'  have  a  free 
border  and  are  firmly  adherent  at  the  opposite  edge, 
resembling  .sitrgical  flaps.  The  scales  are  arranaed 
so  that  the  tree  border  oE  each  is  towards  the  centre 
of  the  circle  or  system  of  circles  to  which  it  belongs. 
The  only  symptom  is  itchin?,  which  is  usunlly  intense. 
When  the  scales  separate,  parallel  lines  of  a  colour 
rather  darker  tlian  the  fawn  colour  of  pityriasis 
versicolor  are  left ;  these  lines  have  a  more  or  less 
concentric  arrangement.  Neorlv  the  whole  body  is 
sometimes  afiected,  but  the  disease  has  no  effect  on 
the  general  health.  Tinea  imbricata  k  contagious ; 
after  inoculation  there  is  an  incubation  period 
lasting  on  an  average  nine  days.  Neitiier  sex  ia 
exempt,  and  children  are  particularly  liable.  The 
imbricated  scales  and  concentric  rings  ate  so  uharan- 
teristic  that  there  is  hardly  any  possibility  of  the 
aSection  being  confused  with  any  other.  The  only 
disease  at  ail  tesembliug  it  ia  tinea  circinata,  from 
which  it  ia  at  once  distinguishable  by  the  centri- 
petal spread  of  the  process.  The  treatment  ia  to 
apply  parasiticides  such  as  the  Hnimentum  iodi  or 
sulphur  ointment.  The  clothes,  etc.,  should  be  dis- 
infected or  destroyed. 

Favus  is  a  disease  caused  bya  fungus,  the  Achorion 
Schoenleinii  (Plate  I..  Pigs.  3  and  i).  The  affection 
is  so  rare  in  England  that  the  replies  to  an  Inquiry 
on  this  subject  addressed  by  me  to  the  eleven  metro- 
politan hospital  BohoolB  a  few  yearn  ago  showed  fcliat 
only  thirteen  cases  had  been  under  treatment  at  these 
institutions  during  the  previous  year.  It  is  more 
common  in  Scotland.     Until  lately  favus  was  com- 


■    FAFUS.  -Ml 

On  hairless  parts  the  lesions  present  the  same 
general  appearance.  In  a  case  which  came  under 
my  observation  *  the  whole  syalp  was  covered  with 
large  patches  of  favus  crusts  (Fig.  18).  A  great  portion 
of  the  back  was  occupied  with  similar  masses  ;  there 
were  also  crusts  on  the  cheeks.  The  nails  of  both 
hands  and  both  feet,  particularly  those  of  the  first 
finger  of  each  hand  and  the  great  toes,  were  thickened, 
uneven,  and  lustreless  ;  in  acme  of  them  no  trace  of 
true  homy  substance  remained,  its  place  being  oecu- 
i  all  over  the  matrix  and  nail-bed  by  an  irregular, 
dirty-yellowish  crust.  The  disease  began 
4en  the  patient  was  twenty-three  years  of  age. 
Rid  lasted  fourteen  years.  She  died  of  acute  phthisis, 
vUch  lasted  neatly  tliree  months,  during  which  the 
ttvuB  spread  over  the  body  with  great  rapidity. 
Tapoai  has  reported  a  case  in  which  a  patient  suffering 
^m  universal  favus  died  with  symptoms  of  severe 
Mtco -intestinal  irritation,  which  was  found  after 
o  be  due  to  the  presence  of  the  favus  fungus 
jl  the  stomach  and  intestine. 

The  disease  is  caused  by  contagion,  the  fungus 
dng  often  derived  from  animals,  especially  from 
nta.  Mice,  rabbits,  fowls,  and  dogs  are  also  subject 
It  grows  much  more  slowly  than  the  ringworm 
_  IB,  and  is  therefore  not  so  easily  transmitted. 
(Tant  of  personal  cleanfiness  is  a  predisposing  factor, 
w  in  persons  who  are  sparing  and  infrequent  in  their 
ablutions  the  fungus  is  more  Likely  to  remain  and 
take  root.  The  fungus  seems  to  find  a  more  favour- 
able soil  for  its  development  on  the  skins  of  persons 
in  weak  health,  especially  those  suSering  from 
phthisis,  than  in  others. 

Pathologically,  the  disease  represents  the  reaction 

of  the  tissues  to  the  irritation  caused  by  the  growth 

~  f  the  fungus.     The  spores  generally  find  then.-  way 

•il.  Joini.  Dniii..  April,  ISHl,  p.  101. 


3r>8       LOCAL    INOCULABLH    DISEASES,     [cuir,  xvu. 

into  the  hair  folliolea,  where  they  grow  round  tin 
seat.  The  faviia  fungus  grows  on  the  epidermis, 
the  density  of  the  growth  causing  pressure  on  the 
parts  below,  thus  crushing  out  the  vitality  of  the  hair 
and  giving  rise  to  atrophic  scarring.  The  character- 
istic cup  shape  is  attributed  by  Unna  to  growth  pro- 
ceediug  more  vigorouslyat  the  sides  than  at  the  centre. 
There  is  some  difference  of  opinion  as  to  whether 
there  is  only  one  or  several  varieties  of  favos 
fungus.  It  was  suggested  by  Quincke  that  there 
are  three  different  species,  Unna  and  Frank  * 
have  also  found  three  varieties,  two  of  which  were 
Buccesafully  inoculated  on  the  healthy  subject,  and 
produced  acutula  presenting  certain  differences  of 
appearance  to  the  naked  eye.  One  of  these,  called 
by  the  authors  Favitg  griseus,  showed  greyish-yellow 
scutula  ;  the  other  {Favus  sul-phureus  cderior)  showed 
sulphur -yellow  scutula,  which  grew  more  quickly 
than  the  former.  Danielsacn.l  however,  as  the  result 
of  a  series  of  experiments,  contends  that  the  Achorion 
Schoenleinii  ia  tlie  only  fungus  of  favus.  Sabraz^flJ 
examined  seventeen  cases  of  favus,  and  in  each 
case  found,  only  the  Achorion  Schoenleinii,  whidi  he 
cultivated  and  inoculated  in  mice  and  in  the  human 
subject,  producing  typical  favus  cups.  He  found  that 
the  female  skin  is  much  more  easily  inoculable  than 
the  male.  On  the  other  hand,  it  has  been  shown  by 
Bodin  §  that  there  is  a  group  of  fungi  intermediate 
between  the  achorion  and  the  trichophyton.  These 
intermediate  forms  are  of  two  kinds  :  mucedinese, 
presenting  the  mycological  characters  of  achoritm, 
but  producing  lesions  of  trichopytic  type  ;  and  othen 
which   have  the  characters    of   trichophyton    and 

*  Jlnt,  Jmm,.  JJeriu.,  May,  183i,  p.  13S. 

t  "AUiuotVcgetuIjlcPutiuiticDu'eBiea,"  Betgen,  iSiO. 

'Ani.  CliH.  dr  Beriffaii^.  Juao  tmiJuiy,  1803, 


I 

I 


produce  favic  lesions.  In  a  communiciition.  to  tlie 
Academie  des  Sciences  Sabrazoa*  referred  to  obser- 
vationB  proving  the  exiatence  of  fungi  intermediate 
between  the  trichophyton  and  the  acliorion. 

The  diagnosis  of  favus  presents  no  difficulty 
in  well-marked  cases,  the  cup-shaped  sulphur- 
coloured  scabs  and  mousy  odour  being  characteristic. 
When,  however,  the  initial  lesions  have  coalesced 
into  dense  crusts,  the  affection  may  resemble  psoriasis 
of  the  scalp  ;  the  scales,  however,  are  less  pearly, 
and  Bcutiila  or  sulphur-yellow  scabs  can  often  be  seen 
about  the  edges  ;  tlie  lustreless  hair  and  atrophic 
scarring  are  also  distinctive  features.  Favus  can  be 
distinguished  from  eczema  and  seborrhoea  by  the  tact 
that  it  is  not  diffuse,  as  the  lesions  in  these  conditions 
are,  but  is  always  bordered  by  a  well-defined  margin. 
It  is  sometimes  very  difficult  to  distinguish  it  from 
ringworm,  and  in  some  cases  the  diagnosis  can  be 
made  only  with  the  help  of  the  microscope,  or  by 
culture  of  the  parasite.  All  the  lesions  should  be 
minutely  examined  with  a  lens  for  remains  o!  the 
yellow  discs  of  favus  or  the  broken  hairs  of  ringworm. 
It  is  sometimes  a  good  plan  to  leave  the  disease  to 
itself  for  a  httle  time,  so  as  to  watch  the  develop- 
ment of  fresh  foci,  when  characteristic  elements  will 
be  recognisable. 

The  prognosis  as  to  cure  is  good,  but  the  disease 
is  sometimes  extremely  refractory  to  treatment.  As 
in  the  case  of  ringworm,  it  is  much  more  easily  dealt 
with  on  hairless  parts  than  on  the  scalp. 

The  treatment  must  be  conducted  on  the  same 
general  lines  as  that  of  ringworm.  The  crusts  must 
be  removed  by  thorough  soaking  with  carbolised  oil  ; 
the  head  should  then  be  washed  with  soft  soap. 
Epilation  should  be  practised,  and  finally  parasiti- 
■ "  s  of  the  same  kind  as  those  used  for  the  destnic- 

'  /i.i/.,May  23,  ISOf. 


370       LOCAL   INOCVLABLK   DISEASES,     [ohap.  s 

tion  of  the  ringworm  funguB  ehould  be  vigorously  1 
rubbed  in.  If  the  nails  are  affected,  avukion  may  1 
be  required  ao  as  to  allow  free  access  to  the  para-  I 
aiticide  agent.  The  appearance  of  fresh  discs  must  I 
be  carefully  watched  for ;  when  found,  they  should  I 
be  at  once  dealt  with  as  before.  After  apparent  cure,^ 
the  patient  must  be  kept  under  observation  for  some  J 
time.  I 

Tinea  versicolor  is  caused  by  a  special  fungus,  I 
the  Microaporon  furfur  (Plate  I.,  Fig.  7).     The  lesions  I 
are  roundish,  slightly  raised,  scaly  patches,  with  &  J 
well-defined  border  ;  they  are  sometimes  discrete  and  I 
irregularly  scattered  about,  but  more  often  they  are  I 
fused  together  bo  as  to  form  large  irregular  areas,  I 
usually  more  on  the  front  of  the  body  than  on  the  f 
back.     The  trunk  is  generally  the  only  part  afFected,  I 
though  occasionally  the  upper  parts  of  the  limbs  are  J 
invaded.     I  have  also  seen  it  on  the  face.     The  char-  | 
acteristic  feature  about  the  lesions  is  the  paculis 
brownish   discoloration    of  which  they  are   the  seat  I 
The  shade   varies  from    "  fawn  "   to   "  liver "  ;    in  1 
persons  who  have  lived  in  hot  climates  it  is  sometiinea 
black,  while  in  coloured  races  it  is  grey  or  whit*.    The 
discoloration  ia  quite  superficial,  affecting  only  the 
uppermost  layers  of  the  epidermis,  ao  that  it  can  in 
great  measure  be  scraped  awav  with  the  finger-nail. 
The  patches  as  a  rule  spread  very  slowly.     The  only 
symptom  caused  by  the  affection  is  itching,  which  is 
not    generally    very    pronounced.     In    persons    who 
perspire   freeh',    however,    the   lesions   may   be   the 
seat  of  slight  inflammation,  and  even  of  an  eczematoid 
process.     In  such  cases  there  may  be  intense  itohin{[. 

The  disease  is  contagious,  but  the  fungus  reqniMff  J 
a  pardciUarly  favourable  soil  and  prolonged  coatadM 
before  it  can  take  root.  Tinea  voraicolor  hs8  beeitf 
produced  by  experimental  inoculation  both  ia  I 
and  in  animals  (Kobner).     It  occurs  chiefly  in  eatly  1 


CHAP,  xvii.]  TINEA    VER81G0L0B.  371 

adult  liie,  and  men.  are  rather  more  liable  to  attack 
than  women.  Profuse  sweating  prepares  the  soil  to 
some  extent  for  the  fungus,  and  for  this  reason 
phthisical  subjectH  are  especially  liable  to  attack. 
Neither  good  health  nor  Bcrupuloua  cleanlioeBH, 
however,  is  an  absolatc  protection. 

The  patches  of  discoloration  are  composed  of 
massea  of  strongly  refracting  spores,  grouped  together 
in  masses  somewhat  resembling  bunches  of  currants 
amidst  interlacing  threads  of  mycelium  (Plate  I,, 
Fig.  7).  They  are  easily  found,  as  they  are  situated 
in  the  superficial  layers  of  the  epithelium. 

The  disease  is  not  unfrequently  mistaken  for  a 
secondary  syphilide,  but  any  doubt  as  to  its  nature 
can  be  set  at  rest  by  scraping  ofi  the  surface  of  the 
discoloured  patch  and  examining  it  microscopically. 

The  tPflatment  consist?  in  thorough  washing  with 
soft  soap  and  warm  water,  afterward'  rubbing  the 
part  with  a  flesh  brush  in  order  to  remove  the  natural 
oiliness  of  the  akin.  The  part  should  then  be  treated 
witli  iodine,  which  not  rnly  effects  a  rapid  cure,  but 
by  its  staining  power  brings  into  view  small  and  ill- 
dpfined  spots.  If  the  smell  of  iodine  la  objectionable, 
a  strong  solution  of  livposulptiite  of  woda  or  sulphur- 
ous acid,  diluted  to  one-fourth  with  wat-er,  maj  be 
used. 

Erythrasma  is  a  Eomewhat  rare  discpse,  and  so 
unimportant  that  it  need  only  be  briefly  referred  to. 
It  is  characterised  by  the  formation  of  brown  patches 
in  warm  and  moist  parts,  such  as  the  axilla,  the  groin, 
the  genito-crural  region,  and  between  the  nates.  The 
lesions  rause  no  symptoms  except  slight  itching. 

The  affection  is  due  to  the  growth  of  a  vegetable 
parasite,  Microsporon  mimitiMimtim  [Plate  T.,  Fig.  ?). 
The  treatment  is  the  same  as  that  recommended 
for  tinea  versicolor. 


CHAPTER   XVIII. 

LOCAL   INOCULABLE    DISEASES    (rmduded). 

III. — Other  MioKO-ORaANisMS.- 

The  local  isoculable  affectioDB  of  the  sldii  whioh  8 
known  to  be  caused  by  an  irritant  oi  microbic  nature 
are  impetigo  contagioBa,   sycosis,   boils,   caibimole,^ 
acne,  malignant  pustule,  and  Delhi  boil. 

Impetig'O  contagiosa  is  a    pustular   eruption 
caused^y  the  inoculation  of  pus  cocci.     The  appear- 
ance of  the  lesions  is  occasionally  preceded  by  some 
amount  of  febrile  disturbance.     Soon  small  erytiie- 
matous  spots  come  out ;   on  these  vesicles  form,  cm- 
taining  a  turbid  fluid,  which  rapidly  becomes  purulent 
(Fig.    19).      They  soon  break,  and  discharge  a  fiuld 
that    quickly    dries    up,    forming    yellowish    scabs 
In  uncleanly  persons  they  are  almost  alwajB  browi 
and    even    black,     from     dirt.       A     charaoteiietti 
feature  ts  that  the  scabs  have  no   halo  of  hypee-fl 
nmia  around  them,  but  look  as  if  they  were  stuck  o 
the  skin  with  gum.     Dotted  about  among  them  a 
pustules,  which  often  run  together  so  as  to  form  scab*  J 
of  considerable  size.     The  scabs  are  at  firet  looee,  ' 
but  afterwards  they  adhere  so  firmly  to  the  skin  ti 
their  removal  requires  some  force  and  is  followed  by  1 
a  little  bleeding.     The  raw  surface  thus  left  secrebea 
a    thick   purulent   discharge,    resembling    honey   in 
appearance  and  consistence,  which  in  its  turn  dries 
into  a  fresh  scab  ("  honeycomb  scab  ").     The  glanda 
in  the  vicinity  not  unfrequently  become  enlarged  a 
suppurate.    After  healing  a  reddish  stain  J 


niarged  and    j 


I 


I 


■    I 


:    •^< 


*  T       - 


vTK     11. 


".•  -.p.  - 


Foot. 


«.;iANT  Cells  of  Lupus. 

-'I'KLAS. 
"'■/.KMA. 
■'■>.MIX[S. 


'J'o  face  p.  37.'). 


OKtAP.  xvm.]     tMPBTlOO  CONTAGIOSA,  373 

which    after  a   time    completely   disappears.      The 
eruption  varies  greatly  in  severity,  being  sometimes 
limited  to  a  few  discrete  lesions,  sometimes  extending 
over  nearly  the  whole  body.     Sometimes  the  distribu- 
tion is  annular,  as  in  a  case  reported  by  Schamberg.* 
The  exposed  parts  are  more  likely  to  be  the  seat  of 
the  disease  than  those  covered  by  the  clothes.     The 
face  is  most  frequently  attacked,  the  lesions  being 
thickest  around  the  mouth  and  the  nostrils  and  on  the 
chin  ;   the  occipital  region  is  another  favourite  situa- 
tion.    In  all  these  places  the  disease  is  more  obstinate 
than  elsewhere.     In  some  cases   the  confluence  of 
numerous  lesions  covers  the  face  with  a  mask  of  scabs. 
Other  parts  may  also  be  the  seat  of  the  disease,  the 
following  being  the  order  of  frequency  in  which  they 
are  attacked :    Scalp,  nape  of  neck,  neck,  upper  ex- 
tremities, hands,  lower  extremities,  belly,  back.     In 
parts  where  the  pustules  are  exposed  to  friction,  as 
on  the  limbs,  they  are  generally  ruptured  in  an  early 
stage  of  their  development,  and  a  flat  irregular  scab, 
surrounded  by  a  more  or  less  pronounced  areola, 
forms    over    them.     These    lesions    were    formerly 
believed  to  constitute  a  distinct  disease,  to  which  the 
name  of  "  ecthyma  "  was  applied  ;   the  condition  is, 
however,  so  frequently  associated  with  contagious 
impetigo  as  to  make  it  certain  that  they  are  modifica- 
tions of  the  same  process. 

Duhring  describes  a  form  of  impetigo  distinct 
from  that  here  referred  to,  in  that  it  is  not  con- 
tagious, that  it  is  pustular  from  the  first,  and  that  all 
the  lesions  come  out  at  once,  not  in  successive  crops. 
My  own  experience  does  not  lead  me  to  agree  with 
Duhring  that  any  form  of  impetigo  is  non-contagious, 
and  the  cases  to  which  his  description  would  apply 
in  other  points  seem  to  me  to  be  simply  examples 
of  a  variety  of  impetigo  contagiosa. 

*  Journ,  Cut,  and  Gen,-  Urinary  Diseases,  May,  1896. 


374         WCAL  INOCULABLE  DISEASES,    [chap. 

Among  the  complications  of  impetigo  contagii 
may  be  meatiooed  boils  and  foIliculitiB. 
healthy  children  the  eruption  is  frequently  pustnlaZ 
from  the  first.  The  disease  often  occurs  epidemically. 
In  such  circumstances  it  runs  a  definite  course,  crops 
of  vesicles  continuing  to  come  out  foi  about  a  week, 
then  drying  up,  the  process  beii^  completed  in  about 
a  fortnight.  In  the  non-epidemic  form  the  affection, 
if  left  to  itself,  may  last  an  indefinite  time. 

Contagious  impetigo  is  much  more  common  in 
children  than  in  adult«.  The  scrofulous  diathesis  is 
a  powerful  modifying  factor.  The  exciting  agents 
are  staphylococci — pyogenes  aureus  and  albus — which 
are  found  in  the  vesicles,  pustules,  and  scabs,  and  in 
the  secTetion  under  the  scabs  {Plate  II.,  Fig.  T). 
Unna,*  who  prefers  to  call  the  disease  "  impetigo 
vulgaris,"  considers  that  it  is  caused  by  a  special 
coccua.  By  the  inoculation  on  himself  of  pure 
cultures"  of  these  micro-organisms,  Bockhardt  pro- 
duced lesions  exactly  similar  to  those  of  impetigo 
contagiosa.  His  results  have  been  confirmed  by 
Wickham  and  othera.f  In  addition  to  the  staphy- 
lococci just  mentioned,  Lerous  says  that  in  four  out 
of  five  cases  he  has  found  a  special  micrococcus, 
which  he  proposes  to  call  the  streptococcus  of 
impetigo. I  The  micro -organisms  are  present  in  the 
inflamed  tissue  in  the  very  first  stage  of  the  eruption. 
Contagious  impetigo  is  closely  allied  pathologically  to 
sycosis  and  boils,  both  of  which  conditions  are  caused 
by  the  staphylococci,  pyogenes  aureus  and  albu?. 
That  processes  presenting  well-marked  clinical  dif- 
ferences may  be  caused  by  the  same  irritant  will  be 
shown  in  the  section  on  tuberculosis  (p.  411).  Th*:, 
affection  is  not  only  contagions  from  one  person  tR 


*'.    /;•  /    »Ji 


-     PLATE    II. 

Fig.  1. — Actinomycosis. 

Fig.  2. — Fungus  of  Madura  Foot. 

Fig.  3. — Tubercle  Bacilli  (Lung). 

Fig.  4.— Lepra  Bacilli  from  Skin. 

Fig.  5. — Anthrax  Bacilli. 

Fig.  6.— Tubercle  Bacilli  in  Giant  Cells  of  Lupus. 

Fig.  7. — Staphylococci  in  Pus. 

Fig.  8.— Streptococci  in  Erysipelas. 

Fig.  9.— Bottle  Bacilli  in  Eczema. 

Fig.  10.— FiLARiA  sanguinis  hominis. 


To  face  p.  37'). 


CHAP.  XVTn.l      IMPETIGO   rOXTAdlOSA.  37.1 

another,  but  is  auto-inocuiable,  the  finger-nails  being 
the  chief  cftrriers  of  the  infective  material.  It  is  a 
frequent  comphcation  of  all  conditions  in  which  there 
is  troublesome  itching,  notably  of  scabies  and  pedi- 
culosis.    It  IB  often,  a  complication  of  vaccination. 

The  diagnosis  rests  mainly  on  the  scabby  appear- 
ance and  discrete  character  of  the  lesions,  the  absence 
of  hypcrapmift  around  them,  aiid  the  inoculahility  of 
the  disehftrgo.  In  favourable  circumstances  con- 
tagious impetigo  tends  to  spontaneous  cure  in  a  few 
weeks,  but  repeated  auto- inoculation  may  cause  it  to 
persist  indefinitely. 

The  treatment  consists  in  the  removal  of  scabs  by 
soaking  in  carbtdised  oil  or  carbolic  add  lotion  (1  in 
100)  and  the  application  of  a  weak  mercurial  oint- 
ment, such  as  ung.  kyd,  armnon.  or  ung.  hyd. 
nitratis  dilute,  siUphur,  or  other  parasiticide  remedy. 
The  whole  of  the  affected  parts  and  the  adjacent 
skin  should  be  washed  with  a  weak  antiseptic,  such 
as  boracic  acid  or  carbolic  lotion,  as  a  measure  both 
of  cure  and  of  prevention.  Scratching  shoald  as  far 
as  possible  be  prevented.  Inflammatory  and  other 
complications  must  be  treated  according  to  the  indi- 
cations. Weakly  and  ill -nourished  subjects  wil!  be 
benefited,  locally  as  well  as  generally,  by  cod-liver 
oil  and  iron. 

Sycosis  is  an  inflammatory  process  caused  by 
microbic  infection,  which  afEects  the  hairy  parts  of 
the  face,  and  especially  the  chin.  Tbe  disease  may 
attack  the  eyebrows,  the  eyelashes,  and  the  axillary 
and  pubic  regions  in  both  Hexes.  The  lesions  are 
acneiform  papules  or  nodules,  which  form  round  the 
hairs  and  develop  into  pustules,  each  of  which  is 
pierced  by  a  hair.  They  gradually  increase  in  number, 
and  may  extend  over  a  large  surface.  The  affection 
generally  begu:^  on  the  upper  lip,  and  may  remain 
limited  to  that  region.     As  the  suppurative  process 


376        WCAL  INOCULABLE  IJI3EA9ES.    [ci 

goes  on  the  liairs  are  looaened,  so  that  they  are  easily 
pulled  out,  a  drop  or  two  of  pua  generally  following 
them.  The  pus  dries  into  thin  brown  or  yellow 
adherent  crusts.  In  bad  cases  the  pustules  may  be 
so  thickly  Bet  together  as  to  form  infiltrations  which 
may  assume  a  fuogating  character.  The  process 
never  extends  beyond  the  limits  of  the  hairy  region. 
Sycosis  does  not  generally  cause  baldness,  becauao  the 
papilla  is  seldom  destroyed,  the  pua  lying  in  a  pouch 
formed  by  the  lining  membrane  of  the  follicle  and 
the  outer  sheath  of  the  hair.  The  disease  may  last 
in  varying  degrees  of  severity  for  an  indefinite  period. 
In  very  chronic  cases  there  is  always  a  good  deal  of 
scarring  from  previoua  lesiona,  and  occasionally 
cheloid  may  form  in  the  scars,  Brocq  has  deecribed, 
under  the  name  of  sycosis  Iwpo'ide,  a  variety  of  foUi- 
culitie  which  begins  at  the  upper  part  of  the  whiskers 
and  travels  downwards ;  there  is  a  narrow  erythe- 
matous margin,  and  the  process  gives  rise  to  m&riced' 
infiltration,  foUowed  by  cicatricial  atrophy.  Sycoeia, 
of  course,  in  its  typical  form  is  peciUiar  to  adult  males, 
but  follicuhtis  of  the  same  character  may  occur  in 
hairy  regions  in  women.  The  disease  is  conte^ons, 
as  Brooke*  has  pointed  out,  It  is  often  con- 
veyed by  the  shaving- brushes  of  barbers  who  art 
wot  particular  about  the  cleanliness  of  their  im- 
plements. 

Pathologically  the  aflection  is  an  inilammabuy 
process  starting  in  the  hair  foUicles,  each  foUiolA 
being,  in  fact,  converted  into  a  small  abscess.  Sycoeift 
is  inoculable  from  one  follicle  to  another  by  the 
transference  of  pus  cocci.  According  to  Unna,  then 
are  two  varieties  of  sycosis,  the  coccogenic  and  ths 
bacillogenic.  The  exciting  cause  of  the  former  is  thfl 
SStaphylococcus  pyogenes  albus  or  aureus ;  of  ihA 
latter,  the  Bacillus  sycosiferus  foetidUB.   The 

■  Bn(.  J<juni.  Dtriii.,  Dec,  1889,  p.  4G7. 


1 

De  ^H 
ss   ^H 


CttiP.  xvni,]  SYCOSIS.  377 

penetrates  more  deeply  into  the  follicle  than  the 
latter.  As  pus  cocci  are  always  present  in  the 
atnioapliere,  it  i8  clear  that  the  soil  must  be  prepared 
in  some  manner  before  they  can  take  root,  otherwise 
the  affection  wonld  be  far  more  common  than  it  ia. 
Tenderness  or  excoriation  of  the  skin  ia  therefore 
probably  a  necessary  condition  for  the  development 
of  Bycosis.  The  sebaceous  glands  are  affected 
secondarily  to  the  hair  follicle  ;  the  sweat  glands  are 
only  occasionally  involved.  The  inflammatory 
nature  of  the  disease,  ita  origin  in  the  folheles,  and 
its  limitation  to  the  hairy  parts  of  the  face  are 
charactfiiistic.  Eczema  is  not,  aa  a  rule,  limited  to 
the  hairy  parts,  and  the  inflammation  in  that  disease 
is  seldom  so  severe  as  m  sycosis.  Tinea  barbte  is 
distinguished  by  its  commencement  in  a  circinate 
scaly  patch,  by  the  early  breaking  of  the  hair,  by  the 
pain  caused  by  extraction  of  the  hair,  by  the  shape  of 
the  pustules,  which  are  conical  and  elevated  by  the 
lumpy  masses  on  the  inflamed  surfaces,  and  by  its 
special  fungus.  Tertiary  syphilitic  ulceration  is  not 
limited  to  the  follicles,  and  is  associated  with  a 
history  of  primiiry  infection  and  marks  of  previous 
or  coincident  specific  lesions. 

Sycosis  is  always  extremely  obstinate ;  and  as 
recurrence  after  apparent  cure  is  common,  the  prac- 
titioner must  not  he  too  sanguine  in  his  prognosis. 
The  treatment  is  to  remove  the  crusts;  then  to 
epilate  (a  process  which,  owing  to  the  loosening  of 
the  hairs  by  the  pus,  is  not  painful),  and  finally  to 
apply  soothing  and  antiparasitic  remedies.  The  re- 
moval of  the  hairs  opens  the  little  abscesses,  and  the 
mouths  of  the  follicles  are  thus  made  patent,  so  that 
remedies  can  penetrate  to  the  seat  of  the  disease.  In 
mild  cases  oleate  of  ntercujy  (1  to  2  fer  cent.)  or 
weak  sulphur  ointment  may  be  used.  When  the 
affection  is  more  severe,  ttrong  sulphur 


F 


k 


378       t/X\iL  IXOCCLABLE   DISEASES,     fcttip.  Jtvltt  T 

paste  (10  to  iO  per  cent.)  or  Unna's  m^olic-meminf 
plaster  muH  should  be  employed, 

Fumnculi,  or  boils,  are  ioflammatorv  awellinga  , 
caused,  as  ehown  by  Bockliardt.  by  the  actjoa  of  the  -^ 
Staphylococci  pyogenes  aureus  and  albus.    Their  se&t  1 
is  either  a  follicle  or  a  sebaceous  or  sweat  gland.  Tfaej-  1 
may  be  single  or  multiple,  in  the  tatter  C4se  being  I 
scattered  about  without  an\~  att-empt  at  grouping,  and  i 
coming  out  in   crops.     In   such   circumstances  th«  I 
process  may  last  a  considerable  time,  constituting  a   | 
condition    to    which    the    term    '"  furunculosis "    is 
applied.     The  lesion  begins  as  a  minute  red  papule, 
which  is  tender,  so  that  the  slightest  movement  causes 
pain,    >Soon  induration  can  be  felt,  and  the  boil  shows 
it«elf  on  the  skin  as  a  nodule  of  varying  size,  pceaenfc- 
ing  the  classical  characters  oi  inflammation.     Reeola- 
tion  may  take  place  within  a  few  days,  the  boil  sub- 
siding   without    suppuration    occurring.     This    con- 
stitutes the  "  blind  boil."    As  a  rule,  however,  it 
"points"   more  or  less  distinctly  on  the  third  -or 
fourth  day,  the  pustule  being  seated  on  an  induivted   , 
base,  aurrnunded  by  a  raised  red  area.     The  iaflftm-  . 
mstory  zone  tends  to  increase,  the  skin  on  the  surboe.  i 
of  the  boil  becomes  purple,  t«nse,  and  glistening,  and  M 
finally  gives  way,  about  the  eighth  day,  in  one  or  mora 
plaoes.     The  central  part  of  the  swelling  is  then  seta 
(o  be  occupied  by  a  white  pulpy  slough  ("core"), 
which  is  thrown  oS  in  a  day  or  two.     Before  rupttim 
till!  boil  and  the  skin  around  it  are  exquisitely  toider,   j 
and   the  heat,   tension,    and  throbbing  make  sleep  i 
impossible.     Lymphangitis    and    lymphadenitiB    are  i 
atten  set  up,  and  there  ie  usually  some  amount  ol  I 
constitutional  disturbance.     After  separation  of  th»  I 
core  thn  symptoms  subside,  and  thi;  resulting  cavity  I 
liealif  up  by  granulation,  a  scar  proportionate  to  tit*  1 
liKO  of  the  boil  Iwing  left.  ( 

A  special  form  of  boil  which  becomes  developwl  I 


U-] 


fvrvnovli. 


in  the  sweat-coils  has  been  described  by  Verneui], 
Dubreuilh,  and  PoUitzer.*  The  latter  records  a  case 
in  which  the  cheeks,  chin,  parts  of  the  neck,  and 
opper  part  of  the  shoulder  were  the  aeat  of  successive 
crops  of  small  tumours,  which  appeared  one  or  two,  or 
by  the  half-dozen,  at  a  time.  The  crops  came  out  at 
intervals  of  a  few  days  to  several  weeks,  and  the 
process  extended  over  eight  months.  T'he  lesion 
begau  as  a  nodule  deeply  seated  in  the  skin.  The 
nodule  was  at  first  neither  painful  nor  tender ;  it 
became  in  a  fortnight  as  large  as  a  pea,  and  slightly 
painful.  The  skin  over  it  was  red.  If  one  of  them 
were  opened  at  this  stage,  a  drop  of  pus  exuded.  If 
left  untouched,  after  a  few  days  a  httle  pus  was 
discharged,  after  which  Bhrinking  and  cicatrisation 
took  place,  the  whole  process  occupying  about  four  * 
weeks.  Two  nodules  were  excised  and  examined, 
when  it  was  found  that  the  tumours  were  evidently 
developed  in  the  sweat-coils,  the  coil  being,  in  the 

I  first  instance,  the    seat  of  infiltration,  and  its    in- 

*  timate   structure  being   finally  lost.     PolUtzer  calls 
afiection     "  hydradenitis     destruens    auppura- 

|l»va." 

Boiia  may  form  on  any  part  of  the  skin,  but  the 
parts  most  frequently  affected  are  the  face,  the  neck, 
and  the  buttocks.  In  the  case  of  single  boils  local 
irritation,  as  by  the  edge  of  a  stiff  collar,  or  friction, 
is  often  the  starting-point  of  the  trouble,  the  slight 
injury  of  the  tissues  thus  caused  making  the  part 
susceptible  to  the  action  of  the  staphylococcus.  If 
the  patient  is  subject  to  boils,  some  underlying  cou- 

^.stitutional  state,  such  as  amemia,  lithEemia,  or 
glycOBUria,  may  be  present.  Furunculosis  may  also 
.  sequel  of  acute  specific  fevers,  particularly 
mall-pox,  or  it  may  be  an  expression  of  some  sep- 

F.m,  Ciil.  aiidUen.-Unnari/  J)hea!ci,Sii.a.,  lS3i  ii,  9, 


380        LOCAL  ISOOULABLE  DISEASES,    [coav.  xvm. 

tictemic  condition.  Boils  may  multiply  themselvea 
by  auto- inoculation,  but  this  does  not  takfi  place,  as 
%  rule,  unless  the  patient  ia  in  a  bad  state  of  health. 
,  or  local  conditions  favourable  to  the  growth  of  the 
pus  cocci  exist.  Boils  are  common  as  secondary 
lesions  in  many  sldn  affections,  notably  in  scabies 
and  eczema. 

The  starting-point  of  the  process  is  a  hair  follicle 
■  sweat  gland. 

There  can  never  be  any  difficulty  about  the 
diag'nosis,  the  appearance  and  course  of  a  boil  being 
abaolutelycharacteristic. 

The  prog'nosis  is  always  favourable  as  regards  the 
cure  of  any  given  lesion  or  set  of  lesions,  but  the 
affection  is  very  apt  to  recur.  Single  boils  are  always 
amenable  to  treatment,  but  auto-inoculation  of  the 
pus  often  makes  definitive  cure  somewhat  difficult. 
In  furunculosis  the  prognosis  largely  depends  on 
the  extent  to  which  the  underlying  constitutional 
state  can  be  remedied. 

The  treatment  of  single  boils  depends  on  the 
stage  which  the  process  hae  reached.  When  just  oom- 
mencing  they  may  often  be  aborted  by  painting  the 
part  with  glycerine  of  belladonna,  or  with  tincture  of. 
iodirK,  three  or  four  times  a  day  ;  by  dabbing  with  a 
saturated  solution  of  boradc  acid  ;  by  the  application 
of  a  compress  steeped  in  spirit  of  camphor  for  a  few 
minutes  at  a  time  several  times  a  day ;  or  by  a 
solution  of  nitrate  of  silver  or  strong  carbolic  add. 
Unna  rcommends  the  use  of  the  fnercuric-carboUe 
■plaster  mull  as  an  abortive  in  the  fiist  stage,  and  as 
limiting  suppuration  to  the  centre,  and  causing  speedy 
and  painless  rupture  in  the  later  stages.  He  says  this 
rupture  thus  brought  about  ia  much  amalJer  than 
oould  be  made  by  incision,  and  soon  closes  under  the 

tec.  In  larger  boils  that  have  necrosed  the  plaster 
mull    accelerates    rupture,   or,   if  an  incision    hoa 


FVRUNOULI. 


I  already  been  made,  ahortena  the  time  of  healing  and 
eases  pain.* 
When  abortive  treatment  iaila  or  is  inapplicable, 
the  boil  should  be  incised  and  scraped  out,  and 
an  antiBeptic  dreaaii^ — iodoform,  carbolic  acid,  or 
Unna's  mercuTic-carbolic  plaster  mull  —  should  be 
applied.  As  each  boil  may  be  a  focus  of  further 
inlection,  it  should  be  destroyed  or  rendered  harm- 
less by  thorough  antisepsis.  For  the  same  reason 
it  is  altogether  unscientific  to  promote  maturation 
by  the  application  of  poultices  and  fomentations. 

Constitutional   treatment   may    be   required   for 

forunculoais.     Insanitary    surroundings    should    be 

remedied   and   the    health    improved   by    measures 

appropriate  to  the  special  incUcations  of  the  case, 

lithsemia,  anfemia,  glycosuria,  etc.,  being  dealt  with 

on  ordinary  principles.     The  drugs  most  generally 

useful  are  iron  and  quinine.     Duhring  finds  arsenic, 

given    *M  doses   of  one  to  three  minims  three  times 

a  day,    beneficial.     Sulphide    of   calcium,    which   is 

^^^^   recommended   by    Ringer    as    almost   a    specific   in 

^^^^L'inrunculoais,  has  not  proved  successful  in  piy  hands. 

^^^^v       Carbuncle  may  be  defined  as  a  boil  aSecting 

^^^^Ri^veral  neighbouring  glands.     The  process  is  akin 

^^^^Bto  furuncle,  but  is  more  severe  in  its  local  efEects, 

^^^^nnd  accompanied  by  greater  constitutional  disturb- 

^^^^Bauce.     The  lesion  commences  as  an  infiltration  in 

^^^^piihe  subcutaneous  tissue  or  deeper  parts  of  the  true 

I  skin;    it  is  at  first  slightly  raised,  firm,  rounded  in 

outUne,  and  bright  red  on  the  surface.     In  mild  cases 

retrogression  may  begin  at  the  end  of  a  week,  and 

.-  complete  resolution  may  take  place.     In  most  cases, 

,  the  process  extends,  and  in  ten  days  or  a 

fortnight  forma  a  deep-seated,  circumscribed  swelhng 

iB  large  as  the  palm  or  larger,  with  a  brawny  base,  the 

I  Dermatology,"  New  Sydeuhnia 


i 


382        LOCAL  INOCULABLE  DISEASES,    [chap.  svm. 

skill  over  it  being  of  a  purple  colour.  Softening  takes 
place  in  the  centre,  and  the  surface  becomes  dotted 
with  suppurating  points,  which  break,  giving  issue  to 
blood-stained  pus.  This  cribriform  mode  of  rupture 
is  oharacteristic  of  carbuncle.  The  carbuncle  often 
continues  to  spread  even  after  the  pus  has  fooad  a 
vent.  The  skin  between  the  holes  stougha,  and  the 
necrotic  mass  or  core  underneath  slowly  separatee! — 
taking  from  fourteen  days  to  two  months  in  the 
process — sometimes  as  a  black,  dry  eachar,  sometimes 
as  a  pultaceouB  mass,  more  frequently  as  a  yellow, 
ragged  slough,  with  a  .most  offensive  smell,  The 
neighbouring  glandi^  are  usually  swollen.  The  procesB 
is  accompanied  by  rigors,  fever,  aching  in  the  back 
and  limbs,  and  general  tnalaise.  Death  may  result, 
especially  in  elderly  or  weakly  subjects,  from  sep- 
tictemia  or  exhaustion,  especially  when  the  lefion 
occurs  on  the  face.  After  separation  of  the  slough 
a  deep,  irregular  cavity  is  left,  which  heals  by  granu- 
lation, a  dense,  puckered  scar,  which  is  not  unfre- 
quently  pigmented,  resulting. 

I  Carbuncle  is  generally  single,  and  occurs  especially 
where  the  skin  ia  thickest — on  the  nape  of  the  neck 
on  the  back,  the  buttocks,  shoulders,  and  foie-arnu. 
It  is  sometimes  seen  on  the  face. 

Pathologically,  the  process  is  identical  with  that  of 
funincutus,  but  the  inflammation  is  deeper  and  more  , 
destructive.     It  is  generally  believed  to  begin  in  the 
pilo-sebaceous  follicles  and  sudoriparous  glands. 

The  exciting  cause  of  carbuncle  is.  as  in  furun- 
4Ulus,  an  invasion  of  staphylococci.  Men  are  more 
irequently  attacked  than  women.  Anything  that 
tends  to  lower  vitality  may  be  a  predisposing  caiiM, 
diabetes  in  particular  being  often  associated  with  titB 
disease.  It  may,  however,  occur  in  persons  appar- 
ently in  perfect  health. 

The  diagnosis  of  carbuncle  can  seldom  be  doubt- 


CHAP,  xvm.]  CARBUNCLE.  383 

ful,  the  multipie  yellow  points  and  openings  being 
sufficient  to  distinguish  it  from  furuncle  ;  and  these 
features,  together  with  its  circumacrihed  outline, 
differentiate  it  from  diffuse  ceUulitis. 

A  guarded  prog'DOSlS  should  always  be  given  in 
cases  of  carbuncle,  especially  when  situated  on  the 
face,  as  death  from  septiciemia  is  not  uncommon. 
The  si^e  and  position  of  the  swelling,  and  the  age 
and  state  of  health  of  t!ie  patient,  are  the  chief 
points  on  whieh  the  prognoaia  must  be  based. 

The  treatment  for  small  carbuncles  ia  the  same 
as  for  boils.  The  free  painting  of  the  surface  with 
glyceritte  of  belladonna  will  ease  the  pain,  reduce  the 
inffammation,  and  possibly  bring  about  resolution, 
Unna  recommends  the  application  of  a  mercury- 
earbolie  j)laster  mull,  the  parts  heing  bathed  with  a 
solution  of  ammonia  or  alkali  before  a  new  plaster  is 
applied.  If  the  skin  is  about  to  break,  a  crucial 
incision  should  be  made  and  the  necrotic  contents  of 
the  swelling  cleared  out  with  a  sharp  spoon.  The 
cavity  should  be  well  scraped  and  all  the  friable 
tissue  removed,  and  the  cavity  should  be  syringed  out 
with  some  strong  antiseptic  solution  such  as  carbolic 
acid,  and  finally  filled  with  iodoform,  subsequent 
treatment  being  on  the  accepted  lines  of  antiseptic 
surgery.  Constitutional  treatment  is  always  re- 
quired. It  should  be  directed  to  supporting  the 
patient's  strength  by  every  available  means — liberal 
diet,  and  the  free  use  of  tonics,  especially  percfUoride 
of  iron  and  quinine.  If  the  pain  is  very  severe 
morphia  should  be  given,  preferably  in  the  form  of 
hypodermic  injections.  Stimulants  should  be  with- 
held till  the  slougli  has  been  cleared  out,  after  which 
wine,  such  as  port  or  burgundy,  may  be  given  with 
great  advantage. 

Slalig'nant  pustule  is  a  disease  caused  by  in< 
oculation  with  the  anthrax  bacillus  (Plate  II.,  Fig. 


38-1      LOCAL  INOCVLABLB  DL^EASES.      [ra 

5) ;    it  corresponds  to  the  splenic  fever  o!  ai 
The  inociUation  givea  rise  to  skin  lesions  followed 
signs  of  constitutional  infection.    The  most  commi 
site  of  inoculation  is  an  exposed  part  of  the  sldzi,  8U( 
as  the  face,  the  neck,  or  the  hands.     The  develop- 
ment of  the  initial  lesion  is  preceded  by  local  itching 
and  burning,  and  at  the  spot  to  which  these  aensa- 
tions  are  referred  a  livid  red  papule  soon  appears. 
this  a  bulla  or  a  pustule  quickly  forms  and 
breaks,  drying  up  into  a  black  gangrenous  eecl 
fringed  with  tiny  vesicles  or  pustules  and  surroundi 
by  a  wide  zone  of  solid  (edematous  infiltration, 
skin  over  which  is  tense  and  violaceous  in  ooloi 
The    gangrenous  process   may    spread  rapidly, 
process  soon  ending  in  death  ;   or  it  may  be  localised, 
in  which  case  a  slough  is  thrown  off  and  the  resulting 
sore    heals     by     granulation.      The     constitutional 
symptoms  are  those  of  septic  fever,  to  which 
patient  may  succumb  within  a  week  or  ' 
severe  cases  recovery  takes  place  slowly. 

The  etiologfy  of  the  disease  is  imphed  in  \\»  d( 
tion.     Inoculation   takes   place   from    handlinj^ 
hides  of  diseased  animals,  and  butchers,  wool-sorters, 
etc..  are  therefore  most  liable  to  infection. 

The  pathological  process  is  local   infli 
reaction,  followed   by  gangrene   and '  general    sepl 
phenomena   due   to   the  introduction   of 
irritant,  the  anthrax  bacillus.     This  is  a  rod-shft] 
micro-organism  which  grows  in  the  blood  and  all 
tissues. 

The  diag'nosis  rests  on  the  presence  of  a  ganp 
ous  patch  surrounded  by  infiltration  i 
whose  occupation  expoties  him  to  infection  with  t 
virus  of  anthrax. 

The  pFO^OSis  depends  on  whether  the  gan£ 
ous  process  continues  to  spread  or  not.     The  seveiil 
of  the  constitutional  symptoms  must  also  be  t 


tional 


THAP.  sviii.]     MAI.mNANT   PVSTVLE.-    ACNK.        385 

into  account.     The  mortality  varies  from  one-tliird  to 
one -half  of  those  attacked. 

The  most  efficacious  treatment  ia  the  immediati' 
and  thorough  excision  of  the  initial  lesion,  or  free 
scraping  on  the  lines  indicated  for  the  treatment  nf 

Dissection  wounds. — The  inoculation  of  septic 
material  from  a  dead  body,  us  when  the  hands  are 
pricked  or  scratched  in  dissecting  or  post-mortem 
work,  may  give  rise  to  pustules  or  small  abscesses  at 
the  seat  of  injury,  or  to  lymphangitis  and  cellulitis, 
which  may  be  followed  by  pyremia.  The  skin  lesions 
must  be  treated  antiseptically,  and  constitutional 
symptoms,  if  they  arise,  be  dealt  with  on  general 
principles. 

Acne  has  been  placed  in  this  group,  although  its 
title  to  lip  looked  upon  as  an  inoculable  affection  in 
the  strict  sense  is  somewhat  questionable.  It  is 
certainly  the  least  inoculable  of  any  of  the  diseases 
inchided  in  the  group  under  consideration,  but  its 
pathological  affinities  with  boils  and  other  suppura- 
tive lesions  in  which  staphylococci  play  a  leading 
part  make  its  provisional  inclusion  in  the  same 
category  convenient.  Acne  is  an  inflammatory 
process  in  and  around  sebaceous  glands,  leading  to  the 
development  of  pustules  and  sometimes  to  scarring. 
The  inflammation  generally  supervenes  on  occlusion 
of  the  duct.  The  plug  causing  the  I '  ' 
the  sebaceous  secretion  itself,  formed  ii 
mixed  with  epithehal  debris,  etc.  (acue  vnlgaria),  or 
some  greasy  material,  e.g.  tar,  derived  from  without. 
The  latter  and  other  forms  of  artificial  acne  caused  by 
drugs  and  chemical  substances  will  be  found  described 
in  the  chapter  on  "  Artificial  Eruptions "  {p.  202). 
The  inflammatory  process  may  also  be  primarily 
due  to  local  circulatory  disorder,  sebaceous  obstruc- 
tion being  a  secondary  o 


itule  ^^ 
1  d^H 


G  LOCAL  INOCVLABLE  DISEASES,  [chap,  s: 

In  acne  VUlg'aris  the  obstruction  may  be 
the  mouth  of  the  sebaceous  ghind-duct,  the  plug  beii  _ 
visible  on  the  surface  as  a  small  black  point  (comedo), 
or  in  the  gland  itself,  when  the  obstructing  materia 
is  seen  as  a  tiny  whitish  mass  in  the  substance  of 
the  skin  (milium).  The  primary  lesion  is  a  red 
papule,  which  may  become  pustular,  the  pustule 
being  seated  on  a  raised  red  base.  The  afiecl 
Ib  met  with  in  varying  degrees  ol  severity,  &om 
few  scattered  papules  to  numerous  lesions  in  » 
stages  oi  development.  The  process  may  be  arrestedT 
in  any  stage,  some  lesions  undergoing  involution, 
while  others  suppurate  and  in  course  ol  time  rupture. 
The  individual  lesions,  as  a  rule,  run  an  acute  course, 
but  the  afiection  as  a  whole  is  chronic,  fresh  cro] 
ol  papules  and  pustules  coming  out  as  others 
appear.  The  pus  may  be  discharged  without 
visible  scar  being  left,  but  where  the  suppuration 
been  extensive  and  deep,  considexable  scarrii^ 
consequent  deformity  may  result.  On  the 
cheloid  occasionally  forms  in  the  cicatrices  (i 
cheloiil).  In  some  cases  the  inflammatory  pi 
extends  to  the  tissues  round  the  sebaceous  gli 
and  a  hard  red  or  purplish  nodule  is  formed, 
seldom  ruptures,  but  leaves  a  livid  indurated  ait 
that  slowly  disappears  (ooie  in^uraia). 

The  favourite  situations  of  the  lesions  of 
vulgaris  are  the  face,  especially  on  the  cheeks, 
forehead,  and  chin,  the  back  of  the  neck,  the 
between  the  shouldere,  and  the  chest.  The  aSection 
may,  however,  develop  wherever  there  are  sebaceous 
glands  ;  thus  it  is  sometimes  seen  on  the  back  of  ths 
thigh  and  arms.  The  lesions  are  tender, 
'      'y  appearance 


tion  gives  rise  to  n 


The  skin  b 


the  lesions  is  usually  more  or  less  greasy. 

The  predisposing*  causes  of  a 


CBAP.  xvin.]  ACNE:  STIOLOoy.  387 

an  aaatomical  factor ;  (2)  certain  physiological  fac- 
tors ;  aad  (li)  a  bacteriological  factor,  althougli  the 
exact  measure  of  its  importance  is  for  the  present  some- 
what doubtful.  The  anatomical  factor  cooaists  of  a 
structural  coarseness  of  skin,  which,  from  its  excessive 
richness  in  large  sebaceous  glands,  is  naturally  greasy 
and  especially  liable  to  retention  of  secretion.  The 
physiological  factors  are  (o)  age,  (b)  reflex  circulatory 
disorder.  Acne  vulgaris  is  essentially  a  disease  of 
puberty,  and  as  the  time  of  the  great  physiological 
change  indicated  by  that  term  varies  within  consider- 
able limits,  the  age  at  which  acne  shows  itself  ranges 
from  twelve  to  twenty-five  years.  With  the  advent 
of  puberty  certain  glands  undergo  great  and  rapid 
development,  and  in  particular  there  is  a  growth  of 
new  hair  in  certain  parts.  These  changes  in  persons 
whose  sebaceous  glands  are  already  inclined  to  over- 
activity are  likely  to  be  followed  by  plugging  of  the 
ducts,  and  consequent  interference  with  the  capillary 
circulation  around  the  gland  and  tendency  to  inflam- 
mation. These  conditions  ate  increased  by  reflex 
circulatory  disturbance  due  to  the  strain  thrown  upon 
the  nervous  system  by  the  changes  taking  place  at 
puberty,  aggravated  in  many  cases  by  disorder  of  the 
digestive  organs,  functional  disturbance  or  irritation 
of  the  sexual  apparatus,  aniemia,  and  in  some  cases, 
probably,  educational  over-pressure.  Lastly,  the 
sebaceous  matter  plugging  the  duct  becomes  a  suit- 
able soil  for  micro-organisms.  There  is  at  present  no 
evidence  to  show  whether  these  are  primary  or 
secondary  factors  in  the  acne  process.  The  Demodex 
folliculorum  (Pig.  16,  c),  which  is  found  in  comedones, 
appears  to  have  no  etiological  importance.  It  is  not 
improbable,  however,  that  further  research  will  lead 
to  the  discovery  of  a  specific  micro-organism  as  the 
cause  of  acne.  In  the  suppurative  stage  staphylo- 
cocci  are   present.     According   as   one   or   other  of 


LOCAL  ISOCCLABLE  DISEASSS.  fcHAP. 


the  factore  mentioned  ia  preponderant,  sub-varietiw 
of  acne  may  be  produced. 

The  pathological  process  is  an  inflammation  arisii^ 
in  the  sebaceous  glands  in  the  manner  already  indi- 
cated, and  in  many  cases  running  on  to  suppnration. 
Inflammatory  changes  are  always  present  in  the  con- 
nective tissue  around  the  lolhcle.  When  suppura- 
tion occurs,  the  pua  may,  if  alight  in  amount,  escape 
by  natural  drainage  through  the  duct,  and  the  gland 
may  in  this  way  escape  destruction  ;  usuaUy,  how- 
ever, both  the  gland  and  the  follicle  are  destroyed, 
and  inore  or  less  of  the  perifollicular  tissue  undergoes 
necrosis,  with  consequent  sear- formation.  In  acne 
indurata  there  ia  fibrosis  for  some  distance  around  the 
follicle.* 

Acne  vulgaris  can,  as  a  rule,  be  recognised  wttb"' 
out  any  difficulty  by  the  presence  of  comedones,  thfli' 
discrete  character  of  the  eruption  and  its  distribu- 
tion, and  the  patient's  age.    Artificial  acne  must  be 
ejccluded  by  inquiry  into  the  patient's  occupation  and 
recent  medical  history.     Rosacea  is  most  common  in 
middle  life,  chiefly  aficcta  the  "  flush  area  "  of  lli*_ 
face,  and  ia  markedly  congestive  in  character,  dilsl 
tion  of  superficial  vessels  being  a  conspicuous  leato: 
Pustular  syphihdes  are  generally  grouped,  which 
never  the  case  with  acne  pustules,  and  there  is  o\' 
evidence  of  the  disease. 

Acne  vulgaris,  even  if  left  untreated,  tends  iA. 
the  course  of  years  to  disappear.     The  duration  of' 
the  affection  can,  however,  generally  be  consideiably 
shortened  by  treatment. 

The  treatment  is  preventive  and  curative 
Patienta  the  texture  of  whose  skin  pred 


'■Hislojulhologj  of  Skin  Di8ea»i«" 


Sf; 


OHAP.  _YvnLl         ACNE:    TREATMENT.  389 

retention  of  the  sebaceouB  secretion  should  wash 
thoroughly  several  times  a  day,  with  the  object  of 
clearing  away  the  coarse  epidermis,  keeping  the 
mouths  of  the  ducta  open,  and  atimulating  the  cir- 
culation. The  face  and  other  parts  Uable  to  attack 
should  he  vigorously  scrubbed  with  soap  and  flannel. 
As  a  further  meaBure  of  prevention,  some  stimulant 
and  parasiticide  ointment  should  be  rubbed  in  ;  for 
this  purpose  sulphur  ointment  (10  grs.  to  the  otmce)  is 
very  useful.  The  general  health  must  at  the  same 
time  be  attended  to.  Alcohol,  tea,  coffee,  and  all 
stimulating  food  that  causes  reflex  flushing  of  the 
skin  should  be  avoided.  Smoking  and  se^^ual 
excitement  are  likely  to   be  injurious  for  the  same 

Curative  treatment  includes  local  and  general 
'measures.  If  suppuration  has  not  yet  occurred,  the 
comedones  should  be  squeezed  out  by  means  of  an 
instrument  suitable  for  the  purpose  :  the  part  should 
then  be  washed  frequently  and  energetically  with  soft 
soap  and  coarse  flannel.  A  mixture  of  spirit  and  soap, 
such  as  the  spiritua  saponis  alkalinus  of  Hebra,  is 
useful  in  dissolving  and  softening  the  sebaceous 
matter.  The  skin  should  be  disinfected  by  applying 
sidphur  ointment  {grs.  %  to  Jj),  rescircin  [grs.  x  "  (o  3/ 
of  ung.  parafjini),  icfUhyot,  or  carbolic-  acid  in  the  form 
of  ointment.  When  suppuration  has  occurred,  the 
pustules  should  be  punctured  or  incised,  and  after- 
wards bathed  with  hot  water  so  as  to  encourage 
bleeding,  and  then  dressed  antiseptically.  The 
cavity  may  with  advantage  be  touched  with  strong 
carbolic  acid  solution.  Each  pustule  must  be  treated 
individually;  the  method  requires  perse  vera  m,'c,  but 
is  effectual.  When  the  inflamed  papules  are  of  con- 
siderable size,  each  one  should  be  isolated  by  covering 
it  with  Unna'a  mercury-carbolie  plaster  mull.  This 
should  be  left  oa  for  about  twelve  hours  or  more  ; 


I 


390        LOCAL  INOCULABLE  DISEASES,     [chap,  j 

after  removal  the  part  should  be  dried  with  cottoo  ] 
wool,  then  washed  with  corrosive  sublimate  soluiicm  I 
(1  in  2,000),  and  covered  with  a  fresh  piece  of  plaster.  [ 
la  all  cases  of  acne  of  the  body,  reinfection  from  the  1 
clothing  should  be  prevented  b)'  frequent  changes  J 
of  the  garment  worn  nest  to  the  afiected  part, 
and  washing  the  adjacent  unaSected  skin  with  an 
antiseptic  wash  or  soap. 

Constitutional  treatment  must  be  directed  to  the 
rectification  of  any  functional  disorder  that  may  be 
a  possible  souice  of  reflex  circulatory  disturbance. 
Particular  attention  must  be  paid  to  the  diet  and    , 
habits,  on  the  lines  already  laid  down  in  speaking  of  . 
prevention.     The  best  tOTiics  are,  generally  speaking,    , 
quinine  and  arsenic,  but  the  special  indications  oi  me'  ■ 
case  must  be  taken  as  guides.     When  the  patient 
presents  evidence  of  a  scrofulous  taint,  cod-liver  oS^m 
and  syrup  of  the  iodide  of  iron  must  be  given.  Careful  J 
regulation  of  the  mode  of  living  is,  however,  of  moie  "1 
use,  as  a  rule,  than  drugs.     The  patient  should  be  in- 
structed to  wear  suitable  clothing — that  is  to  SAy, . 
such  as  keeps  the  body  comfortably  warm  without   j 
causing  irritation — to  take  proper  exercise,  to  batite  -' 
frequently  (the  Turkish  bath  being  especially  useful  | 
for  those  whose  internal  organs  are  sound),  and  to  1 
live  a  wholesome  life  in  hygienic  surroundings. 

Acne  variolifOPmis  is  a  somewhat  rare  form  of  I 
aene,  characterised  by  red,  flat  papules,  which  becontai  J 
pustular,  and  then  dry  up,  forming  scabs.  The  Ui* 
are  at  first  limited  to  the  centre  of  the  lesion,  i 
is  depressed  below  the  level  of  the  periphery.  LaUr'] 
the  scab  covers  the  whole  surface  of  the  papule,  endl'l 
on  separating  it  leaves  a  small  depressed  pennaseiife  ^ 
scar  resembling  a  small-pox  "  pit."  This  process  is  ' 
regarded  by  some  as  a  local  necrosis ;  hence  the  oSbo-*  ' 
sometimes  called  "  acne  nfcrolica."  A  distmc^^  I 
feature  of  this  afiection,  as  compared  with  odUpJ 


^^^^^egarded  h 
|^HHE>»i  is  son 
^^^^^B  %  featuj 


CHAP.  xvuL]       ACNE    VABinUFORMIS.  mi 

vulgaria,  ib  that  the  lesions  are  grouped.  The  fore- 
head is  the  part  moat  commonly  att.aeked,  but  the 
Bcalp  and  the  face  may  be  the  seat  of  the  eruption, 
which  has  also  been  seen  on  the  cheat  and  back.  The 
affection  causes  no  inconvenience  beyond  a  little 
itching  and  the  unsightlineas  of  the  lesions  when  they 
are  on  the  face.  Both  sexes  seem  to  be  equally  liable 
to  this  form  of  acne  ;  it  is  rare  under  the  age  of 
thirty.  Some  authorities  consider  it  to  be  connected 
with  syphilis,  but  with  this  view  I  do  not  agree. 
According  to  Touton,  the  process  is  inflammatory,  and 
leads  to  necrosis  of  the  cutis  and  overlying  epidermis. 
In  a  case  in  which  he  made  careful  observations, 
he  found  four  species  of  micro -organisms,  but  he  is 
inclined  to  look  upon  their  presence  as  secondary, 
and  probably  determined  by  the  antecedent  changes 
in  the  integument.* 

Acne  varioliformis  can  be  identified  by  the  absence 
of  comedones,  by  the  grouping  of  its  lesions,  the 
pitting  which  it  leaves,  and  its  preference  for  the 
forehead  (which  is  so  marked  that  it  is  sometimes 
called  acne  frontalis). 

It  is  curable,  but  recnrreace  is  almost  certain. 

Troatment  must  be  directed  to  the  improve- 
ment of  the  general  health.  Iron  and  cod-liver  oil 
are  particularly  useful.  The  local  treatment  is  that 
recommended  for  acne. 

Among  other  rare  varieties  of  acne  may  be  men- 
tioned one  described  by  Tilbury  Fox  as  "  disseminated 
follicular  lupus,"  but  evidently  having  httle  or  no 
'  affinity  with  the  lupus  process.  According  to  Crocker,t 
who  saw  the  cases,  the  lesions  were  very  like  those  of 
what  IB  now  known  as  adenoma  sebaceum,  but  more 
conical  and  disseminate,  and  not  massed  together  at 
the  naso-labial  fold.  Microscopically,  there  was  fibro- 
1.  2fi.>. 

DDd  BclitiOH,  IKiW,  ]).  711. 


«< 

(p.  »*»■ 

|VriMie.~-CBder  Aaa  dvik  Jnstin  Lenuust» 
<l(W3thel  tor  tlw  fint  tone,  in  ISSJ.  a  Tariet>-  of 
HuwiK  stoautHn  «fiKtiBe  tbe  Upe,  chiefiT  at  the 
fnmBHnitvH.  1W  disMM  is  ftlmoet  pecoli&r  to 
,-KiMk>'>'»l.  Thp  lesKMts,  which  are  generally  sj-m- 
mitrii-it,  rflnsisi  of  "a  eiubeiance  of  the  epitiielium, 
whHMi  IB  )>»«,  which  looks  as  if  it  were  macerated, 
^w  i)«t»chrd.  The  lesion  aometimes  extends 
tftoroM  (lie  lip.  The  derm  is  not  exposed, 
I  being  limited  to  the  epithelium  and 
~  )  otiAract«ristic  feature  is  a  kind  of  " 


CHAP,  xvm.]  PEBLECBE.  393 

whitish  pellicle,  projecting  and  wrinkled  about  the 
corners  of  the  hpa,  which  have  thus  a  fisBuied  appear- 
ance. There  is  often  only  a  single  patch,  divided  by 
the  fissure  into  two  equal  parts  so  as  to  present  the 
appearance  of  the  two  pages  of  an  open  book  (P. 
Rajnnond).  In  other  cases  the  patch  is  multiple,  and 
may  extend  to  the  inside  of  the  hp  at  the  commisBure. 
There  is  httle  or  no  pain,  but  a  feeling  o£  discomfort 
and  heat  which  makes  the  child  constantly  Hck 
its  lips  (pourWcAer  ,■  hence  the  name  perleche).  When 
the  fissures  extend  deeply,  however,  they  Bometimea 
reach  the  dejm,  and  pain  is  felt  on  opening  the  mouth. 
Other  lesions  are  often  associated  with  perUche — 
diphtherioid  or  impetiginous  stomatitis,  crusts,  vesi- 
cular erythema,  etc.  It  has  been  suggested  that 
these  are  all  manifestations  of  one  disease. 

The  duration  of  perleche  is  usually  from  a  fortnight 
to  a  month  ;  sometimes  it  lasts  longer,  possibly, 
us  suggested  by  Lejnaistre,  as  the  result  of  successive 
inoculation.  It  tends  to  spontaneous  recovery,  but 
leaves  behind  a  smooth,  mother-of-pearl  tinted  sur- 
face, which  may  persist  for  months.  Relapse  is 
common.  The  diagnosis  is  easy,  the  only  difficulty 
being  to  distinguish  ■perleche  from  syphilitic  lesions. 
It  is  well  to  regard  all  children  presenting  the  lesions 
described  as  affected  with  syphilis  tiU  it  is  clearly 
established  that  there  is  no  s}rphihs, 

Perleohe  is  said  by  Lemaistre  to  be  caused  by 
the  Streptococcus  plicalilis,  which  was  found  in  all 
cases  examined,  and  which  he  successfully  cultivated. 
Others  have  attributed  the  affection  to  a  variety  of 
the  Staphylococcus  albus,  to  the  Staphylococcus 
aureus,  and  to  any  of  the  microbes  present  in  the 
mouth.  It  is  admitted  by  all  that  the  disease  is 
contagious  and  may  be  epidemic.  Hence  care  should 
be  taken  to  prevent  the  common  use  of  pencils, 
drinking  maga,  towels,  etc.,  in  schools.     The  treat- 


394      LOCAL  IXOCCLABLE  DISEASES.      [ra 

Rient  consists  in  cauteriaation  with  sulphate  of  copper 
or  nitrate  of  silver,  followed  by  the  application  of 
protective  ointment  of  vaseline  and  oxide  of  zinc* 

Fupunculus   Opientalis  (Delhi   boil,    Aleppo 

boil,  Biskra  button)  is  a  tropical  liiHeaee  the  ledos 
of  which  is  a  boil  which  breaks  down,  forming  a  foul 
ulcer.  The  process  is  unattended  with  constitutional 
disturbance.  It  has  been  proved  to  be  inocnlable 
both  iu  men  and  in  animals,  but  the  particular  para- 
site responaible  for  its  production  has  not  yet  been 
identified.  There  is  some  evidence  that  the  poison 
is  water-borne,  and  is  conveyed  into  the  system  either 
by  drinking  or  washing.  The  treatment  is  the  samo' 
8  for  boil  or  carbuncle.t 

Pinta,  carate.  or  "  spotted  sictness,"  ia  an  aSec-. 
tion  endemic  in  the  tropical  regions  of  America.  Ifr 
is  characterieed  by  a  peculiar  discoloration  of  tha 
akin,  with  continuouB  deaquamatinn.  Four  forms  of 
the  affection  are  described— grey,  blue,  red,  and  whiM 
—but  they  are  all  varieties  of  the  same  process.  Tha 
disease  is  probably  caused  by  a  fungus,  though  some 
authorities  are  more  inclined  to  attribute  it  td  a  ' 
bacillus. {  In  the  grey — also  called  the  black — 
variety,  spots  of  a  leaden  hue  appear  on  the  iace,  the  ■ 
tint  deepening  almost  to  black  as  they  spread.  The 
spots  are  irregular  in  shape,  slightly  scaly,  and  do  not 
disappear  on  pressure  ;  the  discoloration  catmot  ba 
rubbed  off.  The  whole  face  may  be  blackened,  i 
making  the  patient  look  like  a  negro,  but  usually  then 
are  patches  of  normal  or  less  discoloured  skin.  PatcbM 

,  *  For  a  fuller  account    of  prrlicAe  (by  JaiH|ii«l)  *w  Brocq^  I 

"Pntique  Dernutolo^qae,"  t.  iii.,  p,  839  et  v/u.     P»ria,  IBm.  J 

'         tFor  a  further  luxwuiit  jw  b  paper  bv  J.Muriaj,   zVmu.   ] 

.   £yiA™.  .W..  1883,  p.  90,  *l 

I  iS>i>  a  "  [ti^purt  on  Conte  to  the  HygiotiJo  Cotntnitleo  of  tbkJ 

D«niutineut  iif  OuDi:]!,  Reuulilic  of  Colonibiu."  publUhcd  In  tlw  •] 

StUlin  'h  Jtrdii-iui  M  Cnura,  Much,  1ND3.       On  lliis  report  tka  1 

deaoipticin  at  the  distoie  here  giTon  is  largely  Insed,  I 


per  H 

ppo^B 
ios  ^H 
nul  ^ 


of  discoloration  also  appear  on  the  limbs,  especially 
m  the  parts  riuli  in  pigment  and  most  expoBed  to  the 
Bun,  Buch  as  the  external  Burfacee  of  the  arms  and 
le^  the  dorsum  of  the  foot,  the  back  of  the  hand,  the 
extensor  aspects  of  the  joints,  etc.  The  trunk  may 
also  bo  the  seat  of  similar  lesions,  but  the  whole  of 
the  skin  is  never  invaded.  Sometimes  there  is  con- 
siderable itcliiug,  and  then  desquamation  is  more 
active.  After  a  time  the  affected  surfaces  become 
hareh  and  rough,  and  the  skin  appears  to  be  thickened 
and  more  vascular  than  normal.  In  this  stage  the 
patients  often  give  off  a  penetrating,  musk-Like  odour. 
There  is  no  sensory  or  other  functional  alteration  in 
the  skin. 

The  blue  variety  also  affects  the  face  and  the 
limbs.  The  spots,  which  are  more  irregular  in  out- 
line than  in  the  grey  variety,  are  of  a  bluish  tint, 
Bometimes  of  a  leaden-grey  shade,  sometimes  violet, 
sometimes  dark  indigo  blue.  The  discoloration  in 
some  cases  occurs  in  numerous  small  patches,  giving 
the  patient  a  "  spotted  "  appearance  ;  in  others  it  is 
diffused  so  generally  over  the  body  that  the  prevailing 
colour  of  the  sldn  is  blue.  Tier  *  denies  the  parasitic 
origin  of  the  disease,  and  considers  that  it  is  the 
attempt  of  Nature  to  render  man's  skin  suitable  to 
tropical  climates.  He  believes  that  the  pigmentary 
changes  are  akin  to  those  caused  by  sunburn. 

In  the  red  variety,  which  attacks  by  preference 
fair  persons  with  a  delicate  skin,  the  distribution  of 
the  lesions  is  the  same  as  in  the  two  already  described, 
but  the  patches  of  discoloration  are  smaller.  The 
affected  parts  arc  blood-red,  or  sometimes  of  the 
colour  of  beetroot.  The  skin  is  rough  and  vascular, 
and  is  often  marked  with  fissures,  which  bleed  easily. 
Itching  is  intense  ;  the  skin  is  dry  and  hypersesthetic. 
This  variety  is  the  most  contagious.  It  is  often 
•  Jotirn,  /fes  la-il.  Cut.  tl  Si/fi/i.,  June,  1897. 


I 


3!ifi        LOCAL  INOCULABLB  DISEASES,    [ooap.  xtto, 

associated  in  the  same  person  with  the  two  previons^ 
deBuribed.  . 

The  white  variety  is  the  terminal  stage  conmioiL 
to  all  the  others.  The  spots  of  discoloratdou  begin 
to  fade  in  the  centre,  and  gradually  ie  away  to  a 
perfectly  white  tint,  especially  in  parte  where  the 
skin  is  thin,  as  on  the  extensor  surfaces  of  joints.  In 
rare  cases  the  spots  are  yellowiah  from  the  first,  and 
soon  pass  into  the  white  stage  without  ever  having 
been  red,  blue,  or  grey.  In  such  cascH  the  disease  is 
limited  to  certain  regions,  such  as  the  roots  of  tha 
hair,  the  parts  about  the  eves,  and  the  hands  and- 
feet, 

There  is  acme  doubt  whether  the  disease  waB 
imported  into  America  from  Africa  by  the  negioee, 
or  whether  it  is  indigenous.  At  the  present  day  it 
is  so  generally  prevalent  among  negroes  that  it  hu'' 
been  said  that  none  of  them  escape  it.* 

The  physicians  of  Colombia  are  almost  unanimnus 
in  looking  upon  the  aSection  as  not  directly  contagi- 
ous. They  believe,  however,  that  it  is  probably 
parasitic,  though  the  micro-organism,  whether  fungus 
w  bacterium,  has  not  yet  been  identified.  In  th« 
regions  where  it  is  endemic  there  is  a  general  belief 
that  the  inoculative  material  is  conveyed  by  mos- 
quitoes. A  tropical  climate,  dirt,  and  pre-existing 
inflantmation  of  the  skin  are  predisposing  factors. 
Both  sexes  are  equally  liable  to  attack,  and  no  age, 
except  early  infancy,  is  exempt.  The  affection  is 
rare  among  well-to-do  people. 

The  disease  may  be  mistaken  for  macular  leprosy, 
but  there  is  no  ana^thesia.  and  the  spots  do  not  fade 
and  reappear  as  in  that  aflection.    Prom  leucodemua 

."iiily  r»f'Tred  to  the  (oIlowinK 
siilTuri  iir  will  Buffer froio  aiwItAd 


oaAP.svm.]        PINTAi  MYOHTOMA.  Sfi7 

it  is  differentiated  by  the  variety  oi  the  pigmentation, 
the  itching,  and  the  roughness  ol  the  skin.  From 
tinea  versicolor  it  is  diatinguished  by  the  coloration, 
and  by  the  distribution  of  the  patches,  which  are 
mostly  situated  on  parte  of  the  skin  exposed  to  the 
light,  whereas  the  Microsporon  furfnr  affects  covered 
regions  such  aa  the  chest  and  the  belly. 

The  treatment  is  the  same  as  that  recommended 
for  tinea  versicolor  (p.  371).  With  regard  to  preven- 
tion, close  contact  with  patients  Huflering  from  the 
disease  should  be  avoided ;  and  in  regions  where  it 
is  endemic  the  local  practitioners  recommend  that 
mosquito  stings  should  be  at  once  treated  with  an 
antiseptic  application,  such  as  carbolised  oil,  boracic 
acid  ointment,  etc.  The  question  of  caraie  in 
Colombia  seems  to  be  in  much  the  same  position  as 
that  of  leprosy  in  India.  The  report  wliiyh  I  have 
quoted  was  presented  in  comphance  with  a  request 
from  the  Government,  which,  in  view  of  the  increasing 
prevalence  of  the  disease,  wished  to  know  whether 
measures  of  segregation  would  be  advisable. 

Mycetoma  (Madura  foot ;  fungus  foot  of  India) 
is  endemic  in  some  parts  of  India,  especially  in 
Madura.  It  occurs  in  two  varieties,  black  and 
pink,  or,  as  Vandyke  Carter  prefers  to  call  them, 
"  melanoid  "  and  "  ochroid."  The  pink  form  is  the 
more  common.  The  distinctive  feature  of  the  black 
variety  is  the  presence  in  the  affected  tissues  oi  black 
granular  particles  resembling  gunpowder  in  the 
earlier  stages,  and  in  later  stages  of  black  or  dark- 
brown  truffle-Uke  masses.  The  latter  exhibit  a  faint 
pink  mould  in  the  earlier  stages  of  development,  and 
at  a  more  advanced  period  characteristic  pale-red, 
ovoid  bodies  resembling  fish-roe.  The  pink  mould 
is  also  visible  in  the  pink  variety  of  mycetoma.  The 
disease  as  a  rule  affects  the  foot  or  the  leg,  sometimes 
the  hand  ;  in  rare  cases  the  shoulders  and  the  scrotum. 


CEAP,  svin.]  AOTINOMYCOSIS.  399 

presenting  the  usual  appearance  chaiacteiiBtic  of 
abecesa.  The  prooeas  ia  very  chronic,  and  there  is 
comparatively  little  pain.  In  course  of  time  the  skin 
breaiva  and  scro-sanious  or  purulent  fluid,  uontainiiiH 


pecuhar  sulphur-yellow  granules,  ia  diacharged.  If 
these  granules  are  examined  microscopically,  the 
actinomyces,  the  ray-like  fungus  cauaing  the  disease, 
will  be  found  {Plate  11.,  Fig.  1).  Males  are,  from 
their  greater  exposure  to  infection,  more  hable  to  the 


400       LOCAL  IKOCVLABLB  DISEASES,    [ohap.  xvm,  I 

disease  than  females.  Pathotogic«lly,  actinomycoBis  I 
is  an  inflammatory  process  excited  by  the  ray  fungus,  I 
wliich  occasiotutDy  involves  the  skiu.  The  diagnosis  j 
will  be  made  clinically  by  a  proceBS  of  excluaion.  A  J 
tumour,  ejspecially  if  situated  in  the  skin  near  th«  j 
jaws,  which  presents  neither  the  characters  i 
Bymptomg  of  a  malignant  growth,  a  syphilitic  gumma,  t 
a  glanderous  abscess,  or  lupus,  should  surest  th«  I 
idea  of  actinomycosis,  and  a  positive  conclueioa  will  ( 
be  reached  by  puncturing  and  examuiing  the  contents 
for  actinomycosis.  The  prognosis  depends  on  th«  | 
situation  of  the  lesions.  If  these  can  be  thoroughly 
removed  the  disease  can  be  fured ;  otherwise  it  will  1 
end  in  death. 

Actinomycosis  can  aomedmeij  be  cured  by  the  j 
internal  administration  of  iodule  of  potassium  aloiw.  ^ 
The  earlier  this  is  begun  the  surer  and  speedier  is  ' 
.   the  effect.     Beginning  with   10  or   15  grains    thnt 
\  timr*  n  day.  it  should  be  steadily  pushed  to  SO,  30, 
40  yniiW,  or  even  larger  doses  if  necessary.     Iodide 
of  potassium  ( I   in   100)  may  also  at  the  same  time 
be  injected  into  the  sinuses  and  fissures.     Surgical 
treatment    is,    however,    generally  required.       This 
consists    in    the    comptetest    pos^ble    removal    or 
destruction  of  the  diseased  tissues.* 

Streptothrix    infection.  —  Foulerton  f    b" 

described  a  case  wtiich  he  regards  as  an  example  of 
an  infcHition  by  a  streptothnx  other  than  the  ray 
,  while  clinically  it  presentwl  nearly  all  the 
B  of  ordinary  actinomycosis.  The  patient  was 
an  aged  forty-six.  who  had  suffered  from  an 
I  in  the  left  axilla,  which  liad  been  opened 
I  sur^cally,  a  unus  running  inwards  and  upwards  for 

e  nf  ■ctiiioint'iisia  iFiK.  ■Hi)  iuTcilviitf 
lbi>  skill  b;  the  author  {Lmrf.  Jime  6,  IISM),  to  whivb  n  lull 
»-.,.._.   ..      ip  to  <l»te  i*  up 
in)|>rdi(>iwlri)  i 


ottiP.  rvm.]       STREPTOTHRIX   INFECTION.  401 

nearly  five  inches  being  left.  Alter  a  time  a,  red 
painful  lump  appeared  above  the  lelt  clavicle;  tliia 
rapidly  increased  in  size,  and  the  Bkin  over  it  soon 
broke.  When  seen  there  was  ill-defined  induration 
round  about,  and  there  were  a  tew  secondary  lumps 
near  the  original  one.  The  aldn  over  the  swelling  was  of 
a  deep  reddish,  and  in  some  places  purpliBh,  colour  ; 
it  was  dotted  here  and  there  with  yellow  spots  varying 
in  size  from  somewhat  larger  than  a  pin's  head  to  a 
small  pea.  These  spots  marked  the  position  of  small 
abaceBses,  each  of  which  contained  a  little  thick 
yellowish  pus.  In  places  where  these  abscesses  had 
broken,  small  punched-out  ulcers  remained,  from 
which  a  thin,  blood-stained,  purulent  discharge 
exuded.  There  were  physical  signs  of  lung  disease. 
No  treatment  had  any  effect,  the  sldn  lesion  gradually 
extending  over  the  back  of  the  left  shoulder.  The 
cUnical  evidence  pointed  to  a  primary  lesion  of  the 
left  lung,  followed  by  extension  of  the  infection 
through  the  chest  wall  to  the  skin.  After  a  stay  of 
four  months  in  the  hospital,  the  patient  left,  and  at 
the  date  of  the  report  nothing  more  had  been  heard 
of  her.  Pure  cultures  of  a  streptothrix  fungus  were 
obtained  from  the  pus  of  a  freshly  opened  abscess. 
Although,  owing  to  the  difficulty  in  obtaining  free 
growth  of  the  fungus,  its  natural  liistory  when  grow- 
ing on  artificial  media  and  its  pathogenicity  in 
animals  were  not  fully  worked  out,  the  evidence  was, 
in  Foulerton's  opinion,  quite  sufficient  to  show  that 
it  did  not  correspond  with  any  of  the  previously 
described  atreptothriceffi.  More  recently  Hayo 
Bruns,  of  Strassbuig,  has  published  a  case  which 
clinically  was  thought  to  be  one  of  actinomycosis, 
but  from  which  he  isolated  a  streptotliris  fungus 
corresponding  in  some  respects  with  that  described 
'  ujFoulerton. 

L  hat  of  these  will  be  found  in  Foulerton's  article 


r 


WCAL  INOCULABLK  DISEASES,     [chac.  xvul 


hero  referred  to.  He  makes  the  general  statement 
that  the  anntomical  results  of  an  infectioa  by  any 
oue  of  these  usually  appear  as  nodulea  of  granulo- 
matous tissue. 

Blastoinycetic  dermatitis. —At  the  meeting 
of  the  AmericaD  Derma  to  logical  As^ciation  is 
\S')i  T.  Caspar  tJilcbrist,  of  Johns  Hopkine  Hos- 
pital, Baltimore,  demonstrated  organisms  in  a  case 
of  supposed  Bciofulodeimia  under  the  care  of  Doliring. 
Gilchrist  suggested  that  these  oiganisms  were  pan* 
sitic  fungi  having  an  etiological  relation  to  the  lesions 
in  connection  with  which  they  were  found.  Two 
years  later  the  same  observer  published  *  a  case  of 
"  blastomycetio  dermatitis "  in  man,  in  which  I 
classified  the  fungus  as  ono  of  the  yeast  famUy. 
conjunction  with  W.  R.  Stokes,  Gilchrist  published 
in  1898  a  report  of  a  case  of  "  pseudo-lupus  vulgaris  " 
caused  by  a  blastomyces,  in  wliich  the  results  of 
experimental  researches  on  animals  were  given.  Tba 
elements  of  the  organism  were  described  as  spheiicai 
and  unicellular,  with  a  double-contoured  enveloping 
membrane,  exhibiting  budding  forms  in  various 
stages  and  never  enclosed  in  cells.  A  careful  study 
of  the  skin  disease  caused  by  this  blastomyces  has 
been  made  by  Nevins  Hyde,  L.  Hekloen,  and  A.  D. 
Bovan,t  who  collected  ail  the  cases  recorded  ' 
up  to  the  dat«  of  their  article,  and  compared  and 
analysed  the  facts  and  phenomena.  On  their  artiole 
the  following  brief  account  of  the  disease  is  mainlj 
based. 

As  far  as  the  symptomatology  can  be  gathered 
from  the  cases  on  record,  the  affection  begins  as  a 
maculo- papule  of  reddish  hue,  wiiich  afterwards 
suppurates,  usually  us  the  result  of  accidental  infec- 
tion.    The  papules  gradually  enlarge  into  tuberclea. 


CHAP,  svm.]  BLASTOMYCHTW  DERMATITIS.        403 

and  the  skin  over  the  area  involved  by  the  growth 
hecomes  raw  and  ulcerated  ;  the  ulcers  spread  widely, 
and  sometimeB  extend  deeply,  destroying  parta  like 
the  ata  nasi  and  the  lip.  The  ulcers  leave  scars  with 
laised  ulcerating  edge,  and  small  ulcers  are  scattered 
irregularly  over  the  acar  area.  The  parts  afiected 
are  the  ear,  forehead,  cheek,  brow,  nose,  scro- 
tum, thigh,  leg,  and  the  dorsum  of  the  fingers. 
hand,  and  wrist.  The  parts  first  attacked  are  chiefly 
the  dorsum  of  the  hand  and  the  front  of  the  leg,  a 
circumstance  wliich  suggests  that  these  regions 
infect  each  other.  In  the  seven  cases  collected  by 
Nevins  Hyde,  Held  o  en,  and  Be  van,  five  of  the 
patients  were  men,  all  of  them  at  or  near  middle 
age  ;  in  some  of  them  there  was  a  family  history  of 
tuberculosis.  The  disease  runs  a  chronic  course, 
lasting  from  five  to  ten  years. 

Blaatomycetic  dermatitis  closely  resembles  tuber^ 
culosis  of  the  skin,  especially  that  form  described  by 
Riehl  and  Paltauf  under  the  title  "  tuberculosis 
verrucosa  cutis  "  (see  p.  iiy).  The  vegetating  forms 
of  syphilis  sometimes  slightly  resemble  the  symptoms 
of  blastomycetic  dermatitis.  The  nature  of  the  disease 
is  recognised  by  the  presence  or  absence  of  the  blasto- 
myces.  From  Darier's  disease  and  other  psoro- 
spermoses,  in  which  the  etiological  factors  are 
coccidia,  blastomycetic  dermatitis  may  be  distin- 
guished by  attention  to  the  following  points  of  differ- 
ence enumerated  by  Gilchrist:  (1)  The  protozoa 
develop  by  sporulation,  whereas  the  plant  forms 
develop  by  gemmation  or  budding  ;  (2)  the  former 
are  larger,  16^  to  30^,  as  contrasted  with  the  lO/i  to 
20^1  of  the  blastomyces ;  (3)  the  protozoan  bodies 
are  found  single  or  in  groups,  while  the  blastomyces 
are  often  seen  in  pairs.  The  features  common  to  both 
protozoal  and  blastomycetic  affections  are :  Epi- 
dermal  hypertrophy ;    the   occurrence   of   multiple 


4M     LOCAt   tSOCVLABLE    MSEASSS.    [chap,  xvnil 


i  in  both  epidermis  and  corium ;  a  similai 
difltriliutiion  of  lesiona  ;  and.  principally,  the  general 
featuTfis  of  \iot\\  scrofuloderniia  and  tuberculosis  ol^ 
the  akin. 

As  far  as  can  be  judged  from  the  slender  basis  0 
BtatiHtica  at  present  existent,  the  prognosis  i 
moat  of  the  cases  ending  in  recovery.  Treatment  I^ 
the  internal  adminiBtration  of  iodide  of  polassv 
has  been  Huccessful  in  causing  the  disappearance  o 
patches  (Bevan,  Shepherd).  The  latter*  gave  t' 
drug  in  doses  of  gr.  xx  thrice  daUy.  After  a  montll 
of  continued  treatment,  great  improvement  resulte 
A  further  course  of  the  same  treatment  effected  ^ 
curo.f 

Elephantiasis  Arabum  is  a  disease  of  tropio 

and  sub-tropii-al  t'ountrles,  tnd  only  very  rarely» 
in  Biirope.  It  is  (.'huract«rised  by  chronic  hyj 
trophy  of  the  skin  and  subcutaneous  tissue,  glvioi 
rise  to  enormous  enlargement  of  a  particular  part  (if 
tln'  body,  generally  one  (Fig.  '1\),  and  in  rare  c 
both,  of  the  lower  limbs  ;  sometimes  it  i) 
(Fig.  22),  one  of  the  labia,  or  the  mamma  (Fig.  23) 
The  lace  is  occasionally  the  seat  of  the  diseoBe. 
is  often  ushered  in  by  febrile  disturbance  ("■ 
pimntoid  fever ").  The  part  attacked  beC 
rapidly  swollen,  owing  to  inflammation  of 
lymphatics^  the  skin  being  tense  and  red  as  i 
erysipelas.  There  is  great  infiltration  of  the  areolkl 
tissue,  and  vesicles  and  bullfe  often  form  and  c" 
charge  a  serous  or  chyle-like  fluid.  When  i 
developed  the  limb  is  often  three  or  four  time 
natural  size  (Fig.  22),  the  swelling  being  hard  a 

*  JowlT..  nflhil.  nurf  f,Vi,.  r,in.  ll„.,  April.  If 

f  For  turOier  iufomiatioD  as  to  btnitumjMitir 

H.  Gideon  WpUb.  y,,c    («*  MrJ.  yon™,,   vol,  l»rii! 

(utMtraoted  iu  Brtl.  JoHra.  Vrrm.,  \9Si,  p,  431)  ■  uuil 

-        -      ,,  iv,^.^  i9oi,p.  301. 


and  Macleod,  Brii.  Jom 


CHiP.  sviii.]      ELEPHANTIASIS   AHABVil.  403 

solid  for  the  most  part,  tiiough  pitting  moderately 
under  strong  pressure.  The  surface  is  often  roughened 
by  a  network  of  dilated  lymphatic  vessels  ;  varicose 
ulcers  alao  frequently  form.  Exacerbations  may  take 


in  Arabum  of  foot  of  n  Miilalti 
Jam  (Giiiuiia),  South  Aineiica. 
IJtr.  fpUdey'i  Ciif.) 


playe  at  irregular  intervals,  their  occurrence  always 
being  heralded  by  febrile  disturbance.  Except  at  theae 
times  there  is  generally  little  pain,  but  the  patient 
is  greatly  inconveoienced  by  the  bulk  of  the  afiected 
part.  After  some  years  the  attacks  of  fever  cease  and 
the  part  remains  permanently  swollen.    The  acrotum 


i 


408      LOCAL   INOGULABLE    DISEASES,     [chap,  xvnx 

countries,  to  the  Filaria  sanguiDis  hominia  (Fig.  16,  H, 
'-  and  Plate  II.,  Fig.  10),  which  takes  up  its  abode  in  the 
lymphatio  trunka  and  dischargee  its  ova  into  the 
lymph  stream ;  obstruction  of  the  lymphatic  circulo- 
tion  is  brought  about  by  the  embryos,  either  mechsni- 
cally  or  by  setting  up  inflammation.  Lymphatic 
obstruction  may  also  be  the  result  of  violent  or 
repeated  inflammation,  as  in  erysipelas,  phlegmasia. 
dolens,  long- continued  eczema,  etc.  ;  in  fact,  any- 
thing that  interferes  with  the  lymphatic  circulation 
may  cause  elephantiasis.  The  disease  spares  neither 
age  nor  sex,  but  is  more  common  in  men  ;■  it  is  some- 
times congenital.  A  malarious  climate  and  poor 
living  arc  predisposing  factors.  Where  it  is  endemic, 
it«  geographical  distribution  appears  to  coincide  with 
that  of  the  mosquito,  which  is  the  intermediate  host 
of  the  filaria  (Manson).  The  principal  change  is  in 
the  subcutaneous  tissue,  which  is  greatly  hypettrd- 
pliied  ;  the  corium  and  epidermis  are  also  considerably 
thickened,  and  papillary  growths  are  not  uncommtin. 
Both  blood  and  lymph  vessels,  musele^,  fasciw, 
nerves,  and  bones  are  aiso  greatly  enlarged. 

The  disease  can  sometimes  be  checked  by  removal 
from  a  district  where  it  is  endemic.  The  symptoms 
can  generally  be  mitigated  by  improvement  of  the 
health,  and  b}'  Hoothing  applications  to  the  aSected 
jiart.  In  contirmed  cases  of  elephantiasis  of  the  leg 
or  scrotum  there  is  no  cure  but  amputation,  JUec- 
tricity  hoe  often  given  good  results.  A  galvanic 
current  of  40  to  60  Trouve  elements  should  be  applied 
from  five  to  ten  minutes,  with  the  positive  pole  on  or 
near  the  sound  part  and  the  negative  at  different 
Bpotg  in  the  affected  region. 


CHAPTER    XIX. 


GENERAL  INOCULABLE    DISEABEa. 


SCROFULODERMIA — TUBERCL'LOUa  UlCEKS — VERRUGA 

Necrooenica — Erythema     Indl'ratum    Scro- 
fulosorum— tobebcuudes — lupus  vulgaeis. 

ToBERoiTLOSis,  syphilia,  leprosy,  yawa,  nod  glaadera 
have  this  featme  in  common — that  each  of  them  is 
caused  by  a  specific  micro-organism,  and  is  therefore 
inoculable  from  one  patient  to  another,  although  the 
period  necessary  for  such  inoculation  to  take  effect,  and" 
othei  conditions,  differ  widely.  That  tuberculosis  and 
leprosy  are  engendered  and  transmitted  by  microbes 
has  been  fully  proved  by  pathological  research  ;  and 
aa  regards  syphilis,  although  the  micro-organism 
which  produces  and  conveys  the  poison  has  not  yet 
been  identified,  the  clinical  evidence  makes  it  certain 
that  the  disease  is  of  parasitic  nature.  Glanders  and 
yaws  are  also  diseases  in  which  the  inoculation  of  a 
specific  virus  is  followed  by  genera!  infection,  and  are 
therefore  unquestionably  parasitic,  though  there  may 
still  be  some  doubt  as  to  the  particular  microbe 
which  initiates  the  process  in  each  case. 

Scrofula  and  Tdbehcle. 

Before  studying  the  effects  of  tuberculous  infeC' 
tion  on  the  skin,  it  will  bo  well,  for  the  sake  of  clear- 
ness, to  define  terms  and  to  indicate  the  relation  in 
which  scrofula  stands  to  tubercle.  The  progress  of 
pathology  has  now  definitively  assigned  to  tubercle 
BO  unoh  that  used  to  be  thought  to  belong  to  scrofula. 


41(1      OKSKRAl  IXtK-I'LABLE  DISEAfmS.  [cKir.  «I. 

that  there  ie  some  danger  of  the  latter  being  swept 
Hway  alto^ther.  The  reason  of  the  confusion  on  this 
subject  that  sdll  exists  to  a  certain  extent  is  that  the 
tprm  "  scrofula  "  has  been  uaed  not  only  as  expressing 
H  partieular  conBtituttonal  state,  but  as  connoting  a 
variety  of  diseased  conditions.  Scrofula  is  not  a 
disease,  but  n  special  predisposition  thereto  ;  it  is  a 
state  of  soil  in  which  bacilli^^specially  tubercle 
Itaoilli— readily  flourish.  In  view  of  the  strong 
aflinity  of  the  tubercle  bacillus  for  the  strumous 
diathesis,  scrofula  might  almost  be  defined  as  poten- 
tial tuberculosis.  It  ia  not,  however,  for  tubercla 
alone  that  scrofula  prepares  the  way,  but  for  many 
other  rliseases.  The  condition,  in  fact,  is  one  of 
ahuormal  vuhierabllity  to  slight  injuries.  Lesiona  in 
a  Hcrofuliius  Hubject  are  apt  to  take  on  a  character  of  l! 
chronio  itiflaaimation  of  a  peculiar  type,  in  whioh  a 
tendency  to  suppuration  and  the  formation  of  un- 
healthy sores  are  the  most  marked  features.  Mucous 
membranes  become  the  seat  of  catarrh  on  very  slight 
irrit<Lti(in,  and  lymphatic  glands  readily  become 
larged.  The  want  of  power  of  resistance  in  scrofulous 
Kubjects  ia  seen  in  the  fact  that  they  suffer 
severely  than  other  persons  from  syphilis  and 
gonorrhwa  :  and  in  tliem  scarlet  fever,  measles,  etc. 
are  more  likely  than  usual  to  run  a  fatal  couise^^^ 
Such  persons  are  also  generally  considered  to  b» 
ire  linbU'  U)  acute  periostitis  and  necrosis  of  bone 
than  healthy  people.  Tlieir  tissues  are  especially 
vulnerable  not  only  to  traumatic  influences,  but  to 
the  action  n(  pathogenic  micro-organisms  of  all  lands, 
especially,  as  already  said,  to  the  liacillus  of  tubttcl«. 
To  sum  up.  scrof\ila  is  merely  a  special  delicacy 
tissue,  making  it  abnormally  sensitive  to  injniii 
influences  of  all  kinds.  Tubercle,  on  the  other  hand^- 
is  a  new  growth,  presenting  peculiar  anatomicd'i 
characteristice,  and  giving  rise  to  definite  l«aoi 


I 

m 


TUBERCULOSIS.  411 

which,  though  varying  in.  appearance  according  to 
the  situation  in  which  they  occur,  and  other  circum- 
Btancea,  are  the  result  oi  a  proecBS  which  is  essentially 
the  same  in  them  all.  To  put  the  relation  of  scrofula 
to  tubercle  into  the  briefest  form,  it  may  be  said  that 
scrofula  is  the  soil,  the  bacillus  the  seed,  and  tuber- 
culosis the  harvest. 

Tuberculosis. 

The  anatomical  element  of  tubercle  is  a  nodule 
consisting  of  a  rounded  mass  of  cella,  containing  in  ite 
centre  one  or  more  large  multi -nucleated  cells  with 
branching  processes — the  so-called  giant  cells.  These 
uaed  to  be  thought  to  be  characteristic  of  tubercle,  but 
they  are  now  known  to  occur  in  other  conditions. 
Tuberculosis  was  first  shown  by  Villemin  to  be  an 
infective  process,  and  in  1882  the  specific  micro- 
organism causing  the  lesions  was  demonstrated  by 
Koch.  The  tubercle  bacillus  (Plate  II.,  Figs.  3  and 
fj)  is  a  rod-like  organism,  about  one-third  of  the  dia- 
meter of  a  red  blood- corpuscle  in  length,  and  slightly 
curved  longitudinally.  It  has  no  independent  power 
of  movement. 

The  bacillus  appears  to  have  a  spefial  affinity  for 
the  giant  cell,  which  is,  so  to  speak,  its  ordinary 
dwelling-place.  In  slowly  growing  tubercle  very  few 
bacilli  are  present,  sometimes  only  one  in  each  giant 
cell ;  hence  it  is  often  extremely  difficult  to  discover 
them.  Koch  demonstrated  the  bacillary  nature  of 
tuberculosis  by  finding  the  micro-organisms  with  tin? 
microscope,  and  by  cultivating  them  to  many  genera- 
tions outeide  the  body  ;  inoculations  of  these  cultures 
in  animals  gave  rise  to  genuine  tuberculous  disease, 
and  from  the  affected  tissues  the  micro-organism  was 
recovered.  Tuberculosis,  therefore,  is  a  form  of 
oTironic  infective  inflammation  caused  by  the  irritant 


CEWERAL  INOCULABLE  DISEASES,  [chap.  iix. 


phthisical  family  history.  The  disease,  according 
to  Kaposi,  is  never  seen  in  perfectly  healthy  personB. 
The  disenae  is  not  commou  after  the  age  of  twenty, 
and  SOX  appears  to  have  little  influence  in  engendering 
a  tendency  thereto.  The  tuberculous  nature  of  the 
disease  has  been  established  by  the  discovery  of 
tubercle  bacilli  in  the  lesions  by  Jacobi  and  Wolff, 
Experimental  inoculations  on  animals,  however,  have 
BO  far  given  negative  results.  The  process  beginning 
in  the  hair  folhclee  and  neighbouring  sebaceous 
glands,  each  papule  is  situated  close  to  the  orifice  of  a 
follicle.     The  papule  is  formed  by  infiltration  of  the 

Ipapillffi,  and  the  central  scale,  or  small  pustule,  on  the 
top  of  the  papule  is  constituted  by  the  heaping  up  of 
hypertrophied  epidermis  or  exudation  at  the  orifice 
of  the  follicle. 
The  dise-ase  can  be  identified  by  the  homogejieity 
of  tlie  papules,  by  their  arrangement  in  groupa,  by 
their  being  situated  chiefly  on  the  trunk,  by  their 
pftinleKsnoas,  by  their  not  projecting  much  from  the 
surface  of  the  skin,  and  by  the  absence  of  itching. 
These  features,  taken  in  combination  with  the  youth 
of  the  patient,  are  anfficient  in  most  cases  to  identify 
the  disease.  It  sometimes  closely  resembles  papular 
eczema  ;  but  in  that  complaint  itching  is  usually  very 
troublesome,  and  the  papules  are  bright  red  and  not 

[ limited    to    the    trunk.     From    lichenoid    ayphiUdea 

^^^^    lichen  scrofulosorum  is  differentiated  chiefly  by  tho 

^^^k    absence  of  any  other  sign  or  history  of  syphilitic 

^^^P  infection.     Moreover,  in  the  former  the  papules  are 

^^H     not  geaerally   arranged  in  groups,   but  mostly  io 

'  circles,  and  they  generally  affect  the  bends  of  jointa. 

They  are  also  very  hard^  and  have  a  shiny  aspect. 

Lichen  scrofulosonim  can  usually  be  cured,  and  even 

if  left  to  itself  is  not  likely  to  cause  any  particular 

iuconvenieiioe.     It  must  be  treated  locally  by  soothing 


1 


OMiP,  xix,j  STRUMOUS   ULOBRS. 

and  mildly  antiseptic  appIicationB,  such  a 

lotion  or  bocacic  acid   ointment,   and   conatitution- 

ally  by  measures  appropriate  to  the  atate  of  health. 

Forms  of  pustular  and  pem.phigoid  character, 
aasooiated  or  not  assoeiated  with  Hchen  serolu- 
loBonim,  are  occasionally  met  with. 

Strumous  ulcers  arise  on  the  skin  In  different 
ways  :  (1)  by  extension  of  the  inflammatory  process 
from  caseating  lymphatic  glands  to  the  skin  covering 
them  ;  (2)  by  the  formation  of  a  nodule  or  circum- 
scribed induration  under  the  skin,  which  becomes 
involved  in  the  process  ;  (3)  by  extension  Irom  bone 
which  is  the  seat  of  tuberculous  osteomyelitis.  When 
a  gland  ia  the  starting-point  of  the  process,  the  akin 
over  it  becomes  red  and  infiltrated,  and  often  adheres 
to  the  gland;  after  a  time  the  akin  breaks,  sinuses 
form,  and  the  tuberculous  process  becomes  com- 
plicated by  more  or  less  profuse  suppuration,  owing 
to  the  entrance  of  pyococci.  When  nodules  develop 
under  the  skin  independently  of  glands,  they  give  rise 
to  what  Erichsen  calls  "  aubcutaneous  scrofulous 
abscess."  The  skin  over  the  nodules  is  raised,  and  at 
first  dusky  purple  in  hue ;  then,  as  the  underlying 
growth  softens,  it  breaks,  giving  issue  to  a  thin  curdy 
discharge,  and  an  ulcer  is  formed  bordered  by  dark- 
bluish  thin  undermined  sldn,  the  vitahty  of  which  is 
too  feeble  to  aUow  of  any  attempt  at  repair.  The  edge 
ia  sometimes  sharp  cut,  but  more  often  ragged ;  the 
floor  is  grey  and  irregular,  the  granulations  are  flabby 
and  cover«l  with  unhealthy  pus.  These  ulcers  gener- 
ally spread  slowly  but  steadily,  and  in  this  way  large 
indolent  sores  may  be  formed  which  are  sometimes 
covered  with  heapod-up  crusts  simulating  rupia. 
Such  ulcers  are  common  on  the  face  and  on  the  hands 
(where  the  process  may  extend  to  the  bones,  con- 
stituting one  form,  of  strumous  dactylitis),  and  they 
are  not  unfrequently  seen  on  the  feet  and  on  the  but- 


41(1     GENERAL  IXOC'VLABLE  DISEASES,  [en 

tocka.  In  a  gentlemaa  iindei  my  care  the  elbows  and 
knees  were  the  eeat  of  the  aSection.  HeaUng  seldom 
takes  place  spontaneously.  These  ulcere  are.  as  a 
rule,  seen  in  young  people  who  have  the  notea  of  the 
scrofulous  constitutjon  plainly  written  on  them  in 
their  physiognomy,  or  in  the  marks  of  similar  lesions 
on  the  neck,  the  nose,  the  eye,  or  elsewhere.  Flat 
ulcers,  with  clean-cut  edges  (as  if  the  skin  hod  beea 
punched  out)  which  tend  to  spread  slowly,  are  some- 
timea  seen  in  old  people  who  bear  scars  of  strumontt 
Hores  with  which  tbey  were  afflicted  in  early  life. 
These  senile  strumous  ulcers  occasionally  assume  tbaj 
character  of  rodent  ulcer  or  epithelial  cancer. 

The  only  conditions  that  are  evex  likely  to  be 
mistaken  for  acrofulodermia  are  syphilis  and  lupus. 
The  syphilitic  ulcer  is  met  with  in  adulhs,  and  has 
not  the  characteristic  undermined  border  ;  moreover, 
the  process  is  generally  much  more  active,  and 
concomitant  symptoms  or  marks  usually  iniUcate  the 
nature  of  the  disease.  The  absence  of  infiltration 
and  of  "  apple-jelly  "  nodules  will  serve  to  distinguish 
scrofulous  lesions  from  lupus.  The  two  conditions  may, 
however,  co-exist,  and  (.eloir*  believes  that  in  thfl 
same  way  syphilis  may  be  mixed  with  scrofulodermia 
in  the  same  subject. 

The  treatment  of  scrofulodermia  must  be 
ducted  on  ordinary  surgical  principles.  AbsceBsea  must 
be  opened  and  their  walls  scraped;  caseous  glandsmust' 
be  removed,  and  ulcers  cleansed  and  stimulated.  The 
unhealthy  undermined  skin  at  the  edge  of  the  ulcets 
must  be  trimmed  away,  the  floor  thoroughly  scraped, 
and  antiseptic  dressings  applied.  The  patient's  con- 
stitution must  at  the  same  time  be  strengthened  by 
plenty  of  good  food,  cod-liver  oil.  iron  and  otJiflV' 
tonics,  according  to  the  indications,  and  especially  by 

air  and  a  wholesome  environment. 

•  Joiir-i.  dtt  Mai.  Vul.,  Seplembet.  tH9!. 


I 
I 


CHAP.  XK.]         TUBERCVWUS     ULCERS.  417 

TubaPCUlous  ulcers.  —  Primary  tuberculosis 
may  occur  oa  the  face,  on  the  breast,  and  eiaewhcre 
in  the  form  of  ulcers  with  an  infiltrated,  ragged,  and 
undermined  edge,  and  a  slightly  indurated  floor 
covered  with  yellowish  tubercles,  moistened  with  a 
thin  and  scanty  secretion.  The  surface  is  often  more 
or  lesa  thickly  crusted  over.  They  are  sometimes 
indolent,  but  usually  they  cause  considerable  pain. 

Occasionally  the  ulcers  are  the  result  of  the  break- 
ing down  of  email  tuberculous  nodes.  The  lesion  may 
be  the  precursor  of  tuberculous  disease  of  the  lung  or 
intestine.  Kobner  •  has  reported  a  case  in  which 
a  tuberculous  ulcer  of  the  chin  preceded  the  develop- 
ment, of  laryngeal  phthisis.  More  commonly,  how- 
ever, such  ulcers  are  secondary  to  pulmonary  or 
intestinal  tuberculosis.  They  are  generally  situated 
at  the  junction  of  Bknn  and  mucous  membrane— about 
the  corner  of  the  mouth  and  margin  of  the  nose  in 
cases  of  lung  disease,  and  at  the  anus,  vulva,  and 
glans  when  the  intestine  is  the  seat  of  the  primary 
lesion.  In  the  former  case  the  ulceration  may  spread 
to  the  mucous  membrane  of  the  tongue,  cheeks,  soft 
palate  and  nose,  and  in  the  latter  to  the  urethra  and 
bladder.  When  the  mucous  membrane  is  the  seat 
of  these  ulcers,  yellow  miliary  tubercles  can  generally 
be  seen  in  their  vicinity.  There  may  be  one  or  several 
ulcers.  They  show  no  tendency  to  heal,  but  slowly 
spread  by  infection  of  the  contiguous  parts,  some- 
times attaining  a  considerable  size.  Occasionally 
they  run  together,  forming  serpiginous  sores.  In  a 
patient  of  mine,  who  died  of  phthisis  at  the  age  of 
forty- two,  numerous  small  ulcers  coalesced  and 
formed  a  large  ulcerated  surface,  which  nearly  sur- 
rounded the  left  ear. 

Tuberculous  ulcers  of  the  skin  are  the  result  of 
1  inoculation    with   tuberculous    matter.     This 

'  BeiTm.  »icd.  Gtm-lln-haft.  Mnrch  \:\  1803. 


GENERAL  1\0LILABLE  Dl'iEisFs    \c.i 

often  occurs  in  patients  suffering  from  tuberculoaia 
hence  their  relative  frequencv  m  'itnations  wh< 
bacilli  in  the  fceees  or  'iputa  t-an  readilv  hnd  their 
into  any  abrasion  of  the  Biuface  that  may  exist, 
have  seen  such  ulcers  begin  in  a  patch  of 
Infection  may  also  he  conveyed  from  one  patient 
another.  This  is  a  not  uncommon  consequence 
ritual  circumeiBion,  when  the  wound  is  sucked  by 
operator  who  is  the  subject  of  tuberculosis.* 
virus  is  also  sometimes  conveyed  by  tattooing. 

The  diagnosis  is  usually  easy,  owing  to 
of  other  signs  of  tuberculosis.     When  the  ulcer  is 
primary,  its  surface  should  be  scraped,  and  the  shreds 
of   tissue   thus   obtained    examined  for  bacilli. 
Kobner's   case,    above  referred   to,    the   lesion   w 
judged  to  be  ayphihtic  by  several  practitioners,  and 
was   oidy  the  failure   of  treatment  based   on   this' 
view  and  the  subsequent  invasion  of  the  lajynx  by 
tubercle  that  revealed  the  nature  of  the  disease. 

Veppuea     necrog-enica     or     post-mortem 
wart. — ^This  is  a  condition  seen  on  the  hands  of 
medical  men,  mortuary  porters,  butchers,  cooks,  and 
other  persona  who  are  in  the  habit  of  handlii^  dasd 
tissue  containing  living  tubercle  bacilli.     FabiT  hM 
noted  the  relative  frequency  of  the  disease  in  coUiera  ; 
this  he  attributes  to  the  wounds  of  the  hands,  Thich 
are  so  common  on  the  hands  of  those  who  handle 
coal.    This  form  of  skin  tuberculosis  is  characterised 
by  the  formation  of  obstinate  red  indurated  wart-l 
growths,  cliiefly  on  the  knuckles  and  in  the  int 
digital  folds,  but  occasionally  on  other  parts  of  tl 
hands,  and  even  on  the  arms.     It  usually  begins 
flat  papule,  which  hy-and-by  becomes  pustular. 
pustule  dries  up  and  forme  a  scab,  which  in  tinu 

•For  H  ilewriiitiou  iit  the  Hpt'dul  dinrapten.  

«d  in  tms  nmuoer  »?  Bernhiudl,  quolod  by  l 
nt.  Jimnt.  HrrHi.,  Murob,  1901). 


'4 

iiisV 


CHAP.  SIX.]      VERRUCA     NECROOENICA.  419 

ofi,  leaving  a  eiuface  made  irregular  by  promiuent 
papillfB.  These  gradually  become  larger  and  harder, 
tiU  they  form  a  warty  maaa,  which  may  spread  slowly 
at  the  edge  for  an  indefinite  time.  Hutc^hinaon  cites  a 
case  in  which  the  growth  continued  to  enlarge  slowly 
for  forty  years.  Sometimes  spontaneous  involution 
takes  place  and  the  warts  diaappear,  leaving  a  scar. 

The  comUdon  appears  to  be  identical  with  that 
described  by  Rieb]  and  Paltauf  *  under  the  name  of 
tuberculosis  verrucosa  cutis-  This  is  a  local  tubercu- 
losis of  the  sldn,  the  aSected  tissues  showing  the 
changes  characteristic  of  tubercle,  together  with  the 
specific  bacillus,  which  is  present  in  larger  numbers 
than  is  the  case  in  lupus.  The  condition  known  as 
lufus  verrucosus,  and  seen  chiefly  on  the  hands  and 
feet,  is  also  a  form  of  local  tuberculosis  of  the  skin, 
having  the  same  characters  as  post-mortem  wart. 
Primary  cutaneous  inoculation  of  tuberculosis  on  the 
exttemitiea  in  patients  who  have  to  attend  to  those 
suffering  from  tuberculosis  frequently  takes  the  form 
oi  verruca  necrogenica. 

The  diseased  tissue  in  all  these  conditions  should 
be  removed  with  salicylic  acid,  applied  by  means 
of  Vnna's  plaster  mull  or  Brooke's  ointment.  If  the 
lesions  are  spreading  actively,  they  should  be  tho- 
roughly destroyed  with  caustics  or  electric  cautery. 

Erythema  induratiun  scrofulosorum  was 
first  described  by  Bazin,  and  has  been  eshauBtively 
studied  by  Colcott  Fox.f  I  have  seen  several 
ejiamples  of  the  affection.  The  special  lesions  are 
chronic,  inflammatory,  deep-seated  nodules,  which 
develop  chiefly  on  the  legs,  and  also  in  other  parts. 
These  nodules  often  closely  resemble  syplulitic 
nodular  gummata.  The  lesions,  which  are  painless, 
it  first  subcutaneous,  and  can  only  be  felt,  not 


420      GENERAL  INOCVLABLE  DISEASES,  [ckas:  ■axTy 

seen.  They  affect  the  back  rather  than  the  front  part 
of  the  leg  ;  the  skio  over  them  occasionally  presents 
a  violet- tinted  discoloration.  They  are  generally 
-  discrete,  but  sometimes  become  fused  together  so  as 
to  form  a  solid  mass  of  infiltration.  They  are  apt  to 
break  down  into  irregular  ulcers.  The  large  majority 
of  patients  are  young  girls,  and  the  disease  is  par- 
ticularly common  in  washerwomen  and  other  women 
whose  occupation  involves  much  standing.  When 
ulceration  occurs  the  affection  is  generally  taken  to  be 
syphilitic,  but  in  typical  cases  no  evidence  of  syphilis 
is  present,  and  anti- syphilitic  treatment  does  harm 
rather  than  good.  In  many  cases  the  patients 
present  clear  signs  of  scrofula,  but  sometimes  they 
seem,  save  for  the  local  affection,  to  be  perfectly 
healthy.  Numerous  lesions  resembling  lichen  acrofu- 
losorum  and  erythema  induratum  scrofulosoniin 
have  recently  been  described  and  discussed  under 
such  names  as  "  folliculitis,"  "  acnitis,"  etc.,  and 
their  relation  to  tuberculosis  suspected.  The  tuber- 
I'ulous  nature  of  the  disease  has  recently  been  proved 
by  Colcott  Fox,  who  excised  a  deep-seated  nodule 
and  submitted  it  to  examination.  Typical  giant  colla 
were  found,  though  not  in  great  abundance.  The 
result  of  an  experimental  inoculation  in  a  guinea-pig 
made  by  Eyre  was  that  the  animal  died  of  tubercu- 
losis.* The  treatment  is  rest  in  the  horiEontal  posi- 
tion, compression  by  bandaging,  and  cod-liver  oil 
internally. 

Tuberculides. — Under  this  name  a  somewhat 
motley  group,  presenting  a  great  variety  in  appear- 
iincc.  but  having  certain  characters  in  common,  tm^ 

*  For  f urtlipr  iuf nnnution  lu  to  the  Aaaxteirr  raportB  wtj^H 
Jlnwilri  dt  Jlena.  rl  ar  .Sy/iJi.,  IHWI  and  IB07,  «>d  Srit.  /d^H 
IltriH,  diuing  the  ume  year.  (U(.  Arif.  Johth,  iVriN. ,  ToL  MH 
p.  'JIU,  imT)  .For  11  lull  acDDiiiit  of  Ihe  Iiutolog;  «f  ttrjt^M 
KiniL  iiutunitnni  ■crotiiloBoriini  ami  of  iuoculauon  rKpvriiM^^H 
tre  Ch.  Audry.  Ahu.  dr  Drrm.  rl  dt  Sffph.,  JtaTcli,  IHUH,  p.2D9^H 


{iHiP.  SIX.]  TUBERCULIDES.  421 

been  provisionally  brought  together.  According  to 
Colcott  Fox,  who  presented  a  mastp.rly  report  of 
these  eruptions  to  the  Fourth  International  (Congress 
of  Dermatology,  "  the  esaential  lesion  is  a  small, 
extremely  indolent  granuloma,  tending  to  undergo 
central  softening  and  death,  and  thus  leaving  scars." 
According  to  difference  in  the  size,  character,  group- 
ing, and  behaviour  of  the  lesions,  a  bewildering 
complexity  of  affections,  with  a  corresponding  com- 
plexity of  nomenclature,  has  been  described  by 
varioua  obaervers.  The  following  are  a  few  of  the 
namea  collected  by  Fox  :  Lupus-pgoriasis  serofulona, 
lollioulitis  exidcerans,  follioulitis  scrofvlosoTwm,  hydra- 
denitia  deitruens  suppuraiiva,  sptraienUis  disseminata 
suppurativa,  acntiis,  acne  tdangeiectodes,  impetigo 
varidifarmis,  and  acne  variolijonmB. 

The  evidence  of  the  tuberculous  nature  of  these 
varied  eruptions  is  not  by  any  means  complete. 
They  are  often,  though  by  no  means  invariably, 
associated  with  tuberculous  disease  in  the  lungs  and 
lymph  glands  or  with  strumous  ulcers  (Fig.  24 
and  Fig.  24a).  The  microscopicaL  evidence  so  far 
obtained  is  inconclusive,  while  the  bacteriological 
evidence  is  absolutely  negative.  EKperimental  inoc- 
ulations have  for  the  most  part  been  unBUCoeasful.  It 
has  been  suggested  by  Hallopeau  and  others  that 
these  tuberculides  may  be  the  result,  not  of  the 
inoculation  of  tubercle,  but  of  the  circulation  in  the 
blood  of  toxins  produced  in  tuberculous  foci  within 
the  body.  In  view  of  the  eruptions  produced  by 
other  kinds  of  toxins  and  by  certain  drugs,  the  pos- 
sibility of  such  an  origin  cannot  be  denied.  But  at 
present  it  is  a  theory  resting  on  no  solid  proof.  Fox 
points  out  that  if  these  tuberculides  are  due  to  the 
implantation  of  tubercle  bacilli,  starting  from  some 
distant  focus  and  coming  by  way  of  the  blood  stream, 
the  organisms  must  be  of  little  virulence  and  are 


4^      GSHERAL  JKOCVLABLE  DISEASES,  [chap.  \ 


'   probably    easily    kiUed.     This    would,    he    i 
!    explain  why  tlie  pathological  chaogeB  fifp  often  in- 
decisive, and  why  inocTilations  fail.     In  the  author's 
experience    tuberculides    are    frequent    sequelae    of  I 
measles,  which,  as  is  well  known,  is  often  the  deter-  ] 
mining  factor  in  the  development  of  phthisis. 

In  a  short  text-hook  a  full  description  of  the  j 
affections  designated  by  the  comprehensive  term  ] 
"  tuberculides  "  would  be  out  of  place.  The  r 
who  desires  fuller  information  is  recommended  to  ' 
consult  Fox's  paper,  which  ia  not  only  a  summary  of  | 
tlie  whole  subject,  but  a  storehouse  of  references  ' 
bearing  thereon. 

Acneiform    tuberculide.— An     affection     de- 
scribed under  tliis    name  presents    sufliciently    dis- 
tinctive features  to  deserve  special  mention.*  J.  M.  H.  I 
Macleod  of  London  and  Oliver  Ormsby  of  ChicKf^  I 
have  recently  made  an  exhaustive  study  of  two  cases.  ' 
The  following  are  the  essential  details  :    Case  1.  The  J 
patient  was  a  baby  with  tuberculous  history  -and  I 
evidences  of  general   tuberculosis — dactylitis,   i 
form  tuberculides  on  the  arms,    hips,   etc.     Hiflto-  j 
logical  examination  revealed  typical  tulierculoua  archi-  I 
tecture  and  tubercle  bacilli  in  the  giant  cells  ;    there'] 
was  also  endophlebitis  in  the  veiuB  of  the  hypoderm.  1 
Case  2.  A  woman,  aged  twenty-five,  with  acneifoim  | 
tuberculides  on  the  legs.     Typical  tuberculous  amhi- 
tecture  was  seen  in  the  sections,  with  periphlebitis  1 
and  endophlebitis.     Macleod  and  Ormsby  condude 
that  acneiform  tuberculides  begin  in  an  affection  of 
the  hypoderm,  the  cause  of  which  is  the  tubeide 
bacillus.     The    process    results    in    a    deep-seated   , 
necrosis,  definitely  tuberculous  in  character, 
is  the  consequence  of  the  invasion  of  the  tuberotiaij 
bacillus  and  its  t«xines. 


F.  Ifrm,.  IWl. 


X.]  LVPVS      VVLGARIS.  423 

Lupus  Vulgraris  is  a  form  of  tuberculosis  of 
the  skin  presenting  anch  marked  clinical  character- 
istics as"  to  make  it  a  distinct  morbid  eptity. 
Though  uudoubtedly  bacillary  in  its  oriein,  its 
virulence  is  comparatively  alight.  Tlie  distinctive 
lesion  ia  a  new  growth  in  the  superficial  or  deep  part 
of  the  corium.  This  neoplastic  nodule  (caUed  by 
Leloir  Iwpoina)  ia  soft,  brownish-red  in  colour,  and 
translucent,  resembling  apple  jelly  (Hutchinson).  The. 
lupua  nodule  is  slow  in  evolution,  and  destroys  t!ie 
tissues  which  it  invades,  either  by  ulceration  ij,upui 
exedens)  or  by  atrophy  {lupui  nan  exedens).  The 
characteristic  nodules  are  at  first  buiied  in  the  skin, 
on  the  surface  of  which  after  a  time  they  show 
themselves  aa  papules  of  the  size  of  a  pin's  head. 
These  are  at  first  dull  red  in  colour  and  become  pale, 
but  do  not  disappear  on  pressure.  They  are  discrete 
and  arranged  in  groups,  sometimes  in  irregular  circles. 
The  papules  gradually  become  larger  and  develop  into 
nodules,  the  intervening  skin  meanwhile  becoming 
thickened  by  cellular  infiltration,  reddened  by  inflam- 
matory stasia  in  the  vessels,  and  somewhat  raised  bo 
as  to  form  a  distinct  patch  ;  at  this  stage  the  apple- 
jelly  nodulea  project  slightly  above  the  stdn.  Their 
tranalucency  varies  according  to  the  thickness  of  the 
epidermis  covering  them.  New  nodulea  spring  np 
around  the  edge  of  the  patch,  which  in  this  way 
spreads  very  slowly  and  may  gradually  invade  a  large 
area  of  akin.  The  surface  of  the  lesions  is  covered 
with  fine  branny  scales,  but  not  so  thickly  as  to  hide 
the  redgronnd  of  the  patch.  The  lupus  tissue  tears 
very  easily,  in  marked  contrast  to  the  tough  corium. 
The  disease  usually  starts  from  a  single  focus,  but 
others  may  arise,  and,  developing  separately  or 
coalescing  with  neighbouring  ones,  may  involve 
almoet  the  whole  body  {lupus  disseminalus).  The 
ptocesB  is,  as  a  rule,  extremely  slow,  and  in  some 


QEWERAL  INOCULABLE  llISBASES.  [c«ap.  XCt.  \ 


indeflnite    tima.     The    patch    may    slowly    undergo 
inTolution  in  the  centre,  &  smooth,  firm  scar  being 
left  resembHng  that  of  a  bum.     This  is  often  bounded  ■ 
by  a  ridge  of  hluiBh-whit*  or  reddish  tubercles,  which  | 
continue  slowly  to  invade  the  surrounding  skin.         y 

In  the    majority    of-  caHes,    however,  ulceration 
takes  place  at  some  time,  the  lupus  tissue  brealdag 
down   and   forming  a    granular  sore   covered    with 
greenish-black    crusts ;     dotted    around    the    edge, 
which  is  ragged,  are  apple-jelly  nodules  in  various  J 
stages  of  development.     The  ulceration  may  e 
through  the  whole  thickness  of  the  skin,  and  in  parts,   ] 
like  the  nose,  where  the  integument  is  thin,  it  some- 
times causes  necrosis  of  cartilage :    it  never,  how- 
ever,   erodes    bone,    a    point    which    conspicuously  ] 
differentiates  it  from  syphilis  and  cancer.     If  th«   | 
inflammatory  process  reaches  any  degree  of  intensity, 
enlargement  of  neighbouring  lymphatic  glands  not 
.  unfrecjuently  follows  ;  this  enlargement  is  considered    . 

^^_      by  Leloir  to  be  due  to  diffusion  of  the  tubercnlotis  J 
^^^k    virus  by  the  lymphatics.     As  a  general  rule,  it  m&y 
^^^1    be  stated  that  the  ulceration  of  lupus  is  extensiye  j 
^^^^  rather  than  deep.     Occasionally,  especially  after  tlw  j 
surface  of  a  lupus  patch  has  been  scraped,  the  prooew 
seems  to  be  quickened  into  considerable  activity,  the   ! 
skin  becoming  hot  and  hypereemic,  rapid  devolop- 
ment  of  fresh  nodules  taking  place,  and  general  febrUC 
symptoms  coming  on.     The  phenomena,  In  fact,  recall 
a  mild  reaction  after  the  injection  of  tuberculin,  and 
are  probably  to  be  explained  by  the  absorption  ol 
bacillary  producte. 

All  phases  of  the  lupus  process  may  be  present  at 
one  and  the  same  time  in  a  given  case.  Often  while 
one  part  of  a  patch  is  in  active  ulceration  auoth«r  ta 
cicatrising,  and  nodules  in  alt  stages  of  development 
are  to  be  seen  on  ite  surface.     In  adults  b 


WAP.  XIX.]   LVPL1S   VULGARIS  :  DlSTJiJBUTiON.  425 

the  iBsions  are  infiltrated  patches  raised  more  at  the 
edge  than  in  the  centre,  and  with  no  translucent 
nodules.  The  difierent  degrees  of  infiltration  of  the 
skin  and  of  intensity  of  the  inflanmiatorj'  process, 
together  with  the  anatomical  peculiarities  of  the  part 
affected,  give  rise  to  the  greatest  diversity  in  the 
appearance  of  the  lesions.  These  variations  are 
PKpresaed  by  such  terms  aa  Iwpua  hypeiiTopMcus, 
papillomalosas,  serpiginosus,  etc.,  which  must  be 
understood  as  indicating  difierences  of  appearance, 
not  of  process. 

Lupus  is  seldom  symmetrical  in  distribution.  The 
favourite  point  of  attack  is  the  face,  especially  the 
nose  and  the  neighbouring  part  of  the  cheek  ;  it  alao 
ocrais  on  the  limbB,  eapeciallv  the  hands  and  feet,  on 
the  trunk,  and  on  the  buttocks.  No  part  of  the  skin 
is  safe  from  invasion,  but,  as  Hutchinson  has  pointed 
out,  the  warmer  a  part  is,  the  less  likely  is  it  to  be 
attacked  by  lupus.  The  disease  is  rare  on  the  genitals 
and  on  the  scalp,  though  it  may  spread  to  these  parts 
from  foci  in  their  neighbourhood.  The  mucous  mem- 
branes of  the  cheeks,  soft  palate,  pharynx,  and  larynx 
are  sometimes  the  seat  of  the  disease,  which  generally 
extends  to  these  parts  from  the  skin  of  the  face  ; 
occasionally,  however,  the  larynx  may  be  attacked 
primarily  ;  the  tympanic  membrane  may  be  invaded 
through  the  external  meatus  from  the  ear  or  through 
the  Eustachian  tube  from  the  throat.  A  patient  of 
mine,  a  lady  past  middle  age,  who  for  years  had  been 
the  subject  of  lupus  of  the  face  and  other  parts  of  the 
skin,  developed  the  disease  in  the  vagina  and  on  the 
OS  uteri.  The  appearances  in  this  case  bore  no  resem- 
blance to  those  described  by  Matthews  Duncan  and 
Thin  in  a  case  which  they  supposed  to  be  an  example 
of  vaginal  lupus,  but  wliich  was  in  all  probability  of 
syphilitic  nature. 

The  course  of  lupus  is  almost  always  extremeli; 


426    OBNKRAL   INOCVLABLF.    /)/SK^SES.  [chap.  six.  | 

Blow,  often  lasting  twenty  or  thirty  years,  or  longer. 
The  process  is  more  active  in  cliildhood  than  in  later 
life,  and  its  activity,  as  a  rule,  becomes  leas  with 
advancing  age.  The  normal  sluggishness  oi  the  process 
is  diversified  by  occasional  episudes  of  unwonted, 
activity,  during  which  the  disease  may  make  con- 
siderable progress.  Tliia  not  unfrequently  occutb 
under  the  influence  of  the  physiological  changes  wliich 
take  place  at  puberty,  or  as  the  result  of  an  attack  of 
some  acute  illness,  such  as  measles  or  scarlet  fever, 
or  of  external  irritation,  as  by  cold.  These  periods  of 
activity  are  followed  by  long  intervals  of  comparative 
quiescence,  the  disease  seeming  almost  to  die  out. 
Spontaneous  cure  sometimes  takes  place,  though  this 
is  too  rare  an  event  to  be  taken  into  account  in 
practice.  Even  when  the  process  does  come  to  ft 
standstill,  this  usually  does  not  occur  until  it  hi 
wrought  irreparable  destruction  on  the  parts  attacki 
leaving  hideous  scars,  obliterated  passages,  and 
formed  hmbs,  which  would  render  life  all  but  intob 
able  for  most  people.  As  a  rule,  lupus  is  unatteni 
with  ^ain. 

The  secondary  efiects  of  lupus  depend  on  tl 
severity  of  the  process,  and  also  on  the  situation 
the  disease.  On  the  face  it  leaves  its  mark  in  destnil 
tion  of  the  nose,  with  Bcarring  of  the  cheekt 
and  enlargement  of  glands,  particularly  of  the  paiot 
Caseation  and  breaking  down  may  take  place  in  thi 
leading  to  the  formation  of  scrofulous  ulcers, 
often  to  profuse  suppuration,  which  undermines  tl 
patient's  health.  Great  development  of  fibrous  tit 
sometimes  takes  place  in  the  cicatrices  and 
limbs ;  this  leads  to  contraction  and  crippling 
joints.  The  skin  not  uncommonly  becomes  adherent^ 
to  the  underlying  faeciE  and  tendons,  the  whole  beii 
giued  together  into  a  dense,  tough  mass,  adherent 
the  bone,  which  is  itself  thickened  and  sclerosed. 


\ 


CHAT.  SIS.]  LUPUS     VULOARIS.  i2', 

ulcerated  parts  may  become  the  seat  ai  warty  vegeta- 
tions [lupus  jaapillotnatostis).  There  is  nothing  pecu- 
liar to  lupuB  in  these  secondary  changes,  which  are 
the  results  of  chronic  inilammation  in  tiBaues  of 
abnormal  vulnerability,  comphcated  by  the  action  of 
pathogenic  micrococci  which  come  in  to  complete  the 
destructive  work  of  the  tubercle  bacillus.  I  have  seen 
pseudo-elephantiasis  of  the  lower  Hmh  due  to  blocking 
of  the  lymphatics  as  a  rare  result  of  lupus  vulgaris.* 
A  still  more  formidable  complicatiou  is  the  develop- 
ment of  epithehoma,  which  takes  place  in  a  certain 
proportion  of  eases.t  (Fig.  25.)  This,  if  1  may 
judge  from  my  own  experience,  is  not  very  common, 
but  Ashibara  has  collected  122  instances. 

Lupus  does  not  appear  to  have  any  effect  on  the 
general  health  except  in  rare  cases.  According  to 
Leloifij:  however,  lupus  of  the  hand  may  become  "  a 
starting-point  of  tuberculous  lymphangitis  with  pro- 
duction of  sorofttlo-tuberculous  gummata  developed 
along  the  course  of  the  lymphatics  attacked,  and 
finally,  under  the  influence  of  the  absorption  of  the 
tuberculous  virus  by  the  lymphatics  of  the  upper 
limb,  determine  a  pidmonary  tuberculosis  of  the 
correaponding  side."  Leloir  looks  upon  the  enlarge- 
ment of  the  glands  which  has  been  described  as  occa- 
sionally taking  place  in  the  neighbourhood  of  lupus 
patches  as  evidence  of  secondary  tuberculous  infec- 
tion, and  this  fact  he  claims  to  have  proved  histologi- 
cally and  experimentally.  Of  seventeen  patients 
under  his  own  observation  in  188-^-86,  ten  presented 
unquestionable    evidence     of    pulmonary    tiibercu- 


'B   HOBpltHi 

JWW-89,  p.  339. 

i  ArrJi.  f.  Dmimlol  if.  >S-/p/i.,  Bd, 
"  Du  Lupus  Vnlgaiie,"  Bcussala.  189C 
lionia  dHVelopetl  in  live  (if  his  US  casae. 

i  A«n.  ./e  Dmn.  ef  rff  Suph..  1886. 


428    GENERAL  ISOCVLABLE  DISEASES,     [chap.  xtx. 

loaiB.*  Doutrelepont  f  has  reported  a  case  in  wliich  a 
healthy  woman,  the  subject  oi  lupus  of  the  face  and 
hmbfl,  rapidly  Buccumbed  to  tuberculous  mcnin^tiB,  as 
proved  by  post-mortem  examination ;  the  lupus  lesions 
were  the  only  discoverable  source  of  InfectiDn. 
Thibierge  has  recorded  the  case  of  a  boy  aged  fifteen, 
who  suffered  from  peritoneal  and  pulmonary  tuber- 
culosis, the  commencement  of  which  dated  from  the 
ciue'of  a  patch  of  lupus  on  the  cheek.  Besnier,  from 
long  clinical  observation,  has  come  to  the  conclusion 
that  secondary  tuberculous  infection  is  a  not  un- 
frequent  result  of  lupus  ;  sometimes  this  takes  place 
rapidly  (within  two  or  three  years),  somctiraBs  very 
slowly  (ten,  twenty,  tliirty  years,  or  longer)  ;  usually, 
he  says,  the  subjects  of  lupus  who  become  phthisical 
do  so  in  a  latent  and  very  slow  manner.  He  pvea 
the  proportion  of  auch  secondary  phthUia  in  hia  own 
practice  as  21  per  cent.  Dubais-Hivenitli  J  states 
that  among  118  patients  under  liis  own  care  suffering 
from  lupus,  eight  died  from  pulmoiiwy  consumption. 
Lailler,  from  observation  extending  over  many  yean 
at  the  St.  Louis  Hospital,  tttates  that  pulmon&ry 
tuberculosis  is  a  frequent  cause  of  death  among 
sufferers  from  lupus.  Renouard  §  found  that  of  137 
caaea  of  lupus,  fifteen  developed  pulmonarv  phthisis. 
Haslund  of  Copenhagen  puts  the  proportion  of 
secondary  pulmonary  infection  in  the  lupus  patieata 
in  his  own  cHnic  at  the  startling  figure  of  liu  per  oeut. 
On  the  other  hand,  Nevins  Hyde  of  Chicago  hu 
never  seen  a  case  of  such  infection ;  and  Broctj'a 
experience  has  been  equally  negative. 

This  divergence  of  opinion  is  sufficient  to  show 
how  dtflicidt  it  is  to  obtain  clinical  evidence  on  &ta 


3,  p.  XXI. 


».,  Juii 


{  Uuated  by  Dubola-HaTvlUth.  Inc. 


LUPUS    VULOARIH.-     ETIOLOGY. 


The 


I  point  which  ia  conclusive  one  way  or  o1 
whole  eubject  bristles  with  difficulties, 
jobvions  source  of  fallacy  being  the  tact  that  both 
lupus  and  pulmonary  phthisis  may  have  a  common 
predisposing  factor,  namely,  tuberculous  inherit- 
ance. My  own  experience  is  that  the  development  of 
secondary  tuberculosis  in  the  lungs  from  a  focus  of 
hipus  on  the  skin  is  decidedly  unfrequent. 
Lupus  is  also  sometimes  complicated  by  wasting 
and  antemia.  Many  patients,  however,  have  all  the 
appearance  of  robust  health  ;  but  as  a  class  sufferers 
from  lupus  are  not  long-lived. 

Etiolog'y. — The  essential  etiological  factor  is  local 
^^^  tuberculous  infection.  The  tubercle  bacillus,  though 
^^^L  most  difficult  to  find,  is  probably  always  present 
^^^H  in  some  stage  of  the  lesion,  and  tuberculous  infection 
^^^B  can  be  produced  by  inoculation  of  cultures  made 
^^^H  from  these  lesions.  Of  the  exact  mode  in  which  the 
^^^1  infection  is  ordinarily  conveyed  little  is  yet  definitely 
^^^f  known.  It  ia  probable  that  the  bacillus  gains  access 
^^H  by  an  accidental  abrasion  of  the  epidermis,  or  it  may 
^^H  eonceivably  bo  carried  to  tbe  skin  by  the  blood  or 
^^H  lymph  after  having  found  its  way  inside  the  body 
^^H  through  one  of  the  natural  passages.  There  are, 
^^H  however,  a  number  of  secondary  causes  which 
^^^B  play  a  more  or  less  important  part  in  the  produc- 
^^^1  tion  of  the  disease.  Youth  is  a  predisposing  inliu- 
^^^H  ence.  The  disease  usually  begins  within  the  first 
^^^H  ten  years  of  life,  occasionaUy  at  puberty,  seldom  later. 
^^^1 '  In  exceptional  inetances  it  develops  in  middle  life,  or 
^^^1  even  in  old  age.  Females  show  considerably  greater 
^^^P  liability  than  males.  The  disease,  while  sparing  no 
^^^1  class,  numbers  more  victims  among  the  poor  than 
^^^1  among  the  well-to-do.  Cold  is  a  predisposing  factor 
^^^P  of  some  importance,  as  evidenced  by  the  greater  fre- 
^^^H  qneucy  of  the  disease  on  exposed  than  covered  parts. 
^^^^k£ven  if  cold  cannot  be  shown  to  have  any  direct 


■  430      GENERAL  INOCULAELE  DISEASES.  [caAP.  lis. 

influence  in  the  production  of  tlie  disease,  undoubtedly 
it  has  a  pernicious  effect  on  the  process  when  once 
established.  Measles  appears  sometimes  to  be  the 
determining  factor  in  the  development  of  luptu. 
H.  G.  AdamBon  *  has  reported  a  case  in  which  mul- 
tiple cutaneous  lupus  followed  an  attack  of  that 
disease,  and  he  refers  to  others  in  which  the  same 
sequence  of  events  was  noticed  by  Du  Castel.  I  have 
myself  seen  cases  of  lupus  made  much  worse  by  the 
supervention  of  measles. 

Pre-existing  lenions  or  scars  form  the  startiiig- 
points  of  the  disease  in  a  certain  proportion  of  coses. 
Slight  injuries,  burns,  sores,  blisters,  infantile  eczema, 
etc.,  are,  according  to  Beanier,  "very  commonly" 
the  immediate  causes  of  lupus.  It  is  obvious  that 
under  such  conditions  the  tubercle  bacillus  may 
more  readily  gain  access  to  the  tissues  than  when 
the  integument  is  intact.  Neiaser  holds  that  most 
cases  of  lupus  of  the  face  have  their  origin  in  a 
diseased  nasal  mucous  membrane.  The  inoculation 
may  be  made  by  a  contaminated  finger  used  to 
"  pick  "  the  nose ;  if  the  mucous  membrane  is  un- 
healthy, the  conditions  are  favourable  to  the  growth 
of  the  micro-organisms,  and  a  tuberculous  focua  is 
established.  Nasal  catarrhs  and  ecaematous  erup- 
tions about  the  nostrils  in  uncleanly  subjects  prepare 
the  soil  for  infection.  I  have  seen  cases  in  whidi 
lupus  apparently  began  in  the  tear-ducts  and  travelled 
down  into  the  nose.  These  facts  may  account  for  the 
marked  predilection  which  the  disease  shows  for  the 
nose.  The  disease  has  been  known  to  begin  in  tie 
vesicles  of  herpes  (Crocker,  Kaposi).  Among  other 
conditions  which  have  been  known  to  be  starting- 
point«  of  lupus  are  eruptions,  suppurating  gl&n^i 
boils,  aiul  syphilitic  lesions. 

"  £rit.  JmiiH.  IMim.,  ISWU,  p.  -JU. 


CHAP,  xrx.]      LVPUti   yULQARlS  :     ETIOLOGY.         431 

The  Btate  ol  the  general  health  has  eo  direct  in- 
fluence on  the  causation  o£  tupua,  and  the  disease 
is  probably  hereditary  only  in  so  far  ae  a  tuber- 
culous inheritance  may  create  a  predisposition 
thereto.  It  haa  been  suggested  by  Baumgarten, 
however,  that  the  bacillus  itself  is  directly  in- 
herited, and  in  that  case  the  origin  of  lupus  might 
be  explained  by  the  settlement  of  tlie  micro-organ- 
ism in  the  skin  of  the  fcetus.  Cases  in  which  lupus 
has  been  directly  inoculated  have  been  reported 
by  Jadassohn  *  and  others.  In  one  case  a  woman 
was  tattooed  on  the  forearm  by  a  man  sufiering 
from  pulmonary  tuberculosis,  from  which  he  after- 
wards died  ;  the  operator  used  his  saliva  to  dilute  the 
ink,  and  typical  lupus  nodules  appeared  on  the 
tattooed  parts,  Beanier  -f  showed  a  case  of  lupus  in 
a  lad  aged  eighteen,  in  whom  the  development  of  the 
disease  had  taken  place  in  a  vaccination  scar,  where 
it  had  developed  within  a  few  months  of  the  opera- 
tion. Graham  Little  X  has  recorded  several  cases  in 
which  lupus  developed  on  vaccination  scats ;  Fos, 
however,  under  whose  observation  some  of  them  had 
been,  does  not  think  they  prove  anything  in  regard 
to  the  transmission  of  lupus  by  vaccinarion.  Dubois- 
Havenith  §  mentions  a  case  which  suggests  the  possi- 
bility of  contagion  in  certain  circumstances  :  two 
sisters,  one  of  whom  had  for  eight  years  had  a  large 
patch  of  lupus  on  the  left  cheek,  shared  the  same  bed. 
For  the  last  two  years  the  other  sister  has  had  a 
lupus  patch  on  the  lobe  of  tiie  right  ear — that  is  to 
say,  the  ear  which  is  sometimes  in  contact  with  her 
sister's  cheek  as  they  lie  in  bed.  Aa  a  rule,  however, 
it  may  be  stated  that  lupns  is  not  contagious. 

•  Dubois- Haveuith,  lor,  ri£. 
t  Ail/i.  ik  Derui.  et  ife  -Si/jih.,  ISHH,  j).  nJH. 
t  Bril.  Joiirn.  Bmn.,  Murcli,  laoi. 
%  Lot.  eil^  p.  3S. 


aEXERAL  lyOCVLABLE  DISEASES,   fcwii 


F 

^^^B  Id  a  well-marked  case  of  lupus  the  dia^jHOSlS  is 

^^^H  ea^y.  The  presence  of  apple-jelly  nodiiles  at  once 
^^^P  iudicstes  the  nature  of  the  process.  A  tj'pjcal  lupus 
I  patch,  with  its  infiltrated  raised  surface,  defined  edge 

r  etudded  with  apple-jelly  nodules,  the  whole  covered 

I  with  !i  moderately  thick  layer  of  scales,  can  hardly 

^^_      be  mistaken  for  anything  eke.     The  disease,  however, 
^^^    may    sometimes    have    to    be    distinguished    from 
^^H'  aypliilis,  scrofulodermia,  lupus  erythematosus,  rodent 
^^f    ulcor,    and   cancer.     The    following   are   the   points 
^^^      differentiating  it  from  sypiiiUs  : — It  begins  in  child- 
hood, whereas  syphilis  begins  in  adult  life  ;  in  its  rate 
of  progress  it  is  to  syphilis  as  the  hour  hand  to  the 
minute  hand  of  a  clock  (Payne) ;  the  ulcers  are  ragged 
inst^-ad  of  sharp-edged ;    the  ulcerated  proceee  never 
involves  bones  ;    lastly,  if  the  lesions  are  eyphiUtic, 
other  traces  of  the  disease  are  sure  to  be  discoverable, 
and  if  any  doubt  should  remain,  a  course  of  anti- 
jr  syphilitic  treatment  will  clear  it  up. 

In  scrofulodermia,  also,   other  evidences  of  the 

isease  are  to  be  seen  on  the  nec'k  or  elsewhere,  in 

the  form  of  enlarged  glands  or  scare.     As  lupus  and 

Bcrotulodermia  not  unfrequently  coejdst,  and  as  the 

treatment  of  both  conditions  is  practically  the  swne, 

the  recognition  of  what  is  lupus  and  what  is  scroAllii 

r  is  a    matter   more   of   academic    than   of  jsactioal 

I  iroportancG. 

The  points  of  distinction  between  lupus  erythema- 
tosus and  lupus  vulgaris  may  be  summed  up  as 
follows :— While  lupua  vulgaris  appears  before 
puberty,  lupus  erythematosus  generally  ehows  it^f 
after  that  period :  the  soft  applc-jeUy  nodule* 
characteristic  o(  lupus  vulgaris  arc  altogether  absent 
in  lupus  erythematosus  ;  while  lupus  viilgaris  usually 
ulcerates  at  some  time  in  its  course,  lupua  erythMna- 
tosus  never  does  so ;  while  lupus  vulgaris  erodes 
cartilage,  lupus  erj-thematosua  never  extends  to  the 


^^OAP.. 


LUPUS   VULGARIS:  DIAGhOSlS 


deeper  parts ;  finally,  lupuB  vulgans  la  not  Bym 
metrical  in  ita  diatribution,  like  lupus  erytliemato^ui 
There  are  caaea,  however  in  wliich  the  characteri-itic 
leaiona  of  lupus  vulgaris  are  masked  by  cedematoua 
swelling,  and  in  such  circumstances  it  may  be  difficult 
to  distinguish  it  from  that  condition  ;  even  then, 
however,  if  the  scaly  covering  of  the  patch  be  removed, 
the  prickle-like  plugs  of  dry  sebaceous  matter  pasaing 
into  the  orifices  of  the  ducts  from  the  lower  aurEaces 
of  the  crusts  will  serve  to  identify  the  condition  as 
lupus  erythematoauB.  The  condition  in  which  lupus 
vulgaris  assumes  the  aspect  of  lupus  erythematosus 
hits  already  been  described.  By  stretching  the  skin 
at  the  spreading  edge  of  the  disease,  however,  small 
am  her- coloured  nodules,  having  the  charactcTB  of 
those  distinctive  of  ordinary  lupus,  can  generally  be 
seen.  Although  such  patches  never  present  any 
trace  of  ulceration,  a  tendency  to  cicatriaatdoo  is 
visible  at  the  border  ;  this  is  never  observed  in  true 
lupus  erythematosus. 

In  its  earliest  stage  lupua  may  sometimes  reaeiuble 
eczema  seborrhceicum,  but  the  appearance  of  the 
apple-jellv  nodules,  the  slow  course  of  the  process,  and 
the  tendency  to  the  formation  of  scars,  will  serve 
to  distinguiah  it  from  that  affection. 

Rodent  ulcer  is  essentially  a  disease  of  later  hfe. 
The  ulcer  is,  as  a  rule,  single  ;  it  is  much  slower  in  its 
course  than  lupua,  and  it  reaches  deeply  into  the 
tiaauea.  It  differs  from  a  lupus  ulcer  in  having  an 
indurated  border  and  a  smooth  floor. 

Epithelioma  is  alao  a  disease  of  later  hfe.  The 
hard  everted  edge,  the  foul  base  often  roughened  with 
warty  formationa  or  sprouting  with  cauliflower -like 
excrescences,  the  implication  of  neigh iDourinji  lym- 
phatic glands,  and  the  aecondary  deposits  in  other 
parts,  will  serve  to  identify  the  disease. 
~'     In    certain    rare  cases,    where    the    lesion.?    are 


434     OENERAL    INOCULABLE   DISEASHS.  [cbat.xc^ 

numerous  and  scattered  about  the  bodv,  and  where 
they  are  exceptionally  scaly,  lupus  may  more  nr  leBB 
closely  Bimujate  pRoriasia  ;  but  on  careful  examina- 
tion there  will  almoet  always  be  found  one  or  two 
patches  at  least  presenting  the  typical  characterB 
of  lupus. 

The  prognosis  is  favourable  as  regards  life,  as 
lupus  seldom,  if  ever,  directly  causes  death.  The 
possibility  of  secondary  tuberculous  infection,  slight 
as  on  the  whole  it  may  be,  must  be  borne  in  mind ; 
nor  should  the  posaibihty  of  the  development  of 
epitheboma  be  forgotten.  Fordyce  of]  New  York 
says  that  the  prognosis  of  epithelioma  arising  on  a 
lupus  base  ■  is  of  greater  gravity  than  that  of  the 
ordinary  cutaneous  form.  As  far  as  recovery  is  con- 
cerned, the  prospects  of  the  patient  depend  on  the 
severity  and  extent  of  the  process,  and  in  an  almost 
equal  degree  on  the  treatment  which  is  applied.  In 
the  most  favourable  circumstances  lupus  is  an 
obstinate  affection,  with  a  pronounced  tendency  to 
recurrence  even  after  the  most  thorough  removal. 
If  the  disease  be  limited  in  extent,  however,  and  t" 
patient  otherwise  healthy,  persevering  treatment  W 
in  a  certain  proportion  of  cases,  bring  about  a  c 
Ab  already  said,  the  process  is  most  active  in  c 
hood,  and  the  older  the  patient  the  more  hop* 
ia  the  prospect  of  treatment  proving  successful. 
Pathologically,  lupus  \TilgariB  is  a  local  t 
fulosis  of  the  skin.  The  essential  lesion  is  a 
growth  resulting  from  the  irritation  caused  by  i 
presence  of  the  tubercle  bacillus.  (Plat*  II,,  Fig.  I 
The  process  begins  in  the  deeper  layers  of  the  cutjl 
the  nodules  displace  the  bundles  of  fibrous  t 
and  as  they  increase  in  siee  they  grow  upwai 
through  the  skin,  destroying  if«  component  demei 
by  pressure,  so  breaking  through  the  papillary  li 
and  emerging  on  the  surface,  where  they  are 


CHAT.  SIX.]     LUPUS   VULGARIS  :  TREATilUNT,      135 

only  ljy  epithelium,  more  or  leas  translucent,  as 
alreiidy  said,  according  to  its  thickness. 

On  microscopic  examination  the  nodules  are  found 
to  be  composed  oi  giant~cella  (Plate  II.,  Fig.  6, 
and  Fig.  26),  surrounded  by  a  layer  of  epitheUoid 
cells,  with  an  outer  envelope  of  ordinary  lymphoid 
or  amaJ]  round  cells.  The  lupua  nodule  ia  practically 
identical  in  atructuie  with  the  tuberculous  nodule, 
and  this  fact  led  Friedlander  and  Koater  to  look 
upon  lupus  38  a  local  tuberculosis  before  this  was 
proved  bacteriologieally  by  Koch.  Tubercle  bacilli 
are  present  in  numbers,  which  probably  vary  with 
the  acuteneas  of  the  caae  ;  even  in  the  growing  edge 
there  ia  often  only  one  in  a  giant  cell.  It  ia  not 
surprising,  therefore,  that  frequently  they  cannot  be 
discovered  on  the  moat  careful  examination.  When 
a  lupua  nodule  has  reached  its  highest  development 
rctrogreasion  sets  in.  This  may  take  one  of  two 
directions  —  namely,  either  fatty  degeneration, 
followed  by  the  formation  of  a  fibrous  cicatrix,  or 
softening  and  ulceration.  Lupus,  however  ex- 
tensive or  disseminated  it  may  be,  shows  com- 
paratively little  tendency  to  become  generalised. 

In  the  treatment  of  lupua  the  object  to  be  aimed 
at  is  the  complete  removal  or  destruction  of  the 
diseased  tissue.  Por  this  purpose  internal  treatment 
is  useless,  although  it  may  sometimes  be  of  service 
indirectly  by  remedying  any  constitutional  condition 
which  favours  the  prohferation  of  pathogenic  micro- 
organisms. In  deciding  upon  the  particular  method 
of  local  treatment  to  be  pursued,  the  practitioner 
rouat  not  be  guided  entirely  by  the  destructive  energy 
of  a  particular  agent  or  procedure  ;  other  points, 
such  as  the  size  and  situation  of  the  lesions,  the 
tolerance  of  pain  in  a  given  patient,  the  length  of 
time  which  the  treatment  will  probably  require,  and 
the  nature   of  the  scar  likely  fo  be  left,  have  to  be 


(lESERAL  INOCULABLE  DLSEASES.  [cHiP.  xjs. 

:n  iato  account,  according  to  the  circumstances  of 
jase.  Again,  the  idiosyncrasy  of  the  disease  itself 
must  be  reckoned  with  :  while  in  some  cases  the 
roughest  handling  does  ifo  harm,  in  others  the  diseftee 
f  ao  angry  a.  nature  that  even  the  mildest  local 
treatment  is  resented.  In  dealing  with  lupus,  as  with 
other  affections  of  the  skin,  the  practitioner  must  feci 
his  way,  and,  while  ruthless  in  his  war  against  the 
disease,  must  never  forget  that  there  ia  a  patient 
behind  it. 

If  lupus  is  superficial,  an  attempt  should  be  made  j 
to  bring  about  exfoliation  of  the  diseased  tissues,  I 
The  best  application  for  this  purpose  is  salicylic  acid,  I 
which  may  be  used  in  the  form  of   Unna's  salieylit  I 
|-  add  ami  creosote  jiaster  muU,  the  latter  drug  being  I 
introduced  to  neutralise   the  pain  caused   by    the  I 
former.     The  parts  should  first  be  softened  with  j>a  ] 
emollient  ointment,  and  then  well  washed  with  soft  ■ 
*  soap,  so  as  to  remove  the  scales.  Care  must  be  takei 
not  to  continue  the  use  of  galicylic  acid  too  long,  and 
to  confine  its  use  as  nearly  as  possible  to  the  afiect«d  , 
t  surface,  so  as  not  to  injure  the  surrounding  f 
■  Another  way  of  employing  salicylic  acid  is  to  add  it  1 
to  glycerine  in  sufficient  quantity  to  form  a  cream, 
with  a  little  creosote,   and  apply  it  on  lint.     For  1 
'  either    of    these    applications    may    be    substituted  -| 
|J  Brooke's  ointment,  which  is  composed  as  follows  ;- 

B     Zinoi  oxiili         jij 

Amyl.  pulv ,>ij 

Vaeelini  albi  ^ 

Hydmrg.  olwitifl  (S  per  cent.)  .  ^ 

Acid.  salicyL grs.  sx 

Ichthyol  II IX 

01.  larajiduliD  ,  ,  . .  (j.h. 

•  ■'APreliminnryTmilnifiit  <)(L>iiinBViil^-iim,"  Bnt-Jmrn.  I 
A'ln.,  Mb; ,  L89U,  p.  Ho. 


CMAt.  XIX.]    LUPOa   VVhOARlS:  fSEATMEKi.:     437 

This  ointment  should  be  vigorously  ruhbed  in  night 
and  morning,  the  part  being  then  thickly  dredged 
over  with  potato- starcii  powder,  I  have  seen  excel- 
lent reaultfl  follow  the  use  of  this  ointment.  If  the 
skin  should  break,  it  should  be  dressed  with  some 
simple  antiseptic  apphcation,  such  as  boracic  acid 
ointment. 

Parasiticide  applications  are  sometimes  very 
useful.  Mercurial  plasters  may  be  apphed,  or  an 
ointment  of  one  or  two  grains  of  bichloride  of  mercury 
to  ike  ounce  of  vasditie  may  be  used.  Prof.  White 
of  Boston  says  that  by  this  method  a  cure  is  effected 
in  a  few  months.  Doutrelepont  *  applies  a  solution 
of  coTTosive  suMimate  of  1  in  1,000  under  guttapercha 
tissue,  and  says  the  method  has  been  very  aucceasful 
in  hia  lianda.  Dubois-Havenitb.f  on  the  other  hand, 
who  has  frequently  tried  it,  baa  had  "  variable,  but 
always  incomplete,  results."  Bichloride  of  mercury 
has  also  been  injected  into  lupus  patches  by  Doutrele- 
pont, Tansini,  and  others,  with  a  beneficial  effect. 
Harrison  X  of  Clifton  claims  to  have  cured  lupus  by 
impregnating  the  afiected  tissues  with  sulphurous 
acid  in  ike  nascent  state.  An  aqueous  solution  oj 
hyposutpkile  of  soda,  grs.  40  to  '%}  (No.  1  lotion,  or 
night  application),  is  appUed  to  the  affected  parte  by 
means  of  lint  covered  with  guttapercha  tissue  or 
oilskin,  the  object  being  to  saturate  the  tissues 
thoroughly  with  this  soda  salt.  The  following  morn- 
ing a  lotion,  consisting  of  pure  hydrochloric  aeid 
(B.P.)  ]i\y  in  waier  '^j  (No.  2,  or  day  application),  is 
applied.  In  this  way  a  quantity  of  nascent  Hulphur 
and  sulphurous  acid  is  said  to  be  formed  deep  m  the 
diseased  structures.  The  lotions  are  changed  night 
and  day,  and  the  treatment  must  be  continued  for 

*  Mamlth.f.  fiakt.  Derm.,  18S4,  Ku.  1. 

f  La:  fi(..p.  107. 

1  Bril.  Med,  JoHi-n.,  Augoat  G,  1SH2. 


}-43S    OMBflAl  imCVLABLB  DlUKAfiES.    [t-KAt.  xiK. 


^^^V  weeks,  The  result,  according  to  Harrison,  is  that  the 
^^^B' lupus  tissue  is  destioyed,  sc:aba  aad  scales  quickly 
^^^^dWppear,  and  an  ulcerated  surface — which  soon 
^^^K  shows  a  tendency  to  lieal^is  produced.  It  ia 
^^^■, probable,  however,  that  by  thia  method  only  the 
^^^F 'Organisms  which  cause  suppuration  and  ulceration 
^^^  are  destroyed,  the  lupus  process  itself  being  un- 
touched. 

Cliemical  caustics  are  often  very  useful  if  applieil 
in  a  thorough  manner.  Here  the  question  of  an- 
ffiatheticB  naturally  presents  itself.  The  injection  of 
cocaine  round  the  patch  of  lupus  to  be  operated  on 
will  ofte.n  duU  the  sense  of  pain  sufficiently  for  the 
purpose  in  view.  The  adviaabihty  of  a  general 
antesthetic,  and  the  choice  of  an  agent  if  such  be 
thought  necessary,  must  depend  on  the  special  ciiooin- 
stances  of  the  case.  Among  chemical  caustics  nitraU 
of  sUver  holds  the  first  place,  and  is  still  the  favourite 
r^edy  for  lupus  with  some  very  experienced  derma- 
tologists. It  acts  only  on  the  diseased  tissue,  and 
may  thus  be  very  freely  applied.     The  patch  should 

»be  deeply  grooved  with   the  soUd  stick  in  various 
directions  till  the  whole  ia  destroyed.     The  procedure 
is  extremely  painful  both  at  the  time  of  the  operatitm 
and  for  some  hours  afterwards.     It  has  the  advantage 
that  it  causes  no  bleeding,  and  the  parte  require  no 
special  attention  between  the  visits.     Equally  good 
results,  however,  can  be  obtained  by  milder  measures. 
Acid  nitrate  of  mercury,  applied  on  the  end  of  a  ^toht 
tipped  with  cotton-wool,  is  a  more  eflicient  cattttio 
than  nitrate  of  silver ;  but  it  is  also  more  painful,  and 
^^_    ^ves  rise  to  unsightly  scars.  Ladic  acid  is  useful  for  the 
^^L  treatment  of  ulcerated  surfaces  ;    it  causes  compaiB' 
^^H  I  lively  Uttle  pain,  but  as  it  acts  impartially  on  souitd 
^^^P  and  on  diseased  tissue,  the  neighbouring  parts  mittt 
be  protected  when  it  is  used.     It  is  most  applicable 
to  lupus  of  mucous  membranes.       '      ''■oiJ   J*"" 


cHii'.  SLs.]     LVPUS   VULGARIH:  TBBATldENT.      43il 

destroys  lupus  tissue,  but  tlie  appliisation  causes 
severe  pain,  and  arsenical  poisoning  is  not  imposs'ible 
unless  great  care  be  taken.  The  following  is  Hebra's 
formula : — 

Arsenioua  auid  gra.  10 

ArtifioUl  cmnabsf         . .         . .         . .     58b 

Rose  ointment  . .         . .         .  ■         ■  ■     5^ 

This  is  spread  on  linen  and  applied  evenly  on 
strips,  over  which  a  piece  of  lint  is  firmly  bandaged. 
The  caustic  should  be  left  in  situ  for  twenty-four 
hours,  when  the  parts  are  carefully  cleansed  and  the 
paste  re-applied.  CUoride  of  zinc  is  extremely  useful 
as  a  caustic  agent,  especially  as  a  supplement  to 
surgical  measures.  It  may  be  applied  in  solution  oi 
equal  parts  of  chloride  of  zinc  and  alcohol,  or  in  the 
form  of  a  paste  composed  as  foUows  : — 

»  Chloride  of  zinc  ...      . .         . .     Jivj 

Powdered  opium  . .         . .         . .     Jjsa 

Hydrochloric  acid         . .         . .         , .     gvj 
Boiling  water  to  . .         . .         . .     5»i 

Diaaolro.     To  one  ounce  of  the  solutiou  add  two   drachma 
oE  wlieateu  flour  [Middlesex  HoBp.  Ph.). 

PyrogaUic  add  is  extremely  useful  in  most  cases. 
It  has  a  selective  action  on  the  tissues,  and  as  a  rule 
causes  comparatively  little  pain ;  to  this  rule,  how- 
ever, there  are  exceptions,  a  fact  which  the  practi- 
tioner will  do  well  to  bear  in  mind.  It  may  be 
applied  in  the  form  of  a  plaster-mull  or  as  an  ointment 
(10  per  cent.),  or  in  a  saturated  ethereal  solution.  The 
latter  form  is  much  used  by  Beanier.  He  brushes 
the  solution  over  the  affected  surface,  which  is  then 
covered  with  traumaticin  ;  this  is*  repeated  till  all  the 
lupus  nodules  have  been  destroyed.  Pyrogallic  acid 
is  particularly  useful  In  the  after-treatment  of  patches 
that  have  been  subjected  to  eraaion,  scarification,  or 
cauterisation.     It  may  be  combined  with   salicyhc 


440    GENERAL  INOCULABLE  DISEASES,     [el 

add  in   IQ  per  eent.  in  collodion,  or  in  tlie  form  of  | 
ointment. 

The  mechanical  treatment  of  lupus  includea 
excision,  erasion,  scariScation,  and  cauterisatioa 
(a)  simple  and  (b)  electrical. 

Excision  gives  excellent  results  if  the  whole  of  the 
disease  can  be  removed  without  leaving  too  large  h 
breach  of  surface.  The  operation  is  chiefly  applicable 
in  the  case  of  limited  patches  situated  on  the  Umbs 
01  trunk.  Healing  of  the  wound  is  greatly  aided  by 
transplantation  of  skin  after  the  manner  of  Thierscb. 
In  this  way  comparatively  large  gaps  in  the  tegu- 
mentary  covering  have  been  filled  up.  The  moet 
thorough  removal  of  the  lupus  tissue,  however, 
afiords  no  absolute  guarantee  against  recurrence. 
Excision  is,  for  obvious  reasons,  seldom,  if  ever, 
applicable  in  lupus  of  the  face. 

Erosion  or  scraping  is  useful  when  the  diseasA 
is  ejctensive.  The  ulcerated  surface  is  scraped  out 
with  Volkmann's  spoon,  just  like  a  tuberculous 
joint.  The  instruments  used  vary  in  size  and  shape, 
according  to  the  different  parts  on  which  they  have 
to  be  employed.  The  scraping  must  be  done  with 
some  amount  of  force  ;  and  it  will  be  found  that  the 
underlying  healthy  tissue  is  much  tougher  than  tite 
diseased  structures,  which  break  down  readily  ondaT' 
the  curette.  A  practised  operotor  knows  when  b« 
has  got  down  to  healthy  tissue  by  the  resistutoe 
which  he  feels.  Bleeding  may  be  checked  by  preason 
with  pieces  of  cotton-wool.  However  llioroughlj'  tb* 
lupuH  tissue  may  seem  to  have  been  scraped  BWftV, 
fresh  nodules  are  almost  cextain  to  make  that 
appearance.  They  should  be  at  once  scraped  aiTBf 
or  broken  up.  For  this  purpose  a  double-threkd«d 
Bcrew  instrument  devised  by  me  will  be  found  useful. 
Some  powerful  parasiticide  substance,  such  as  _ 

carbolic  acid  or  bichloride  of  mercury  (1  in  2,O0t9*j 


i«HAP.  Xix,]     LUPUS   VVLOARIS  :   TREATMEXT.      441 

should  be  used  to  wash  tlie  raw  surface,  and  the 
wound  should  be  dieasod  antiseptically.  Erasion 
13  a  valuable  method  o{  treatment,  but  as  a  rule  it 
requireu  to  be  supplemented  by  chemical  agents  such 
as  pyrogallic  acid  or  chloride  of  zinc,  which  complete 
the  work  of  destruction.  Veiel  supplements  erasion 
by  multiple  puncture,  stabbing  the  scraped  surface 
in  hundi-eds  of  points  with  a  narrow-bladed  knife. 
These  stabs  are  as  close  together  as  possible.  The 
process  is  repeated  three,  five,  and  even  eight  times 
within  a  fortnight  or  a  month.  The  following  method, 
which  was  communicated  to  me  by  Lord  Lister, 
answers  well.  After  the  diseased  tissue  has  been 
thoroughly  scraped  out  and  the  bleeding  has  ceased, 
the  holes  are  filled  up  with  fuming  nitric  acid,  which, 
after  being  allowed  to  saturate  the  tissues  for  a  few 
moments,  is  neutralised  by  a  solution  of  bicarbonate 
of  soda.  When  the  eServeacence  has  entirely  ceased 
the  part  is  dressed  in  the  usual  way.  There  is  hardly 
any  subsequent  pain,  and  the  results  are  excellent. 

Scarification  consists  in  ploughing  up  the  diseased 
patch  in  close-set  parallel  furrows,  so  that  ali  the 
nodules  are  broken  up.  A  lupus  patch  may  be 
scarified  in  diSeient  directions,  the  lines  crossing 
each  other  so  that  no  point  shali  escape  the  knife. 
The  secret  of  successful  scarification  is  to  use  very 
sharp  instruments,  and  to  multiply  the  incisions  so  as 
to  cover  the  whole  surface  in  such  a  way  that  the 
diseased  tissue  shall  be,  as  It  were,  thoroughly  minced 
up  and  the  nutrient  vessels  destroyed  or  occluded. 
The  scarification  should  be  carried  below  the  level  of 
the  new  foimation  without  going  beyond  the  hmit 
of  the  true  skin.  The  treatment  should  always  be 
begun  at  the  edge.  The  bleeding  can  easily  be 
checked  by  pressure  with  cotton-wool,  and  the  pain 
i  the  operation  can  be  to  a  large  extent  mitigated 
f  the  previous  use  of  cocaine,     Scarification  leaves 


1 


442      (JBNEltAL  INOCVLABLK  D18KASBS.  [ctiap.  Icrt.J 

a  better  acar  than  ai:rajimg,  and  ia  tlierdore  morel 
suitable  when  tlie  face  ia  the  Beat  of  the  disease,  f 
The  lesulte  on  the  whole  are  satisfactory,  though  I 
recurrence  takes  place  in  about  as  large  a  proportion  -I 

cases  as  after  other  methods  of  treatment.     The  1 
objections  to  it  are  that  it  nec^essarily  requires  a  long  I 
time,  during  which  the  sufierer'a  patience  or  health 
may  give  way ;  it  is  also  attended  with  a  conaiderabla 
amount  of  pain,  and  the  loss  of  blood  which  it  caa 

y  in  the  aggregate  be  of  serious  consequence  ii 
weakly  patient.  A  still  graver  objection  against  it  is  J 
urged  by  Besnier,  who  states  that  secondary  tuber-  I 
culous  infection  is  vexy  hkely  to  be  cauaed  during  the  1 
process  of  scarification,  particles  of  the  diseased  tifwue  ' 
being  carried  away  in  the  blood  and  inoculated  in 
some  other  part   of  the   surface.     Though   I   have 

irated  on  a  large  number  of  cases  in  this  way,  I 
hiive  never  seen  Euch  a  result  iollow. 

Cauterisation  with  Paquelin's  cautery  ia  a  severe  I 
method,  which  should  hardly  ever  be  used  ejcoept  J 
when  it  may  be  of  importance  to  destroy  the  disease  T 
very  rapidly.  It  destroys  lupus  in  a  minimum  of  ^ 
time,  but  at  the  expense  of  a  maximum  of  cicatrix, 
with  all  the  Hubsequent  possibihties  of  deformity  ami  j 
disablement.  The  method  should  be  reserved  for  the  ] 
destruction  of  small  recurrent  nodules.  The  galvano- 
cautery  is  more  generally  applicable,  and  its  effect  Is  J 
much  more  under  the  operator's  control.  It  may  be  t 
used  by  way  of  puncture,  the  affected  tissues  b  '  _ 
as  it  were,  tattooed  with  the  incandescent  point,  witiil  J 
which  the  apple-jelly  nodules  are  individualty  1 
attacked.  Galvano-cauterisation  can  be  used  \ 
primary  method,  the  aSected  auiface  being,  as  ia  the  ] 
case  of  scariGcation,  first  attacked  at  the  edge, 
also  very  useful  as  a  supplementary  method,  aftei  J 
erasiun  or  scarificatiou,  for  the  destruction  of  recuireat  *. 
nodules.     Besnier  thinks  that  the  use  of  the  gal^uio-  I 


:ix.]    LUPUS  VULGARIS  :  TREATMBNT.     443 

cautery  is  muuh  less  likely  to  be  iollowed  by  auto- 
inoculation  than  procedures  which  are  attended  with 


The  treatment  by  meana  of  concentrated  light  in- 
troduced by  Finsen  of  Copenhagen  has  given  good 
resulte  in  the  hands  ol  himself  and  Bie.*     The  latter, 
indesd,  says  that  in  the  vast  majority  of  cases  the 
result  has  been  so  certain  and  so  constant  that  when 
it  fails  he  doubts  the  accuracy  of  the  diagnosis.     In 
my  own  cases  it  has  been  successful,  but  the  good 
IresTilts  are  not  always  lasting.     The  treatment  is 
|bapecially  suited  to  cases   in  which   the  disease  is 
KKuper&cial  and  of  small  extent.      Tlie  application  of 
^^ogaltic  acid  in  a  5  per  cent,  ointment  is  a  useful 
Kwjuvant  in  reducing  thickening  of  tissues.     The  use 
l>of  light  may  often  be  usefully  supplemented  by  the 
K  .application   of  the    X-rays,f    especially    when    the 
■Jiucous  membrane  is  attacked. 

B  The  fact  that  the  primary  focus  of  lupus  is  often 
^^tuated  within  the  nose  supphes  an  explanation  of 
Kthe  difficulty  of  permanently  curing  the  disease.  As 
Kiong  as  the  original  source  of  the  trouble  lemains, 
ElB-infection  of  the  skin  may  take  place  again  and 
■again.  My  attention  was  first  drawn  to  this  source 
■  iof  difficulty  in  the  treatment  of  lupus  by  Pinsen. 
W.  An  important  practical  point  that  must  be  borne 
I  in  mind  in  connection  with  all  the  severer  methods  of 
B  treatment  is  to  know  when  to  hold  one's  hand. 
V,When  inflammation  is  severe,  and  the  affected  tissues 
■tare  proportionately  irritable,  soothing  applications 
Bl|uust  be  used  for  a  time.  For  this  purpose  caiamine 
Keu;  iead  lotion  will  be  found  most  useful.      Radical 

^P    *  Biit.  Med.  Joiirii.,  September  SO,  !899. 

H^  ■)■  For  reports  of  CBBeb  under  the  care  of  the  author,  assiated  by 
■sr.  Dure,  iut  Biil.  Mrd.  Jmirii..  Feb.  0,  IHOI,  and  Mny  31,  l!K):i. 
W^  »'™- Sequaira,  B,it.  Mai.  Jtmiii.,  Feb.  9,  IQUl.  Matguret  M. 
Hnmrpe  and  Ttiurston  Hollaudiu  Arch.  ofSMHtacii  Ray  Sue.,  Ubj, 
KUOl ;  and  Everett  Smith  In  Fhiladaltihitt  Med.Juuni.,  Qec.  1,  1900. 


GSNERAl  ISOCVLAHLE  DISEASES.  [cHAf.  S 

treatment  should  not  be  proceeded  with  till  the  in- 
flammatory condition  has  been  aubdued. 

With  regard  to  the  choice  of  a  method  adapted  to 
the  »ituatioa  of  the  disease,  it  may  be  stated  in 
I  general  terms  that  on  the  face  Bcarification.  tollowed 
if  necessary   by  galvano-cautery,  and  oh  the  trunk 
and  limbs  erasion,  followed  in   the   a&me  way   by 
fflilvano-eautery,  are  the  moat  suitable  procedures. 
In  either  case   the  initial   advantage   obtained  by 
mechanical  treatment  will  need  to  be  followed  up  by 
chemical  caustics  and  parasiticide  agents.     There  is 
0  general  formula  for  the  treatment  of  lupus.    Each 
case  must  be  treated  in  accordance  with  its  require- 
ments, and  each  of  the  methods  described  has  it«  own 
special  advantages  when  used  in  the  proper  circum- 
stances.    As  already  said,  the  practitioner  will  find 
it  necessary  to  study  the  manner  In  which  the  disease 
responds   to  different   modes  of  treatment,   always 
keeping  in  mind  the  object  t«  be  aimed  at^namely, 
the  destruction   of  the  new   growth.     In   the   vast 
majority   of  cases   it  will   be   found  that  difierent 
methods  will  have  to  be  employed  at  different  stages, 
while  occasionally  it  will  be  advantageous  to  suspend 
all  treatment  for  a  time  until  the  disease  has,  as  it 
were,  lost  the  tolerance  which  prolonged  medicaUon 
has   produced.      The    apphcation   of   chemical  eub- 
frtances  will  cure  only  milder  forms  of  lupus  where 
the  disease  is  superficial.      Un  the  other  hand,  there    ' 
ia  no  mechanicaJ  method,  however  severe,  that  will  i 
infallibly  prevent  recurrence.     The  best  resulta  will   I 
be  obtained  by  a  judicious  combination  of  mechanical  j 
¥rith   chemical   treatment.     The   patient  should   ba  \ 
kept  for  a  considerable  time  under  strict  observation,    j 
BO  that  any  fresh  outbreak  of  the  disease  may  be  I 
treated  at  once. 

CoQstitutionHl  treatment  must  be  carried  out  n 
.general  principles.    In  a  certain  proportion  of  o 


IX.)     LUPUS   VULGARIS  :  TREATMENT.      415 

the  patients  preaent  no  evidence  of  iU-health,  and 
therefore  require  no  internal  medication.  There  is  no 
internal  remedy  that  has  any  specific  eSect  op  lupus. 
Arsenic,  the  administration  of  which  is  a  kind  of 
ceremonial  observance  which  some  practitioners  con- 
eider  indispensable  in  all  caaee  of  skin  disease,  is 
uaelesH,  Besuier  gives  iodoform,  and  Morel-Lavall^e 
has  tried  subcutaneous  injections  of  the  same  sub- 
stance with  some  success ;  but  the  results  have  not 
been  sufficiently  convincing  to  bring  the  method  into 
general  favoui.  The  same  may  bo  said  as  regards 
LlmJiffe  of  potassium,  advocated  by  Duhring.  If  the 
I  patient  is  oi  scrofulous  constitution,  the  treatment 

■  appropriate  for  that  condition  is  indicated.  Cod-liver 
■'Oil  in  such  cases  appears  to  have  a  decidedly  favour- 
viable  effect.  Good  food,  sea  air,  and  attention  to 
■•hygiene  are  powerful  adjuvants  in  the  treatment  of 
Bflerofulous  individuals.  Other  unfavourable  condi- 
f  tions — such  as  anremia,  chlorosis,  etc. — must  be  dealt 
I  irith  by  appropriate  measures. 

I  Tuberculin,  although  certainly  not  the  specific 
I  which  it  was  at  first  believed  to  be,  has  still,  in  my 
l^epi^ion,  a  distinct  place  in  the  therapeutics  of  lupus. 

■  I'he  injections  sometimes  cause  an  immediate  re- 
■jaction  of  such  violence  that  it  quickens  the  activity 
I,  of  the  process,  and  in  the  most  favourable  circum- 
B- stances  the  temporary  improvement  that  follows 
ft  them  speedily   disappears.*     Notwithstanding   this. 

■  ■tuberculin  seems  to  modify  the  lupus  process  in  such 
■.'ft  way  that  the  disease  becomes  more  amenable  than 

■  liefore  to  local  treatment.  My  own  experience  has 
K,l>een  decidedly  encouraging,  all  the  more  since  my 
B-parher  expectations  were  grievously  disappointed. 
VOf  twelve  cases  in  which  I  gave  the  tuberculin  treat- 

^K  *  li  ia  worth  meiitiouing  tint  liipua  suiiietiines  uiiilergojs 
^nMngiileriiljle  temporary  improYeniBut  undtr  the  iiiHuautB  or  ail 
■ittaclc  of  erpipelM. 


1446    GENERAL  INOCULABLE  DISEASES,     [chap.  six. 
meat  a  full  trial,  there  was  not  one  that  did  not  within 
B  compaTatively  short  time  relapse  to  a  condition  aa 
bad  as  before  the  treatment.     Further  observation, 
however,  has  convinced  me  that  the  tuberculin,  while 
failing  by  itself  to  effect  a  cure,  preventa  recurrence 
when  the  disease  has  been  destroyed  by  other  means. 
The  patients  referred  to  were,  after  the  failure  of  the 
tuberculin,  'treated  by   the  ordinary   chemical   and 
mechanical  methods,  and  may  now  be  looked  upon  as 
practically  cured.     As  treatment  of  the  same  kind  had 
been  tried  in  all  these  cases  for  years  previously 
without  permanent  success,  the  apparent  abolition  of 
the  tendency  to  recurrence  must  be  placed  to  the 
^^_     credit  of  the  tuberculin.     I  consider,  therefore,  that 
^^^L. »  course  of  tubeiculin  injections  should  be  a  pre- 
^^^f  liminary  to  the  treatment  of  lupus  by  any  of  the 
^^^P  Goethoda  that  have  been  described.     It  is,  however, 
^^^    absolutely  contra-indicated  if  there  be  any  reason  to 
suspect  the  esistence  of  visceral  tuberculosis. 

Ihave  tried  thenewertuberculin (TR) inaserieaot 
cases,  with  resulte  which,  though  brilliant  at  first,  have 
since  proved  disappointing.*  Thyroid  feeding,  recom- 
mended by  Byrom  Bramwell,  has  not  beeji  effective  is 
f  hands  in  lupus.  In  some  cases  of  scrofulodermia, 
iwever,  it  has  been  of  service.  I  have  given  uret^in 
I  Mveral  cases,  but  the  results  have  been  disappointing. 
At  the  International  Congress  of  Dermatology, 
[  held  at  Vienna  in  1892,  Hans  von  Hebra  showed  some 
B  of  lupus  which  he  had  treated  by  subcutaneous 
f  injections  of  thiosinamin.  The  injections  caused 
local  reaction  without  constitutional  disturbance,  and 
[  seemed  to  influence  lupus  tissue  favourably  and  to 
I  make  cicatricial  tissue  soft  and  phable.  Tommasoli  f 
[  faied  injections  of  dog's  serum  in  Inpus,  but  with  no 
I  Tery  brilliant  results. 

,  IS9T. 


Syphilis  is  a,  disease  caused  by  the  introduction  into 
the  system  of  a  specific  poiaon.'  The  virus  is  probably 
produced  by  a  micro-organism,  but  this  has  not  yet 
been  definitively  identified.  The  poison  is  inoculated 
— that  is,  conveyed  by  direct  contact;  an  abrasion  of 
surface  on  the  part  of  the  recipient  facilitates  the 
introduction  of  the  virus,  but  is  by  no  means  a 
necessary  condition  of  infection.  The  disease  is,  in 
the  vast  majority  of  cases,  transmitted  during  coitus, 
but  infection  may  take  place  on  any  part  of  the  body 
in  which  the  poison  is  implanted.  It  may  be 
acquired,  or  it  may  be  inherited — either  from  a  dis- 
eased father  (sperm  inheritance)  or  from  a  diseased 
mother  (germ  inheritance).  Germ  inheritance  may 
take  place  whether  the  mother  be  the  subject  of 
a3^hilis  at  the  time  of  conception,  or  whether  she 
contract  the  disease  at  any  period  during  gestation  ; 
thus,  as  pointed  out  by  Hutchinson,  the  child  has  a 
much  greater  chance  of  being  infected  by  the  mother 
than  by  the  father.  Both  parents  may.  of  course,  be 
syphilitic,  and  the  offspring  will  in  these  circum- 
Htances  have  a  double  chance  of  being  infected  ;  but 
there  is  no  evidence  to  show  that  the  resultant  disease 
is  of  a  severer  type  than  when  the  poison  is  drawn 
from  only  one  source.  What  is  inherited  in  syphilis 
is  not  merely,  as  in  the  case  of  tuberculosis,  a  pre- 
dispoaitioii  to  a  particular  disease,  but  the  actual 


«8     GENERA!.  l.VOCULABLE  DISEASES,     [chap.* 

virus  itself,  Tm><lififid.  it  may  be,  by  itfi  pusaaitK  ihrougb 
tli:-  pnicnts 

la  whatever  way  t)ie  poJMiDn  ia  tranamitted.  tli 
disease  is  always  one  and  the  same  ;  but  the  severity 
of  its  manifestations  may  be  very  greatly  modified 
either  by  the  constitutional  peculiarity  of  the  patient, 
pr  by  treatment,  or  by  a  combination  of  both  these 
factors. 

Syphilis  is  really  a  specific  exanthematoua  fever, 
"  diluted  by  time,"  to  use  the  happy  ejcpression  ol 
Moxon.     It  presents  a  close  analogy  to  small-pox 
for  instance,  if  we  suppose  the  cniptive  stage  to  be 
drawn  out  into  months  instead  of  days,  and  the 
Bequelffi  to  come  on  after  years  instead  of  weekB,  the 
following  stages  can  be  recognised  in  a  typical  CAse    ~ 
acquired  s>phibs      (1)  a  latent  period,  which  i]lt6r^J 
venes  between  tl  e  date  of  contagion  and  the  earliettftj 
sign  of  local  infection     (_)  an  inciibati&n  -jmiod,  whici 
includes    the    formation    nnd    development    of 
chancre  and  enhrgement  of  the  nearest  lymphatlo] 
glands;  (^)  a  period  of  twttMJOTi,  including  the 
fever  with  its  associated  phenomena  up  to  the  appear' 
ance  of  the  general  eruption;    {4)  an  entjititie  pfrioi, 
with  early   nnd  late  development  of  characterietio 
lesions  on  the  skin  and  mucous  memhraneB,  and  IB 
the  glands  ;    (5)  a  period  of  qutescencf  :   (fi)  a  peril 
of  najudtp,  consisting  of  late  local  so-called  "  teitiaiy 
lesions.     For  practical  purposes  Ricord's  divieioa 
syphilis  into  three  stages — primary,  seeundaiy, 
tertiary — is  convenient,   and  corresponds  with 
acruracy  to  natura)  divisions  in  the  clinical  histoi 
of  the  disease.     It  is  necessary,  however,  that 
conception  should  Le  formed  of  the  exact  state 
tilings  indicated  by  these   terms.     In  thi 
stage,  during  the  development  and  contiuaaaoe 
the  initial  lesion,  syphilid  is  a  local  disease,  and  tlifi'.j 
vims  ran  be  conveyed  only  by  direct  contagion  fraHk 


id  the 

case  of  ^H 
i]lt6r^^H 
Barlie«ft:^H 
,which.H 
of  t^H 
iphatlo^^l 
qMcifie^H 


K.]  fiYPHlUH.  iW 

the  local  sore.  In  the  secoadary  stage — representiao 
tliH  eruptive  period  of  a  specific  fever— syphilis 
becomes  a  genera!  disease,  wLich  manifesta  itself  by 
canstitutional  symptomB  due  to  the  difiusioa  and 
multiplication  of  the  poisonous  products  in  the  blood  : 
in  this  stage  the  blood  and  all  the  fluid  tissues  contain 
the  specific  virus ;  and  the  infection  tan  ,be  trans- 
mitted by  the  aecretJon  from  any  of  the  lesions,  and 
possibly  by  the  saliva  and  other  normal  fluids,  though 
Hutchinson  considers  tKie  improbable..  In  the 
tertiary  stage  flypliilis  once  more  becomes  a  local 
disease  ;  it  is  then  a  disease  not  of  the  blood  but  of 
the  tissues,  and  the  lesions  have  only  local  contagious 
properties. 

It  must  be  understood  that  In  many  cases  it  is 
not  only  the  specific  virus  of  syphilis  that  is  inocu- 
lated, since  the  poison  seldom  exists  in  an  absolutely 
pure  state.  The  sorea  become  infected  by  various 
micro -organisms  which  cause  inflammation  and  sup- 
puration, and  these  parasites,  together  with  the  pro- 
ducts of  their  activity,  are  often  conveyed  with  the 
syphihtic  viius.  These  extraneous  infective  matters 
produce  lesions  of  a  peculiar  kind,  which  may  com- 
plicate and  in  some  cases  overshadow  the  specific 
effect  ol  the  syphihtic  poison. 

Primary  lesioo.^ — The  primary  lesion  generally 
appears  from  three  to  four  weeks  after  exposure  lo 
contagion— hardly  ever  less  than  two,  or  more  than 
six,  weeks.  The  appearance  of  the  lesion  varies 
according  to  its  situation.  When  situated  iu  a  typical 
position,  as  on  the  glans  penis  or  labium,  the  first 
perceptible  change  is  a  minute  red  spot.  In  a  week 
or  ten  days  this  grows  into  a  nodiJe  with  definite 
margin.  A  marked  characteristic  of  this  nodule  is  its 
hardness.  The  induration  is  seldom  very  distinct 
before  five  weeks  have  elapsed  from  the  date  of 
inoculation.     There  is  usually  more  or  less  itching, 


450     GENERAL  INOCULABLE  DISEASES,     (chap.  sx. 

though  thia  may  lie  totally  absent.  Ulceration  gener- 
ally takes  plaue,  and  the  resulting  sore  preaents  a 
minutely  granular  floor,  secreting  a  small  quantity 
of  thin  liquid,  and  bounded  by  a  definite  but  not  raised 
border.  The  base  of  the  ulcer  is  dietinetly  indurated. 
Sometimes  the  lesiou  is  limited  to  a  desquamating 
papule  which  does  not  ulcerate,  but  may  undei^o 
involution  so  rapidly  that  the  patient,  unless  he  has 
been  on  the  look-out  for  it,  may  be  unconscious  of  it« 
presence.  On  the  other  hand,  it  may  persist  for 
months.  Simultaneously  with  the  induration  of  the 
chancre,  the  nearest  set  of  lymphatic  glands  becomes 
enlarged  and  hard.  The  primary  sore  has  a  natural 
tendency  to  heal,  the  induration  gradually  disappear- 
ing and  a  scar  being  left.  When  unmodified  by  treat- 
ment the  primary  lesion  seldom  lasts  less  than  two 
months.  There  is  usually  only  one  primary  sore,  but 
occasionally  there  may  be  several,  the  number  depend- 
ing on  the  number  of  points  at  which  the  virus  has 
been  inoculated  at  the  time  of  contagion.  1  have 
seen  five  sores,  having  the  characters  of  the  hard 
chancre,  on  a  patient's  arm  at  the  same  time. 

Chancres,  when  acquired  during  sexual  inter- 
course, are  generally  situated  on  the  frenum  and 
inner  surfaces  of  the  prepuce.  The  glans,  the  margii 
of  the  prepuce  {where  the  chancre  is  often  multiple), 
the  orifice  of  the  meatus,  the  mucous  membranes  of 
the  ttrethra  within  the  meatus,  and  the  skin  of  the 
penis,  are  also  common  situations.  In  the  female 
the  inner  surfaces  of  the  labia  majora  and  the  nymphn 
are  the  most  frequent  sites  of  hard  sores  ;  they  are 
also  met  with  on  the  clitoris  and  on  the  oh  uteri.  The 
^vagina  seems  to  be  protected  from  inoculation  by 
^^e  thickness  of  its  epithelium.  Chancres  are  more 
'requently  multiple  in  women  than  in  men,  probably 
owing  to  the  greater  opportunities  of  auto -inoculation. 
Chancres  also  occur  on  the  fingern  {as  in  mldwivee  and 


CHAr.  IS.]      flYPHILlN  :     PRIMARY   LF.SIOS.  451 

Burgeons),  on  the  nipples  (in  wet  nurses),  on  the  lips, 
cheeks,  or  tongue,  from  smoking  infected  pipes,  drink- 
ing out  of  infected  glaseea,  etc.  ;  they  may  also 
develop  on  vaccination  scars  or  on  any  parts  of  the 
body  where  the  poison  may  be  inoculated  by  a.  bite  or 
other  injury.  Dentists'  inatrumenta  have  occasionally 
been  vehicles  of  the  syphilitic  poison.*  The  disease 
has  been  communicated  by  tattooing.  A  hard  sore 
has  been  known  to  develop  on  the  [>er.ic  of  an  infant, 
after  ritual  circumcision,  when  the  disgusting  method 
— now  abandoned  in  Great  Britain — of  stopping  bleed- 
ing by  suction  was  adopted.  Hard  sores  may  also  be 
met  with  in  extraordinary  situations  as  the  result  of 
unnatural  vice,  but  probably  the  great  majority  of 
extragenital  chancres  are  contracted  accidentally. 

Wide  differences  are  observed  in  the  appearance  of 
chancres,  these  being  chiefly  due  to  the  anatomical 
peculiarities  of  the  part  on  which  the  chancre  is 
situated.  Thus,  a  chancre  on  the  glana  is  usually 
definitely  circumscribed  as  well  as  indurated,  whilst 
a  chancre  of  the  cheek  presents  a  diffuse  tense  cedema 
in  which  the  edge  of  the  sore  is  lost.  The  chancre  that 
affects  the  bed  of  the  nail  is  scarcely  ever  indurated, 
and  often  suppurates  very  freely  (Hutchinson).  On 
other  parts,  and  especially  on  the  face,  chancres  some- 
times attain  an  enormous  size,  and  may  lose  the 
ordinary  characters  of  infecting  syphilitic  sores  and 
simulate  malignant  disease.  Again,  chancres  are 
greatly  influenced  by  treatment,  the  administration 
of  mercury  lessening  induration  to  a  remarkable 
extent  and  shortening  the  course  of  the  lesion.  Apart, 
however,  from  differences  in  appearance  determined 
by  anatomical  conditions,  and  modifications  caused  by 
treatment,  great  variations  are  observed  in  chancres. 
In  the  incubation  period  there  may  be  nothing  beyond 
a  small  dusky  spot  wiiich  lasts  for  a  few  days  and 

•  Bolkloy  :  Now  Tort  Odontological  Society,  1890. 


45-2     GENERAL  ISOCVLABLE  DISEASES,     [a 

then  disappears,  leaving  a  brown  staia.  On  the  other 
hand,  there  may  be  an  obstinate  ulcer  with  marked 
induration,  lasting  a  year  or  more,  and  leavings  scar. 
The  induration  may  recur  from  time  to  time,  even  as 
,g  as  seven  or  eight  years  after  its  complete  dis- 
appearance (Hutchinson). 

The  primary  sore  has  a  protective  influence  like 
that  of  vaccination,  but,  like  the  latter  also,  the 
immunity  which  it  confers  is  neither  absolute  nor 
permanent  in  all  cases.  Instances  of  reinfection  are 
not  very  rare,  but  the  manifestations  of  the  disease 
are  usually  much  milder  in  the  second  than  in  the  finit 
attack. 

As  already  said,  there  i^  frequently  a  double 
inoculation,  infective  matter  o!  inflammatory  origin 
being  introduced  at  the  same  time  as  the  specific 
virus  of  syphilis.  In  this  way  "  soft "  sores  are 
produced.  These  sores  are  hardly  ever  seen  except 
on  the  genitals.  They  are  usually  multiple,  and  can 
reproduce  themselves  in  the  patient  by  secondary 
inoculation.  The  typical  soft  sore  has  a  sharply-cut, 
punched-out  margin,  and  a  grey,  unhealthy-looking, 
base  with  a  considerable  zone  of  inflamed  skin  aroi 
it.  The  lymphatic  glands  in  the  neighbourhood 
come  enlarged,  and  the  several  glands  of  a  group 
become  matted  together  by  inflammatory  exudation. 
It  is  probable  that  soft  sores  are  produced  by  a  specific 
micro-organism,  but  as  to  this  nothing  definite  can  be 
said  at  present. 

It  must  be  clearly  understood  that  although  tlui] 
infective  sore  is  called,  in  accordance  with  ite  most* 
obvious  physical  character,  "  hard,"  and  the  BOB-' 
infecting  sore  by  way  of  distinction  "soft,"  neitlier 
of  these  characters  is  sufTiciently  constant  to  be  made 
an  absolute  criteiion  of  the  nature  of  a  given  Ban. 
An  infecting  sore  u  not  always  hard ;  on  the  lip,  foH 
exHmpie,  there  is  seldom  any  marked  induration.  On 


1 
I 


I 


Doking^^H 
ironnd^^H 
odbe-^ 


X.]    SYPHILIS:  SECONDARY  LESIONS.       463 

the  other  hand.'a  sore  at  first  aoit  may  after  a  few 
Sleeks  become  indurated,  and  be  followed  in  due  course 
y  the  development  of  constitutional  syphilis. 

Herpes,  which,  as  already  said,  may  occur  on  the 

^nitals  in  either  sex  as  the  result  of  simple  irritation, 

sometimes  follows  both  infecting  and  non-infecting 

A  previously -existing  herpes  may  conceal  a 

Jchancre,  a  taut  which  should  always  be  borne  iu  mind 

I  ftlien  the  herpep  occurs  in  newly -married  perKons. 

i  venereal  sore  may  become  the  seat  of  pha- 
pgedsena,  probably  from  infection  with  some  new 
Tbe  ulcerative  process  assumes  a  more  violent 
|jfihatacter,  and  spreads  rapidly  both  in  are^  and  in 
■.depth ;  the  edge  of  the  ulcer  becomes  irregular,  and 
■"ploughing  frequently  takes  place.  The  ulcer  is  very 
1  painful,  and  serious  hemorrhage  is  sometimes  pro- 
l.fluced  from  erosion  of  the  arterioles.  Great  destruc* 
l.tion  may  be  wrought  by  this  process,  the  penis  being 
i^jmetimea  entirely  eaten  away.  The  contagion, 
T  which  probably  always  originates  from  venereal  sores 
F  (Hutchinson),  may  spread  through  a  hospital,  attack- 
f  ing  all  operation  and  other  wounds. 

Secondary  lesions.— If  a  case   of   syphilitic 
J'jmfection  be  left  fco  itself,  symptoms  of  constitutional 
^disturbance  may  be  expected  to  show  themselves  in 
I  bom  seven  to  nine  weeks  after  inoculation.     Their 
I  onset  may  be  prevented  or  indefinitely  delayed  by 
I  proper   treatment,    but  sometimes   thoy    will   show 
I  tiiemselves,   even  after  a  piolonged  adminietiation 
I 'of  mercury,  as  soon  as  the  drug  is  discontinued.     The 
•■onset  of  the  secondary  or  eruptive  stage  is,  in  the 
majority  of  cases,  marked  by  little  or  no  constitu- 
tional disturbance.     In  some  cases,   however,   it  is 
ushered    in    by    distinct    febrile    phenomena.     The 
patient  feels  unwell,  languid,  and  weak,  and  com- 
~  plains  of  loss  of  appetite,  with  headache  and  pains  in 
[he  joints,  muscles,  and  bones,  especially  those  lying 


—    _--:eL 


ff 


-      -  -  J-^ 


r 


••■ 


.  I  * 


:f 


I    I 


'   * 


'  ■'< ; 

■'til  ■  • 

'•■•k\  ,„ 


\ 


454     OENERAf.  INOCVLABLE  DISEASES,    [chap.  xx. 

just  under  the  skin — the  tibi»,  ulnte,  and  clavicies. 
All  these  symptoms  are  usually  aggravated  at  njght. 
The  temperature  curve  often  aliowe  a  marked  evoning 
rise.  Occasionally  the  fever  runs  estraordinarily 
high,  as  in  a  caae  reported  by  Bumey  Yeo,  in  which 
for  several -■weeks  it  ranged  from  J(K)°  P.  to  KM*^  F. 
The  pyrexia  may  be  out  of  all  proportion  to  the  skin 
eniptioQ  ;  but  generally,  when  the  eruption  is  un- 
usually severe,  the  fever  runs  higher  than  in  ordinary 
cases  (Hutchioflon).  In  rare  cases  the  constitutional 
disturbance  is  so  great,  and  lasts  so  long,  that  the 
nature  of  the  disease  mtty  not  be  suspected  for  some 
time,  the  symptoms  being  attributed  to  some  obscure 
form  of  blood-poisoning.  The  eruption  is  erythema- 
tous in  character,  and  is  known  as  syphilitic  roseola. 
It  shows  iteelt  as  a  macular  mottling,  resembling 
measles,  but  rather  more  dusky,  scattered  more  or 
less  thickly  over  the  chest  and  belly.  The  raah  varies 
in  intensity  according  to  the  temperature  and  the 
amount  of  clothing  worn.  It  is  very  evanescent, 
often  disappearing  in  a  few  hours,  and  coming  out 
again  as  suddenly.  Coincidentiy  with  the  roseola, 
slight  superficial  ulcers  form  on  the  tonsils  ;  these  are 
often  so  painless  and  so  transient  that  the  patient 
may  be  unaware  of  their  existence.  Even  if  there 
be  no  definite  ulceration  of  the  throat,  the  mucous 
membrane  is  congested,  being,  in  fact,  the  seat  of  an 
eruption  similar  to  the  roseola  on  the  skin.  The  rash 
generally  begins  to  fade  within  a  fortnight  of  its 
appearance,  giving  place  to  a  papular  or  follicular 
(Fig.  27)  eruption  which  comes  out  on  the  trunk, 
limbs,  and  neck.  The  papules  are  small,  tense,  and 
firm,  with  smooth  or  slightly  scaly  tops.  They 
increase  in  size  by  peripheral  extension,  the  older 
central  parts  undergoing  atrophy  or  necrosis,  Occa- 
uonally  the  eruption  assumes  corymbose  form 
(Fig.  2S).      Sometimes,  though  very  rarely,  vesicles 


d 


CHAP.  XX.]    STPHILIS  :  SECONDARY  LESIONS.       455 

are  formed,  or  suppuration  may  supervene  and 
give  rise  to  pustules. 

In  the  early  stage  the  pustules  dry  up  and  form 
scabs,  underneath  which  no  ulceration  takes  place, 
and  consequently  no  acar  is  left.  In  the  later  stages 
the  breaking  down  of  the  papule  is  followed  by  an 
ulcerative  process  with  rapid  drying  of  the  secretion 
into  crusta ;  as  the  ulcer  spreads  at  the  edge,  each 
successive  layer  of-  crust  is  necessarily  larger  than  the 
one  immediately  above  it,  and  a  pyramidal  structure 
somewhat  resembling  a  limpet-shell  is  thus  formed,  to 
which,  from  its  shell-like  appearance,  the  term 
"  rupia  "  is  apphed.  Sometimes  the  crusting  process 
begins  in  the  drying  up  of  a  bulla.  Rupial  lesions  are 
hardly  ever  met  with  till  from  six  months  to  a  year 
from  the  appearance  o£  the  primary  sore,  and  then 
usually  only  in  persons  who  have  neglected  treatment 
or  whose  health  has  broken  down.  Supia  always 
leaves  scars,  and  is  generally  symmetrical. 

All  the  early  secondary  eruptions  are  modifica- 
tions of  one  process,  angio- neurosis,  the  mechanism 
of  which  has  been  described  in  a  former  chapter. 
Hypersemia  of  the  papillffl  in  particular  spots  gives 
rise  to  red  patches  which  may  be  evanescent  (roseola), 
or  may  persist  as  isolated  blotches  for  a  longer  or 
shorter  time  (macular  syphilides).  These  macular, 
which  vary  In  colour  from  a  delicate  rose  to  a  pale 
violet  or  dusky-bluish  or  eveu  brownish  red,  have  a 
smooth  surface,  and  being  partly  infiltrations  do  not 
disappear  <'omp!etely  on  pressure.  They  are  seen 
chiefly  on  the  chest  and  abdomen,  often  on  the  flexor 
aspects  of  the  extremities,  seldom  on  the  face.  They 
cause  no  subjective  symptoms.  Scattered  among  the 
maculse  or  on  them  may  often  be  seen  papules 
{macule -papular  sjqjhilides).  These  syphilides  last  a 
variable  time,  and  leave  stains  the  depth  of  which  is 
proportionate  to  the  length  of  time  the  lesions  have 


43(1.     GESKRAL  INOCVLAHLE  DISEASES,     [ci 


A  remarkable  property  in  these  and  other 
forma  of  secondary  eruption  is  that  they  axe  made 
more  conspicuous  by  the  action  of  cold  on  the  auiface 
of  the  skin.     In  association  with  the  macular  sypl 
lides,  alopecia,  either  general  oi  in  patches,  is  oft 
observed.    Alopecia  areata  is  sometimes,  howevi 
the  earliest  sign  of  secondary  syphilis. 

Hyperfemia  of  the  papillss  is  often  followed 
infiltration  of  inflammatory  products,  and  in  this  wi 
a  papule  is  produced  (papular  syphilide).     Papules, 
already  said,   often  arise  in  connection  with  tlie 
maculte  ;  they  may  also  develop  independently.     Two 
varieties  of  these  lesions  may  be  distinguished — the 
small  and  the  large.     The  former  vary  in  size  from  a 
pin's  head  to  a  linseed  ;   they  are  at  first  red,  after- 
wards brownish  in  colour,  have  a  shining  surface,  and 
feel  like  small  shot.     They  are  thickest   over  the 
abdomen,  chest,  shoulders,  and  upper  limbs,  more 
sparsely  scattered  over  the  back  and  the  legs.  Involu- 
tion takes  place  slowly,  and  the  st^in  left  behind  is 
long  in  dying  away,  and  is  sometimes  followed  by  a 
shallow  depression  which  may  last  tor  years. 
small  papule  is  not  very  common  as  an  early  lesii 
and  is  generally  looked  upon  as  a  sign  that  the  diat 
is  of  a  severe  type.    The  large  papule  may  develop 
directly  out  of  the  macular  syphilide,  or  may  be  pro- 
duced  by    the    gradual    enlargement   of    the    small 
variety.     It  may  be  as  large  as  a  pea.  but  is  generally 
flattened  on  the  surface.     It  afiects  the  whole  body 
pretty  impartially,   sometimes  forming   a  kind   of 
circlet  on  the  brow  round  the  margin  of  the  hair 
{corona   veneris).     The   evolution   of   the   papule 
irregular.     Some  persist  as  such  and  increase  in  ' 
by  peripheral  extension,  undergoing  iavolution 
while  in  the  centre.    Aa  they  shrink  they  becoi 
scaly  on  the  surface ;  if  the  formation  of  scales  is  at  i 
■tL'tive,  the  lesions  often  come  to  bear  a  tolerably  cl( 


p.  XL^I 


by  ft^ 

sioD^H 
leas^H 


f" 

1 

L 

J 

^ 

-y 

i//^ 

■ 

B'^^FlO.  29.— CiRCISATE  Squasious  SvrKlLllJi:  V 

111.    \VlllTF1Kl.l/8    ^B 

^^r  *56     GENERAL   INOCVLABLE   DISEASES,    [chap.  SX-^B 

I  resemblance  to  patches  of  psoriasis  (Figs.  29  and  30).  ^^M 

'  Desquamation   frequently    persists    after    completfr^^^ 

^^^  subsidence  oi  the  papule.    In  other  cases,  as  already^H 

^^L  said,  the  papules  become  transformed  into  vesiolM^H 

^^H  and  pustules.   With  regard  to  the  vesicular  forms,  i^^H 

^^V  must  be  noted  that  they  have  no  affinity  with  tlie'^H 


eczematous  process  ;  the  latter,  as  pointed  out  i 
previous  chapter,  is  catarrhal,  but  in  the  productaon 
of  syphilitic  lesions  of  the  sldn  the  element  of 
catarrh  has  no  place. 

A  further  stage  in  the  development  o!  the  papule  J 
is  reached  by  the  occurrence  of  overgrowth  of  the  I 
papillffi,  giving  rise  to  warty  conditions,  the  favourite'^ 
seats  of  which  are  the  tongue  and  the  genitals.     If  ' 
the  lesion  is  situated  in  a  moist  part,  the  hypertrophied 
papillse  are  covered  with  sodden  white  epitheliom 
(moist  papule,  or  mucous  papule  or  patch).     A  mor« 
marked  degree  of  hypertrophy  transforms  the  moist  J 


marked  degree  of  hypertrophy  transforms  the  moist  ^H 

papule  into  a  mucous  tubercle  or  condyloma.     The  ^H 

difference  between  warts  and  condylomata  is  th&t^H 

^^^        while  in  the  former  the  overgrown  papillte  are  free,  in  ^H 

^^^L       the  latter  they  are  welded  into  a  coherent  mass  bj'^^| 

^^^^        swelling  of  the  intervening  tissue.  ^^M 

^^V  At  wJiat  may  be  called  the  height  of  the  eruptive'^H 

^^^         stage  of  syphilis  the  lesions  present  almost  every  con-  ^H 

r  ceivable  variety  of  type.     Not  only  the  simple  elft*^^| 

mentary  lesions  that  have  been  described  may  be  seen  ^^M 

I  mingled  together  in  every  phase  of  development,  but^H 

mixed  fonns,  of  a  complexity  that  bafltes  descriptioa, 

may  be  observed.    In  this  way  almost  every  loiown 

skin  afiection  may  be  more  or  less  closely  simulated. 

Thus  one  secondary  eruption  will  simulate  a  copaiba  ■ 

'rash,  or  varicella,  or  even  variola  ;    another,  lichen;, J 

another,    impetigo   or  acne ;     another,    alopecia   orS 

leucodermia.    Purpura  is  not  unfrcquf  ntly  among  th«l 

manifestations  of  constitutional  syphilis,  and  pig* 

mentation  of  the  skin  may  be  produced  without  a  p 


CHAP,  sx.]    SYPHILIS  :  SECONDARY   LESIONS.      469 

exJBting  lesion  by  transudation  of  the  colouring  matter 
of  tlie  blood.  At  a  later  period  this  polymorphous 
character  of  the  eruption  usually  gives  place  to  simple 
ulcerative  or  squamous  lesions.  The  eruptive  period 
as  a  whole  may  last  for  months.  As  regards  the 
duration  of  the  individual  lesions  little  ia  known.  The 
stains  will  often  last  for  years.  In  one  case  I  have 
seen  the  pigmentation  was  still  visible  more  than 
twenty  years  after  the  secondary  lesion  of  which  it 
was  a  legacy  had  disappeared. 

There  are  certain  general  characters  which  distin- 
guish secondary  eruptions.  Though  no  single  one  of 
these  is  pathognomonic,  the  combination  of  two  or 
more  of  them  affords  primd  jade  evidence  of  a 
syphilitic  origin,  and  the  combination  of  several 
is  quite  conclusive.  In  the  first  place,  secondary 
eruptions  are  usually  symmelriad.  This  arises  from 
the  fact  that  syphilis  in  the  stage  represented  by 
these  leeiona  is  a  general  and  not  a  local  disease. 
Again,  secondary  eruptions  are  polymorphous.  This 
is  the  most  distinctive  characteristic  of  the  eruption 
taken  as  a  whole.  Not  only  are  the  individual 
lesions  multiform,  but  the  grouping  of  them  presents 
the  greatest  diversity  of  appearance.  Sometimes  the 
papules  are  arranged  in  lines  like  lichen  ruber  planus  ; 
or  the  papules,  pustules,  etc.,  may  be  set  in  isolated 
patches  or  irregular  clusters ;  or  the  arrangement 
may  be  coryraboee,  several  lesions  being  clustered 
together,  or  a  large  one  being  surrounded  by  a  circlet 
of  smaller  ones,  as  in  erythema  iris.  Secondary 
lesions,  both  on  the  skin  and  on  the  mucous  membrane, 
have  a  tendency  to  assume  crescentic  outlines.  Not 
only  may  all  the  diflerent  elementary  lesions  be 
present  at  the  same  time,  but  they  are  there  in  all 
stages  of  their  development.  Only  erythema  mul- 
tiforme and  dermatitis  herpetiformis  in  their  most 
variegated  aspect  can  be  compared  as  regards  poly- 


480     GENERAL  INOCUI.AHLE  DISEASES,    [chap.  XX.  | 

morphism  with  the  eruptive  stage  of  syphilis.  "Vha 
lesions  in  the  latter  case,  however,  have  tliis  charactei' 
diatinguishing  them  sharply  from  both  these  condi- 
tionB — namely,  the  absence  of  itching.  The  c<Aou,t  of 
secondary  lesions  is  remarkable,  but  not  being  pecu- 
liar  to  them,  can  hardly  be  taken  as  a  trustworthy 
guide  to  their  nature.  The  prevailing  tone  of  these 
lesions  is  a  tint  resembling  the  lean  of  raw  ham, 
pasRing  into  a  coppery  colour,  and  leaving  a  permanent 
brown  pigmentation.  The  coppery  colour  of  a  lesion 
may  be  suggestive,  but  taken  by  itself  it  is 
paratively  little  clinical  importance,  and  a  diagnosis, 
of  aypWhs  should  never  be  based  on  that  alone. 
regards  position,  the  first  rash,  as  abeady  said,  comesl 
out  on  the  front  of  the  abdomen,  next  on  the  chest, 
then  on  the  front  of  the  arms  and  the  back  of  the  leg% 
next  on  the  palms  and  soles,  the  back  and  sides  ol 
the  neck,  and  Hometimes  on  the  face.  The  scaly 
lesions  which  simulate  psoriasia  affect  the  flexor 
rather  than  the  extensor  surfaces  of  the  limbs,  ajld 
are  seldom  seen  on  the  tips  of  the  elbows  and  knees, 
the  typical  situations  of  true  psoriasis.  The  epi-;, 
gastric  and  hypochondriac  regions,  the  nape  of  th^'. 
neck,  and  the  forehead  near  the  margin  of  the  hair, 
are  situations  much  affected  by  syphilitic  lesions. 

The  earliest  local  manifestations  of  constitutional 
syphilis  on  mucous  membranes  ate,  as  has  been  said, 
small  ulcers  on  the  tonsils.  These  have  usually  more 
or  less  the  outhne  of  a  horseshoe,  with  a  yellowiak 
floor  and  greyish-white  borders'  They  generally  pan 
away  quickly.  At  a  later  period  mucous  patches 
and  mucous  tubercles  may  form  on  the  dieeks, 
tongue,  gums,  lips,  about  the  anus  and  vulva,  and 
under  the  prepuce ;  these  patches  may  prove 
obstinate. 

Besides  the  lesions  of  the  skin  and  muco 
brane  which  have  been  described,  all  the  other  tiaaaeflj 


I 


CHAP.  XX.  1    SYPHILLH  :  SEGOl^DARY   LESIONS.      401 

of  the  body — especially  the  eye,  the  bones  and  their 
perioBteum,  the  joints,  and  the  nervous  system — are 
liable  to  become  involved.  Iritis  is  of  common 
occurrence  from  four  to  seven  months  after  infection  ; 
and  there  may  be  symmetrical  retinitis.  The  ear 
mfty  be  the  seat  of  otitis  media  and  interna.  Slight 
periostitis  and  synovitis,  giving  rise  to  tenderness  of 
the  bones  and  rheumatoid  pains,  are  coimnon.  Local- 
ised aniBsthesia,  due  to  peripheral  neuritis,  is  said  to 
occur  (Fournier).  All  these  symptoms  are  said  to 
be  symmetrical,  and  subside  spontaneously  in  a  short 
time.  Permanent  blindness  or  deafness  may,  how- 
ever, result  from  the  inflammation  of  the  retina  and 
internal  ear. 

In  most  cases  secondary  lesions  disappear  under 
treatment,  and  in  about  six  months  the  patient  may 
seem  to  be  entirely  free  from  the  disease.  He  may, 
however,  remain  liable  from  time  to  time  to  "  re- 
minders "  in  the  form  of  lesions  intermediate  in  type 
between  the  secondary  and  the  tertiary  forma,  and 
partaking  to  some  extent  of  the  characters  of  both. 
Among  these  "  intermediate  "  lesions  are  sores  on  the 
sides  of  the  tongue,  and  white  patches  with  thicken- 
ing on  its  dorsum  (the  so-called  psoriasis  linguje  or 
leucoplakia),  red  scaly  areas  with  sinuous  outlines  on 
the  scrotum,  and  patches  of  induration,  covered  with 
layers  of  thickened  and  desquamating  epithelium 
on  the  palms  of  the  hands  (the  so-called  palmar 
psoriasis).  The  character  which  chiefly  differentiates 
these  from  tertiary  lesions  is  that  they  tend  to  be 
symmetrical, 

The  exact  duration  of  the  secondary  stage,  that  is 
to  say,  of  the  constitutional  infectivity  of  the  disease, 
is  unknown.  Almost  all  examples  of  accidental  con- 
tagion during  tlie  secondary  period  occur  within  a 
comparatively  short  time  of  its  commencement.  The 
cutaneous  and  other  phenomenaj  as  a  rule,  cease  by 


4fi2     GENERAL  INOCULABLE  DISEASES. 


the  end  of  the  first  year,  but  sometimea  the  later 
secondary  eruptionB  may  continue  until  the  tertiary 
local  lesions  make  their  appearance.  This  usually 
occurs  in  the  third  year,  but  it  may  take  place  as 
late  as  twenty  years  after  infection.  It  must  be' 
understood  that  there  is  no  sharp  line  of  demarcation' 
between  the  secondary  and  tertiary  stages  ;  on  tWj 
contrary,  these  occasionally  overlap.  I  have  frfr 
quently  seen  in  badly  nourished  patients  lesions  of 
tertiary  type  develop  before  those  of  the  secondary 
stage  had  disappeared. 

The  course  of  syphilis  as  a  whole  is  progressiva, 
with  periods  of  latency  of  variable  length.  There 
are  certain  circumstances,  such  as  age,  sex,  personal 
habits  and  surroundings,  the  state  of  the  general 
health,  and  treatment,  which  may  have  a  modifyinf; 
influence  on  its  course  and  manifestations.  As  regards 
age,  syphilis  is  usually  mildest  in  young  adults,  and 
severest  in  infants.  Females,  as  a  rule,  suffer  more 
than  males,  as  the  primary  sore  in  them  often  escapes 
observation,  and  treatment  is  therefore  not  begun  till 
the  disease  has  become  firmly  established  in  the 
system.  The  influence  of  the  personal  surroundinge 
and  habits  of  the  patient  is  seen  in  the  fact  that  the 
disease  is  generally  worst  in  those  who  are  insuffi- 
ciently fed  and  clothed,  and  who  are  of  uncleanly 
or  dissipated  habits.  In  a  young  adult  of  sound  con- 
stitution it  generally  can  be  stamped  out  within  a 
year  of  inoculation,  and  gives  no  further  trouble.  As 
regards  the  state  of  health,  scrofula,  gout,  and  riieB- 
matism  all  seriously  aggravate  the  disease,  and  the 
presence  of  renal  mischief  is  a  grave  complicatioa. 
When  the  disease  has  ceased  to  give  open  proof  oi  its- 
presence,  it  may  be  stirred  up  into  activity  by  any* 
thing  that  injuriously  affects  the  health.  Treatment 
has  unquestionably  the  most  powerful  influence  ofL; 
the  course  of  syphilis.    Hutchinson  says,  and  I  quit* 


r 

'I 

J 

m 


CH4P.  XX.]    SYPHtUS  :  TERTIARY  LESIONS.  463 

agree  with  him,  that  if  the  time  between  the  develop- 
ment of  the  primary  sore  and  the  period  at  which 
aecondaty  manifestations  are  wont  to  show  themselves 
ia  fully  taken  advantage  of,  the  secondary  stage  will 
be  modiiied  in  its  course. 

Tertiary  lesions.— In  the  tertiary  stage  syphilis 
is  again  a  local  disease,  and  the  lesions  therefore  show 
no  tendency  to  synunetrical  arrangement.  AU  tissues 
may  be  attacked,  the  process  consisting  of  slow  in- 
flammatory infiltration.  The  infiltration  is  at  first 
difluse,  but  becomes  intensified  at  certain  points, 
resulting  in  the  formation  of  nodules  (gummata).  A 
gumma  is  a  new  growth  which  begins  as  a  localised 
infiltration  of  the  connective  tissue  with  small  round 
cells.  A  nodule  is  thus  made  in  which  new  vessels 
appear,  and  which  grows  in  size  by  infiltration  of  the 
surrounding  parts,  forming  a  new  growth  composed 
of  granulation  tissue.  After  attaining  a  certain  size 
the  tumoui  undergoes  fatty  degeneration,  after  which 
it  softens  and  often  breaks  down  into  an  ulcer,  which 
heals  when  the  mass  has  separated.  The  efiects  of 
the  process  vary  according  to  the  nature  of  the  tissue 
in  which  it  takes  place.  When  the  infiltration  is 
situated  near  the  surface  of  the  integument,  tlie 
breaking  down  of  gummata  gives  rise  to  ulcers  with  a 
hard  raised  edge  and  an  indurated  base.  A  charac- 
teristic feature  of  tertiary  ulcers  ia  their  tendency  to 
become  serpiginous.  They  have  sinuous  outlines, 
and  show  Uttlfe  or  no  tendency  to  spontaneous  cure. 
Sometimes,  however,  they  heal  and  leave  dense  scars, 
or  they  may  cicatrise  at  one  part  while  continuing  to 
spread  at  another.  They  are  usually  few.  On  the 
skin  the  more  common  position  oE  tertiary  lesions  is 
on  the  forehead  at  the  margin  of  the  scalp  (constitut- 
ing a  later  form  o£  corona  uenww  than  the  papular 
eruption  already  described),  the  upper  parts  oi  the 
legs,  the  sldu  oi  the  genitals  in  both  sexes,  the  nape 


i 


4(U     CESEIiAL  INOaULABLE  DISEASES,     [os 

of  the  neck,  »nd  the  back  ;  frequeatly  ako  the  poll 
or  sole  on  one  side  (Fig.  31).     Tertiary  lesions 
the    skin   are    not   unfrequently    lupoid 
and  they  may  simulate  lupus  very  closely  (Fig. 
The    chief   point   of    distiDction  is  that  their 
gresa  is  more    rapid  than    that  of   iuput 
On  the    mucous    membranes  tertiary  lesions   hv 
the  characters  of  chronic  inflammation  with 
tion,  followed  by  the  formation  of  tough  cica^t 
tiaaue   and    thickening.      This    may  le 
narrowing    of    natural   passages    (pharynx,    reel 
vulva).     Gummata   may   also  form   in   any  at 
internal  organs ;    the  tongue,  the  muscles,  the  " 
and  the  periosteum,  the  brain  and  spinal  cord 
their  coverings,  the  nerves,  the  testicle,  and  ofel 
viscera  are  all  liable  to  attack.     Sclerosis  of  the  ^i 
cord,   and  of  the  small  blood-vessels  and  art«r 
leading  to  the  formation  of  aneurysms  or  amylud 
disease,    are    of   occasional    occurrence.     When    the 
skin  is  close  to  the  periosteum  it  is  often  afiected 
secondarily   to   the   latter.     Tertiary   lesions   Dearly 
always  leave  enduring  marks  of  their  presence 
atrophic  scars,  with  thickening. 

Hereditary  syphilis.— The  signs  of  heredil 
syphilis  do  not  usually  show  themselves  until  tl 
weeks  or  a  month  after  birth.  The  child  is  almost 
invariably  free  from  any  lesion  of  the  skin  or  other 
parts  when  born,  but  a  few  cases  of  nndoubtwdly 
congenital  syphilis  have  been  tepoited  by  practitioi 
who  have  had  opportunities  of  seeing  large  numl 
of  children  immediately  after  birth  in  lying-in 
pitals.  In  some  cases  a  form  of  bullous  pemphi] 
eruption  occurs  within  a  day  or  two  after  birth, 
may  cause  death  «-itliin  a  week.  This  attacks 
part  of  the  skin,  but  has  a  special  procli\-ity  for 
and  solea.  The  hrst  symptom,  however,  is  usn 
form  of  chronic  coryza  (anufflee).     This  is  followed 


aarly 


Fig.  S!,— SvpniT.is  of  Sole  of  Foot:  Cutaneous  Gumma 

WITH    HYPERKEBATOSIS   (22   YEAHa   AFTETi   INPUCTIOS). 


Fig.  .■JS.-.V(io(xin  i.atr  Svphh.ik  (\tu,  \\« 


'■■^^i^ 


I   : 


I    ! 


'    I 


i 

1  cc 


X.]         HEREDITARY    SYPHILIS,  465 

a  skin  eruptiou,  which  may  be  papular,  scaly,  pustular, 
bullous.  Condj'lomata  about  the  buttonk  axe 
common.  Like  the  secondary  eruptions  in  the  adult, 
the  general  eruption  is  symmetrical  in  distribution 
and  transient  in  duration.  Polymorphism  is  also  a 
frequent  characteristic  of  infantile  syphilis,  and  the 
colour  approximateB  to  the  tint  of  the  lean  of  raw 
bam,  as  is  seen  in  the  adult.  In  fat  babies  the  lesions 
frequently  have  the  character  of  intertrigo,  and  the 
irritation  of  the  urine  and  fteces  gives  rise  to  sores 
about  the  nates,  and  especially  about  the  anus. 
Peeling  patehes  of  erythema  on  the  face  and  neck 
are  common.  Sores  are  also  apt  to  form  about  the 
corners  of  the  mouth.  The  face  often  presents  a 
peculiarly  senile  aspect ;  this,  however,  is  not  con- 
stant. The  eruption  h  accompanied  by  wasting, 
debility,  and  fretfulneas.  The  symptoma_itffi_gener- 
ally  at  their  height  in  the  second,  third,  and  fo;Mt]j__ 
months  after  birth.  The  affection  often  ends  in 
death,  but  if  the  child  survive  the  symptoms  will, 
as  a  rule,  have  disappeared  by  the  end  of  the  fet 
year  of  hfe. 

After  the  first  year  there  comes  a  period  of 
latency,  which  may  last  a  variable  time.  Up  to  the 
age  of  eighteen  or  twenty  inflammatory  affections  of 
tlie  eye  and  ear  are  frequent,  hut  the  skin  is  not 
usually  the  seat  of  any  special  lesions.  There  are  no 
scaly  or  papular  eruptions,  and  only  in  the  rarest  cases 
any  ulcerative  processes  with  the  serpiginous  character 
which  has  been  described  as  being  distinctive  of  ter- 
tiary syphilis  in  the  adult.  Of  the  late  manifestations 
of  inherited  syphiha  in  adult  age  comparatively  Uttle 
ia.lfflfiail-  1  have  seen  a  case  in  which  there  waa 
ulceration  of  the  pharynx,  accompanied  by  an  erup- 
tion on  the  face  somewhat  reaembhng  lupus. 

Inherited  syphilis  as  such  cannot  be  transmitted. 
The  stage  of  the  acquired  disease  in  the  parent  makes 


40G     GENERAL  ISOCULABLE  DISEASES,     [chap,  x 

no  difference  in  tlie  disease  tliat  ia  tranBmitted. 
different  children  may  inherit  it  in  varying  degreei 
of  severity.  It  ia  only  in  extremely  rare  cases  that  a 
parent  in  the  tertiary  stage  transmits  the  diseai 
— indeed,  in  my  opinion,  it  ia  doubtful  if  this  evM 
happens. 

The  diag'nosis  of  syphilis  is  usually  auificiently  ' 
easy.     The  induration  of  the  primary  lesion,  together 
with  the  enlargement  and  hardening  of  the  neaieat 
lymphatic  glands,  is  in  most  cases  siifficiently  charac- 
teristic to  enable  the  practitioner  to  give  a  positive 
opinion.     It  must  be   remembered,   however,   that 
hardness  is  not  a  constant  feature  of  infecting  Botes, 
especially  when  seated  on  the  lips  or  on  other  parts  » 
where  the  tissue  is  loose  ;  nor,  on  the  other  hand,  c^i^J 
a  chancre  be  at  once  pronounced  to  be  non-infeeti 
because  oi  the  absence  of  induration.    The  prin 
eore  is  most  Ukeiv  to  be  overlooked  in  women,  and  4 
very  careful  examination  should  therefore  be  i 
whenever  possible.     Primary  sores  in  unusual  aitiu 
tions,  as  on  the  face,  may  sometimes  present  djffiei 
ties  ;    the  practitioner  should  never  allow  bimseli  t 
be  misled  by  preconceived  ideas  as  to  the  impiobai^ 
bility  of  contagion,  but  ehould  judge  each  case  BoWy« 
on   the    evidence   before    him.     The    discriminaticai 
between  a  primary  sore  on  the  face  and  malignant 
disease  can  often  be  made  by  the  age  of  the  patient 
and  by  the   chronicity  of  the  process.    In  some 
instances,  however,  a  sure  diagnosis  can  be  amve4  J 
at  only  after  a  certain  length  of  time.     In  syphilw^M 
more  than  in  any  other   disease,  the   truth  can  Wl 
determined  only  by  taking  a  comprehensive  view  V^M 
all  the  circumstances  of  the  case — the  history  of  t' " 
lesions,  their  characters,  course  and  termination,  ■ 
the  effect  of  treatment  upon  them.    When  there  i 
a  clear  history  of  infection  or  exposure  thereto,  I " 
eecondary  lesions  can  generally  easily  be  r 


CHAV.  XX.]  SYPHILIS :  [DIAONOSIS.  467 

TLe  mimicry  of  syphilis  may,  however,  occasionally 
perplex  the  observer.  The  general  distinctive  charac- 
ters of  aecondary  lesions  that  have  been  aet  forth — 
symmetry,  coppery  colour,  position,  polymorphism, 
and  absence  of  itching,  together  with  enlarged  glands, 
sore  thioat  or  tongue — will  in  most  cases  suffice  to 
identify  the  disease,  even  in  the  absence  of  a  definite 
history  or  mark  of  a  primary  aore.  It  miiet,  however, 
be  repeated  that  it  is  not  the  presence  of  any  one  of 
these  characters,  nor  even  the  combination  of  two  or 
three  of  them,  that  can  be  relied  upon  ;  only  the  sum 
of  them  can  be  taken  ae  affording  solid  gi'ound  for 
the  diagnosis  of  syphihs.  When  there  is  any  doubt, 
the  whole  cutaneous  surface  should  be  examined,  and 
in  this  way  a  characteristic  lesion  or  mark  wiU  usually 
be  discovered  which  will  give  the  clue  that  is  wanted. 
Apart  from  the  general  characteristics  that  have 
been  mentioned,  there  are  certain  features  whereby 
the  elementary  lesions  themselves  may  be  distin- 
guished from  similar  ones  not  syphilitic  in  origin. 
Thus,  in  the  case  of  macular  syphihdes,  a  cool  atmo- 
sphere will  bring  them  out  in  vivid  colours,  even  when 
almost  completely  faded.  From  the  erythematous 
drug  rashes  they  are  difierentiated  by  the  absence  of 
itching  or  burning  ;  tinea  versicolor  and  ringworm 
of  the  body,  both  of  which  are  occasionally  simulated 
more  or  toss  closely  by  macular  syphihdes,  can  be 
identified  by  their  respective  parasites.  Seborrhcea 
corporis  is  often  very  difficult  to  distinguish  from 
a  macular  syphilide  ;  indeed,  the  two  afiectiona  are  ' 
often  associated.  The  wider  distribution  of  the 
syphiiide  and  the  other  evidences  of  the  disease  will 
settle  the  diagnosis.  Squamous  syphilides  may 
sometimes  be  the  seat  of  such  an  amount  of  scale 
formation  as  to  be  mistaken  for  ordinary  psoriusis. 
Again,  a  papular  rash  in  circles  may  simulate  an 
annular  psoriasis.    In  either  case  the  syphilitic  natux^ 


i 


GENERAL  hVOCULABLE  DISEASES,     [chap.  ss. 

of  the  leeion  can  usually  be  determined  by  the  poly- 
morphism of  the  eruption  and  the  distribution  of  tha 
disease,  the  elbows  and  knees,  which  are  the  favourite 
situations  of  psoriasis,  being  as  a  rule  avoided  by  the 
syphilitic  eruption.  Moreover,  while  paoriaaia  piefen 
the  extensor  aspects,  the  papular  syphilide  has  a 
partiality  for  the  flexor  surfaces  of  the  limbs  ;  thers 
is  also  a  difierence  in  the  appearance  of  the  Bcales^ 
those  of  the  syphihtic  lesion  being  thin  and  dirty 
white,  while  those  of  psoriasis  have  a  eharacteiistio 
silvery  sheen,  and  are  heaped  up  in  layers.  The 
history  is  of  importance  in  both  cases.  The  aubjeci 
of  true  psoriasis  will,  aa  a  rule,  have  had  several 
previous  attacks,  and  the  disease  can  often  be  traced 
back  to  early  life.  In  syphilis,  on  the  other  hand,  a 
particular  lesion  is  seldom  repeated.  The  peculiar 
papular  eruption  of  the  palms  and  soles  which  occurs 
symmetrically  as  a  secondary,  and  unilaterally 
tertiary,  lesion,  and  which  is  sometimes  inappropri' 
ately  called  "  syphilitic  psoriasis,"  may  sometimes  b6 
confused  with  the  dry  chronic  eczema  tliat  is 
with  in  the  same  situation.  The  small  papular- 
syphilide  may  occasionally  be  difficult  to  distinguisb- 
feom  a  widely  diffused  lichen  ruber  planus ;  in  "  ' 
latter,  however,  the  rash  is  uniform,  the  papules 
generally  arranged  in  lines,  and  itching  is  uso&Ujn 
severe.  Eczematous  lesions  can  generally  be  dia- 
tiuguished  from  those  due  to  s^'ptulis  by  the  catarrhal' 
character  of  the  process,  by  their  itching,  and  by  " 
absence  of  other  signs  of  syphilis. 

Pustular  syphilides  occasionally  resemble  vario< 
Acne  varioliformis  is  sometimes  simulated  by  sypi 
Here  the  diagnosis  must  be  based  chiefly  on 
absence  of  other  signs  of  constitutional  disease.  ' 
cutaneous  gununata  may  be  mistaken  for  abscess, 
on  this  supposition  may  be  opened,  when  they 
issue  not  to  pus,   but   to  a  gummy   liquid. 


OHAP.  XX.]  SYPHILIS.-  DIAGNOSIS:  409 

broakiDg  down  of  a  gumma  on  the  leg  may  give  rise  to 
an  ulcer  resembiijig  the  ordinary  callous  ulcer;  the 
true  nature  of  the  sore  will  be  revealed  by  its  proving 
refractory  to  ordinary  treatment  and  giving  way  to 
antiayphilitic  remedies.  From  lupus  syphilitic  leaions 
can  usually  be  distinguished  by  the  absence  of  the 
characteristic  apple-jelly  nodules,  by  the  comparative 
rapidity  of  the  process,  and  by  the  age  of  the  patient, 
lupus  usually  commencing  in  early  life.  Rodent  ulcer 
and  epithelioma  may  sometimes  have  to  be  dis- 
tinguished from  tertiary  lesions.  As  a  rule,  in  the 
cancerous  ulcer  a  process  of  new  growth  has  preceded 
the  ulceration,  and  the  characteristic  hard  edge  and 
red,  shining  dry  floor  of  the  malignant  nicer  will 
generally  serve  to  identify  it.  The  position  of  rodent 
ulcer  on  the  upper  part  of  the  cheek,  near  the  eyelid, 
or  the  side  of  the  nose,  or  the  temple,  is  another 
distinguishing  feature.  Lastly,  the  age  of  the  patient 
counts  for  something,  rodent  ulcer,  or  epithelioma  of 
the  face,  occurring  as  a  rule  only  in  people  past 
middle  life. 

The  diagnosis  of  inherited  syphilis  in  early  infancy 
is  at  times  extremely  easy,  but  at  other  times  a 
matter  of  great  difficulty.  Snuifles,  the  wizened  old- 
mannish  aspect,  the  coppery  eruptions,  and  the  sores 
about  the  mouth  and  anus,  make  up  a  sum  of  clinical 
phenomena  that  is  characteristic,  In  some  cases  the 
history  of  the  parents  helps  to  elucidate  the  difficulty. 
In  the  adult  who  has  been  the  subject  of  infantile 
syphilis  the  signs  of  the  disease  are  seen  in  "  the 
square  forehead  with  prominent  frontal  eminences 
like  budding  horns,  the  sunken  nose,  the  soft,  pale, 
earthy-tinted  skin,  and  the  scars  about  the  angles  of 
the  mouth,"  *  and  in  the  pegged  and  notched  upper 
incisor  and  canine  teeth.  Besides  these,  signs  of 
interstitial  keratitis  and  choroiditis  are  often  present, 
•  Hutchinson,  "  Syphilia,"  p.  8i, 


470 


GENERAL  INOCVLABLE  DISEASES,    [chat.  xxJ 
legacy  froia 


■  been  left  as  i 


and  deafness  n 
previous  otitis. 

The  prognosis  of  aypliitis  depends  on  the  age 
general  health  of  the  patient,  on  the  eeverity  of  tl 
disease,  and  especially  on  the  treatment.  Aa  alread] 
said,  young  adults  will,  under  proper  conditioi 
recover  as  a  rule  within  a  year  of  contagion, 
persons  of  unhealthy  constitution,  or  alcohol  hal 
or  hving  in  insanitoiy  surroundings,  the  prospect 
much  leas  favourable.  Syphilis  contracted  in  midt' 
life  is  very  intractable,  some  authorities  going  bo 
as  to  say  that  if  inoculated  after  the  age  of  forty  it 
incurable.  The  mildness  of  the  earlier  ttymptoi 
affords  no  guarantee  against  the  appeaiance  of 
tiary  lesions  of  great  and  even  fatal  severity. 
most  important  element  in  the  prognosis,  however, 
the  treatment. 

The  pathology  of  syphilis  is  that  of  chronic 
flammation,  in  all  probability  caused  by  the 
of  a  specific  micro-organism.     On  this  point,  howeTi 
proof  is  still  wanting.    In  1SS4  Lustgarten  deecril 
a  bacillus  which  he  had  found  in  syphilitic  lesjons 
primary,  secondaiy,  and  tertiary  ;   this  bacillns  took 
the  same  stdn  as  those  of  tuberculosis  and  lepro^, 
but,  unlike  these,  it  could  be  decolorised  by  mean      ' 
nitric  and  hydrochloric  acids.     A  bacillus  preseal 
the  same  characters  has,  however,  since  been  fbi 
by  other  investigators  in  smegma  and  oth«  ni 
secretions.     Micrococci    have    been    discovered 
difFeient  syphilitic  iesioiis  by  Klebs  and  other  pal 
ologists.     The  hard  sore  presents  no  special  strncf 
features ;  the  process  is  simply  one  of  cell  infiltration' 
with    little     trace    of    inflammatory    action.     The 
secondary  lesions  represent  more  or  less  advanced 
degrees   of  the   angio -neurotic  process,    the   papule 
being  the  rudimentary  form  out  of  which  all  the 
leaions  of  that  stage  are  developed.     In  the 


»tg 


CHAT,  ss.]         SYPHlLIf!:  TRKATMENT.  471 

the  gumma  may  be  called  the  parent  of  the  tertiary 
leeions. 

In  the  treatment  of  syphilis  the  object  to  be 
aimed  at  in  the  first  instance  ia  to  lemoye  the  poiaon, 
if  possible  before  it  has  infected  the' constitntion,  or 
if  that  is  impracticable,  to  destroy  it  or  neutrahse  its 
aption.  If  the  primary  sore  is  in  a  suitable  position, 
it  alioujd  at  once  be  removed  liy  amputation.  If, 
liowever,  tlie  sore  has  existed  some  time  and  the 
neighbouring  glands  are  enlarged,  mechanical  removal 
is  useless.  The  sore  should  then  be  treated  antiaepti- 
eally.  and  the  internal  administration  of  mercury 
should  at  once  be  begun.  It  is  coming  to  be  recog- 
nised that  this  drug,  if  given  in  small  doses  frequently 
repeated,  is  an  excellent  tonic,  promoting  tissue' 
change  and  increasing  the  number  of  blood- corpuscles. 
The  parasiticide  action  of  the  drug  must  also  be  taken 
into  account.  In  syphilis,  therefore,  mercury  acts  in 
three  ways :  first,  by  improving  the  general  health, 
and  thus  increasing  the  resistance  of  the  organism  to 
the  poison  ;  secondly,  by  promoting  metabolism,  and 
thereby  favouring  the  elimination  of  the  virus, 
especially  by  the  saliva ;  thirdly,  by  destroying  the 
poison  in  the  blood  when  given  internally  and  in  the 
tissues  when  applied  locally,*  There  are  undoubtedly 
some  persons  with  whom  mercury  in  any  dose  dis- 
agrees, but  unless  the  idiosyncrasy  be  very  pro- 
nounced, the  effects  of  the  mercury  will  probably  be 
less  injurious  than  those  of  the  syphilitic  poison. 

Mercury  may  be  given  in  various  ways.  By  the 
mouth,  the  form  which  I  usually  adopt  is  not  grey 
powder,  but  blue  pUl  (gr.  1  to  3  t.d.].  Grey  powder 
is  often  used,  but  in  my  opinion  ia  much  more 
uncertain  in  its  action,      Plummer'e  fUl  is  an  especi- 

•  EridencB  as  to  the  exact  aotion  of  loercurj  ou  Bjiihilis  hai 
recentiy  been  oSereii  bv  Jmitin  and  others  {Bril.  Joiirii.  Sirii'., 
vol.  ix.,  1S97). 


qiul 


472     OENKKAL  INOCULABLE  DISEASES,     ("oi 

ally  useful  form  of  administerii^  mercury  over  loi 
periode,  as  there  is  little  riek  of  its  producing  aallvi 
tion.     I  usually  give  2J  grains  night  and  mornin 
Perckloride.  of  merouri/  may  be  given  by  the  moul 
(gr.  jL  lo  -,'jj),  or  in  the  form  of  intranmscuJaT 
jection  by  the  method  suggested  by  Bloxam. 
solution  is    prepared    by    dissolving   3!!    grains 
perchloride    of    mercury    and    16    grains    of     pure 
chloride  of  ammonium  in  distilled  water  sufficient  to 
yield  two  fluid  ounces  of  product.     Ten  minims  equal 
one-tliird  grain  of  salt,     Ten  minims,  or  less, 
ing  to  circumstances,  should  be  injected  once 
into  the  gluteal  muscles.     I  have  watched  many 
his  cases,  and  have  never  seen  local   abscess  pr*'' 
duced,  nor  any  other  bad  symptom.     The  adminiatja- 
tioa  of  mercury  should  not  at  lirst  be  pushed  to  tlie 
full  physiological  limit ;    it  is  generally  sufficient  to 
produce  slight  tenderness  of  the  gums.     Salivataon 
should  always  be  avoided  if  possible  ;  when  it  occurs 
the  lesions,  indeed,  are  very  rapidly  cured,  but  the 
suspension  of  the  drug  which  it  necessitates  is  likdj. 
to  be  followed  by  troublesome  consequences  later. 

During  a  course  of  mercury  the  patient  shouid 
particularly  careful  to  keep  his  teeth  perfectly  clet 
in  order  to  minimise  the  risk  of  stomatitis  ;  for 
same  reason  it  will  be  prudent  for  him  to  refrain 
smoking.  He  must  also  be  careful  when  he  goes 
to  guard  himself  against  cold,  and  he  must  be 
ticular  in  his  diet,  so  as  to  avoid  disturbance  of 
bowels.  Tonics,  such  as  iron,  quinine,  etc.,  are  to 
certain  extent  antagonistic  to  mercury  ;  ifldeed, 
drug  has  a  better  chance  of  produinng  its  fiiu< 
beneficial  effect  when  the  patient  is  kept  a  little  b« ' 
his  ordinary  standard  of  health. 

Under  the  influence  of  mercury  adnunisl 
steadily  in  small  doses — that  is,  short  of  porml 
and  ptyaliam — the    primary  lesion  will  speedfly 


X.]        SYPBILIS  .■  TREATMENT.  473 

cured  and  the  last  trace  of  induration  will  disappear 
in  about  a  month. 

Afl  has  already  been  said,  \i  the  administration  ol 
mercury  be  begun  before  the  disease  has  entered  on 
the  constitutional  stage,  it  will  often  happen  that  no 
secondary  lesions  develop.  Nevertheless,  the  mer- 
curial medication  should  be  continued  for  six  or  even 
even  nine  months  ;  its  suspension  within  tbat  period 
is  apt  to  be  followed  by  the  speedy  appearance  of 
secondary  manifestations.  If  such  do  show  them- 
selves, they  are  comparatively  trivial.  In  cases  in 
which  secondary  lesions  have  developed,  it  will  be 
wise  to  persevere  with  the  mercury  for  at  least  one 
year  after  the  disappearance  of  tlie  eruption.  The 
prolonged  exhibition  of  mercury  also  makes  the 
subsequent  development  of  tertiary  lesions  less 
likely,  though  it  cannot  be  considered  an  absolute 
safeguard.  As  a  general  rule  of  practice  it  may  be 
laid  down  that  in  ordinary  cases  the  administration 
of  mercury  should  be  continued,  with  occasional  inter- 
missions, for  two^ — sometimes  even  three — years. 
The  patient  may  then  be  considered  tolerably  safe 
from  further  manifestations  of  the  disease.  There  is 
no  fear  of  disordering  the  health  by  giving  mercury 
in  small  doses  for  several  months ;  on  the  contrary, 
patients  so  treated  as  a  rule  visibly  improve  in  their 
general  condition. 

The  constitutional  effect  of  mercury  may  also  be 
obtained  by  means  of  inunction.  This  method  is  often 
useful  when  the  drug  disagrees  if  given  by  the  mouth. 
Inunction  is  carried  out  by  rubbing  blue  ointment 
vigorously  into  the  patient's  skin.  It  must  be  rubbed 
into  difierent  places  from  day  to  day,  otherwise  a 
mercurial  eruption  is  almost  sure  to  be  produced. 
The  ointment  must  not  be  washed  ofi  for  some  hours  ; 
the  usual  plan  is  for  the  patient  to  wrap  himself  in 
flannel  and  go  to  bed,  taking  a  warm  bath  when  he 


474     GENERAL  ISOCULABLB  DISEASES.     [ubat.S^ 

geta  lip  on  tlio  iollowing  moniing.  The  tuunctioD 
system  is  very  thorougidy  carried  out  by  trained 
rubbers  under  medical  supervision  at  Ais-la-Chapelle, 
Wiesbaden,  and  other  places,  and  the  usual  course 
lasts  a  month.  The  method  can,  however,  be  car- 
ried out  with  artificial  bathe  at  special  institu- 
tions in  this  conntry,  or  at  the  patient's  own  home, 
though  without  the  advantage  belonging  to  a  watering- 
place  "  cure,"  namely  the  regimen  and  general  dis- 
cipline to  which  patients  at  such  places  have  to 
submit. 

Another  way  of  introducing  mercury  into  the 
system  is  by  the  vapour  balk.  This  is  especially 
useful  in  rupia  and  ulcerating  lorms  of  the  disease. 
Calomel  (from  one  scruple  to  half  a  drar-hm),  mixed 
with  water,  is  vaporised  over  a  small  lamp,  and  the 
patient  sits  (from  a  quarter  to  half  an  hour)  on  a 
cliair  over  the  lamp,  enveloped  in  a  cloak.  Fumiga- 
tion has  the  same  advantages  as  inunction,  but  both 
have  the  drawback  of  requiring  the  expenditure  of 
much  time  and  trouble. 

Mercury  may  also  be  used  locally  with  great 
advantage  in  the  treatment  of  the  more  severe 
secondary  syphilides.  It  may  be  applied  to  the  akin 
in  the  form  of  an  ointment  containing  gr.  iv.  to  xx 
of  the  ammonio-chloride  lo  the  ounce  of  lard,  or  oteatc 
of  inercury  I  to  2  per  cent.  The  appUcation  of 
calomel  to  mucous  tubercles  soon  causes  their  dis- 
appearance. In  the  mouth  and  throat  mercury  may 
be  used  as  a  gargle  in  the  form  of  j  (o  1  gr.  of  per- 
iMoride  of  mercury  in  "^viij  of  dklUled  water. 

In  ccngenitu)  syphilis  the  best  method  of  lid- 
ministering  niemury  is  the  inunction  of  mercurial 
ointment  combined  with  tonic  treatment.  If  the  skin 
eruption  is  very  copious,  grey  powder,  gr.  j  or  leta 
thrice  daily,  should  be  substituted  for  the  inui 
iratcli  being  kept  lest  the  treatment  caui 


tTiir.  XX.]  SYFHILJS :  TREATMENT.  475 

The  child  ehould  remain  under  observation  at  least 
one  year. 

In  the  treatment  of  tertiary  lesions  ioditie  of 
potassium  Is  the  moat  important  drug.  As  in  this 
stage  syphilis  is  a  purely  local  disease,  the  drug  is 
not  given  as  an  antidote  to  any  poison  that  may  be 
supposed  to  be  still  lingering  in  the  system,  but 
because  of  the  peculiar  property  possessed  by  iodine 
oi  causing  the  absorption  of  inflammatory  products 
and  hypertrophied  tissue.  It  is  well  to  begin  with 
small  doses  and  gradually  increase  them  as  required. 

Iodide  of  potassium  frequently  has  a  very  depress- 
ing efiect  on  the  patient,  and  the  iodide  of  sodium 
may  often  advantageously  be  substituted  for  it,  or 
the  iodides  of  sodium,  potassium,  and  ammonium 
may  be  combined.  The  addition  of  ammonia  greatly 
inereases  the  efficacy  of  the  iodides.  The  tendency 
of  the  iodides  to  cause  skin  lesions  of  a  pecuHar 
character  must  not  be  forgotten,  and  the  practitioner 
must  be  careful  not  to  push  the  drug  under  the  mis- 
taken notion  that  such  lesions  are  syphilitic.  When, 
tissue  change  is  slow  the  iodide  may  be  combined 
with  perchloiide  of  mercury  as  follows  : — 

R  Hydrarg.  bicblor.  . ,  , .         ■  -     gr-    1*0 

_  PotnsB,  iodid,     . .         . .         . .         . .     gr.  v. 

I  Sp.  »ramoD.  arom 5m. 

1  Aq-  ftd  H 

Sometimes,  after  a  prolonged  administration  of  the 
iodides  they  seem  to  lose  their  efiect.  In  such 
circumstances  it  is  well  to  suspend  the  drug  for  a 
time  and  give  mercury  in  place  of  it,  returning  again 
at  a  later  period  to  the  iodide,  if  necessary.  The 
effect  of  thl.s  alteration  of  treatment  is  often  very 
marked. 

Tertiary  lesions  can  often  be  cured  by  local  treat- 
ment alone.     For  this  purpose  there  is  nothing  so 


'  by  I 


GENEIiAL  ISnCVLABLE  DISEASES,     [chap.  JdtT 

rapid  or  bo  sure  in  its  efiects  as  iodoform,  which  may 
be  applied  either  aa  a  powder  (dusted  on  or  blown 
over  the  aSected  surface  with  an  insufflator)  or  in  the 
form  of  an  ointment  (5j  to  jj  of  vasiiiTie  or  lard).  On 
account  of  the  disagreeable  smell  of  iodoform,  iodtd 
or  dermatd  may  be  substituted  for  it.  Ulcerating 
patches  can  irequently  be  dealt  with  efficiently  by 
the  free  application  of  acid  nitrate  of  mercury, 
being  taken  thoroughly  to  destroy  the  lesion. 

The  general  principles  of  treatment  of  syphili 
may  be  summed  up  aa  follows  : — If  the  patient  comes 
under  observation  aa  soon  as  the  primary  lesion  has 
appeared,  remove  it  with  the  knife  ;  in  any  ease, 
begin  the  internal  administration  of  mercury  at  once. 
Continue  this  for  a  year,  or,  if  secondary  eymptoms 
manifest  themselves,  for  two  or  even  three  years.  If 
the  patient  cannot  bear  the  mercury  when  given 
by  the  mouth,  try  one  or  all  the  other  methods 
described.  If  tertiary  lesions  develop,  give  iodide  of 
potassium,  sodium,  or  ammonium,  or  all  three,  dis- 
continuing the  administration  if  any  sign  of  iodism 
shows  itself.  Use  antiseptics  locally.  If  at  any 
stage  oE  the  disease  the  general  health  shows  signs  of 
failing,  use  general  tonic  treatment,  especially  cod- 
liver  oil  and  iron,  good  food,  and  sea  ai 


il 


Leprosy — Yaw  s — G  landers. 

LepPOSy  is  an  infective  disease  endemic  in  certain 
parte  oi  the  world,  manifesting  itself  primarily  by 
lesions  of  the  skin  or  oi  the  peripheral  nerves,  and 
secondarily  attacking  most  of  the  other  tissues  and 
organs  of  the  body,  uodermining  the  constitution, 
running  a  slow  course,  and  leading  directly  or  jn- 
directly  to  death.  All  cases  of  leprosy  have  certain 
features  in  common,  and  the  disease  presents  a 
definite  succession  of  stages.  The  inctibatioti  etage 
usually  extends  over  two  or  three  years,  aomctimea 
much  longer.  Danielsaen  and  Boeck  record  a  case 
in  which  it  lasted  ten  years,  and  I  have  seen  one  in 
which  the  evidence  pointed  to  an  incubation  period 
of  eight  years.  A  prodromal  period  usually  follows, 
analogous  to  the  febrile  stage  of  syphilis.  The  patient 
complains  of  languor  and  drowsiness,  muscular  and 
mental  weakness,  headache  and  giddiness,  dyspepsia, 
dryness  of  the  nose,  and  opistaxis.  General  sweating 
is  often  a  prominent  symptom,  and  sometimes  local 
anidrosis  may  be  observed.  Constipation  or  diarrhosa 
may  be  present,  but  according  to  Leloir  this  is  excep- 
tional. Next  comes  the  period  of  invasion,  usually 
marked  by  a  rigor  and  great  rise  of  temperature, 
as  high  as  103"  F.  or  lOi"  F. 

After  a  variable  period  the  characteriatic  leprous 
spots  appear  on  the  face,  hmbs,  or  trunk,  the  most 
common  positions  being  the  face,  especially  the  foc^- 


478    GENERAL  INOGULABLE  DISEASES,     [ci 


f 

^^H  lieadj  the  nose,  the  cheeks,  and  the  ears;  the  ex-' 
^^H  tensor  surfaces  ol  the  limbs  and  the  buttocks  arei 
^^^E  also  not  unfrequently  the  seat  oi  the  eruption.  Tha 
^^^K  maculae  consUt  of  erythematous  patches  in  wliicli: 
^^^V  not  only  hypersemia  but  a  certain  amount  of  infiltra- 
^^^P  tion  is  usually  present,  and  of  areas  in  which  the 
^^^  pigment  is  either  increased  or  dimini<ilied.  Ab  in 
r  small-pos,  the    fever    and   other   symptoma    of    in- 

vasion subside  on  the  appearance  of  the  eruption. 
The  maculsc  vary  according  to  the  natural  colour  of 
the  skin.    In  white  races  they  are  usually  of  a  light 
I  red  colour ;  in  Norway  they  are  generally  lenticular 

_  crimson  patches  (Danielssen  and  Boeck).     The  colour 

^^_  is  brighter  at  the  edge  than  in  the  centre,  which  may 
^^^  become  white  and  atrophic.  The  size  of  the  spots 
^^H  varies  from  that  of  a  pin's  head  to  the  palm  of  the  hand 
^^f  or  larger.  They  are  smooth  and  shining,  with  a  well- 
I  defined  outhne.     On  the  face  they  may  simuUte  sun- 

'  blain,  or,  by  their  ahghtly  raised  margin  and  the  con- 

I  fluence  of  two  or  three  of  them,  they  may  present  the 

^^^      appearance  of  erythema  gyratum.     Fresh  crops 
^^^L    maculse  continue  to  come  out  at  irregular  intervi 
^^^1    for  a  considerable  time,  each  outburst  being  accoi 
^^^K   panied  by  some  exacerbation  of  the  febrile 
^^^V    mena.     The  spots  are  not  at  first  the  seat  of  all 
^^^B    sensation.     They  may,  however,  be  byperaest' 
^^^V  1>ut  later,  as  a  rule,  they  become  more  or  less 
^^^T    thetic,  according  to  the  amount  of  pressure  of  tl 
I  leprous  infiltration  on  the  peripheral   nerves.     "" 

I  aneeBtheaia   is,    however,    often  not   limited   to 

macules,  areas  of  apparently  normal  skin  being  foi 
'  to   have   lost  their  sensibility.     It  is   often   by 

accidental  discovery  of  this  kind  that  the  patiant 
made  aware  that  he  is  the  subject  of  I  ~ 

tus  membranes  are,  as  a  rule,  not 
ted  at  this  stage  (Leioir). 
o  far  the  cutaneous  manifestations 


i 


,]  LEPROSY.  479 

to  all  cases  of  leprosy,  w.itli  the  usual  variations  of 
intenaity  in  diiierent  individuala.  As  a  general  rule, 
the  prodromata  are  more  conapicuous  and  severe  in 
the  case  of  a  developing  skin  leprosy  than  in  the 
nervous  form  of  the  affection.  In  the  latter  there 
may  be  little  or  no  fever,  but  rather  a  persistent 
feeling  of  cliilliness,  and  the  other  symptoms  of  con- 
stitutional disorder  may  be  almost  entirely  absent. 

In  its  subsequent  course  leprosy  may  follow  one  of 
two  difierent  hues  of  evolution,  according  as  the 
disease  directs  the  weight  of  its  attack  against  the 
skin  or  thn  peripheral  nervous  system.  In  a  certain 
proportion  of  cases  both  forms  may  be  combined,  and 
thus  three  distinct  types  of  leprosy  are  met  with — 
namely,  (1)  akin,  tubercular,  or  nodular  leprosy ; 
(2)  nerve,  or  anffisthetic,  leprosy ;  (3)  mixed  or  com- 
plete leprosy.  The  least  common  of  these  varieties 
is  the  last.  Of  the  two  others,  the  antesthetic  form  is 
moat  frequent  in  tropical  countries,  and  the  nodular 
in  Europe.  Though  pathologically  the  aame  disease, 
they  present  such  marked  ehnical  diflerences  that 
they  require  to  be  described  separately. 

Skin  leprosy. — After  a  period  of  invasion 
varying  from  a  few  weeks  to  some  months,  the 
mactdra  undergo  tiansformation  into  nodules  by 
sudden  increase  of  inflammatory  infiltration  ;  they 
also  develop  independently  in  the  skin  and  under  it. 
The  evolution  of  the  nodules  is  usualiy  very  slow, 
but  in  rare  cases  it  may  be  comparatively  rapid,  being 
ushered  in  by  an  er)iihematous  blush,  simulating 
erysipelas  and  accompanied  by  fcl>rile  phenomena. 
Their  size,  when  fully  developed,  varies  from  that  of  a 
small  shot  to  that  of  a  filbert  or  larger.  They  are 
round  or  oval  in  outline,  raised  considerably  above 
the  level  of  the  skin,  and  sometimes  surrounded  by 
a  considerable  zone  of  diffuse  inflhration.  Some- 
times they  have  the  normal  tint  of  the  skin,  but  the 


480    GENEJiAh  INOCULABLE  DISEASES,     [okap.  i 

colour    varies   greatly   according    to   the    degre 
inflammftbory  reaction.     When  this  in  slight  they 
eiraulatc  lupus  nodulea  ;  at  other  times  their  browai 
red  tint  makes  them  resemble  syphilitic  papoli 
When  the  skin  around  is  congested  they  may  simulal 
erythema  nodosum  or  rosacea  ;    when  Buppuratu 
occurs    they    may    resemble    sycosis.     As    in    othei 
chronic  inflammations  of  the  slun,  tcUngiectosis  may 
be  observed  on  the  surface  of  the  nodules.     The  local 
temperature  is  sometimes  above  the  normal.     The 
nodules  are  elastic  to  the  touch,  conveying  to 
finger  an  indiarubher-hke  sensation,  resembling 
noticed  in  early  gunimata.     At  first  they  arfl  soi 
times  hyperEesthetic,  later  they  generally  become 
seat  of  temporary  or  permanent  ansestheaia.     In  some 
cases  Hensation  ia  not  altered.     Extensive  areas  of 
skin  are  frequently  involved  in  the  process   o!  in- 
flammatory inhltrstion,  and  Rrm  flat  plat«8,   as 
hard  cedema,   with  either  a  smooth   or  a   noduli 
surface,  can  be  felt. 

This  most  frequently  occurs  on  the  limbs,  but 
sometimes  seen  on  the  face.     The  colour  of  ti 
plates  is  at  first  red  or  purple,  and  afterwards  di 
into  brown  or  even  black.     Tliey  are  met  wilh  p.hi( 
in    the    most    chronic    cases.     The    affected    skin, 
especially  in  the  nodular  stage,  is  often  tlie  seat  of 
aeborrhcea.     This  gives  the  nodules,  especially  on  the 
face,    a    characteristic    burnished    appearance.     In^ 
negroes  the  whole  akin,   even  where  there  are 
apparent  lesions,  is  usually  greasy,  and  h; 
feeling  to  the  touch  (Hillis).     The  hairs  iu  the  aff* 
areas   fall   out.     In    their  distribution    the   nodi 
present  certain  peculiarities  distinguishing  them 
particularly   from   syphilitic   lesions.     In    the 
majority  of  cases  the  face  and  the  ears  are  the 
points  attacked.     The  massing  of  the  nodules  on 
brow  (Fig.  ;J3),  and  the  cnnaeijuent  deepening  of 


482      ilENEBAL  l.WCHLABLE  niSnASES.  [cb 

The  nodules  sometimes  develop  in  the  first  instancfll 
on  the  limba  or  the  buttocks.     They  may  for  a  tini^ 

e  coniiiied  to  the  regions  in  which  they  first  makij 
their  appearance,  but,  as  the  disease  progresseB,  ires 
crops  of  them  cotae  out  on  the  arms,  the  trunk,  an 
the  abdomen.     On  the  upper  limbs  the  usual  pow^ 
tionw  where  the  nodules  are  found  are  the  back  ol 
the   elbows,    the   poatero- ex- 
ternal aspect  of  the  forearms, 
the  wrists,  and    the  postero- 
lateral aspects  of  the  fingei 
The   terminal    phalanges    art  I 
the  lii^t  to   be  alfected.     OuJ 
the  lower  limbs   the    ■ 
ponding  regions  are  the  osua] 
seats  01  nodules.     The  nai' 
(■specially  those  of   the  toa 
are  often  involved,  and 
come  deformed.    On  the  chest-l 
and    belly    the     nodules    arav 
usually  small ;  at  the  top  of  ' 
the  thigh,  in  Scarpa's  triangle, 
they  are  larger  and  more  nu- 
merous.   They  are  extremely 
Fig.  34.-Piima  of  iho  Ear  ^^^^  ^^  the  hairy  scalp.   Dea- 
otaperwmsnReniigfFoiD  quamation     of    the      cntiol«;j 
Nodular  Leprosy.  covering    the    nodules    is    ofjl 

(»mu  iiie  Hinu COM «  Fin.  83.)  common  occunence  ;    it  nujn 
be  excessive,    giving  rise    Af 
an  appearance  somewhat  resembling  ichthyosis. 

The  mucous  membranes  also  are  frequently  t 
seat  of  nodules,  the  parts  usually  attacked  t  '  _ 
conjunctiva  and  the  mucous  lining  of  the  nose,  moatii^  .1 
pharynx,  and  larynx.  In  these  sitiiatjons  tb«J 
nodules  have  a  red  or  grey  colour,  and  may  leeemMt  j 
Bvphilitic  lesions.  When  the  tongue 
inmtrated,  the  nodules  ore  separated  by  de{ 


ottAP.  SSI.]  NODULAR  LBPHOSY.  483 

wliich  may  aimulate  syphilitic  fiBsures.  T!ie  aflected 
parts  are  usually  aniestlietic  in  thi'  later  stages, 
though  the  sense  of  taste  is  long  retained.  The 
breath  has  a  peculiai  sickening  fostor.  In  the  nasal 
fossffi  destiuctive  ulceration  of  the  septum  oft-en  leads 
to  flattoninj;  of  the  nose,  lesembling  that  seen  in 
syphilis.  In  the  eye  the  leprouB  inflammation  often 
extends  from  the  cornea  to  the  iris,  causing  great  pain 
itnd  slow  destcuction  of  the  globe.  The  thickening  of 
the  laryngeal  mucous  membrane  gives  rise  to  lioarse- 
neB»,  and  as  the  infiltration  proceeds  and  the  vocal 
cords  become  more  and  more  immobilised,  the  voice 
is  reduced  to  a  whisper.  The  gradual  narrowing  of 
the  glottis  that  results  leads  to  increasing  difficulty 
in  breathing,  and  the  audden  occurrence  of  redema 
of  the  larynx  not  unfrequently  makes  tracheotomy 
necessary, 

This  stage  of  leprosy  is  usually  very  slowly  pro- 
gressive. The  nodules  increase  in  size,  and  while 
fresh  crops  appear  from  time  to  time,  some  of  the 
older  nodules  undergo  softening. 

Sooner  or  later  the  process  entMs  on  a  new  phase 
by  the  supervention  of  ulceration.  Both  on  the  akin 
and  on  the  mucous  membranes  nodules  have  a  natural 
tendency  to  break  down,  though  in  rare  instances 
they  may,  like  the  lesions  iu  tubercle  and  ayphilia, 
undergo  cicatricial  shrinking  without  previous  ulcera- 
tion. In  a  few  cases  the  disintegration  is  brought 
about  by  a  suppurative  process.  The  nodules  become 
transformed  into  pustules  which  open  and  discharge 
their  contents,  leaving  steep- bordered  ulcers.  These 
as  a  rule  soon  heal,  leaving  scare. 

Often  the  nodules  and  plates  become  red,  itchy, 
or  painful,  soften  and  break  down,  leaving  an  ulcer 
with  a  hard,  prominent,  sinwus  edge  and  a  grey  base, 
which  secretes  a  puruleat,  sometimes  sanious  dis- 
charge.   These  ulcers,  like  those  of  the  corresponding 


OEHERAL  INOCVLABLE  DISEASES,  [ci 

period  of  ayphilis,  will  usually  cicatrise  under  txea 
ment,  but  they  often  leave  hideous  deiormities.    WbcQ 
neglected  a  mote  acute  inftaramatory  process  i 
supervene  and  cause  rapid  extenttion  oi  the   ulo< 
especially  on  the  fingers  and  toes,  and  implication  i 
tendons,   bones,    and   joints,    which   often  leads 
f^anRrene,     These  processes  may  be  complicated  I 
the    enlargement    and     suppuration    of    lymphatl 
glands,  especially  those  in  the  inguinal  and  cervioi' 
regions.     The  hvet,   spleen,   and  mesenteric    glai 
may  be  enlarged.     If  the  patient  survive  and   1 
ulcers  heal,  the  peripheral  nerves  may  become  aSectq 
and  the  phenomena  of  nei  ve  leprosy  supervene. 

Nerve  leprosy. — As  already  said,  theprodron 
symptoms  of  both  varieties  of  leprosy  are  essentia] 
the  same.     There  are,  however,  certain  mJuoF  r'" 
ences   by    which    the    experienced    practitioner  i 
sometimes  foretell  along  which  line  the  evolution  < 
the  disease  will  probably  proceed.     While  the  c. 
tutional  disturbance  and  the  eruptive  phenomena  a 
as  a  rule,  more  marked  when  the  disease  is  aboat  | 
make  the  skin  the  particular  object  of  its  attack,  I 
advent  of  the  anteathetic  form  is  often  foreahadowi 
by  neuralgic  pains  and  cutaneous  liypcrnatheBia. 
patient  will  experience  the  sensation  of  "  pins  i 
needles  "  when  alight  pressure  is  made  over  the  t 
of  superficial  nerves.     Neuralgic  pain  in  the  great  t 
has  sometimes  been  mistaken  for  gout.     Rheumatc 
pains,  backache,  and  lumbago  are  of  frequent  o 
renise.     Pigmentary  changes  in  the  fkin  following  t 
maculte  of  the  invasion  period  are  much  more  com 
in  ansesthetic  than  in  nodular  leprosy.     These  o1 
are  nf  two  kinds  ;    in  some  the  alferted  area  ii 
than  the  natural  skin — sometimes  even  absofatM 
white ;    in  others,   again,  it    is    deeply   pig 
the  staining  being  brown  in  light-skinned  races,  a 
often  of  ebony  blackness  in  dark  races.     Tin  | 


a.]  KERVE    LEPROSY. 


tntyd  p-itchea  are  usually  Bymmetrical,  occundng 
liefly  on  the  face,  limbs,  and  trunk.  Tliey  Are  rare 
on  mucous  membranes,  and  unknown  on  the  scalp. 
Towards  the  end  ol  the  eruptive  period,  H  not  before, 
the  pigment  often  disappears  from  the  macules,  and 
scarring  frequently  occurs.  On  these  depigmented 
areas  aneesthesia  often  develops,  Anidrosis,  which 
may  or  may  not  have  been  preceded  by  hyperidrosis, 
occurs  on  the  afEected  areas  and  around  them  ;  the 
secretion  of  sebum  is  arrested,  the  hairs  become 
blanched  and  fall  out.  The  falling-out  of  the  eye- 
brows is  in  some  places  looked  upon  by  the  laity  as 
the  first  sign  of  leprosy. 

A  point  of  difference  between  the  macules  of 
nodular  leprosy  and  those  of  the  antesthetic  form 
is  that  while  the  former,  aa  already  said,  become 
converted  into  nodules  by  the  formation  of  inflam- 
matory new  tissue,  in  nerve  leprosy  only  pig- 
mentary changes  occur.  These  may  be  fugitive  ; 
on  the  other  hand,  they  are  sometimes  permanent. 
In  some  rare  cases  they  may  be  altogether  wanting. 
The  eruptive  stage  is  ushered  in  by  intensification  of 
neuralgic  pains,  with  hypereesthesia,  often  intense, 
of  the  macular  areas  and  the  skin  around  them, 
indicating  a  further  development  of  the  neuritic 
process  which  is  the  underlying  pathological  factor  in 
this  form  of  leprosy.  The  neuralgic  pains  increase  in 
severity,  and  an  eruption  of  bullous  lesions  takes 
place  which  are  independent  of  the  macules,  though 
they  may  affect  the  same  eite  (Leloir). 

The  bullous  eruption,  like  pemphigus,  is  of  ex- 
tremely rapid  development,  and  its  appearance  may  be 
preceded  by  fever  and  general  disturbance.  The  bullse 
usually  appear  one  by  one.  Their  size  varies  from  that 
of  a  miliet-aeed  to  that  of  a  turkey's  egg.  They  have 
absolutely  the  same  characters  as  those  of  ordinary 
pemphigus.     They  increase  rapidly,  sonia\ita\ft&  ^^«r 


^^K     48r>      GENERAL  INOCULABLE  DISEASES,  [chap,  xic^f 

^^^1    coming  doubled  in  sise  in  a  few  days.    They  mptui^| 
^^^F    and  form  n  large  CTuat,  generally  leaving  a  pale  patc^H 
^^^      bordered  by  a  brown  ring,  sometimes  a  brown  patch, 
rarely  a  scar.     On  rem.oving  the  crust  a  grey  surface 
is  exposed,  consisting  of  altered  rete,  the  epidermis 
being  cast  off  by  suppuration.     Thus  thick  yellow 
scabs  or  crusts  may  be  formed,  sometimes  resembliuj^l 
rupia.     A  succest^ion  of  crusts  may  form  and  {all  o^^| 
leaving  at  last  a  granulating  surface,  which  in  tJii0^| 
gives  place  to  a  very  white  sear.     Sometimes  th^^ 
bulla  aborts  and  a  parchment-like  scale  forms  and 
separates,  leaving  a  liypeMesthetic  ulcer.     The  bullooa 
eruption  chiefly  afiects  the  hands  and  feet,  the  backs 
of  the  elbows,  and  the  fronts  of  the  knees,  but  it  iom  ~ 
be  found  on  any  part  of  the  body.    It  may  continqi 
for  years,  and  after  it  has  disappeared  ulcers  mm 
remain.     During  the  period  oc<!upied  by  the  bulloql 
eruption,  nodular  thickenings  form  on  the  peripheE 
nerve  trunks,  and  in  certain  situations,  as  on  the  ulni 
nerve  at  the  elbow,  they  can  easily  be  felt. 

The  eruption  at  this  stage  may  remain  more  or 
less  stationary  for  years,  or  it  may  spread  all  over  the 
body,  making  the  whole  akin,  or  extensive  areas  of  it, 
atrophied  and  white.  On  the  face  the  sldn  haa  often 
a  peculiar  tense  appearance,  as  though  drawn  too 
tightly  over  the  features,  giving  the  countenance  ■ 
lixcd,  expressionless  look.  Meanwhile,  the  peripheral 
neuritis  becomes  more  and  more  general,  uid  i 
diiferpiit  nerves  are  involved,  a  great  varie^  i 
paralytic  and  trophit-ti»^«rotic  symptoms  is  indue 
.Amonit  these  are:— (1)  HyperwatJietia.  Thia  i 
persist  for  yi'ar».  It  generally  begins  on  the  lin_ 
sometimes  on  tlio  fiiitc.  and  the  trunk  is  not  ■ 
frequently  [ifTi'e(.<ul,  Wiill(ing,  and  even  the  raisiBg 
food  to  the  mouth,  niiiv  In-  iniiiOMsilile.  (2)  iVeurol 
pains.  These  are  paroxy^nial.  often  coming  on 
Ifl^t.    They  arc  often  of  e  -iasity.    Thicks 


X] 


NERVE    LEPROSY. 


inga  can  frequently  be  felt  on  the  afieeted  nerves. 
(3)  Alterations  in  the  sweat  secretion.'  This  is  a 
frequent  phenomenon.  The  seoretion  may  be  sup- 
pressed on  the  limbs,  while  at  the  same  time  there 
may  be  excessive  sweating  on  the  trunk.  At  a  later 
stage,  as  the  neuritis  progresses,  (4)  anrsstkesia  usually 
takes  the  place  of  hypertesthesia.  It  begins  ou  the 
limbs,  and  very  rarely  attacks  the  trunk.  On  the  face 
it  has  the  same  diatribution  as  the  previous  neuralgia. 
The  loss  of  sensation  is  at  first  confined  to  the  skin,  but 


— Claw-liltB  Huniis  in  \  cr 


O 


in  time  it  extends  to  the  subcutaneous  tissue  and 
becomes  absolute.  The  mucous  membranes  of  the 
mouth,  eye,  and  nose  maj  also  become  utterly 
insensitive.  As  a  result  of  paralysis  {'i]  muscular 
atrapky  is  observed,  especially  in  the  hands  The 
thenar  and  hypothenar  eminences  are  the  first  to 
waste,  then  the  interossei ;  wnat  drop  occurs  and 
the  second  and  third  phalanges  are  bent  mwards 
giving  the  fingers  the  aspect  of  claws  (Fig  Vt)  The 
feet  are  often  similarly  affected,  so  that  progressive 
muscular  atrophy  is  simulated.  Sometimes  the 
muscular  atrophy  is  masked  by  hard  cedema. 


lati      GENERAL  INOGULABLE  DISEASES,  [ckap. 

Among  other  changes  due  to  the  advancing  netiril 
purulent  tonjunotivitis,  thickening  of  the  conjnnctiva,- 
ulcer  of  the  cornea,  and  iritis  may  occur.  The  septum 
nasi  may  undergo  absorption,  with  the  result  that  thi- 
nose  fails  in.  The  gums  may  shiink  and  the  teeth 
fall  out.  Matiiations  are  of  frequent  occurrence. 
The  atrophied,  shrivelled  skin  ulcerates,  and  as  the 
ulcers  deepen  joints  are  laid  open  and  phalanges  drop. 
ofi.  Such  mutilations  are  confined  to  the  hands  and 
feet ;  the  tarsus  and  carpus  are  rarely  affected.. 
Mutilation  may  also  result  from  interstitisl  absoip'' 
tion  of  the  phalangeal,  metacarpal,  or  metataraal! 
liones,  unaccompanied  hy  ulceration.  The  stumpin 
are  often  bullous.  The  nails  may  be  greatly  d*-' 
formed,  but  they  do  not  usually  drop  ofi  ior  a  long 
time.  In  some  cases  a  blue  soft  spot  appears  on 
antesthetic  area  after  a  febrile  attack.  The 
breaks  and  the  matter  escapes,  leaving  an  indoli 
ulcer  which  gradually  excavates  the  tissuea,  li  _ 
bare  muscles  and  bones.  At  this  stage  the  patii 
may  die  of  pyiemia.  In  other  cases  dry  gangrene  of 
the  fingers  and  toes  supervenes.  The  hands  and  feet 
may  become  the  seat  of  perforating  ulcers,  exactly 
resembling  those  seen  in  cases  of  locomotor  ataxy. 
Gastric  "  crises  "  similar  to  those  occurring  in  tliat 
disease  are  also  of  not  unfrequent  occuirence  in 
leprosy. 

In  the  last  stage  of  the  disease  the  deforokity 
horrible.     The  intelligence  is  often  lost,  and  i 
occurs  from  colliquative  dianlicea,  marasmus,  tel 
convulsions,  intercurrent  pneumonia,  or  pleuriay. 
the  nodular  form  of  the  disease  phthisis  and  nephni 
are  frequent  complications,  and  one  or  other  of 
diseases  is  in  a  considerable  proportion 
direct  cause  of  death. 

Mixed  Leprosy. — in  some  cases  of  leproay 
k  nodular  skin  lesions  and  the  changes  due  to  * 


1 


:l]  leprosy  :  ETIOLOGY.  489 

neuritis  are  present.  In  such  cireninBtanoeB  tlie 
features  of  the  two  forms  are  combined.  Anteethetic 
leprosy  may  supervene  on  the  nodular  form,  but  it  ia 
more  often  the  case  that  the  latter  shows  itself  some 
months  after  the  commencement  of  the  former.  Some 
cases,  however,  are  from  the  outset  of  the  mixed  or 
■'  complete  "  type,  and  in  these  the  disease  runs  u 
more  rapid  course  than  in  either  of  the  other  varieties. 
The  etiology  of  leprosy  is  still  wrapped  inagood 
deal  of  obscurity.  The  existence  of  a  specific  bacillus 
in  the  tissues  affected  with  the  disease  was  proved 
by  Armauer  Hansen  in  1874,  and  the  evidence  that 
this  micro- organism  is  the  exciting  cause  of  leprosy 
ia  now  generally  accepted  as  conclusive  ;  very  little, 
however,  is  deliiitely  known  aa  to  the  actual  mode  of 
infection,  or  as  to  the  conditions  necessary  tor  the 
growth  of  the  germ.  Among  the  predisposing  causes 
are  prolonged  exposure  to  cold  and  wet,  insufficient 
and  improper  food,  and  generally  anything  that 
depresses  the  health.  The  wide  geographical  dis- 
tribution of  leprosy  seems  to  negative  the  idea  that 
climate  ia  a  factor  in  its  causation.  It  is  endemic  in 
certain  linuted  regions  in  Norway,  and  to  a  much  less 
extent  in  Sweden,  in  Russia  (especially  on  the  shores 
of  the  Baltic),  in  Italy,  France,  Spain,  Portugal, 
Greece,  and  Turkey.  In  Asia  it  is  largely  prevalent 
in  China,  India,  Turkestan,  and  elsewhere.  In  Africa, 
which  used  to  be  looked  upon  as  its  birthplace,  it  is 
also  widely  difiused.  In  North  America  it  ia  found 
in  scattered  spots  :  in  Central  America  it  is  relatively 
common  ;  and  in  some  parts  of  South  America, 
especially  in  Brazil,  it  may  almost  be  said  to  be  rife. 
In  the  West  Indies  it  is  not  uncommon  ;  it  occurs  in 
parts  of  Australasia,  and  it  rages  with  almost  epi- 
demic virulence  in  the  Sandwich  Islands,  into  which 
it  was  first  imported  within  the  memory  of  men  not 
much  past  middle  age.    It  ceased  to  be  eo.dftTsa.'i  vn 


490      GENERAL  INOGULABLE  DISEASES,  [chap. 

Great  liritain  towards  the  end  oi  the  sixteenth 
tiiry,  though  what  is  believed  to  have  been  the 
case  oi  native  origin  occurred  in  the  Shetland  Isles 
as  late  ap  the  beginning  oi  the  nineteenth  century. 

A  olimatic  ieature  common  to  most'  of  the 
favourite  haunts  ot  leprosy  is  the  proximity  of  water, 
but  tbe  exceptions  to  this  rule  are  sufficiently 
numeroiiB  to  forbid  its  being  made  the  basis  of  an  in- 
duction. That  some  peculiarity  of  climate,  or  perhaps 
rather  nf  soil,  has  a  very  decided  influence  on  the 
development  of  leprosy  is  clearly  shown  by  the  fact 
that  the  children  of  lepers — who,  from  living  under  thtt. 
same  conditions  as  their  parents  and  in  frequent  and 
intimate  contact  with  them,  are  particularly  likely  to 
be  attac'ked — have  an  excellent  chance  of  escape  if 
they  are  removed  from  the  infected  district  at  i 
early  af!e.  Even  when  the  disease  has  actually  pv( 
signs  of  its  presence,  it  sometimes  seems  to  be  arrest 
or  at  least  greatly  modified,  by  transfexence  of 
patient  to  a  place  free  from  leprosy  {Hutchiiisonl 

The  real  problem  in  the  causation  of  ieprosy  n 
to  determme  how  the  bacillus  gains  access  to  tbe 
body.  From  ancient  times  the  food  has  been  regarded 
as  the  vehicle  of  the  poison,  fSsh  being  looked  upon 
with  especial  suspicion.  There  is,  however,  no  trust- 
worthy evidence  of  the  disease  ever  having  been 
conveyed  by  food  of  any  kind ;  and,  as  regards  fish  in 
particular,  there  is  abundant  proof  that  persona  may 
contract  leprosy  who  have  never  had  the  oppor- 
tunity of  eating  fish.  From  the  analogy  of  kindred 
dtseaseH  like  syphilis  and  tuberculosia,  it  is  probable 
that  the  virus  of  leprosy  is  transmitted  by  inooolo*' 
tion,  though  the  prolonged  incubation  period  of  tl 
disease  makes  it  very  difficult  to  trace  individi 
cases  to  definite  contagion.  Experimental  inoct 
tion  in  the  human  subject  has  so  far  given 
or^  ambiguous  resulbt,  and  in  spite  of 


1 

lastV 


I 


™£K4p.  XXL]  LEPBOSr  :   ETIOLOGY.  491 

attempts  by  some  oi  thp  m.08t  experienced  bacteriolo- 
psts  of  the  day,  it  ia  doubtful  whether  the  bacillus 
has  yet  been  successfully  cultivated.  In  a  few  cases, 
iiowever,  leprosy  has  been  communicated  by  vaccina- 
tion.* 

If  the  bacillary  origin  of  kprosy  bo  admitted,  it 
is  impossible  to  escape  from  the  conclusion  that  the 
disease  is  at  least  potentially  contagious ;  and  what  ia 
known  as  to  its  mode  of  spreading,  both  in  ancient 
times  and  in  our  own  day,  affords  strong  presumptive 
evidence  that  contagion  is  the  principal  element  in  its 
diffusion.  On  any  other  theory  it  is  impossible  to 
explain  the  development  and  dissemination  of  leprosy 
in  a  perfectly  virgin  soil  like  that  of  the  Sandwich 
Islands,  following  the  importation  of  the  disease 
from  without.  The  decrease  in  the  prevalence  of  the 
disease  which  has  always  followed  strict  isolation 
of  lepers  is  a  practical  proof  of  its  contagious  nature. 
Few  people,  I  imagine^  will  agree  with  Hutchinson 
that  the  extinction  of  leprosy  throughout  Europe 
in  the  sixteenth  century  was  a  result  of  the  Reforma- 
tion and  the  diminished  consumption  of  fish,  wluch 
was  one  of  the  consequences  of  that  event.  The 
stamping  out  of  the  disease  is  much  more  hkely  to 
have  been  the  resnlt  of  the  terribly  drastic  methods 
of  "  segregation  "  adopted  by  our  forefathers,  com- 
bined with  a  general  improvement  in  the  mode  of 

Coniirmatory  evidence  is  afforded  by  the  modem 
instance  of  Madagascar,  where,  since  segregation  of 
lepers  has  been  abandoned,  the  disease  which  pre- 
viously was  of  very  limited  distribution,  has  rapidly 
increased.     It  is  certain,   however,  that  leprosy  is 

■  Two  caaea  iu  which  this  occurrod  have  bean  raportfiJ  1)V 
Dflubler,  Moualik.  f.  prnki,  itoiM.,  Bd.  viii.,  )f.  123.      OILars 
'    lU  teported  by  Aruiug.  ^itA./.  /Jmih.  h.  ^/j/t.,  Jsuuiury, 


482      GENERAL  IXOCULABLE  DISEASES.   [oh*p. 

not  contagious  iu  the  sense  in  which  syphili 
conttkgious,  but  only  in  a  limited  sense,  like  tuberule. 
The  bacillus  may  be  implanted  by  contact,  but  it  can 
take  root  only  when  the  soil  is  particularly  favour- 
able to  its  development.  In  what  this  favourable 
condition  of  the  soil  consists  is  not  exactly  known, 
but  it  is  probable  that  the  mode  of  life,  hygienic 
eurrouudines,  and  constitutional  state  of  the  patient 
have  a  powerful  influence  iu  determining  the  d^iree 
of  his  susceptibility  to  the  infection. 

Heredity  has  probably  only  an  indirect  influent 
As  the  children  usually  inherit  not  only  their  con- 
stitution, but  their  social  condition  and  environmi 
from  their  parents,  they  may  no  doubt  inherit  there- 
with  a  soil  favourable  to  the  growth  of  the  bacilliu. 
Many  cases  of  supposed  hereditary  tranamiaaion  of 

:  disease  are   really   examples  of  contagion,    in_ 
which   the   intimacy   of  family    hfe  affords  speci 
opportunities.     The  age  at  which  the  disease  usi 
appears — from  eight  to  fifteen  years— is  against  ttu! 
notion  of  its  being  to  any  large  extent  hereditary.* 

The  patholog'y  of  leprosy  is  that  of  inflanunatiaa] 
beginning  in  the  skin  or  in  the  peripheral  netrcs, 
response  to  irritation  by  the  specific  micro-orgt 
which  is  the  actual  cause  of  the  disease.  The  lepi 
nodule  is  composed  of  granulation  tissue  togel 
with  special  "  lepra  cells "  and  giant  cells.  Tl 
essential  part  of  the  leprous  process  is  the  infiltratioB 
nf  the  tissues  of  the  affected  parts  with  tliia  modified 
granulation  tissue,  and  the  slownesa  nf  the  process 
a«  compared  with  lupus  and  syphilis  is  owing  to  the 


1 


slight  vascularity  of  the  i 
the  change  eommencea  in  the  c 


'  growth.     In  the  slua  I 
i  the  giadur  r 


*   For  a  lull  Bipoaitioli  of    liresciit  viewi  uu   lli< 
tniuiiioiuian   oud  heredity  of  leiirusy,  .rr  IIih  "Be,    _ 
3V«uia«tit>ii«  of  the  luternational  Ccaigteaa  on  Lo)>ro7,  ] 


CHAP,  sxi.]  LEPROSY  .■  PATIlOLOdY.  4fi3 

ally  increasing  pressure  oi  the  infiltration  material 
on  the  vessels,  glands,  and  follicles  destroys  the 
normal  elements  ol  the  integument ;  these  are 
replaced  by  the  leprous  neoplasm,  which  in  turn 
becomes  disintegrated,  cauaing  deep  ulcers.  In 
nerve  leprosy  the  infiltration  takes  place  around  the 
trunks  of  the  peripheral  nerves  and  penetrates 
hetween  their  fibres,  at  first  irritating  them  (thuR 
causing  hyperjesthesia),  then  compressing  them 
(causing  antesthesia),  and  destroying  their  con- 
ductivity (thus  giving  rise  to  paralysis).  The 
bacillus  (Plate  II.,  Fig.  4)  is  a  straight  or  very  slightly 
curved  rod-shaped  organism,  about  siiVo  of  an  inch 
in  length.  The  bacilli  occur  in  clumps  within  the 
lepra  ceils  in  the  lesions  of  the  skin,  mucous  mem- 
branea,  and  other  aSected  tissues ;  the  blood- 
vessels going  to  the  part  are  sometimes  seen  thickly 
packed  with  them.  The  same  bacillus  ia  found  in 
the  diseased  tissues  taken  from  lepers  in  every  part 
of  the  world,  and  it  can  always  be  discovered  if 
properly  looked  for.  The  reason  of  the  failure  of 
experimental  inoculations  may  possibly  be  that 
passage  through  an  intermediate  host  is  necessary 
to  make  the  bacillus  capable  of  growing  in  the  animal 
body.  According  as  the  bacilli  invade  the  difierent 
internal  organs,  various  complications  may  be  induced. 
There  are  many  points  of  resemblance  between  tuber- 
culosis and  leprosy  ;  nothing  is  yet  definitely  known, 
however,  as  to  the  coimection  between  them,  beyond 
the  fact  that  the  afieeted  tissues  react  lo  tuberculin, 
and  a  considerable  proportion  of  lepers  die  of  phthisis. 
In  a  weU  marked  case  of  leprosy,  whether  of  the 
nodular  or  the  ansesthetic  form,  the  diagnosis  presents 
no  difficulty.  In  the  prodromal  stage  the  symptoms 
may  sometimes  suggest  rheumatism  or  malaria,  but 
the  appearance  of  the  leprous  spots  or  of  antesthetic 
patches  will  soon  reveal  the  nature  of  the  disease. 


p 


49*      GESBEAL  INOOULABIE  DISHASSS.  [chap.  XXt.M 

In  the  macular  period  there  may  occasionaUy  be  si 
possibility  of  confusion  with  erythema  or  syphiliticil 
roseola.     In  the  former,  however,  there  is  no  disordei 
of  sensation,  and  little  or  no  constitutional  disturb 
ance,  and  the  lesions  are  transitory  ;  while  the  latt 
can  often  be  excluded  by  the  absence  of  history  « 
a  primary  sore  and  of  other  characteristic  signs  t 
the  disease.     In  the  nodular  and  ulcerative  stage* 
the  lesions  of  leprosy  sometimes  bear  a  more  or  let 
close  resemblance  to  those  of  syphilis  and  lupus,  bnn^ 
the  presence  of  anesthesia  will  generally  serve  tol 
identify  the  disease.    It  should  be  remembered,  hoi 
ever,  that  leprosy  and  syphilis  sometimes  co-exiat.,fl 
In  the  early  stage  of  nodular  leprosy  the  nodules  a 
occasionally  exactly  hke  those  of  erythema  uodosui 

and  the  resemblance  may  be  all  the  closer  from,  thj 

presence  of  pains  about  the  joints.     The  rapid  dia^ 
appearance  of  the  lumps  in  the  former  condition  will 
speedily  remove  all  doubt ;    but  if  the  patient  has 
lived  in  a  leprous  district  for  any  time,  it  will  be  well 
to  reserve  judgment  for  a  while  as  to  the  nature  of  the 

The  progrnosis  of  leprosy  as  regards  cure  is  of  tbvj 
gloomiest.     In  some  very  exceptional  cases,  howevei 
permanent  recovery  has  been  known  to  take  plac 
The  prospect  is  more  favourable  in  the  pure  am 
thetic  than  in  the  nodular  form  of  the  disease, 
average  duration  of  life  in  the  former  is  about  twei 
and  in  the  latter  about  ten  years.     Nodular  IcprOAjT 
sometimes  runs  a  very  acute  course,  however,  proving 
fatal  in  a  year ;    and,  on  the  other  hand,  in  nerve 
leprosy  life  may  be  prolonged  for  thirty  or  forty  yean. 
Early  treatment,  and  especially  removal  from  as  ■ 
infected  district,  may  do  something  to  improve  tbitil 
patient's    condition    and    increase    his    chances    (rfl 
recovery. 

The  treatment  of  lepro>='-  ■— -st  be  directed  to  t] 


L1HAP.  ssn.l  LEPROSY  :  TREATMENT.  405 

alleviation  of  symptoms  aud  to  the  improvement  of 
the  sufferer's  general  health,  There  is  no  antidote 
for  the  disease.  Tuberculin,  which  at  first  seamed  to 
offer  a  hope  that  a  curative  agent  had  bcpD  dis- 
covered, only  quickens  the  activity  of  the  pcoceas. 
The  serum  treatment,  which  has  had  a  considerable 
trial,  has  not  up  to  the  present  given  aiil  isfactory 
results.  Ohaidmoogra  oU  (from  the  tjt/ii«cardia 
odoTaia)  given  internally  in  doses  of  three  miftims  or 
more  thrice  daily  after  meals,  and  ruhbed  i'lr  two  or 
three  hours  a  day  in  the  form  of  an  ointment  Jirmpoaed 
of  equal  parts  of  the  oil  and  lard,  occasio:iah/  does 
good.  Arsenic  is  sometimes  of  marked  use,  especially 
in  the  skin  variety.  Gurjun  oil  (from  dipterocarfus 
turbinaivs)  given  internally  in  an  emulsion  consisting 
of  one  part  of  the  oU  to  three  of  lime-water {'^&a),  and 
applied  locally  {in  the  same  way  as  the  Chauimoogra 
ointment)  in  a  liniment  of  equal  parts  of  the  oil  and 
lime-water,  is  also  well  spoken  ol  by  those  who  have 
tried  it  in  the  tropics.  Sulphur  hatha  are  useful, 
Bspecially  in  the  tropics,  where  scabies  is  a  frequent 
comphcation  of  leprosy.  The  ulcers  and  other 
lesions  must  be  treated  on  general  surgical  principles, 
the  most  scrupulous  cleanliness  and  the  strictest 
antisepsis  being  cardinal  principles  in  the  local  treat- 
ment, not  only  for  the  sake  of  the  patient,  but  of  those 
who  have  to  minister  to  him.  Nerve- stretching  and 
evacuation  of  the  leprous  infiltration  lying  within  the 
nerve  sheath  are  not  unfrequently  followed  by  good 
results  to  the  peripheral  portions  of  the  limb  supplied 
by  the  nerves.  When  the  throat  is  the  seat  of 
disease  the  practitioner  must  always  be  prepared  to 
perform  tracheotomy.  The  constitutional  symptoms 
may  also  be  treated  on  general  principles,  quimne 
being  given  in  full  doses  when  iever  is  present,  and 
diarrhcea  and  other  complications  being  dealt  with 
by  the  usual  remedies.     Cod-liver  oU  and  a  liberal 


1 


4S0     GENERAL  INOCULABLE  DISEASES,  [chap. 

supply  of  nnnrishing  food,  with  Btimnlaiits  according 
to  incQcations,  are  most  important  adjuncts  to  medical 
and  surgical  treatment.  The  patient  should,  if 
possible,  be  removed  at  the  earUest  moment  from  aB]§ 
place  in  which  the  disease  is  endemic. 

Strict  isolation  is  the  only  trustworthy  i 
checking  the  spread  of  leprosy,  as  is  shown  by  the  ft 
perience  of  Norway.  Segregation,  if  properly  carried 
out,  is  not  only  a  protection  to  the  community  atl 
large,  but  is  greatly  to  the  advantage  of  the  lep« 
themselves,  who  thus  receive  better  treatment  thai 
they  could  otherwise,  in  the  majority  of  cbm 
command. 

Yaws  * — also  known  as  frambcesia  {from 
French  framboise,  a  raspberry),  the  paranghi 
Ceylon,  the  coco  of  Fiji,  Amboyna  button,  etc.- 
disease  caused  by  the  inoculation  of  a  specific  ^ 
characterised  by  eruptive  and  ulcerative  leeiona  of  ti 
skin,  with  involvement  of  the  other  tissues  in  the  lata 
stages,  and  generally  by  greater  or  less  constitiitiai 
disturbance.  It  is  endemic  on  the  Went  Coast  t 
Africa,  la  the  West  Indies,  in  some  parts  of  Noi 
and  South  America,  in  Madagascar,  Oylon,  and  Ottri 
tropical  countries. 

Four  distinct  stages  are  recognised  in  the  evoM 
tion  of  the  disease.  The  incubation  period  is 
as  lasting  from  three  to  ten  weeks.  The  ] 
■period  corresponds  with  the  life-history  of  tlie  iiM 
fation  sore.  This  consists  of  a  papule,  which  i 
appear  on  the  lip,  the  breast,  the  groin,  the  genita 
or  the  perineum.  In  about  a  week  this  papid 
becomes  yellow  at  the  apex,  and  seven  days  lati 
discharges  and  dries  up  into  a  scab.  On  Temovi 
this  scab  a  small  ulcer  with  raised  edge  and  a  £ 


•The  , 


l>  siiuuly  luuDcled 


ly  luuQi 


cHiP.  ixi.]  YAtVa.  497 

covered  with  gianulations  is  discovered.  The  ulcer 
lieala  in  a  fortnight,  but  may  persiat  for  two  months  ; 
it  leaves  an  inaigniiicant  scar. 

The  secondary  stage  begins,  about  a  month  after 
the  appearance  ol  the  iooculation  sore,  with  lebrile 
plienoraena,  intermittent  iu  type,  and  of  greater  or 
less  intensity ;  sometimes  with  graver  symptoms  of 
constitutional  disorder,  such  as  albuminuria,  hiema- 
turia,  or  epiataxis.  After  a  variable  time  from  the 
onset  of  the  fever  an  eruption  oi  tiny  red  apots,  like 
those  of "  prickly  heat,"  appears,  the  fever  generally 
subsiding  as  the  rash  becomes  developed.  The 
eruption,  which  is  preceded  by  itching,  appears  in 
the  form  of  small  papules  on  the  face  and  neck,  and 
spreads  downwards,  the  whole  body  being  covered 
usually  by  the  end  oi  the  third  day.  In  a.  week  the 
papules  become  yellow  on  the  top,  and  begin  to 
increase  in  size,  so  that  by  the  end  of  the  third  week 
they  measure  a  quarter  of  an  inch  in  width  and  an 
eighth  of  an  inch  in  height.  Meanwhile  the  yellow 
heads  have  become  transformed  into  scabs,  beneath 
which  is  a  heap  of  granulations  grouped  together  bo 
as  to  present  the  appearance  of  a  raspberry  ;  this  is 
the  characteristic  lesion  of  yaws.  The  grapulaticns 
secrete  a  small  amount  of  pus,  and  the  lesions  give  ofi 
a  musty  odour,  After  a  tim.e  the  granulations  lose 
their  florid  aspect  and  become  pale  or  even  white. 
Sometimes  the  papules  are  arranged  in  rings,  especi- 
ally round  the  eyes,  nose,  mouth,  and  genitals.  They 
arc  eometimes  seen  innide  the  mouth  and  the  vagina, 
also  in  the  nasal  fosste  and  the  external  auditory 
meatus.  The  ulcerated  papules  dce  only  plightly 
sensitive,  but  itching  as  a  rule  is  very  prnn ounce d . 
In  most  canes  healing  takes  place  beneath  the  scabs, 
which  separate  about  the  end  of  the  secoud  month 
from  the  appearance  of  the  rash.  Pale  spots  are  left, 
which  in  negroes  become  darker  and  in  whites  li^Wtet 


tAP.  ^H 


498    UENERAL  ISQL'OLABLE  DISEASES,     [ti 

than  the  aurroandiug  skin.  The  Bpota  are  geu« 
permanent',  and  are  mgst  conspicuous  about 
mouth,  chin,  and  lower  jaw. 

The  lesions  are  always  accompanied  by  a  great 
OF  leHsei  amouat  of  ansemia  ;  in  weakly  persons,  and 
in  cases  where  treatment  is  neglected,  healing  may  be 
greatly  protracted.  The  papules  may  remain  stationai 
for  many  mouths,  oi  they  may  extend  and 
coalescence  form  large,  deep  ulcers,  which  leave  ci 
siderable  deformities  or  cause  death  from  septicEBi 
pyemia,  or  exhaustion.  In  the  palms  and  soles  t1 
ulcers  iisually  nssumo  the  form  of  fiseuiea.  In  chil- 
dren the  disease  runs  an  ai;ute  course  ;  in  the  adull 
the  process  ia  more  chronic.  The  description  of  tire 
eruptive  stage  which  has  been  given  apphes  to 
majority  of  cases,  but  variations  in  the  appeal 
and  especially  in  the  amount,  of  the  eruption,  are 
infrequent.  Thus,  instead  of  dehnite  papuh 
slightly  scaly  patches  may  be  visible.  Somed 
eruption  is  limited  to  the  extensor  aspect  of 
forearm  and  leg. 

In  unfavourable  cases  a  tertiary  jieriod,  chararter- 
ised  by  lesione  no  longer  limited  to  the  skin,  but 
involving  the  deep  tissues,  may  supervene.  The 
most  characteristic  tertiary  lesion  is  a  nodular 
infiltration  of  the  subcutaneous  tissue,  generally 
leading  to  the  formation  of  superficial  ulcers,  which 
spread  serpiginoualy.  New  nodules  frequently  appeal 
in  the  neighbourhood  of  the  older  ones,  and  i 
resembling  syphilitic  gummata  may  form  and 
down  into  ulcers.  The  favourite  position  of 
late  ulcers  ia  the  leg  below  the  knee,  eapeelaUy  roi 
the  ankle.  They  are  aUo  common  about  the  Jipa, 
and  may  be  met  with  in  any  part  of  the  body.  Peep 
tiesiires  are  often  present  ou  the  hands  and  feet ; 
the  pain  on  walking  caused  by  them 
situation  gives  rise  to  a  characteristic 


CHiP.  SSL]  YAWS.  499 

the  other  lesions  of  the  tertiary  period  are  destruc- 
tive ulcerations  of  the  pharynx,  soft  palate,  and 
septum  ;  nodes  on  the  clavicle,  sternum,  ulna,  tibia 
and  the  metacarpal  and  metatarsal  bones,  which  may 
(five  rise  to  permanent  thickening,  or  break  down  and 
cause  ulcers ;  chronic  dactylitis ;  chronic  arthritis, 
resembling  white  swelling  ;  and  myositis,  leading  to 
contractures.  If  the  late  affection  is  severe,  grave 
aniemia  may  be  produced,  and  may  terminate  in 
cachexia  and  death. 

The  essential  element  in  the  etiolog'y  of  yaws  is 
a  specific  poison,  which  is  conveyed  into  the  system 
by  inoculation  chiefly  by  direct  contact,  as  by 
kissing,  sexual  intercourse,  etc.  ;  sometimes  appar- 
ently indirectly  by  flies.  An  abrasion  of  the  tegu- 
mentary  surface  does  not  seem  to  be  a  necessary 
condition  of  the  implantation  of  the  poison.  From 
the  analogy  of  other  inoculable  diseases  it  is  probable 
that  the  cause  of  the  affection  is  a  specific  micro- 
organism ;  but  so  far  none  has  been  discovered,  and 
inoculations  on  animals  have  yielded  only  negative 
results.  An  attack  of  yaws  usually  confers  immunity, 
but  in  some  cases  two  or  more  attacks  have  occurred 
in  the  same  individual.  The  lesions  are  not  aufco- 
inoculable.  Among  the  predisposing  causes  of  yaws 
are  —  (1)  a  tropical  climate — it  is  ooramonest  in 
damp,  liilly,  isolated  regions  ;  (3)  tender  age — it  is 
most  frequent  in  children  under  ten,  and  is  hardly 
ever  contracted  after  thirty-five ;  (3)  mode  of  life — 
it  is  commonest  in  the  poor  and  in  those  living 
amidst  insanitary  surroundings  ;  (4)  race — it  is  most 
common  in  Africans :  no  race,  however,  is  exempt. 
It  is  never  congenital,  and  is  probably  hereditary 
only  in  the  sense  in  which  leprosy  is  so — that  is,  from 
the  inheritance  of  conditions  that  favour  its  produc- 
tion, and  from  the  opportunities  of  contagion  pre- 
sented by  family  life. 


600    GENERAL  INOGULABLE  DISEASES,     [ohap.  i 

The  pathology  of   yawg  is  tbat  of   dermatitl 
limited  to  the  papillary  layer,  gradually  penetratia 
into  the  corium,  and   involving    thp 
the  skin.     As  already  said,  the  exciting  c 
inflammatory  process  has  not  yet  been  discovers 
but  it  is  probably  a  micro-organism. 

It  has  been  contended  by  some  authorities  t 
yaws  is  a  form  of  syphilis,  modified  by  race  j 
climate,  but,  though  it  prenents  many  points  i 
analogy  with  syphilis,  I  am  inclined  to  agree  with  RaB_ 
and  others,  who  have  had  extensive  opportunities  of 
studying  the  disease  clinically,*  that  on  the  whole  the 
balance  of  evidence  is  against  its  being  syphilie.!" 
Further  pathological  research  is  required  to  sett' 
the  luestion. 

The  diagrnosis  of  yaws  is,  as  a  rule,  easy ; 
aspect  of  the  lesions,  and  especially  the  raspbeiz 
like  nodule,  being  characteristic.  From  syphihs  i 
can  be  distinguislied  by  the  following  features  :- 
occurs  chiefly  in  children ;  the  primary  lesion  in,  a 
a  rule,  extra -genital,  never  indurated,  and 
phagedfenic  ;  in  the  secondary  stage  the  eruption  j| 
neither  symmetrical  nor  polymorphous,  and  itchi 
is  a  prominent  symptom  ;  finally,  other  charactetii 
marks  of  syphilis — iritis,  sores  on  the  tongue  i 
anus,  alopecia,  etc.  —  are  conspicuous  by 
absence.  Yaws,  when  properly  treated,  is  altogetlri 
a  milder  disease  than  syphUis.  The  stigmata  < 
hereditary  syphilis,  notched  teetli,  scars  about  |" 
mouth,  etc.,  are  also  wanting. 

As  regards  prog'nosis,  I  he  disease  as  a  rule  t 
to  spontaneous  recovery  unless  the  conditions  oi  li 


*  Srt  pflrtioiiliirlj  I 
n  Cm™  of  TnWB,'' J(p 


uvea  Rake,  "  Fnat-n 


n  disvussinn  of  titii  diHthictiu 
VBwe,  irf  DaiuelB,  Jin',  ./'•urn.  D"n<., 
Powell,  iitrf.,  p.  «7. 


tHA3-.  XXI.]  7 A  WS :     OLANDEliS.  GUI 

»f  the  patient  be  of  the  most  unfavourable  nature. 
Death  may  occur  from  neglect,  but  by  proper 
treatment  the  discuae  can  always  be  cured,  and  in 
most  casea  its  manifestations  can  be  hmited  to  tlie 
skin  and  mucous  membranes. 

The  treatment  must  consist  in  improving  the 
constitution  and  hygienic  surroundings  of  the  patient. 
The  inoculation  sore  is  best  treated  hy  simple  anti- 
septic applications.  The  fever  must  be  dealt  with  on 
ordinary  principles  by  quinine  or  the  saHcylates.  Bat 
lays  great  stress  on  diaphoresis,  and  he  gives 
ammonium  carbonate  with  the  double  object  of 
inducing  sweating  and  promoting  the  alkalinity  of 
the  secretions.  In  the  eruptive  stage  sulphur  baths 
and  calomel  fumigations  are  useful.  These  should 
be  followed  by  tonics,  especiiilly  iron  and  cod-liver 
oil.  In  the  tertiary  stage  mercury  and  iodide  of 
potassium,  are  the  most  efB.cient  remedies.  Rat  is  of 
opinion  that  in  yaws,  as  in  syphilis,  the  real  curative 
agent  is  mercury,  the  iodidea  helping  by  promoting 
the  absorption  of  inflammatory  products.  Others, 
however,  contend  that  mercury  is  uaeleas.  In  any 
casQ  it  should  never  be  given  in  the  early  sta^e,  as  it 
aggravates  the  disease.  Ulcers  should  be  treated 
locally  with  black  wash,  weak  solutions  of  perchloride 
of  mercurv,  or  iodoform. 

Glanders  is  a  disease  caused  by  a  specific  poison 
derived  from  the  horse,  which  gives  rise  to  lesions  of 
the  skin,  mucous  membranes,  and  lymphatic  glands, 
and  to  general  constitutional  infection  usually  ending 
in  death.  Glanders  may  run  an  acute  or  subacute 
or  a  chronic  course,  the  former  as  a  rule  terminating 
fatally  within  six  weeks,  the  latter  persisting  for 
months  or  even  years,  and  sometimes  ending  in 
recovery.  One  of  the  earhest  symptoms  is  a  peculiar 
discharge  from  the  nostrils,  the  mucous  membrane 
of  which  is  violently  inflamed  and  ulcerated.  \a.  •Oat 


602      GENERAL  IflOCUfMBLE  DISEASES,  [chap.  xu. 

aeuter  casca ;  in  the  chronic  form  this  discharge  is 
often  slight  or  altogether  absent.  It  is  Qot  always 
easy  to  ascertain  tlie  site  of  inoculation.  Generally, 
however,  it  is  found  that  the  poison  has  gained  admis- 
sion through  a  wound  or  atrasion  on  the  face  or  the 
hands.  The  local  inilanunatory  reaction  around  this 
point  is  usually  severe,  and  ulceration  results,  the 
sore  having  a  foul  appearance  with  irregular  edges. 
The  neighbouring  lymphatic  vessels  and  )flands  are 
generally  enlarged  and  inflamed.  The  skin  lesions 
appear  within  three  weeks  or  a  month  of  the  date  of 
inocuUtion,  aw  groups  of  red  spots  that  soon  develop 
into  papules.  These  develop  into  vesicles  or  bullte, 
which  run  together  and  form- pustules  that  jjive  rise 
to  widespread  ulceration  covered  with  foul  crusU 
or  with  black  gangrenous  shreds.  Subcutaneous 
infiltrations  form  and  break  down  into  large  ulcers. 
The  (enlargement  of  the  lymphatic  gland?  gives  rise  to 
nodules,  not  only  in  the  neighbourhood  of  the  site  of 
inoculation,  but  elsewhere  ("  farcy  buds  ").  Tbe«p 
oft«n  suppurate  and  break  down  into  ragged,  sloughy 
ulcers.  Nearly  the  whole  surface  of  the  skin  may  be 
covered  with  lesions  of  these  various  types.  The 
general  symptoms  of  glanders  vary  according  to  the 
aouteness  of  the  process.  They  begin  in  from  three 
or  four  days  to  as  many  weeks  of  the  date  of  inocula- 
tion, and  in  their  general  character  renemble  rheu- 
matic fever.  In  the  acute  and  subacute  cases  thi^ 
symptoms  rapidly  increase  in  intensity,  and  the 
patient  sinks  into  a  typhoid  condition,  in  which  he 
speedily  passes  away.  Death  also  occurs  from 
pyiemia  in  a  certain  proportion  ol  cases.  In  chronic 
glanders  severe  and  extensive  ulceration  mity  tnlce 
place.  (Pig.  36,  See  also  Besnier's  description, 
"  International  Atlas  of  Rare  Skin  Diseases,") 

The  etiologry  of  glanders  has  been  elucidated  by 
LoetRnt,  Oharrin,  and  others,  who  have  proved  t" 


ISL]  aiANDEBS.  5«3 

it  is  due  to  a  bacillua  somewhat  resembliTig  that  of 
tubercle.  The  aflection  is  almost  always  conveyed 
to  the  human  subject  from  the  horse  in  the  dis- 
charge from  the  nostrils  or  from  the  ulcers.     It  is 


therefore  found  almost  exclusively  ia  persons  whose 
occupation  brings  them  m«ch  in  contact  with  that 
animal.  It  has,  Siowever,  been  known  to  be  com- 
municated from  man  to  man,  and  the  lamented  death 
of  the  diatinguiahed  Russian  scientist  fi.e&niaQ.  ■qo'^ 


kKH    GENERAL  IXOCULABLE  DISEASES.     [oHip.  xxi. 


^^^■qpaiiy  years  ago  from  glanders  contracted  in  the 
^^^K-MUTse  of  certain  laboratory  experlmentB  may  be 
^^^■'tftken  as  an  example  of  its  direct  transmission  bv 
^^^E  tnoculatiou. 

^^^P        In  H  well-marked  case  the  diagnosis  can  be  made 

^^^^  Irom    the    clinical    phenomena   alone.     In    doubtfal 

cases  the  nature  of  the  disease  can  be  established  by 

the  reaction  which  takes  place  after  the  subcutaneous 

injection  of  mallein,  a  substance  discovered  by  Hell- 

»mau,  wliich  it  is  sufficient  to  describe  here  as  bearing 
the  savon  relation  to  the  virus  of  glanders  that  tuhei- 
CUlin  does  to  that  of  tuberculosis. 
In  the  acnter  forms  death  invariably  occurs  within 
I  a  few  weeks  ;    in  the  chronic  variety  recovery  takes 

place  in  about  50  per  cent. 

The  treatment  of  acute  glanders  ia  utterly  un- 
satisfactory, no  drug  appearing  to  have  any  ioflneooe 
on  the  course  of  the  disease.  Ctuonic  cases  muat  be 
treated  both  constitutionally  and  locally  on  general 
principles.  There  appears  to  be  reason  to  belicvf 
that  in  the  injection  of  malleiu  a  method  of  preven- 
tive inoculation  has  been  discovered,  but  bo  far  as  I 
am  aware  no  experiments  in  this  direction  have  rrt 
been  made  on  the  human  subject. 


—DISEASES    OF  THE 


CHAPTER    XXII. 

DISEASES    OF    tJKIN-GLASDS   AND    EPIDERMIC 
APPENDAGES   (HAIR   AND   NAILS). 

I.— Diseases  op  the  Skin-Glands. 

The  sebaceous  and  sudoriparous  glands  may  be 
disordered  in  th.eiE  functions  hy  excess,  diminution, 
or  alteration  in  the  character  of  their  natural  secre- 
tion ;  and  they  may  become  inflamed,  either  primarily 
or  secondarily  to  the  functional  disorder,  with  the 
result  that  structural  changes  are  often  brought 
about  in  the  integument  and  its  appendages. 

ft 

^W^SebOPrhcea  is  a  condition  of  ovor-activity  ci 
^tlie  sebaceous  glands,  leading  to  increase  and  altera- 
tion of  theii  secretion.  It  otcurs  in  two  principal 
forms :  (1)  a  dry  form,  in  which  the  solid  fatty  consti- 
tuents of  the  sebum  are  in  excess,  and  the  excreted 
material  appears  in  the  shape  of  dense  scaly  masses, 
generally  more  or  less  greasy  both  to  sight  and  touch 
[sehorrhcea  sicca) ;  (2)  an  oily  form,  in  which  the  fluid 
part  of  the  secretion  predominates,  the  discharge 
often  being  visible  aa  oily  drops  at  the  mouths  of  the 
ducts,  and  making  the  skin  look  and  feel  as  if  it  had 
been  anointed  with  oil  {seborrhcea  oleosa).  Both  these 
forma  are  most  common  on  the  scalp.  The  condition 
most  frequently  observed  is  a  slight  greasy  scurfiness, 
the  thickness  and  colour  of  which  vary  greatly, 
according  to  the  trouble  that  is  taken  to  keep  the 
parts  clean.  A  peculiar  salmon  tint,  which  is  fre- 
quently seen  in  seborrhosic  lesions,  ie,  ■^lo'oaWs.-^ ,  ■*»' 


^^K.  BOB      IJISKASES  OF  THE  SKI.V-GLANOS.  [ci 

^^^1  Buggeuted  by  fiiooke,  due  to  the  superposition  of  the 

^^^P  yellow  colour  of  the  greasy  secretion  and  niasBes  of 

^^^  cornified  epithelium  over  the  red  of  the  subjacent 

r  hyperemia.     On  the  heads  of  infants  aeborrhoea  may 

I  give    riae    to    large    dirty-yellowiBli    greasy    masses, 

I  generally  thickest  about  the  anterior  fontanelle ;  the 

^^^f  surface  underneath  these  accumulatioDS  is    usually 

^^^B  pale,  but  sometimes  it  is  iuflamed.     In  adults  such 

^^^K  concretions  are  rare,  but  desquamation  may  be  very 

^^^V  abunilant,    the    scales    being    sometimes    distinctly 

^^H  gteasy,  sometimes  dry  and  powdery.     The  conditioa 

^^^B  u  often  accompanied  by  more  or  less  Itching,  but  not 

^^^r  un[re<|uent1y  the  only  sign  that  reveals  Its  presence 

^^^  to  the  patient  is  the  shower  of  scales  (dandiutf) 
which  falls  from  his  head  when  he  brushes  his  hair, 
or  accumulates  on  the  collar  of  hia  coat  during  the 

^^^  day.     Dry  seborrhcea  is  generally  accompanied  by 

^^^L  loss  of  luiir,  which  loses  its  gloss  from  the  want  o{  ito 

^^^V  natural  lubricant,  and  withers  from  want  of  nourish- 

^^^P  ment.     The   eyebrows,  moustache,    and    beard     are 

^^^P  sometimes,  though  much  less  frequently  than    tha 

^^^B  scalp,  the  i^e^it  of  dry  seborrhipa. 

^^^V  On  the  face  the  oily  form  is  the  more  commoo. 

^^^r  Thfi  discharge  dries  and  gives  rise  to  yellowish  ot 

I  reddish-brown  cakes  of  greasy  scales  that  often  liavA 
a  hyiicrsBmic  base  and  a  fringe  of  papules  about  tha 

L  edge.     Ri'ddish  blotches  frequently  remain  for  a  con- 

^^^  slderahlo  time  after  the  seborrhceic  process  has  couia 

^^K  to  an  end.     The  afiection  shows  a  marked  prefereuca 

^^^^  foe  the  middle  third  of  the  face,  especially  the  aln  tut 

^^^T  the  nos'i  and  the  naao-labial  furrow,  and  it  is  often 

^^^  limited  to  that  region.     In  elderly  persona  the  con- 

r  dition   in   this   situation   sometimes,  appears   to   be 

1  connected    with    the    development    of    epithelioma 

^^^  (Jamiesou).     The  coraers  of  the  moutli  and  the  ears 

^^K  aie  also  frequent  seats  of  oily  seborrhcco.     The  iiy 

^^B  Jonn  ia  chiefly  seen  in  part^aa  iiom  the  tniddb  ■ 


1 


f  CHAP.  KXIL]  SEJtORRHCEA.  607 

line.  It  is  met  with  in  the  form  ot  small  scaly  patches 
that  are  sometimes  slightly  hypertemic. 

Both  forms  oi  seborrhrea  occur  on  the  trunk  and 
limbs.  The  lesions  have  the  same  general  characters 
as  those  on  the  lace.  On  the  genitals  and  perinaaum, 
and  in  the  genito-crural  fold,  seboirhtea  of  the  oily 
variety  is  common,  but  the  distinctive  characters  of 
the  lesions  ale  in  these  regions  often  lost  in  the 
secondary  erythematous  and  eczematoid  eondiiiona 
that  are  apt  to  become  developed  there.  On  the 
labia  the  irritation  of  the  rancid,  greasy  maseea  not 
unfrequently  gives  lise  to  ulceration,  which  mii;bt 
pos,iibl7  he  mistaken  ior  soft  chancre. 

Seborrhcea  almost  invariably  begins  on  the  scalp, 
and  in  the  large  majority  of  cases  it  is  confined  to  that 
part.  From  the  scalp  it  spreads-  downwards  to  the 
face,  the  body,  and  the  limbs;  and  it  may  be  taken 
as  a  rule,  to  which  the  exceptions  are  fewer  in  pro- 
portion to  the  care  used  in  investigation,  that  when 
seborrhoeic  lesions  are  found  on  any  part  of  the  body, 
clear  evidence  of  seborrhcea,  present  or  past,  will  be 
fomid  on  the  scalp  (Unna). 

Among  predisposing  causes  of  seborrlifea  are  all 
conditions  that  give  rise  to  constitutional  weakness, 
notably  syphilis  and  acute  fevers.  Jacques  *  main- 
tains that  the  starting-point  of  the  affection  is  always 
some  form  of  gastro- intestinal  disturbance,  constipa- 
tion being  that  most  fi'equently  met  with.  His 
theory  is  that,  the  chemical  processes  of  digestion 
being  disordered,  toxins  are  produced  which  affect 
the  sebaceous  glands,  either  through  the  medium  of 
the  sympathetic  or  during  their  ehmination  through 
the  skin.     I  agree  with  Brooke,f  however,  that  the 

•  "  De  I'Etut  B^bom'iquo  rio  la  [leau  et  de  bob  rappoits  qvoc 
les  dermatoseB,"  Parin,  189^. 

leful  and  enggeaCire  paper,  •'  Tlie  Bfltation  of  the 
a  oilier  Affeotjona  of  the  Skill," 
a-8S,  p.  25a. 


^^P  sot 


DISEASES  OF  THE  SKlN-OLANIi:^.  [ct 


N 
^ 


majority  of  persons  who  are  the  subjects  of  seborThtea 
are  in  robust  health.  Indeed,  the  afiection  ia 
common  that  if  constitutional  weakness  or  derange- 
ment were  a  necessary  condition  of  its  production, 
the  general  standard  of  health  in  civilised  countriea 
must  be  assumed  to  be  much  lower  than  medical 
experience  shows  it  to  be. 

That  the  severer  forms  of  the  disease  are  often. 
aasociated  with  some  disorder  of  the  health  provea 
nothing  more  than  that,  like  other  pathological  pro- 
cesseg,  it  ttourishes  beat  in  a  coi^enial  soil.  The 
determining  factor  in  the  production  of  seborrhoea  iSi 
probably  the  irritation  set  up  by  a  parasitic  ageut. 
jt  must  be  admitted  that  the  reasons  that  can  be  givea 
ioi  this  behcf  are  at  present  almost  wholly  of  an, 
a  priori  character,  but  they  are  nevertheless  ol 
considerable  weight.  It  is  difficult  to  explain  the 
occurrence  of  the  affection  in  persons  of  all  agee,. 
classes,  and  modes  of  life,  and  in  the  most  diverse 
oiicumstancea  of  health  and  skin  texture,  without 
postulating  an  external  cause  working  independently' 
of  such  conditions.  That  the  amplest  opportunitaeft 
for  invasion  by  micro-organisms  exist  has  been 
shown  by  Taenzer,  who  isolated  about  eigfa^ 
varieties  of  bacteria  and  fungi  from  the  scales  and 
secretion  of  eczema  seborrhceicum,*  The  fact,  estab- 
lished by  clinical  observation,  that  seborrhcea  almost 
always  spreads  downwards  from  the  head  is  prol>- 
ably  to  be  accounted  for  by  direct  infection  by  the 
patient's  fingers,  and  possibly  also  by  falling  scalei. 
It  is  not  unlikely  that  more  tlian  one  micro-orgamam 
may  take  a  part  in  the  production  ol  the  afiectioD,  or 
further  invasion  may  take  place  after  the  proceea  hut 
been  started.  This  would  help  to  explain  the  differ* 
ences  in  the  appearance  and  severity  of  the  disease. 

' MimaM,./.  piakl.  D^rm.,  ISSS.  Bi'   -"     Nc.  17.  \:  «1B. 


THAP.  sxir.]      SEBOHHlllHA  :    PATHOLOGY.  509 

Thepatholog'y  of  seborrhceaia  therefore  "  appar- 
pntly  a  dermatitis  caused  by  the  presence  ai  one  or 
possibly  several  micro -organiaina,  and  leading  to  a 
specific  irritation  of  the  fat-forming  functions  of  the 
skin  "  (Brooke).  Unna's  view  that  the  seat  of  the 
process  is  the  sudoriparous  and  not  the  sebaceous 
apparatus  has  not  found  general  acceptance  among 
dermatologists,  but  it  is  not  improbable  that  among 
the  processes  comprised  under  the  name  of  seborrhwa 
there  may  ba  some  in  which  the  sweat  glands  are 
[■.oncemed  as  well  as  the  sebaceous  glands.  Consis- 
tently with  the  opinion  just  referred  to,  TJnna  regards 
all  the  conditions  that  have  been  described  in  the 
present  chapter  not  as  seborrhcea  proper,  but  as 
aeborrhceio  eczema.  That  seborrhcea  prepares  the  soU 
for  other  diseases,  and  notably  for  eczema,  has  already 
been  stated,  and  it  may  be  admitted  that  it  is  often 
difficult  to  draw  the  line  accurately  between  the  two 
conditions,  so  as  to  be  able  to  say  just  where  seborrhcea 
ends  and  seborrhisic  eczema  begins.  But  to  call  every 
case  of  scurfiness  of  the  scalp  eczema  .  (which  is 
essentially  a  catarrhal  process)  seems  to  me  either  a 
pathological  misconception  or  an  abuse  of  terms. 
Sabouraud  has  recently  described  a  specific  micro- 
bacillus  which,  according  to  him,  occurs  both  in 
seborrhcea  oleosa  and  in  alopecia  areata,  ai)d  is  pre- 
sumably the  cause  of  both  diseases.  Experimental 
evidence  from  inoculatdon  is  still  wanting,  however, 
and  the  French  investigator's  results  still  await  con- 
firmation by  other  workers.* 

■  .Vcf  Sahouraud,  "Outlie  I'aitliolojrvorSi.>.<-n-riniii  niul  Ali>j>pcm, 
Areiitii,"  Ami.  de  Darin,  ride  Si/.u*.,  v.. I  ,i,,  '■-■'"  .  |.,.  j'.:i.  li!(i, 
1)77.  "Hil  t*"J-l.  and  vol.  riii.,  p.  2-J7  ;    I  /  "V".-, 

TOl.   «i.,  p.   1^4:   ceriews  by  Dr.  Li.-li         .  /..«vn. 

Ilmu.,    vol.    ii.,    p.    4M,    181)6);    an. I    ■- .' or. 

May,  IHa?);  alao  a.  discnsBion  on  aelinitli.. .  uni  i.i|..i,,..  i.t  the 
Soe.  FnuicaUe  (1b  Derm,  ot  de  Syph.  {.-J"",  '!<  I'm,,,  i'  il.-  fiijuli., 
ToL  Tiii.,  p.  611,  June,  IBST). 


TheH 
rkadV 

4 


SIO     DISEASES  OP  THE  SEl N-GLAflDS.     [ct 

The  diagnosis  of  typical  seborrhosa  of  the  oily^ 
iriety  can  hardly  ever  present  any  difficulty.  Ttut] 
characteristic  greasineas  of  the  lesionB,  the  marked  I 
preference  for  the  scalp,  the  frequent  limitataon  of 
the  eruption  thereto,  and  its  downward  spread,  nutke 
up  a  clinical  picture  that  is  readily  recognised  in  most 
cases.  The  dry  form  is  often  by  no  means  ta&y  to 
distinguish  from  psoriasis.  The  character  of  the 
Bcalea  diifere  considerably  in  well-marked  cases,  those 
of  psoriasis  being  bright  and  silvery,  while  those  of 
Beborrhcea  are  less  gliEtening,  softer,  and  greasier. 
This  alone,  however,  is  not  a  safe  guide.  In  such 
cases  the  starting-point  of  the  eruption  is  the  distinc- 
tive feature,  seborrhcea  beginning,  as  already  said,  on 
the  eoalp,  and  tending  to  spruad  downwards,  while 
psoriasis  almost  invariably  commences  on  the  elbows 
and  kneea,  and  spreads  upwards.  When  this  mark 
fails  us,  a  diagnosis  may  be  almost  impossible, 
is  important  to  bear  in  mind  thai'  both  aSections  may  I 

Treatment.  — Aa  seborrha?a  is  a  local  disease,  it  I 
can  be  cured  by  local  measures,  internal  medicatioB;  I 
being  necessary  only  when  the  general  health  is  1 
Bot  satisfactory.  The  scaly  masses  must  b«  I 
removed  by  washing  with  soap  and  wat«r,  and  I 
the  surface  underneath  soothed  with  emoUieat  1 
applications  if  inflamed.  Parasiticides  should  next  | 
be  applied,  the  strength  being  carefully  adapted  1 
to  the  tolerance  of  the  skin.  Of  these  1  trust  most  I 
to  sulphur  in  the  ordinary  run  of  cases.  This  may  f 
be  applied  as  a  lotion  composed  of  ^ss  to  3/  o/ 1 
precipkaied  sulphur  in  '^viij  of  diacilled  water.  Thia  I 
should  be  rubbed  gently  in  (after  being  thoroughly  I 
shaken)  with  a  little  brush,  care  being  taken  to  touoli  J 
the  hair  as  little  as  possible.  The  best  time  for  the  I 
application  is  at  bed-time,  on  account  of  the  smell  o(J 
the  sulphur  ;   in  severe  ■'  'liould  be  made  t   ' 


□KiP.  xxu.]      SEBQRRIKEA:     TREATMENT.  511 

a  day.  When  the  mixture  of  the  lotion  and  the 
products  of  secretion  have  formed  a  crnat,  thij"  should 
be  removed  and  the  aulpliur  reapplied.  The  sulphur 
may  also  be  apphed  in  the  form  of  a  powder  mixed 
with  oxide  of  zinc,  powdered  talc,  etc.  Brocq  speaks, 
well  of  the  following  combination  : — 

Salieylit  add gra.  xxs 

Powdered  hydcochlorate  of  pQooarpia  rtb    xv 

Powdered  Bulplmr         . .         . .         . .  jiij 

Borate  of  soda gts.  ixxv 

Starch,  powder  . .  .  .  . .  Tiiiss, 

Powderpd  talo    . .         . .         . .         -  -  Sj  iiis?. 


'I  he  amount  of  aulphur  may  be  increased  to  ^v,  that 
fi  borate  of  soda  to  Sijss,  the  powder  forming  the 
vehicle  being  proportionately  increased  ;  or  the  latter 
may  be  replaced  by  finely-powdered  calcined  maq- 
nesia,  oxide  of  zinc,  submlrate  of  bismuth,  and  talc. 
After  cleansing  the  head,  if  necessary,  a  layer  of  this 
powder  is  parefuUy  applied  to  the  scalp  (not  to  the 
hair)  every  night.  When  the  scalp  is  dry,  sulphur  is 
best  applied  in  the  form  of  an  ointment  or  pomade 
consisting  of  from  10  to  tiO  grains  of  precipitated 
sulphur  to  an  ounce  of  lanolin,  or  a  drachm  of  the 
sulphur  to  an  ounce  of  pure  vaseline  with  the  addition 
of  a  little  salicyhc  acid.  Precipitated  sulphur  in  cold 
cream  in  the  proportion  of  1  in  10  makes  a  good 
apphcation.  The  following  formula,  proposed  by 
Vidal,  is  useful:^ 

Preoipitftted  aulplmc 5jm 

Cocao  butter      . ,  . .  5<j^ 

Caator  oil  . .  . .  . .     5itba 

Balsam  of  Peru,  or  tincture  of  benzoio, 
to  scent  the  pomade , .         ..  ..     q.3. 

From  half  a  draekm  to  a  drachm,  of  tincture  of  can- 
thitTules  may  be  added  to  promote  the  growth  of  the 


ST    M"  ^^ 

.J  a  ^^ 


k 


612     DISEASES  OF  THE  SKIN-OLANDS.     [chap.  ssmM 

If  sulphur  irritates  the  akin  resorcin  is  on 
efficient  substitute.  It  oau  be  used  in  the  form  of 
an  ointment :  Ijt  ResoTcini  gr.  xv,  ung.  paraffini 
^y.      MBrcurial    applications     may     be     used    when 

.  sulphur  is  objected  to,  either  in  the  form  of  a.  lotion 
containing  5  to  25  grains  of  corrosive  svHimatu  in 
liij  to  3t7  of  alcohol  (90°  C),  mlh  disliUed  water  or 
rose-water  to  make  up  to  two  pints ;  or  of  a  poinad«, 
composed  of  y^ow  precipitate  7J  to  15  grains, 

■  vasdine  or  lanolin  ^v;  or  calomd  15  grains,  tanni 
.10  to  40  grains,  vasdin  or  lanolin  Tyvij.  Naphlhol  ^ 
is  often  of  great  service.  The  scalp  should  first  be 
thoroughly  cleansed  with  naphtholated  oil  (1  per 
cent.)  and  naphthoi  soap,  and  afterwards  washed  for 
a  week  with  an  alcoholic  solution  of  naphthoi  (1  to  2. 
per  cent.).  The  same  substance  may  be  used  in  tliej 
form  of  a  pomade,  in  the  strength  of  20  grains  ttt- 
the  ounce.  Jamiesou  uses  an  ointment  com^ 
of  tannic  acid  5/,  pure  glycerine  q.s.,  vasdine  5Ji 
unQnentum  aq.  rosm  '^).  The  use  of  this  should  bs'j 
combined  with  daily  wasliing  with  spiritus  saponi 
(Ukalinus  and  warm  water,  the  washing  becomiim;  h 
frequent  as  the  seborrhcea  improves.  When  only  on» 
washing  a  week  is  required,  the  spiritus  saposis 
alkahnuB  may  with  advantage  be  replaced  by 
infusion  of  quUlaya  hark  applied  hot.  The  restora- 
tion of  the  hair  may  be  promoted  by  the  meUiods 
for  the  treatment  of  baldness  which  are  describml 
farther  on. 

Seborrhoea  corporis.  —  Under  this  n&m« 
Duhring  and  others  have  described  what  they  coo- 
sider  to  be  a  special  form  of  seborrhoea.  The  eruption' 
is  most  frequently  seen  on  the  front  of  the  chest, 
the  sternum,  and  on  the  back  between  the  shoulder- 
blades.  The  lesions  appear  first  in  the  form  of 
red  papules  (hence  the  afiection  is  sometimes  called.; 
seborrhcea    papulosa),    which    speedily   coalesce    inM^; 


CHAF.  XXU.J  SEBORRHIHA  CORPORIS.  513 

patches.  These  clear  up  in  the  centre  while  con- 
tinuing to  spread  at  the  edge ;  eircinate  lesions  are 
thus  formed,  the  ring,  however,  being  seldom  com- 
plete. When  one  circle  meets  another  the  parts 
touching  each  other,  as  usual,  fade  away,  the  remain- 
ing segments  often  forming  wavy  lines.  The  lesions 
ate  slightly  raised,  covered  with  greasy  scales,  and 
usually  of  a  .pinldah-salmon  tint ;  if  the  scales  are 
rubbed  aS  an  actively  growing  patch,  the  underlying 
surface  is  seen  to  be  bright  red.  The  affection  some- 
times spreads  extensively  over  the  trunk  by  rapid 
advance  of  the  edge  of  already  existing  lesions,  and 
by  the  development  of  new  foci  among  them.  The 
only  symptom  is  slight  itching.  The  disease  is 
almost  invariably  associated  with  aeborrhtsa  of  the 
scalp,  and  the  lesions  are  sometimes  actually  con- 
tinuous with  those  on  the  head.  There  can  be  httle 
doubt  that  it  is  identical  with  seborrhrea  of  the  scalp, 
though  possibly,  as  suggested  by  Brooke,*  the  more 
highly  developed  type  of  lesions  may  be  the  result 
of  the  action  of  some  more  deeply  penetrating  and 
aggressive  micro-organism  than  is  present  in  the 
ordinary  forma  of  seborrhcea. 

There  has  been  a  great  deal  of  discussion  as  to 
T>lie  true  nature  of  the  affection,  which  has  been 
variously  regarded  as  a  form  of  lichen  (L.  circum- 
scriplus,  armtdaius,  gyraius,  etc.),  and  an  eczema  as 
well  as  a  seborrhcea.  Payne,  while  admitting  that 
the  starting-point  of  each  so-calied  papule  is  a  sebace- 
ous gland,  thinks  there  is  sometliing  more  than  over- 
secretion.  In  his  opinion,  the  bright  red  colour  of 
the  papules  and  margins  of  the  patches  indicates  not 
only  hypertemia  but  dilatation  and  elongation  of  tlie 
capillary  vessels.  My  own  view  is  that  the  process  is 
originally   a   seborrhosa,    the   hyperffimia    being  the 


1 


bU     DhSKAHES   OF   THE  SKIN-OLANDS.   [ct 

raaponse  to  irritatioa  caused  by  the  sweat  and  by  the 
friction  of  the  underclothing.  Aa  a  matter  of  fact, 
the  afiection  is  chiefly  seen  in  persons  who  perapire 
freely,  and  especially  in  those  who  wear  thick,  coarss 
underclothing  ;  hence  it  has  been  termed  "  flannel 
rash."  It  neglected,  it  passes  generally  into  eczema, 
and  in  many  cases  it  is  doubtless  a  seborrhceic  eczema 
from  the  firat. 

The  afiection  may  sometimes  be  mistaken  for 
tinea  versicolor,  but  the  absence  of  the  fuagus 
peculiar  to  the  latter  is  decisive. 

Treatment  should  be  on  the  same  general  linea 
as  that  of  seborrhceic  eczema.  The  underclothing 
must  be  of  unirritating  texture,  and  should  be  fre- 
quently changed.  A  simple  parasiticide  application, 
after  the  parts  have  been  thoroughly  cleansed,  will 
effect  a  cure. 

J.  F.  Payne,*  though  holding  that  no  internal 
treatment  is  necessary,  says  two  points  have  to  be 
borne  in  mind  :  Gastric  dyspepsia,  though  it  cannot 
produce  seborrhea,  may  aggravate  it  when  present, 
ohie9y  by  causing  cutaneous  irritation  and  scratching ; 
the  same  is  true  of  constipation.  Hence  it  is  well  I« 
oorrect  these  conditions.  Again,  the  general  nutri- 
tton  of  the  sldn  may  be  bad,  ami  it  may  be  advan- 
tageous to  give  a  short  course  of  arsenic. 

Hilium  ia  a  small,  white,  pearly  mass,  generally 
of  the  size  of  a  millet-seed  (hence  the  name),  situated 
just  under  the  epidermis,  chiefly  in  situations  where 
the  skin  is  thin  and  tbe.re  is  Uttle  or  no  subcutaneous 
fat.  Milia  are  seen  most  frequently  on  the  facp, 
especially  on  the  cheeks,  temples,  eyelids,  and  fore- 
head, Bometimoa  on  the  penis  and  scrotum,  and  on 
the  inner  surface  of  the  labia  minora.  Tbey  vary  in 
number,  and  are  generally  scattered  about  without 

liiitfi."Nvi.l'.inuf  W-ii^ie.-'  vol,  \-m.,  p.  ;ia. 


i 

■  early 


a.] 


ly  sign  of  grmiping,  except  occasionally,  when  they 
lassed  about  the  inner  cantlms.  In  the 
early  stage  of  their  development  they  are  sometimes 
translucent,  and  after  growing  to  a  certain  siae  they 
may  remain  stationary.  They  are  hard  and  freely 
movable  iu  the  skin.  On  the  eyelids  and  scrotum, 
however,    they    generally    run    together,     forming 


flat  1 


whic 


desetve  the  name  of  "cutaneous  calculi."  Crocker* 
describes  a  special  lorm  in  which  flat,  pale  yellow 
accumulations  are  seen  around  the  orifices  of  the 
glands,  especiaUy  on  the  forehead  and  face,  in  the 
form  of  tiny  discs,  with  a  minute,  slightly  depressed 
puncture  in  the  centre.  The  condition  suggests  a 
fatty  degeneration  of  the  epithelium  round  a  follicle 
— in  fact,  a  true  atheroma  of  the  skin. 

Milia  are  not  unfrequently  seen  in  children  at  the 
breast,  but  most  often  in  young  adults.  They  some- 
times follow  acute  forms  of  inflammation  of  the  skin, 
es  pemphigus  and  erysipelas ;  they  occasionally  form 
in  the  scars  left  by  the  lesions  of  syphilis  and  lupus. 

Miha  are  generaUy  considered  to  be  plugs  of 
sebaceous  material,  differing  from  comedones  in  being 
deeply  seated  in  the  acini  of  the  glands  and  in  having 
no  opening  towards  the  exterior.  Eobinaon,  how- 
ever, suggests  that  there  are  two  forms  :  one  con- 
sisting of  misplaced  embryonic  tissue  from  a  hair 
follicle  or  from  the  rete,  containing  no  fatty  epithelium 
and  having  no  opening ;  the  other,  a  deep-seated 
comedo  containing  fatty  epithehum  and  cholesterin. 
Milia  are  often  associated  with  acne. 

The  little  tumours  can  be  turned  out  through  a 
i^mall  incision,  A  little  iodine  or  strong  carbolic  may 
be  applied  to  the  sac  to  prevent  recurrence. 

Comedones  (Fig.3T)  are  smiall  massesof  sebaceous 
■  matter  plugging  the  ducts  of  sebaceous  glands.     They 

•  "  DieeMBH  of  the  Skin,"  seoond  edition,  p.  70-1. 


k 


516    DISEASES   OF    THE   SKlN-alAS'ns.   [ci 

are  most  coumon  in  adolescents,  but  are  sometim 
seen  in  children.     They  show  on  the  surface  ol  t 
skin  aa  pointed  papules  with  a  black  top.     The  blM 
colour  is  due  partly  to  cornification  of  the  epidennicpfl 
cells,  partly  to  dirt.     They  are  most  frequently  b 
oil  the  face,  especially  about  the  nose,  the  cheeks,  sad^ 
the  forehead,  and  on  the  back  and  phest.     Wliot 
numerous  they  produce  an  appearance  like  grains  c 
gunpowder  embedded  in  the  skin.     When  squM 
out  they  look  not  unhke  small  maggots.     A  parasitfl 
the  Demodex  or  Acarus  folliculorum,  can  Hometim 
be  found  in  comedones,  but  does  not  seem  to  hayi 
any  causal  relntion  therewith.     It  has,  however,  I 
suggested  that  comedones  may  sometimes  be  of  baclg 
rial  origin.     By  themselves  comedones  are  harmlei 
except  for  the  disfigurement  which  they  cause  ; 
persons  in  whom  they  are  numerous  are  generally  th^ 
subjects  of  oiiy  seborrhcea,  and  the  inflammataon  e 
the  plugs  very  frequently  gives  rise  to  acne. 

The  treatment  is  to  squeeze  them  out,  either  J 
with  the  finger-nails  or  with  a  special  instrujneut 
This  httle  operation  should  be  done  gently,  aa 
comedones  are  apt  to  become  inflamed  if  roughly 
handled.  Extrusion  of  tlie  plugs  should  be  fol- 
lowed by  washing  with  soft  aoap  and  hot  watotu 
and  vigorous  friction,  and  the  application  of  . 
paste  composed  of  kaolin  jw,  glt/cerine  ^iij, 
vinegar  51),  or  a  weak  sulphuT  or  resorcin  1 
merU.  Internal  treatment  directed  to  the  atimtt>J 
lation  of  the  hepatic,  digestive,  and  menstr 
functions,  according  to  indication,  is  often  of  servujvJ 

Grouped  comedones  have  Ijeen  described  bjrj 
Thin   and  others  which  appear  to  be  etiologicall;  ~ 
connected  with  dyspepsia  and  to  have  no  relation  t 
acne.     Their  favourite  situation  te  the  "  duBh  b 
of  the  face,  and  they  form  symmetrical  groups  i 
black    points    amaller    than    ordinary    oomedtn 


HYPBRWROSJS. 


imilar  leBions  have  been  aeen  on  the  trunk,  Ijut  with- 
groiiping.     These    comedoneB    have    little    ten- 
■dency  to  become  inflamed. 

2. — DISEASES   OF  THE   SWEAT-GLANDS. 

The  sweat-glands  may  be  the  seat  of  functional 
disorder,  the  secretion  being  increased  in  amount, 
suppressed,  or  altered  in  character  ;  or  they  may  be 
obstructed,  with  or  without  inflammation. 

HypeFidrosis  is  a  condition  in  which  the  secre- 
tion of  sweat  is  excessive  either  over  the  whole  skin 
or  in  some  particular  region.  With  the  so-called 
"  critical  Bweatiim"  of  certain  febrile  conditions  we 
have  nothing  to  do  here.  Universal  hyperidrosis 
may  occur  as  a  result  o!  excessive  heat,  as  in  the 
sudarium  of  a  Turkish  bath  :  or  of  unwonted  muscular 
exertion  in  a  person  "  out  of  training  "  ;  or  of  violent 
mental  emotion  of  a  depressing  kind  ("  cold  sweat  ")  ; 
or  as  a  form  of  rapid  tissue  waste  in  phthisis,  leprosy, 
or  other  wasting  diseases.  When  localised,  hyper- 
idrosis may  be  unilateral,  or  may  be  confined  to 
particular  regions,  such  as  the  palms  and  soles,  and 
especially  hot  covered  parts,  such  as  the  axillro  and 
genital  regions,  where  the  glands  are  larger.  In 
the  latter  situations  the  secretion  may  not  only  be 
excessive,  tut  may  have  an  offensive  smell  (brom- 
idrosis).  In  such  situations  intertrigo  and  eezematoid 
eruptions  are  often  induced  by  the  irritation  caused 
by  the  decomposed  secretion.  Occasionally  hyper- 
idrosis may  be  limited  to  the  area  of  distribution  of  a 
particular  nerve — e.y.  the  fifth.  The  symptom  may 
be  continuous,  or  it  may  be  excited  by  mental  emotion 
or  by  movement,  as  in  mastication,  etc.  When  the 
palina  and  soles  are  the  seat  of  affection,  it  is  often 
symmetrical,  and  may  be  so  severe  as  to  lead  to  a 
thickened,  sodden,  macerated  condition  of  the  alfiii, 
making  the   use  of  the  hand  or  foot  painful  and 


I 


61B    DISEASES    OF    THE   SKIN-QLA^DS.   [oe 

difficult.     Tn  some  cases  Jamieson  *  haa  noticed 
peculiar  delicate  pink  tint  of  tlie  inner  side  of  tl 
palm  and  the  ball  oi  the  little  finger  and  thumb.' 
HyperidroBis  may  be  peraiatent,  or  it  may  disappear 
with  the  tfimporary  disorder  of  health  on  which  it  is 
dependent. 

The  affection  is  probably  due  to  disordered  inDer- 
vation ;    it  is  Bometimes  congenital,  and  it  may  be 
hereditary.     Physiological  esperimentB  have  shown 
that  sweating  may  follow  paralysis  of  the  sympathetic 
and  stimulation  of  sensory  nerves.     Localised  sweal 
ing  is  also  sometimes  associated  with  central  nervoi 
disease,  or  with  injury  to  nervous  cords. 
occaBionally  of  hysterical  origin.     A  moist  palm  is 
characteristic  of  tipplers.     The  fluid  itself  presents 
abnormahty.     The  prognosis  depends  on  the  natni 
of  the  cause  producing  the  condition,  and  this  ofti 
cannot  be  recognised. 

The  treatment  must  be  directed  to  the  improve- 
ment of  the  general  health  by  tonics,  etc,      Hdta- 
donna  is  sometimes  useful :     it  may  be  given  in  tl 
form  of  full  doses  of  the  tincture,  or  ol  hypodi 
injections  of  atroj>ia,  y^  of  a  grain,  increated  up 
^.    Ergot   may  also  be  of  service.     Crocker 
well  of  sulphur,  a  level  teaspoonfnl  of  the  preoipitat 
sulphur  being  given  in  milk  twice  a  day.     Diurett 
as  suggested  by  Besnier,  may  be  useful  by  divertiiii 
the  excess  of  fluid  into  another  channel.      Locally 
inunction  of  bdladonna  oirUment  or  linimeni  is  oft 
beneiicial,  and  faradisation  may  do  good.     When 
soles  of  the  feet  are  thickened  and  tender  a  useful  pi 
is  to  powder  the  stockings  and  boof«  with  very  fii 
boric  acid  every  day,  the  boots  being  fitt«d  with  code 
socks,  which  should  be  washed  in  boric  acid  lotios 
daily   (Thin).     Excessive  sweating  in  the  axilla  or 
elsewhere  may  be  checked  for  a  time  by  preaaing   ^1 
•  -'DiBBBsesof  theSkio/'p,  T5. 


i 


[I.]  BROMIDROSIS.  619 

very  hot  aponge  to  the  part  for  a  few  minutes  ;  boric 
acid  powder  or  salicylic  acid  -powder  (3  per  ce7it.)  may 
tlien  be  dusted  on. 

Bromidrosis,  or  foul-amellmg  sweat,  sometimes 
odcura  in  general  conditiona,  such  as  rheumatic  fever, 
UTsemia,  ecurvy.  etc.  It  is  only,  however,  as  an  idio- 
pathic condition  that  it  concerns  us  here.  It  may 
or  may  not  be  associated  with  excessive  secretion. 
Though  oocflsionally  general,  it  is  most  commonly 
loealiaed,  the  parta  moat  frequently  affected  being  the 
feet,  where  the  decomposition  of  the  sweat  gives  rise 
to  a  rank  and  Bickening  stench.  The  soles  of  the  feet 
liecome  sodden  and  macerated,  and  so  tender  that 
walking  is  sometimes  impossible  ;  in  severe  oases 
inflammation  and  exfoliation  of  the  skin  often  occur. 
In  other  parts  of  the  body,  such  as  the  axillBS  and 
perinffium,  the  smell  is  less  rancid  and  more  fusty  in 
character. 

Bromidrosis  of  the  feet  is  usually  observed  in 
young  persons  whose  occupation  involves  a  great  deal 
i>f  standing,  especially  domestic  servants  and  soldiers. 
It  is  often  associated  with  flat-foot,  and  is  not  infre- 
quent in  those  who  wear  waterproof  coverings  for 
the  feet,  especially  when  this  is  combined  with 
deficient  cleanlinesa.  The  sweat  ha«  no  smell  when 
first  secreted,  and  the  fretor  is  probably  due  to  the 
presence  of  a  special  micro-organism— the  Bacterium 
fcetidum  (Thin). 

The  treatment  must  consist  in  the  most  scrupu- 
lous cleanhnesB,  the  feet  being  frequently  washed,  and 
the  stockings  being  changed  before  the  sweat  with 
which  they  are  soaked  lias  had  time  to  decompose. 
■./The  method  of  disinfection  with  boric  acid,  already 
Becribed,  should  also  be  employed.  The  plan 
idopted  in  the  German  army  of  rubbing  the  feet  with 
utton  suet  mixed  mth  2  per  cent,  of  salicyUc  acid  is 

y  useful  both  in  correcting  foBtor  and  in  ^ieift\AM>-^ 


daide 
bado^H 


I 


DISEASES   OF   THE  SKIN-GLANDS.  [obap 

derness.  The  occaBional  application  of  a 
10  per  cent,  solnlion  of  chromic  add  is  also 
beneficia]. 

Chromldrosis. — Under  certain  very  rare 
ditiona  the  sweat  and  the  sebaceouK  secretion  may 
ootoured,  the  tint  generally  being  some  shade  of  blu«, 
but  red,  green,  yellow,  violet,  and  even  black  sweat- 
_  has  been  observed.  The  phenomenon  is  generally 
localised  and  occuib  symmetrically.  A  favourite 
situation  is  the  eyeUds,  the  cheeks,  forehead,  and  aide 
of  the  nose  coming  nest  in  frequency.  In  rare 
the  whole  of  the  face,  the  cheat,  the  belly,  the 
of  the  hands  and  bends  of  the  limbs,  especially 
axiiltu  and  groins,  are  the  seat  of  the  alTection.  Tlifl 
amount  of  pigmentation  varies  at  different  times  in 
the  same  ease,  being  generally  worst  in  women  joat 
before  a  menstrual  period.  Constipation  or  some 
other  disorder  of  the  health  is  generuUy  associi 
with  the  condition.  In  the  large  majority  of  i 
the  patients  are  women — mosfiy  young  and 
married.  The  neurotic  temperament  is  a  ptedia] 
ing  cause,  the  determining  factor  of  the  attack 
seeming  to  be  mental  shock  or  emotion. 

The  disease  is  in  all  probability  primanly 
neurosis.  It  has  been  suggested  that  the  col< 
is  due  to  the  presence  of  indlcan,  which  beet 
oxidised  by  exposure  to  the  air  or  by 
into  indigo.  The  question,  however,  is  still  invob 
in  obscurity.  In  making  a  diagnosis  our  first  cbi« 
suuh  cases  must  be  to  exclude  fraud.  80  suggestiva 
imposture,  indeed,  is  the  whole  thing  that  some  har 
expressed  their  disbeUef  in  the  geuuineneBs  of 
phenomenon.  Renewal  of  the  pigmentation 
however,  sometimes  been  observed  in  (.'ircumataju 
that  appear  to  preclude  the  possibihty  ol  deceptJonJ 
The  prognosis  is  always  good  as  regards  the  ultimcf 
di.iappearance  of  the  coloration,  but  thi 


uttAP.  xKn.]  CHROMIDROSIH.  5-21 

may  persist  for  years.  Tieatineiit  nnist  be  directed 
to  the  improvement  of  the  general  health;  local 
medication  is  uaeleas. 

("oloured  sweating  has  also  been  observed  as  the 
result  of  the  ingestion  of  copper  (green  sweat)  or  iron 
(blue  sweat),  or  associated  with  the  presence  of 
certain  bacteria,  aa-in  the  red  sweat  not  unfrequently 
seen  in  the  axJll»  and  genital  regions,  and  sometimes 
in  yeUow  and  blue  sweat.  In  such  cases  of  red  sweat 
the  microbes  attach  themselves  to  the  hair-shaft  and 
worm  themselves  into  its  substance.  The  condition 
is  most  common  in  persons  who  are  in  a  weak  state  of 
health,  and  whose  hair  is  fair  or  reddish  in  hue.  The 
affection  is  not  strictly  a  form  ol  cliromidtosis,  the 
sweat  itself  not  being  coloured  at  the  time  of  its 
excretion,  but  acting  as  a  solvent  for  the  colouring 
matter  in  the  masses  attached  to  the  hair.  The 
fungus  has  been  cultivated  by  Kiieas.*  Examination 
of  pure  cultures  showed  the  cocci  frequently  arranged 
in  pairs  and  tetrads,  hke  the  Micrococcus  tetragonus. 

Bloody  sweat  may  also  occur  as  a  reault  of  the 
extravasation  of  blood  into  the  coils  and  dueta  of 
sweat  glands.  This  condition  may  in  very  rare  cases 
follow  great  mental  emotion  in  persons  of  excitable 
temperament,  or  it  may  be  a  form  of  vicarious 
menstruation.  It  is  sometimes  also  seen  in  new-born 
babes,  and  in  such  a  case  has  been  known  to  prove 
fatal.  It  is  usually  localised,  the  parts  afiected  lieing 
the  face,  the  hand.s,  the  feet,  the  navel,  etc.  Tieat- 
ment  can  only  be  directed  to  the  removal  of  the  cause, 
which  in  adults  is  almost  invariably  the  hysterical 
temperament. 

Phosphorescent  sweating  has  been  seen  in  certain 
rare  cases  after  eating  phosp  bores  cent  fish,  or  even  as 
QU  idiopathic  phenomenon.     A   caae  in   which    the 

•Hatt»ell,  '  "...  -l/irf,  S[«.j.  ;Pl.iluilBlphirt),  Jiily.lSy'A- 


622    DISEASES  OF  THE  .SKIX-OLANDS.  [okap.  : 

body-linen    became    liuninou-s    after    extraordint 
exertion    is    on    lecoid.*     Tlie    phosphoi 
believed  to  be  duo  to  bacilb. 

Uridrosis  is  du^  to  the  presence  of  urea  anj 
otlie.r  iirinary  constituents  in  the  sweat.  Urea  I 
normally  present  in  minute  quantities  in  tbat  b 
tion,   but  nnde/  certain   conditions,   as   in   chole 

emia,  etc.,  the  amount  may  be  bo  much  incrr 
that  the  skin  may  be  coated  with  white  crystals,  aafl 
it  were  covered  with  hoar-frost.     The  sweat  haa  f 
urinous  smell. 

AnidrosiS,  or  diminntion  of  the  sweat  Recreti 
may  be  associated  witb  certain  general  conditi 
Buch  as  diabetes,  fever,  etc.  ;  or  it  may  be  due  tdf 
congenital  anomaly  in  tbe  structure  of  the  skda,  asiI 
ichthvosia,  or  to  a  diseased  condition  of  the  skin,  tta^ 

psoriasis,  eczema,  or  sclerodcrmia ;  or  it  may  be  t    

result  of  disordered  innervation,  aa  in  anniistbetic 
leprosy,  or  of  malnutrition.  It  may  also  be  depen- 
dent on  a  purely  mechanical  cause,  such  as  obstructicn 
of  the  sweat  ducts  by  epithelial  debrix,  owing  i 
imperfect  washing.  The  secretion  may  be  men 
diminished  or  may  be  totally  suppressed,  aod  '' 
whole  skin  or  only  some  particular  area  may  | 
affected.  Anidrosis  .-arely  occurs  aa  an  iudependt 
affection.  The  only  symptom  besides  the  <"' 
able  dryness  of  the  skin  is  a  feeUng  of  falness  i 
tension  on  exposure  to  heat.  In  casefl  due  t«  t 
genital  anomaly  treatment  is  useless  ;  in  othor  c 
general  invigorating  treatment  and  stimulatjon  of  ti 
skin  by  massage  and  hot  baths  may  be  useful. 

Sudamina  or  miliaria  are  small  vesicle«.  loftlr-" 
ing  like  drops  of  dew  on  the  skin  (Jamieeon).     Thrv 
are  due  to  obstruction  of  the  sweat  duets,  with  or 
without  inflammation.     The  fluid  contained  in  the 
vesicles  is  simply  the  imprisoned  sweat,  which,  beinfl 

■  Carpeutar's  "  Fh;nalo|c,v,"  iwveutli  edition,  IMS,  p,  IOOl    ^| 


CHAP.  KKU.]  SUDAMmA.  G23 

prevented  from  issuing  by  the  natural  orifice,  is  effused 
under  the  homy  layer.  The  obstruction  is  (renerally 
caused  by  an  epithelial  plu^,  formpd  while  the  funo- 
tional  activity  of  the  sweat  gland  is  suspended,  as  in 
fevers.  Sometimes  sudamina  occur  on  a  dry  and  hot 
skin  where  perspiiation,  bo  far  from  being  excessive, 
has  been  deficient.  The  parts  chiefly  afiect*d  are 
the  chest  and  the  belly,  but  the  vesicles  may  form 
wherever  there  are  sweat  ducts  to  be  blocked  up. 
They  are  as  a  rule  set  close  together,  but  are  not  often 
conHnent.  They  undergo  no  change,  and  disappear 
completely  in  a  few  days.  Sometimes  they  come  out 
in  Buccessive  crops.  In  some  cases  an  inflammatory 
process,  which  may  be  primary  or  secondary  develops 
in  and  about  the  glands.  The  lesions  in  this  case  are 
bright  red  papules  (mUiaria  rubra)  the  size  of  a  pin's 
point,  which  are  sometimes  vesicular  or  pustular 
{mUiaria  alba)  on  the  top.  The  lesions  are  discrete, 
though  thickly  aggregated,  and  the  fluid  contained  in 
the  vesicles  is  serous,  being  the  result  of  inflammatory 
exudation.  The  vesicles  and  pustules  do  not  burst 
spontaneously,  but  dry  up  in  a  few  days,  forming 
small  scales,  which  soon  separate.  The  individual 
lesions  are  very  short-lived,  but  the  affection  may  be 
kept  up  for  some  time  by  successive  crops  of  eruption. 
More  or  leas  itching  is  generally  complained  of.  The 
appearance  of  the  lesions  is  so  characteristic  that  there 
can  hardly  ever  be  any  doubt  as  to  the  diagncsia. 
Miliaria  rubra  may  sometimes  resemble  the  vesicular 
stage  of  eczema,  but  there  is  no  formation  of  patches 
and  no  "  weeping  "  ;  the  affection,  moreover,  is  very 
transitory.  A  sweat  rash  in  a  chfld  may  suggest  the 
exanthem  of  an  acute  specific  fever,  but  the  abienee 
of  constitutional  disturbance  will  generally  prevent 
such  a  mistake.  It  is  important,  however,  to  re^ 
member  that  sudamina  may  be  associated  with  a 
scarlatinal  or  other  febrile  rash  ;    they  are  especially 


524     ntSEASES   OF    THE   HKfX-GLAXDS.  [ohap.  j 

common  in  typhoid.     lUJliaria  almost    always  yield 
readily  to  treatment,  but  relapae  is  common.     It  is 
only  wlien  tlie  retention  ot  the  secretion   is  com-  . 
plicated  by  inflammation  that  treatment  is  reqni 
Dusting  with    a  httle    protective   powder    and   1 
application  oi  a  coohng  ointment  are    all    that   iA 
necesHary. 

The  so-called  strophulus,  or  "  red  gum."  or 
"  lichen  infantum,"  is  a  iorm  of  miliaria  due  to  tot^ 
warm  clothing.     The  remedy  is  obvious. 

Miliaria  papulosa,  or  "prietly  heat,"  is  1 
form  oJ  miliaria  rubra,  sometimes  called  "  lichen  tio- 
picus"  on  account  of  the  papular  lesions  by  wliich  it 
is  oliaracterised.  The  special  pathological  feature  of 
prickly  iieat  is  that  the  inflammation  in  the  sweat 
gland  is  primary,  and  is  the  cause  of  the  obstruction 
of  the  duct.  The  lesions  are  tiny  acuminate  papules, 
bright  red  in  colour  and  thickly  clustered  togetbpr. 
but  not  confluent,  with  a  few  vesicles  and  pustulee 
scattered  about  between  them.  The  eruption  n 
preceded  by  profuse  sweating.  The  lesions  come 
out  suddenly,  and  give  rise  to  pricking  and  tinglini; 
of  extreme  intensity.  The  affection  shows  a  pre- 
ference for  covered  parts  (trunk,  limbs,  upper  jmrt 
of  forehead),  and  it  usually  extends  over  large  aiviu. 
Prickly  heat  is  moat  common  in  the  tropics,  but  it 
is  cot  unknown  in  England,  especially  in  persob* 
who  liave  had  it  before.  Fat  people,  and  those  who 
perspire  frealy,  are  most  liable  to  it,  and  the  itritatioil 
of  clotliing,  especially  flannel,  sometimes  appears  ta 
be  a  det«rmining  factor.  One  attack  predisposes  to 
another.  Prickly  heat  in  some  degree  resembtw 
papular  ecsema,  but  the  circumstances  of  its  oocn^ 
rence  and  it*  Huddnii  disappearance  will  eerve  lo 
distinguish  it. 

By  way  of  treatment,  saline  diuretics,  sucb  as  tfae 
acetate    and    nitrate    I'f    potash,    are    very    uaeluL 


CHAP,  xxii-l         DISEASES  OF  THE  HAIR.  525 

Locally  a  soothing  or  evaporating  lotion  or  a  uooling 
ointment  will  give  relief.  Alkaline  or  bran  baths  are 
also  beneficial.  The  diet  should  be  non- stimulating, 
and  alcohol  should  be  taken  only  in  the  greatrest 
moderation.  Any  cause  of  irritation  in  the  clothing 
should  be  removed.  Care  should  be  taken  to  prevent 
chill,  and  for  this  reaaon  woollen  underclothing 
should  be  worn. 

A  pecidiar  form  of  miliary  eruption  on  the  face 
has  been  described  by  G.  T.  Jackson,  Rosenthal,  and 
Crocker,*  under  the  name  of  "  dysidrosis "  of  the 
face.  The  lesions  consisted  of  small  vesicles  resemb- 
ling sudamioa,  but  grouped  so  as  to  form  patches, 
which  persisted  without  any  apparent  tendency  to 
spontaneous  recovery.  The  lesions  gave  rise  to 
itching,  but  there  was  no  sign  of  inflammation.  The 
condition  appeared  in  Croi:ker's  case  to  he  associated 
with  dyspepsia,  the  lesions  being  more  prominent 
after  meals. 

H.^DiaBiSES  OF  THE  Haie. 

Diseases  of  the  hair  depend  on  pathological 
changes  in  the  follicle.  These  consist  of  inflamma- 
tion in  and  around  the  hair  sac,  and  trophic  changes 
leading  on  the  one  hand  to  overgrowth  and  on  the 
other  to  deficiency  of  pigment,  atrophy,  and  total 
destruction  of  the  hair.  Concretions  ol  various  kindB 
may  also  form  on  the  hair-shaft.  Besides  these 
conditions  there  are  the  parasitic  diseases,  such  as 
ringworm,  tavus,  etc. 

The  inflammatory  processes  which  most  frequently 
attack  the  hair  follicle  have  already  been  described 
under  the  head  of  "  Sycosis,"  and  incidentally  with 
pityriasis  rubra  pilaris,  lichenj  and  other  conditions. 
A  special  form  of  chronic  folliculitis  of  the  scalp 

'  "DinEaBUs  ..f  tlifi  Skill,"  set.md  eilition.  Lonil^-ii,  !Sli:i, 
p.  6S7. 


F 


nlSKA.SES     OF    THE     HAIR. 


1 


(folliculitis  decalvans)  which  leads  to  cicatricial 
bnldnesa    has    lie  en    described    by    Quinquaud    and 
others.     The  affection  is  at  first  sight  somewhat  like  _ 
alopecia  areata,  but  at  the  edge  of  the  bare  patchei 
a  small  red  papule  or  patch  of  erythema  can  ' 
surrounding  each  individual  hair   follicle.     I   haV< 
had  two  well-marked  cases  under  my  care,  one  in  a 
young  woman,  the  other  in  a  man.     The  microscopj 
appearances    are    those    of   perifolliculitis,    and   pni 
cocci    are    present.     Quinquaud    also    found    othi 
micro- organisms   which   be   thinks  peculiar  to   thin 
condition.     The  process  is  extremely  chrome,   i 
treatment  has  little  effect.     The  indications  are  t 
check  the  spread  of  the  disease  and  promote  tlH 
growth  of  the  hair.     For  this  purpose  parnsiticideq 
followed  by  stimulant  applications,  should  be  trie<J 
Pringle  has  found  epilation  suoceaaful. 

Another  inflammatory  process,  affecting  the  scalp  " 
and  ending  in  atrophy  of  the  hair  foUicles,  is  described 
by  Kaposi  under  the  name  of  dermatitis  papillaris 
Capillitii.     It  commences  at  the  edge  of  the  scalp  on 
the  back  of  the  neck,  and  spreads  upwards  towards 
the  crown  of  the  head.     The  initial  lesions  aie  small 
papules,  which  soon  coalesce  into  Inrge  iaspberrv-lik« 
VHKBtations    in    the    occipital    region.     They    bleeds 
easily,  and  an  ofiensive  discharge  oozes  out  betweAril 
tliu  papillte,  while  absceiases  form  beneath  and  undto^l 
mine  them.     These  masses  are  composed  of  granulafl 
tion  tissue      After  a  time  they  shrink  and  becota^| 
converted  into  connective  tissue.     The  process  eausa^j 
lialdnoss  in  some  places  from  atrophy  of  the  hai^| 
ftilliolns,  while  in  others  a  kind  of  cheloid,  with  taft^l 
tif  hair  projecting  through  tlie  hypertiophied  ncifl 
tisHue,  is  produced  (actut  chetoid).    The  affection  ]fl 
known  ill  France  as  sycosis  fXii'Slonmtni^f-  and  /offM»B 
lilr  il'/iilante;  in  Germany  Hti  yackenkdoid  (Uuiatja 
Huil  in  V'ienna  as  syoosis  itnv  '        "'rmis  (NeumanD)i  1 


CHAP.  SSI!.]        OVERGROWTH     OF     HAIR.  527 

The  adjective  "  frambcesilorinia  "  indicates  the  raiap- 
berry-like  {frambiEsia)  growth  which  is  the  charac- 
teristic lesion  of  the  disease.* 

OvePffPOWth  of  hair  may  occui  either  as  an 
exaggeration  of  the  natural  growth  in  hairy  parts,  or 
as  an  abnormal  growth  in  hairless  regions,  as  on  the 
upper  lip  01  the  chin  in  women  ;  or  it  may  be  uni- 
verael.  Some  anomaly  of  dentition  is  often  assocjated 
with  general  hirsuties.  Dark-complexioned  persons 
are  more  liable  to  overgrowth  of  hair  than  fair 
persons.  The  condition  is  not  unfrequently  here- 
ditary ;  it  may  be  congenital,  or  may  become 
developed  at  any  period  of  life,  being  most  common 
in  women  at  and  after  the  chmacteric.  Hirsuties  is 
a  frequent  accompaniment  o!  insanity  in  women, 
:\nd  it  is  sometimes  associated  with  disorder  of  the 
menstrua!  function,  and  with  barrenness.  Some- 
times the  condition  follows  a  severe  illness.  Over- 
growth of  hail  may  also  be  the  result  of  local  irrita- 
tion, as  by  bliateriug  or  stimulating  applications. 
The  condition  is  as  a  rule  persistent,  unless  it  can  he 
got  rid  of  by  treatment.  It  is  only  in,  the  slighter 
cases,  however,  that  this  offers  any  chance  of  success. 

The  only  efiective  treatment  is  by  electrolysis, 
but  this  is  apphcable  only  in  a  very  small  propor- 
tion of  cases.  Electrolysis  should  be  used  only 
when  the  superfluous  hairs  are  thick,  dark  and  well 
defined ;  the  method  is  unsuitable  in  cases  whSre 
there  is  a  lafge  undergrowth  of  finer  hair  which 
cannot  be  dealt  with.  Bach  hair  bulb  should  be 
destroyed  separately  with  a  needle  connected  with 
the  negative  pole  of  a  galvanic  battery  passed  down 
to  the  bottom  of  the  follicle,  in  a  direction  parallel 

*  For  0.  careful  deacriptiaii  of  tliis  diaeuse.  nhich  is  verv  rare 
in  this  country,  with  a  full  bi 
tioii  of  a  m.fp!)Bny-liko  growth 
".  .%(*.,  Juiia,  1900  ;  aUtracI 


DlfiEASE.S    OF     THK    HAIR.         [chat,  kxii- 

to  the  hair-Bhaft.  The  circuit  is  completed  by  the 
patient's  Riasping  tte  positive  pole.  When  bubbles 
of  froth  are  seen  the  needle  ia  withdrawn  and  the 
hair- IB  extracted  with  forceps;  if  it  ia  not  per- 
fectly looae  the  needle  must  be  reintroduced.  Two 
r  three  dozen  hairs  may  tbus  be  destroyed  at  & 
Bitting.  The  operation  ia  not  very  painful,  and 
the  patient  is  usually  so  anxious  to  be  rid  of  the 
deformity  that  Bhe  will  bear  the  discomfort  without 
flinching.  The  operation  leaves  a  small  red  papule. 
which  in  time  gives  place  to  a  macule  so  small  as  l« 
be  invisible  except  on  close  inspection.  If  the 
procedure  is  followed  by  any  discomfort,  the  part 
should  be  bathed  vnth  warm  wat«r  and  a  sootliing 
lotion  applied.  The  operation  sometimes  requires  to 
be  repefited,  ia  coDsequence  either  of  the  folli<-ln 
Laving  been  imperfectly  destroyed  in  the  first 
instance,  or  of  the  fine  downy  hairs  becoming  coarser 
when  the  others  have  been  got  rid  of.  The  great 
source  of  failure  is  the  uncertainty  of  the  direction 
taken  by  the  hair  within  the  folUcle,  and  the  conse- 
quent djfliculty  of  reaching  the  bulb  with  the  elec- 
trode. To  meet  this  difficulty  Stem  •  suggests  that 
the  bair  should  first  be  pulled  out  with  forceps,  and 
the  needle  then  at  once  passed  into  the  follicle  while 
it  ia  still  wide  open.  The  method  undoubtedly 
requires  skill  on  the  part  of  the  operator  and  pfi- 
severance  on  that  of  the  patient,  but  when  properly 
used  it  gives  satisfactory  results  in  a  limited  number 
(il  caees.  The  X-raya  have  also  been  used  with  satisfac- 
tory results  ;  but  I  do  not  recommend  this  metliud 
on  account  of  the  risk  involved.f  When  the  growth 
ie  too  abundant  for  electrolysis  to  be  practiralJe, 

*  Thrrayful.m-I.,-  iloi.atihtjie,  August,  18P2. 
.  t  For  raocB   inlonualiou   on   this    piut   -™   rreiind,    •■  [>u 

gegenwirtige    Stiuid   dor   RadJiEniipluc,"   Spi»n,taWrnck   rnu 


CHAP,  XIII.]      TRICHORRHEXIS    NODOSA.  5-29 

shaving  ia  the  only  alternative.  Pulling  out  the  hair 
with  tweezers  only  makes  it  grow  moie  vigorously. 
Depilatories  hardly  ever  do  permanent  goofi,  and 
often  do  harm.  As  some  uterine  affection  or  other 
derangement  oE  the  health  is  generally  associated  with 
the  condition,  the  local  procedure  should,  when 
necessary,  be  complemented  by  appropriate  treat- 
ment of  the  visceral  disorder. 

Atrophic  changes  in  the  hair  may  be  the 

result  of  senile  decay,  or  of  some  constitutional  affec- 
tion, such  as  an  acute  fever,  phthiaia,  diabetes,  etc. 
They  may  also  occur,  independently  of  any  systemic 
cause,  as  the  result  of  local  processes.  The  hairs 
liecome  dry,  lose  their  natural  glossiness,  and  split 
or  break.  When  the  hair  is  long  it  often  splits  at 
the  end  :  in  some  cases  the  splitting  appears  tw 
take  place  from  the  root,  ho  that  at  first  sight  there 
would  appear  to  be  several  haira  emerging  from  one 
follicle.  Associated  with  this  condition  pustular 
folliculitis  is  sometimes  observed,  but  it  is  not  clear 
whether  this  is  a  cause  or  a  consequence  of  the 
affection  of  the  hair. 

Trichorrhexis  nodosa  is  a.  nodular  condition 
of  the  hair  which  was  first  described  by  Erasmus 
Wilson  and  afterwards  more  fully  by  Biegel.  It 
occurs  chiefly  in  men.  The  beard,  whiskera,  and 
moustache  ore  more  hable  to  attack  than  the  hair  of 
the  head,  but  the  hair  of  any  part  of  the  body  may 
be  affected.  Little  bead-like  swellings  of  a  whitish 
appearance,  hke  "  nits,"  are  seen  at  regular  intervals 
along  the  hair-shaft,  and  at  these  spots  the  cortex 
gives  way  under  the  shghteat  strain,  the  mediilla 
remaining  unbroken  (Fig.  -iS)  Between  the  nodes 
the  hair  is  normal.  The  condition  is  considered  by 
P.  Raymond  *  to  be  of  parasitic  origin,  the  cortex 

•  Jm,.  lit  Ikrm.  et  de  S./pi...  tome  ii.,  1891. 


r 


nl8EASES   OF    THE   HAIH. 


[Cf 


beiDg  eroded  by  a  diplocoecuB  somewhat  larger  tha) 
StaphylococcTiB  pyogenes.     Raymond    believes 

aSection  to  be  communicable,  i 
fact  wliitli  may  account  for  i 
apparent  hereditary  transnuBeio] 

The  trefitnient  consists  i 
strengthening  tLe  hair  by  f 
quent  shaving.  In  view  of  t 
poiisible  parasitic  origin  of  tlM 
affection,  epilation  of  the  dis- 
eased hairs,  followed  by  the 
application  of  an  antiseptic 
lotion,  would  appear  to  oSer 
the  be!at  chance  of  succeE 
The  general  health  must 
he     improved     by    appropriaM 


A  curious   condition  o! 
hair  (monilethrix  oi  1 
hair)    was    first    described 
Walter   Smith.*  of    Dublin,  i 
which    the    hair-shaft  all    alonf 
\U     length     presents      spindla 
shaped    enlargements    at   f 
vals,    connected  by  con&tiicte 
portions ;  the  latter  are  alil 
devoid  of   colour,  tlie 
seenaing    to    be  massed 
I  nodes.       The     hairs     break 
the    narrow    parts.      The    co 
dition  affects  the  hair  all    ov 
the  body.     It  generally  begins  soon  after  birth,  aud  1 
is  occaaiooallv  hereditiry ;  it  has  also  been  known  to 
come  on  after  nervons  shock  (Unna).     It  appears  Ii 
me  to  be  due  to  a  succession  of  atrophic  i ' 


-TriLhoiTheiis 


■,  J/rrf.  Jw< 


->.  201. 


CHAP,  xxn.]       ORBYNESS    OF     THE     HAIR.  531 

periodic  intervals,  the  apparently  swollen  parts  of 
the  hair  representing  the  normal  shaft,  and  the 
conattictiona  the  atrophied  portions.  Some  consider 
the  affection  to  be  of  tropbo- neurotic  origin.* 

GreyneSS  of  the  hair  is  generally  a  senile 
change,  but  may  occur  quite  early  in  life  aa  a  result 
of  disease,  nervous  shock,  or  long-contimied  nervous 
exhaustion.  It  is  sometimes  congenital,  and  occa- 
sionally hereditary.  There  ia  a  family  in  the  south 
of  France  both  the  male  and  female  members  of 
which  have  had  for  three  hundred  years  a  naturaT 
badge  in  the  shape  oJ  a  lock  of  white  hair,  generally 
situated  over  the  forehead.  The  hair  has  been 
known  to  become  grey  or  even  white  suddenly  under 
the  influence  of  terror  or  grief.  In  neurotic  subjects 
greynesB  may  be  tempoiary,  coming  on  with  an 
attack  of  neuralgia  and  disappearing  when  the  pain 
subsides.  The  hair  generaUy  remtlns  discoloured, 
but  occasionally  the  pigment  may  bt  restored  if  the 
cause  that  produced  the  greynaja  is  removed. 
Treatment  can  be  of  use  only  when  the  condition 
has  followed  some  exceptional  nervous  strain  in  a 
person  not  beyond  middle  age.  Even  then,  how- 
ever, the  prospect  of  a  cure  is  extremely  doubtful. 
Nerve-tonics  may  possibly  be  of  service,  and  jabo- 
randi  given  internally  in  the  form  of  tincture  (iTixv), 
or  hypodermic  ally  as  hydTocMorale  of  pUocarpin 
(gr.  f\,  to  -J-),  may  be  useful. 

Some  cases  are  on  record  of  the  natural  colour  of 
the  hair  changing  from  fair,  for  instance,  to  black, 
under  the  influence  of  pilocarpin  injections  used  for 
some  other  purpose.  The  hair  has  also  been  known 
to  change  colour  after  a  severe   illness.     Artificial 


171)  !  Pajtie,    T'ti'.   , 
ny,  Brii.  Jouni.  Harm., 


'  032  DISEASES   OF    THE    HAIB.  [chap.  rsiL 

discoioiation  may  be  produced  without  the  applica- 
tion ol  a  dye.  Workmen  who  have  to  lisiiidie  aniline 
dyes  have  often  deep  red-brown  hair ;  the  hair  ot 
copper-smeltera  often  turns  green,  that  of  worken 
in  cobalt  mines  blue,  etc. 

Alopecia,  oi  baldness,  is  usually  a  senile  cUauge. 
but  may  occur  quite  early  in  life,  or  may  be  congenital. 
It  is  comparatively  rate  in  women.  The  tendency 
to  baldness  is  often  hereditary.  It  is  a  freqaent 
symptom  of  secondary  sypiulis,  and  it  sometimes 
occurs  in  the  later  stages  of  that  disease  as  the  result 
r  of  ulcerative  processes.  Early  baldness  may  also  br 
\j,h  consequence  of  any  fever  or  othex  geneiTal  dise^we 
that  interferes  with  nutrition.  Apart  from  any 
such  cause,  however,  it  may  be  produced  by  a  com- 
plex set  of  factors,  such  as  (1)  the  shape  of  the  skull. 
the  sides  being  so  prominent  that  the  temporal  arteries 
are  easily  compressed  by  the  hat ;  (2)  venous  stagna- 
tion owing  to  the  same  cause ;  (.1)  profuse  perspira- 
tion with  decomposition  of  the  secretion,  anil 
afterwards  invasion  by  bacteria,  leading  to  rotting  ol 
the  hair ;  (i)  chronic  dry  sebiirrhcea  of  the  scalp. 
These  factors  may  be  combined  in  varyinR  degrw* 
.  The  great  cause  of  premature  baldness  is,  however, 
the  one  last  named,  its  effect  being  no  doubt  largely 
aided  by  the  wearing  of  hard  unventilated  hate. 
Sabouraud  *  has  described  a  micro- bacillus  of  uilr 
aeborrhcea,  which  he  considers  specific.  When  this 
parasite  finds  its  way  into  the  hair  fol]i<']e  it  is  said 
to  cause  first,  sebaceous  hypersecretion;  then,  hj-p«- 
trophy  of  the  sebaceous  glands ;    next,  prof^eosivo 

^^^     ^pillary  hypertrophy;    finally,  death  of  the  hair. 

^^L  The  mierobic  theory  of  baldness,  though  ftttractive. 

^^H  cannot  be  regarded  as  at  present  resting  on  a  solid 

^^B'       -  Ami.de  liirm,  rl  d«  "j/iih.,  t.  Tiii.,  N.>.  li,  InHT ;  OBlluwa;. 
^^H  Hbt.  IBBT.     Sn  alto  Sabouruad,  "  Seborcb^S  et  CulTitiN,"  Pute, 


t 


ALOPECIA. 


633 


basis  of  proof,  Parker  *  has  recently  propounded 
a  theory  that  alopecia  ifi  due  to  auto-intoxinatiou 
with  some  substance  derived  Irom  the  lungs  owing  to 
decomposition  of  organic  material  normally  present 
in  respired  air  when  this  air  is  retained  in  the  air 
vesicles.  The  apices  are  the  places  of  retention, 
owing  to  diaphragmatic  breatliing.  This,  he  thinks, 
explains  the  comparative  unfrequency  of  baldness  in  . 
women,  in  whom  breathing  h  normally  of  the 
"  costo-superior  "  type. 

The  treatment  of  confirmed  baldness  is  not  very 
satisfactory.  If  the  falling  out  of  the  hair  has  fol- 
lowed an  acute  illness  or  is  a  symptom  of  syphilis, 
the  hair  will  generally  grow  again  as  the  patient 
refovers  his  health.  Local  stimulation  will  often 
hasten  the  process.  In  elderly  people  no  treatment 
will  restore  hair  lost  through  natural  decay,  but  in 
younger  persons  the  development  of  commencing 
baldness  may  somelimes  be  checked  and  the  growth 
of  new  hair  promoted  by  local  treatment  directed  to 
the  prevention  of  dryness,  the  cure  of  seborrhcea.  and 
the  improvement  of  the  nutrition  of  the  hair-roots. 
For  the  former  purpose  the  application  of  fatty  or 
oily  matter,  and  especially  of  lanolin  diluted  with 
vaseline  and  teilh  some  weak  aniineptic  added,  is  very 
usefuJ.  For  seborrhcea  the  treatment  already  recom- 
mended for  that  condition  should  be  adopted.  The 
nutrition  of  the  hair-bulbs  may  be  improved  by 
stimulant  lotions  which  redden  the  scalp  and  bring 
a  larger  amount  of  blood  to  the  affected  parts. 
For  this  purpose  the  following  formula  is  of  upe  : — 

H     Borate  of  soda  3» 

Saliuylic  acid      . .         . .         . .         .  ■     5ij 

Tiiioture  of  oantharides  . .         . .     Jt] 

Buy  rum  3xsy 

Rose-water         . .         . .  . .         . .     ^ 

Boiling  water  enough  to  make  a  plot  luid  a  half. 
■  2fiiit  Yurk  Xed.  Steoril,  July  13,  1901. 


534 


hISSASES  Of   THE  HAlft.  [cbap.  J 


The  boraii  and  salicylic  acid,  should  first  be  diBSolvi 
in  the  boiling  water ;  the  bay  nun,  etc.,  should  th( 
be  udded  to  the  solution,  wh'cli  should  be  ttlleK 
before  use.     Hebra's  formula— 

B    Tr.  maciiiis         grma.   6 

01.  oUtig.  .  . .  . .  . .  . .  .t     on 

— may  sometimeri  be  useful.     1  have  soraetimes 
good  results  from  the  following  : — 

R     Chloral  hydrat.  . .  , .       ^i'j 


This  should  be  sharply  rubbed  in,  night  and  mon  ^ 
Besnier  recommends  the  application  of  equal  fxxrta  o 
acetic  acid  and  chloroform  ;  this  should  beused.witfe 
caution,  or  it  may  cause  irritation.  The  lollowinf;  u 
aieo  sometimes  of  service  : — 


R    Aoid.  BolicyL 

Siilpli.  pnccipit&t. 
Nuphtliol  S 
VaBelini   . . 


gre.  X 

3i 


As  restoration  of  the  hair  has  been  observed  to  folio 
the  admini  strati  on  of  thyroid  extract  and  feeding  wit 
thyroid  in  mvxtedema,  possibly  the  admiiuBtration  i 
that  substance  in  some  form  might  be  useful  i 
alope<^ia. 

Alopecia  areata  k  a  peculiar  form  of  baldna 
generally  occurring  in  patches,  which  may  gradually 
spread  over  a  considerable  area.  The  aSection  ia 
characterised  by  suddenness  of  onset,  and  in  aeven 
cases  by  the  rapidity  of  its  extension.  It  generally 
begins  on  the,  scalp,  and  if  often  limited  to  tliat 
region ;  it  may,  however,  be  universal,  the  hair 
fulling  out  all  over  the  body,  and  leaving  the  patient 
not  only  with  an  absolutely  bald  head,  but  without 
eyebrows,   eye-laslies,   whtokera,  beard,  moustach«, 


CHAP.  XKU.]  AWPECIA     AREATA.  535 

asillary  or  pubic  haira.     Tn  such  cases  the  nails  both 
of  the  fingers  and  toe.a  oftcE  fail  out  with  the  hair. 

The  usual  course  of  events  ia  aoniewhat  as 
follows : — One  or  more  small  patches  suddenly 
make  their  appearance  on  a  scalp  otherwise  perfectly 
healthy.  These  initial  patches  are  most  com* 
monly  situated  on  one  side  or  other  of  the  occiput, 
over  the  ridge  marking  the  point  of  insertion  of  the 
trapezius  muscle  ;  on  one  side  or  other  of  the  vertex  ; 
and  above  and  behind  the  ears.  In  the  early  stage 
the  skin  of  the  patch  is  aomewhat  red,  but  later  it 
acquires  the  whiteneas  and  amoothness  of  a  billiard 
hall.  Sensation  is  unaffected,  but  the  aldn  on  the 
patch  reacta  decidedly  less  to  stimulant  aubstances 
than  the  rest  of  the  scalp.  The  smooth  bald  patches 
are  sharply  defined  from  the  neighbouring  healthy 
parts,  but  the  hairs  at  the  edge  are  looser  than  norma!, 
and,  on  careful  search,  in  aome  cases  short  hairs  can 
be  found  that  show  distinct  signs  of  atrophy  close  to 
the  root,  giving  them  the  shape  of  a  point  of  exclama- 
tion (  !  ).  Sometimes  the  patches  are  small,  round, 
and  distinctly  depressed  below  the  level  of  the  sur- 
rounding skiiL  Generally  they  continue  spreading 
for  a  time,  and  may  coalesce  with  others,  forming 
denuded  areas  of  irregular  outhne.  When  the 
affection  has  lasted  aome  time  the  skin  of  the  patches 
is  thinned  and  adherent  to  the  underlying  tiasiiea,  so 
that  it  cannot  be  pinched  up  or  moved  upon  them. 
Restoration  of  the  hair  takes  place,  sooner  or  later, 
in  most  cases,  but  the  process  is  as  a  rule  a  long  one, 
and  several  auccessive  crops  of  downy  hair  may  grow 
and  wither  away  again  before  the  patJihes  are 
definitively  covered  over.  Even  after  complete 
restoration,  however,  relapse  is  not  uncommon.  In 
some  cases  the  baldness  is  permanent,  but  it  is  diffi- 
cult to  give  a  definite  prognosis  on  this  point,  as 
complete  restoration  of  the  hair  has  been  knowt\.  ^ 


DlH/iA.'iliS    OF    THE    HAIR. 


[VI 


take  place  after  ten  and,  ia  one  case,  sixteen  year8.*Jj| 
As   long  as   there  is  no  great  thinning  or    loss   < 
mobility  in  the  aSected  sldn,  there  is  a  fair  proepecU 
that  the  liair  will  be  restored  within  a  year. 

inces  of  early  recovery  diminish  in  proportia 
to  the  shrinkage  of  the  skin  and  the  age  of  tlu 
patient. 

The  etiolog'y  of   alopecia  areata  is  somewh) 
obscure.     There  are  two  theories  oa  to  ita  product! 
BOiae  eonsidcring  it  to  be  a  neurosis,  others  inclii 
to  the  belie!  that  it  is  due  to  micro-organisms. 
it  is  at  least  sonu^times  neurotic  in  origin  appears  t 
me  to  be  proved  by  its  not  unfrequent  occurrence  a 
an  immediate  sequel  of  mental  shock,  such  as  fright  j^ 
il   also  often  seems  to  be  directly  connected  witJ 
prolonged  mental  distress  or  worry.     I  have  know 
total  alopecia  occur  in  a  lady  within  forty-eight  hoin^ 
of  receiving  news  of  the  death  of  her  son.     Stepp 
has  recorded  a  catfe  in  which  complete  loss  of  the 
scalp  hairs  followed  thp  shock  n(  a  railway  ncctdent. 
It  is  generally  stated  to  be  more  common  in  the  n 
thttu  in  the  female  sex  :    Laasar  gives  the  proport 
as  seven  males  to  three  females ;    Crocker,  on  1 
ground  of  his  own  experience,  denies  that  there  is  a 
marked  difierence  between  the  sexes,  though  i 
the  figures  which  he  gives  show  a  preponderance  ( 
males.     It  is  most  common  in  young  persons,  i 
rare   after   forty.    The    largest   body   of   statistii 
collected  is  that  which  formed  the  basis  of  Noiu 
Walker's  introductory  remarks  at  the  Iatemati< 
Congress  of  Dermatology  held  in  Paris  in  lOOO.f 


*  UichelaDu,  quoted  by  Jamiesou,  ''DUeiuet>  (if   tha  S 
Kdinburgti.  18S8,  p.  106. 

1-  S™     the     TmnmBliBiin     of     the     Congren       (SwotUMt  a_ 
Dmualolcigy,   p.  3SS),  and  a  report  enibodyin^;  tlie  nnulta  u(9 

Beries  of  Invpafigations  on  nlop«.Tii  .■uKilii  liv   N'timii 

and  Marion  Hanhdl-RuFhwcil.  S-vl.  .Vnt.  '  .;.,l  S-. 


[I.]  ALOPECIA     AREATA.  MT 

statistical  examiuation  of  the  records  of  4,000  cases 
of  skill  diseases  at  tte  Edinburgh  Royal  Infirmary 
showed  that  alopecia  areata  formed,  roughly,  3  per 
cent,  of  the  whole ;  that  there  was  a  greater  suscep- 
tibiUtj-  in  males  than  in  females,  and  the  most  com- 
mon age  of  incidence  was  between  ten  and  twenty. 

Alopecia  areata  occasionally  follows  the  track  of 
a  particular  nerve,  such  as  the  supra-orbital,  in  its  dis- 
tribution, and  it  has  been  known  to  be  consecutive 
to  injury  to  the  sympathetic  nerve.  Leloir  ex- 
amined histologically  cutaneous  nerves  from  the 
afEected  surface,  and  in  one  case  they  presented  all 
the  signs  of  atrophic  neuritis.  Cases  illustrating  the 
marked  influence  of  nerve  lesions  in  producing 
alopecia  areata  have  been  published  by  Schutz.*  A 
fact  in  some  degree  confirmatory  of  the  neurotic  origin 
of  alopecia  areata  is  its  occasional  association  with 
leucodermia.  On  the  other  hand,  in  only  one  of  the 
i,000  cases  investigated  by  Norman  Walker  and 
Marion  Marshall-Rockwell  was  a  possible  nerve  in- 
fluence suggested,  and  these  writers  conclude  that 
the  nervous  element  in  this  disease  has  been  greatly 
over-rated. 

The  parasitic  theory  at  present  rests  more  on 
clinical  than  on  pathological  evidence.  Some  years 
ago  Kazanli  "f  reported  the  discovery  of  a  microbe 
which  he  beheved  to  be  specific,  and  micrococci  have 
been  found  by  Robinson  and  others  in  the  root-shoatha 
of  the  liair  around  tbe  affected  areas,  and  also  tn  the 
lymph-spaces  of  the  corium  and  subpapillary  layer  ; 
but  the  few  investigators  who  Lave  seen  these  micro- 
organisms are  not  agreed  as  to  their  characters  ;  and 
even  if  their  existence  be  admitted,  there  is  no  clear 
proof    of    their    causal    relation    to    the    process. 


S38  DISEASES   OF   THE   UAIH.         (.ohap.  sun. 

Sftbourauii,*  who  has  made  esteneive  researcliea  on 
the  subject,  conoludes  that  alopecia  areata  is  of 
microhic  origin,  the  folliclea  being  occupied  by 
ianumeTable  colonies  in  the  early  stage  of  the  disease  ; 
later,  when  the  area  patch  has  been  definitely  con- 
stituted, no  microbe  can  be  found.  He  holds  that 
seborrhcea  oleosa  and  alopwia  areata  are  essentially 
identical  processes,  Norman  Walker  and  Miss 
Marshall- Rockwell  foimd  that  affected  hairs  inoculated 
on  SabouTaud's  medium  produced  a  glistening  wlitte 
growth  due  to  the  Staphylococcus  epidemiidis  albtm 
(Welch).  Welch  himself,  however,  states  that  this 
organism  is  constantly  found  on  the  skin  even  after 
sterilisation  of  the  surface  with  antiseptics.  Only  in 
one  of  Norman  Walker's  cases  did  a  brick-red  growtli 
develop  such  as  is  produced  bv  SabouraudV  bacillns. 
In  two  of  his  cases  pieces  of  skin  were  excised,  and 
organisms  were  found  in  the  folliclea  and  slight  in- 
flammatory changes  in  tho  epidermis.  In  70  per 
cent,  of  the  cases  seborrhoja  was  present. 

There  ia  some  reason  to  believe  that  alopecia 
areata  may  in  certain  circumstances  be  trannmitted 
from  one  patient  to  another,  and  in  France  epidemics 
of  fdade  are  not  unfrequent  in  schools  and  in  regi- 
ments, the  medium  of  conveyance  in  the  latter  case 
being  thought  to  be  the  common  shears  by  which  the 
hair  ia  trimmed  to  the  regulation  length.  In  eighteen 
of  the  4,000  cases  investigated  by  Norman  Walker 
there  was  a  history  of  possible  contagion.  Decisive 
proof  of  contagion  is  still  wanting,  however ;  and  it  is 
certain  that  even  if  the  affection  be  contagious,  such 
a  combination  of  conditions  must  be  required  for  it 
to  take  place  that  transmipsion  is  altogether  excep- 
tional. 

A  condition  apparently  identical  with  alopM'in 


u.] 


ALOPECIA    AREATA. 


530 


areata  has  been  prcxluced  by  exposure  to  the  Riintgen 

There  appears  to  be  Bome  reason  to  believe  that 
the  frequency  cf  the  disease  is  incieasing,  at  leaat 
in  eome  places.  Laasar  •  finds  the  percentage  of 
alopecia  areata  to  be  I'i  of  all  cases  treated  by  him. 

The  trefltmeilt  should  be  directed  to  the  im- 
provement of  the  general  health,  if  there  be  any  need 
for  this,  by  tonics  (especially  iron),  by  aea-bathing,  and 
other  invigorating  measures,  such  as  manage  and 
electricity.  The  subcutaneous  injection  of  hydro- 
cMoTote  of  pilocarpin  (^,  of  a  grain)  has  proved  suc- 
cessful in  my  hands  in  a  limited  number  of  cases. 
Locally,  strong  stimulatioa  is  indicated  ;  for  this  pur- 
pose chryaarobin  5j  to  3J  0/  lard,  or  5m  to  5/  of  landin 
and  oil  should  be  rubbed  into  the  patches  night  and 
morning  with  proper  precaution.  The  moat  usually 
accepted  treatment  is  blistering,  for  which  purpose 
acetum  cantharidis  may  be  used ;  it  should  be  apphed 
to  the  patches  and  the  scalp  around  them.  The  same 
efiect  may  be  produced  by  croton  oil,  or  oH  of  mustard, 
in  the  following  formula  ; — 
OL  sinapia 


OLri 


M. 


51 


This  should  be  painted  on,  not  rubbed  in,  once  or 
twice  a  day.  Jamieson  speaks  highly  of  the  following 
formula  of  Erasmus  Wilson  :— 


640  DISEASES  OF   THE   HAIH.        [chap.  ixii. 

This  is  to  be  rubbed  gently  into  the  bald  part,  at 
first  once,  afterwards  twice  a  day  ;  in  the  later  stagee- 
faradiBin  is  sometimes  useful.  All  these  Tarioua 
remedies  act  in  the  some  way— that  ia  to  say,  by  iiH 
creasing  tl\e  flow  of  blood  to  the  part  and  thereby 
improving  the  nutrition  of  the  hair  follicles.  SaboU' 
raud  recommends  the  use  of  sulphur  in  a  vehicle  of 

e  fatty  substance  which  will  mix  readily  with  tho 
fats  of  the  skin. 

The  routine  treatment  adopted  by  LaBsai 
S  antiseptic  in  character.  The  head  is  washed  daily 
for  a  few  minutes  with  a  strong  tar  soap,  which  is  then 
sluiced  off,  ah«r  which  the  head  is  dried.  The  scalp 
is  then  treated  successively  with  2  -per  ceiU.  suUimatt 
tdution,  absoljUe  aloohol  with  the  addition  of  J  la 
1  per  cent,  naphthol,  and  finally  with  2  per  cent, 
talicylic  acid  in  oil.  By  this  treatment  he  afliniw 
that  in  all  fairly  recent  cases  the  disease  is  brought  to 
a  standstill  at  once. 

Bulkley  applies  strong  liquid  carbolic  acid 
once  every  two  weeks  to  the  affected  areas,  tba 
extent  of  surface  treated  at  one  time  not  exceed- 
ing two  square  inches.  The  method  is  punful, 
but  is  said  to  be  efficacious.  It  must  be  remembered 
that,  whatever  remedy  may  be  employed,  spontaaeoiu 
cure  often  takes  place,  especially  in  young  people,  so 
that  too  much  credit  must  not  be  giveu  to  drugs. 

Lassar  thinks  that  the  Finsen  light  method  baa  a 
great  future  before  It  in  the  treatment  of  alopeicia 
areata. 

Certain  concrdions  are  sometimes  seen  on  the 
hairs.  The  most  common  of  these  is  lepothrix* 
which  is  confined  to  the  hairs  of  the  asillee  and  tho 
scrotum.  To  the  naked  eye  the  hairs  are  duU  and 
lustreless,  with  ragged  borders  ;  they  are  so  brittle 
that  they  break  on  the  least  traction.  On  inicn»-  j 
BCOpic  examination  the  affected  hair  is  seen  to  b*  I 


CHAP.  Kxn.)  ALOPECIA     AREATA.  641 

BUiTounded  more  or  less  completely  with  irregular 
masses  of  coueretion,  ia  whicii  some  of  the  fibres  of 
the  cortex  are  embedded.  In  the  axilla  the  concre- 
tion is  often  red  in  colour,  owing  to  the  presence  of 
the  micrococcus  which  produces  red  sweat  in  that 
situation  ;  as  this  red  colour  is  not  seen  in  the  scrotal 
hairs,  the  association  in  the  axilUe  is  probably  acci- 
dental. Glasgow  Patteson  discovered  a  short  bacillus 
which  penetrates  iinder  the  cortical  scales  and  is  con- 
stantly present  in  lepothrix.  The  condition,  which 
ia  tolerably  common,  gives  rise  to  no  symptoms. 
The  application  of  parasiticide  agents  would  probably 
be  the  most  hopeful  line  of  treatment. 

Piedra  is  an  affection  seen  almost  exclusively 
among  the  natives,  especially  the  women,  in  the 
district  of  Cauca,  in  Colombia  (South  America).  It 
has  also  been  seen  in  Europe.  In  men  the  beard 
sometimes  suffers.  The  concretions  are  small,  black, 
gritty  particles,  which  cling  to  the  shaft  of  the  hair. 
They  are  so  hard  that  they  rattle  when  the  hair  is 
combed.  They  consist  of  closely  aggregated  pig- 
mented Bpore-hke  bodies,  due  to  a  fungus.  The 
afiected  hair  has  an  acid  smell,  and  the  condition  is 
believed  by  some  to  be  connected  with  the  use  of  a 
peculiar  oily  substance  for  lubricating  purposes.* 
The  treatment  should  evidently  be  antiparasitic. 

Tinea  nodosa  f  is  a  nodular  conoretion,  also 
consisting  of  fungus  spores,  sometimes  affecting  the 
hair  of  the  whiskers,  beard,  or  moustache.  It  weakens 
the  hair,  which  splits  and  breaks.     Clipping  the  hairs 

*  Arc  a  pjippr  1iv  tlie  .iiith.iv  in  f«th.  Truiix..  vul.  xxx.,  1S7!>, 
p.  411,  HQdJiiLel-li.'tioy  {.liwi.ili   /(-.m.  ci  ./r  A^//.A,,  tdI.  ii..  IBBS, 

byUiiiia  (Li-MiiiN  /..■/.-■■'I'nf.  li.-rliri.  ISBfil  anil  BebrBad.  See 
tlia  report  of  a.miti'oscrjpii'rjl  exjiiutujitioti  of  thflEe  L'fl^eaby  Traebeler 

t  This  ttllection 
the  anthoi  (Lancet, 


DISEASES   OF    THE    NAILS,  [oi 


—Diseases  of  the  Nails. 


a 

to 

The  nails  aie  often  involved  in  processes — EUch  u 
eczema,  peoiiasls,  lichen  ruber  planus,  favus,  Ting- 
worm — ^which  affect  the  integument  generally ;  the 
lesions  of  these  epidermic  appendages  in  such  cases 
have  been  described  with  the  diseases  in  question. 
The  nails  may  also  be  tlte  seat  of  trophic  changes 
which  may  be  due  to  senile  atrophy  or  to  acute  illness, 
or  may  occur  without  any  apparent  cause.  Some- 
times the  longitudinal  strlie  are  exaggerat«d  ;  some- 
times transverse  furrows  remain  as  records  of  a  fever 
or  other  severe  illness ;  sometimes  white  spoU 
become  developed,  owing  to  the  presence  of  air 
between  the  lamella.  Shedding  of  the  nails  mat* 
occur,  as  already  said,  as  a  part  of  the  process  of 
alopecia  areata,  or  in  association  with  diatietcs, 
syphilis,  locomotor  ataxy,  and  other  nervous  dis- 
orders. Pigmentary  and  degenerative  changes  mav 
also  occur  in  the  nails  as  the  result  of  occupation,  a« 
in  dyers,  washerwomen,  jewellers,  and  others. 

Apart  from  tliese  various  causes,  the  matrix  of 
the  nails  may  be  the  seat  of  pathological  processes 
similar  to  those  affecting  other  tissues.  Iiiflammft- 
tion  (onychia)  may  occur ;  this  may  be  idiopathic 
OI  may  follow  injury,  or  may  be  a  manifestation  <A 
syphilis  or  the  result  of  direct  tubercular  infection 
{oni/chia  maligna),  fn  the  latter  case  the  condition  is 
frequently  associated  with  scrofulous  lesions  in  the 
eyelid  and  elsewhere.  If  the  process  is  acute,  there 
is  great  pam  and  redness  ;  suppuration  takes  place 
beneath  the  nail,  which  is  discoloured  an<l  thickened, 
and  is  tinally  pushed  out  of  it«  bed  and  thrown  nS, 
leaving  an  unhealthy  sore.     This  may  heal,  or  the 


CHAP.  xxiL]  INGROWING     TOE-NAIL.  543 

inflammation  may  involve  the  lymphaticB,  and  give 
rise  to  paronychia  or  whitlow.  The  treatment  for 
onychia  is  to  remove  the  nail,  if  it  has  not  already 
been  thrown  ofi,  and  apply  antiseptic  dressings.  The 
general  health  may  also  require  attention. 

A  special  variety  of  paronychia  is  caused  hy  in- 
fiXOWing  toe-nail,  a  condition  that  generally  occurs 
as  the  result  of  pressure  by  tight  boots,  or  of  irritation 
by  the  edge  of  a  badly-cut  nail.  Ulceration  takes 
place  on  one  side  of  the  nail  (generally  that  of  the  big 
toe),  which  becomes  embedded  in  inflanunatory  tissue, 
so  tlm  walking  is  rendered  impossible.  The  treat- 
ment in  bad  cases  ia  to  divide  tlie  nail  with  scissors, 
and  remove  the  two  halves  separately.  As  this  opera- 
tion is  extremely  painful,  an  anassthetic  will  be  neces- 
sary. The  bare  surface  must  then  be  dressed  anti- 
septically.  In  less  severe  cases  the  granulations  may 
be  destroyed  with  acid  nitrate  of  mercury,  the  nail 
scraped  thin  in  the  middle,  and  trimmed  smooth,  so 
that  there  is  no  sharp  edge  to  irritate  the  tissues,  and 
an  antiseptic  dressing  applied. 

Hypertrophy  of  the  nails  (onychauxis)  some- 
times occurs,  the  whole  nail  becoming  thickened,  and 
the  free  end  growing  out  to  a  great  length  and  some- 
times becoming  twisted  like  a  ram's  horn  (onycho- 
gryphosis).  The  condition  is  more  common  on 
the  toes  than  on  the  fingers.  The  treatment  is 
removal  of  the  superfluous  part  after  soaking  in  hot 
water. 


CHAPTER     XXIII. 

NEW  GROWTHS. 

As  our  knowledge  of  the  etiology  o{  disease  tn 
so  will  the  group  of  new  growths  diminish,  and  a 
it  is  a  moot  question  whether  Home  of  the  eiipp< 
f  growths  may  not  be  of  parasitic  oripn.     ~ 
this  question  is  finally  settled  there  must  always  t 
group  of  affections  of  doubtful  causation  which,  f 
the  preaence  of  more  or  less  circumscribed  tumoun 
may  be  classed  as  new  growths.    The  term  miu 
however,  be  taken  strictly  in  its  anatomical  seiu 
and   not  as  meaning  sometliing  sui  generit. 
plasms  may  bo  provisionally  classilied  into  (1)  growtJi 
aSecting  connective  and  other  tissues  of  mesoblastdi 
origin,   and   (2)  growths  affecting  epithelial   C 
either  alone  or  in  addition  to  the  connective  tieBUM 
The  fonnOT  category  includes  :— 

1.  Cheloicl  and  fibroniB. 

2.  Lipoma. 

3.  NiuviiB  pigtiit>nt4>«iLs  (niolc). 

4.  NiEViiH  TftsDiilaris  (capillar) 

5.  Tel&ngiectaaia. 

6.  LTmpliangiomu. 

7.  Myoma. 

8.  Mycoais  fungoidps. 

9.  Sarcoma. 

The  latter  class  embraces  the  following  ;- 

.  Papilloma,  lacluding  n-artti.  hnriiB,  tuitl  cotiui. 


1        '' 

Adenoma. 

1 

MoUuaouro  pontiii 

1 

Darier's  disense. 

r      "■ 

Rodent  ulcer. 

Pagel'B  diac«»e. 

7. 

Cancer. 

LL] 


SEHACE0U3    GY8TS. 


L  scientific  classificatiou  of  new  growtiiB  ia  at 
Ij)re8ent  impossible,  it  has  been  thougiit  beat  here  to 
l^adopt  the  clinical  division  into  tumouTB  of  benign  and 
1  tumours  of  malignant  nature,  which  has  at  least  the 
I  advantage  of  being  practicaUy  convenient. 

I. — Benign  New  Growths. 
Under  this  head  are  placed  all  new  growths  which 
are  strictly  local  in  their  development,  and  though 
sometimes  attaining  great  dimensions,  remaiD  localised 
throughout  their  course,  and  which  when  completely 
removed  do  not  recui.     As  a  rule,  benign  tumours 
are  homologous  in  Btructure — that  is  to  say,  they  are 
overgrowths  of  tissues  normally  present  in  the  region 
from  which  they  spring.     Thus  the  group  embraces 
cystic  tumours,  arising  from  the  distension  of  pre- 
existing spaces  (sebaceous  and  atheromatous  cysts), 
and  local  overgrowth  of  gland  structure  (adenoma 
sebaceum),  of  connective  tissue  (cheloid  and  fibroma), 
of  muscular  tissue  (myoma),  of  nerve  (neuroma),  of 
blood-vessels    (telangiectasis,    nievus),    and    of    the 
lymphatic  system.     In  addition  to  these  are  certain 
growths  associated  with  degenerative  changes  in  the 
skin,  and  of  doubtful  pathological  nature,  though 
known  clinically  to  be  benign — such  as  colloid  milium 
of  the  skin,  xanthoma,  and  molluscum  contagiosum. 
Sebaceous  cysts  are  most  commonly    seen  on 
the  scalp,  the  face,  and  the  back,  but  they  may 
develop  in  any  part  of  the  aldn  supphed  with  sebace- 
ous glands.     They  occur  more  frequently  in  women 
than  in  men.     There  may  be  one  or  several  cysts. 
They  are  rouoded  in  shape,  often  somewhat  flattened 
on  the  top,  and  may  be  as  large  as  an  orange.    They 
grow  slowly,  and  cause  no  pain  unless  they  become 
inflamed.     To  the  touch  they  feel  like  lumps  of  dough. 
The  duct  may  be  patent,  so  that  some  of  tlie  contents 
can  be  pressed  out,  or  it  may  be  closed ;  the  latter  is 


] 


646  BENIGN    NEW    GROWTHS,     [chap,  xxot.] 

the  more  common  condition  when  they  are  situated 
on  the  scalp.  The  sldn  over  them  is  generally  hormal, 
though  somewhat  redder  than  the  aurrounding  porta. 
When  the  cysts  are  inflamed  the  akin  becomes  bright 
red  and  the  tiuaour  itseli  feels  softer  and  sometimes 
breaks  down  into  a  fungating  ulcer.  There  is  some 
doubt  as  to  the  pathology  of  these  growths.  Paget 
regarded  them  as  now  growths,  but  most  observers 
believe  them  to  be  retention  cysts,  the  accumulation 
of  epidermic  dAbris  and  sebaceous  matter  in  the 
follicle  causing  expansion  of  its  cavity,  with  secondary 
hypertrophy  of  their  walls.  Sebaceous  cysts  are  dia- 
tijiguisheil  from  fatty  tumours  by  the  absence  of 
lobulation,  and  the  fact  that  the  contents  can  be 
squeezed  out  when  there  is  an  opening.  They  should 
be  emptied  out  through  a  small  incision. 

Dermoid  cysts  occasionally  occur  on  the  slcin. 
They  are  often  very  numerous,  and  resemble  fibn>- 
mata,  but  on  cutting  into  them  a  sebaceous-looking 
material  escapes.  They  should  be  excised,  unleas 
their  number  makes  interference  undesirable. 

The  cystic  tumours  of  the  skin  caused  by  Cysti- 
cercua  cellulosff,  echinococcus,  etc.,  have  already  beea 
referred  to. 

Adenoma   sebaceum   occurs   chiefly  on  th« 

face.  The  lesions  are  small,  Arm,  whitish,  or  yellowish 
papules — -or  rather  tiny  solid  tumours — firmly  em- 
bedded in  the  skin  at  different  depths  or  projecting 
from  it,  and  varying  in  size  from  that  of  a  pin's  point 
to  that  of  a  pea.  Sometimes  they  are  red,  owing  \a 
dilatation  of  the  capillary  vessels  on  their  surface,  and 
intermingled  with  them  are  numerous  telangiectsaee. 
The  lesions  are  usually  symmetrical  in  disttibutioOr 
and  though  tlUckiy  crowded  together,  do  not 
together  to  form  patches.  The  tumours  present 
opening,  but  when  they  are  pricked,  inspiaeatcd 
Bebum  can  be  squeezed  out  of  them.     They  cause 


1 


ni.]         ADENOMA    SEBACEUM,  547 

i  rule,  though,  occasioiiaily  tliey 
are  painful  in  cold  weather.  The  condition  is  gener- 
ally congenital,  but  further  crops  of  lesions  appear 
after  birth,  especially  at  puberty.  They  undergo 
little  change,  though  some  of  the  lesions  may  under- 
go Bpontaneous  involution.  Rosacea  is  sometimes 
aasociated  with  the  condition.  Other  textural  defects 
in  the  skin — warts,  nievi,  keratosis  pilaris,  etc— often 
coexist  with  adenoma  sebaceum ;  and  the  patients  are 
generally  of  a  low  grade  of  mental  development,  often 
imbeciles  or  epileptics.  According  to  Pringle,  to 
whom  we  owe  an  excellent  account  of  ttuB  disease,* 
the  essential  lesions  consist  of  an  increase  in  number 
and  complexity  of  the  sebaceous  glands,  recalling  at 
first  sight  the  general  appearances  of  sections  of  the 
hypertrophic  masses  sometimes  seen  in  advanced 
rosacea.  The  condition  is  probably  due  to  excessive 
development  of  gland  structures  from  superHuous 
embryonic  remains  in  the  skin. 

The  appearance  of  the  httle  firm  tumours,  thickly 
groiiped  about  the  sides  of  the  nose,  intermingled  with 
telangiectases,  with  the  history  of  congenital  origin  and 
the  association  of  other  anomalous  conditions  of  the 
akin  and  mental  deficiency,  will  suffice  in  most  cases 
to  identify  the  disease. 

No  internal  medication  has  any  effect  on  the 
condition.  Pringle  found  that  attempts  to  scoop, 
gouge,  or  bore  out  the  little  tumours  with  instruments 
used  for  such  purposes  in  cases  of  lupus  were  painful 
and  unsatisfactory,  owing  to  the  depth  at  which  they 
were  situated  and  the  firmness  with  which  they  were 
embedded.  Superficial  scarification  was  also  un- 
successful. Electrolysis  has  been  used  by  Crocker 
with  success  in  a  case  in  which  the  nodules  were  not 


648  BENIGN    NEW    GROWTHS.       [chap,  xjoii;  ^ 

Choloid. — The  normal  procesa  of  healing  by 
Becond  intention  is  a  tiansformation  of  vaacult^ 
embryonie  (granulation)  tissue  into  fibrous  tissue. 
Sometimes  the  translormation  is  tardily  effected;  J 
the  granulations  continue  to  form,  and  are  cQiiveit«d  I 
into  imperfect  but  excessive  scar  tissue— hyper-  1 
trophied  cicatrix.  A  still  further  departure  from  the 
normal  results  in  the  formation  of  distinct  fibrous 
growths — scar  cheloid.  In  some  cases  growths  of 
fibrous  tissue  reserabhng  scar  cheloid  arise  without 
any  previous  wound  having  been  noticed  ;  these  casee 
have  been  classed  together  as  spontaneous  or  true 
cheloid.  A  remarkable  example  of  this  has  been 
recorded  by  Walter  Smith.*  The  apparently  spon- 
taneous cheloid  is  most  frequently  observed  on  th* 
trunk,  especially  over  the  sternum,  and  on  the  face  _ 
and  when  it  is  remembered  how  frequently  acne 
pustules  or  slight  injuries  and  the  resulting  scars  an 
overlooked  in  these  ports,  the  use  of  the  term  "  spon- 
taneous "  is  probably  unjustifiable.  Hence  the  t«rm 
"  cheloid  "  will  be  used  here  to  denote  all  forma.  The 
term  "  hypertrophied  cicatrix  "  should  be  confined  to 
cases  in  which  the  growth  does  not  extend  bt^yond 
the  limits  of  the  wound,  "  cheloid  "  being  used  to 
denote  the  condition  when  it  has  so  existed. 

The  primary  lesion  is  a  white  or  pinkish  swell- 
ing, wliich  may  project  above  the  level  of  the  skin 
or  may  he  within  the  corium.  Sometimes  dilated 
vessels  ore  viable  on  the  surface.  Tlie  shape  of  the 
swelling  difiere  according  to  its  oiigin.  Usually  tb' 
tends  to  assume  a  rounded  contour,  but  it  may  \m 
depressed  in  the  centre  and  it  may  extend  latrrally 
by  claw-like  processes — whence  the  name  "  chelcdd "" 
(from  xnKSi,  a  claw).  Occasionally  it  has  a  wartj". 
mpect,  constituting  the  verrucose  cicatricial  tumour 
or  warty  scar.    Cheloid  is  a  result  of  active  growth) 


I 


t  the  edge  and  by  no  mefins  always  con- 
imitig  itself  to  the  site  ol  the  scar,  but  extending 
beyond  it.  In  such  c^ses  it  is  possible  that  the 
process  may  be  infective. 

Whilst  cheloid  may  appear  over  any  part  oi  the 
body,  it  is  commonest  over  the  sternum  and  the  rest 
of  the  trunk,  and  on  the  face  and  head.  Most  exten- 
sive formation  of  cheloid  tumours  has  been  observed 
after  small-pox.  The  tumours  form  in  a  few  weeks, 
and  usually  continue  to  enlarge  for  a  long  time. 
Sometimes  they  undergo  involution.  In  a  case  oi 
Goodhart's,  large  cheloid  tumours  which  formed  all 
over  the  body  after  small-pox,  had  disappeared  at  the 
end  of  a  few  months.  Hutchinson  thinks  this 
tendency  to  involution  is  most  marked  in  young 
subjects.  As  a  ruie,  during  many  years  the  tumours 
either  remain  stationary  or  enlarge  very  slowly. 

The  tumours  are  usually  tender,  and  may  be  the 
seat  of  itching,  pain,  and  burning.  Sometimes  they 
give  rise  to  no  symptoms.  The  immediate  cause  of 
cheloid  is  unknown.  The  tumour  occurs  at  all  ages, 
but  chiefly  between  fifteen  and  fifty.  It  is  more 
conamon  in  negroes  than  in  whites. 

Virchow  explains  multiple  cheloid  as  the  result  of 
an  irritation,  the  degree  of  wfiich  ia  marked  by  the 
extent  of  the  leaons.  The  tumours  are  covered  by 
epidermis,  wliich  may  be  considerably  thinned,  so 
that  the  papillte  may  be  absent.  The  bulk  of  the' 
growth  consists  of  fibrous  tissue,  more  cellular  and 
vascular  than  normal  scai  tissue.  The  diagnosis 
presents  no  difficulty,  the  scar-like  appearance  and 
ciaw-like  processes  of  the  tumours  being  characteristic. 
Removal  or  destruction  of  cheloid  is  never  successful. 
Pressure  with  an  elastic  bandage,  massage,  and  deep 
gashing  of  the  tumour  in  difierent  directions,  so  as  to 
divide  as  many  vessels  as  possible,  give  good  results 
in    some    cases.      The    application    of    u-nguetUum 


^ 


BEKIOX    yEW    GROWTHS.      [qhap.  sxm. 

hifdrargyri  and  other  preparations  of  mercury  is  often 
followed  by  good  resulta.  Electrolysis  answers  well 
when  the  growth  is  small.  Even  in  the  case  of  growths 
of  moderate  size  I  have  seen  complete  cure  effected 
by  electrolysis  applied  once  a  week  for  some  time, 
followed  by  daily  massage.  When  cheloid  is  painful, 
cocaine  should  be  injected  in  and  around  the  tumour, 
or  belladonna  ox  opium  may  be  applied  locally. 

Fibroma. — Under  this  head  are  included  soft 
fibrous  growths  (fibroma  molloccum),  firm  tibromatA, 
neuio- fibromata,  and  diffuse  fibroma,  which  is  ona 
form  of  dermatolysis. 

Fibroma  moUuscum  is  a  pear-shaped  or 
rounded  fibrous  tumour,  covered  aa  a  rule  by  smootli 
skin,  and  varying  in  size  from  a  pin's  head  to  all 
orange.  This  tumour  is  not  uncommon,  and  is  almost 
always  multiple.  Usually  the  growths  are  peduncu- 
lated, but  sometimes  they  form  flat  masses  embedded 
in  the  corium.  Occasionally  they  occur  in  immense 
numbers,  and  then  the  sebaceous  glands  in  the  skin 
covering  them  may  be  dilated,  and  in  uncleanly 
persons  the  excessive  secretion  of  sebum  by  decompo- 
sition may  give  rise  to  oflensive  odours.  Wickham  * 
has  called  attention  to  the  association  of  brownish 
pigmentary  stains  and  violet- coloured  prominence! 
and  blotches  in  association  with  these  growths.  Thl^ 
are  commonest  on  the  trunk  (Fig.  39),  then  on  tlta 
head  and  face,  and  after  that  on  the  limbs  ;  they  «n, 
rare  on  the  palms  and  soles.  They  have  been  met 
with  on  the  tongue  and  buccal  mucous  membrane 
(Crocker).  The  tumours  tend  to  increase  in  size  and' 
number,  but  they  may  remain  stationary  for  yeaif^ 
Occasionally  they  slough  and  ulcerate.  They  csusB 
no  pain,  except  when  infiamed  owing  to  accidental 

The  growths  consist  chiefly  of  lax  fibrous  tisdutl 


i 


n 

<^    ^s^ 

( 

■ 

G.    10.— Vl>S    BECKLINOHAUaEN'.-t    DlSFABE    (DB.   WHITFIBL 
CASE,    li)01). 

J 

If 


;  I 


■ 

i 


I 


I 


i 


I 


CHAP,  ssin.]         FIBROMA     HOLLUSCUM.  5J1 

sparingly  supplied  with  blood-vesselfl  and  containing 
a  few  nervcH,  Nothing  in  known  as  to  the  etiology  of 
the  condition.  The  origin  of  the  growths  has  been 
variously  traced  to  the  corium  and  the  subcutaneous 
tissue  (Viichow).  They  may  appear  in  early  child- 
hood. They  are  distinguished  from  fatty  tumours 
by  the  fact  that  they  are  pedunculated  and  present 
no  trace  of  lobulation,  and  from  sebaceous  cysts  by 
their  aobd  structure. 

The  treatment  is  removal  by  hgature,  galvano- 
cautery,  or  the  knife,  special  precautions  being 
taken  against  haimorrhage,  which  may  be  formidable. 
They  may,  however,  be  so  numerous  as  to  render 
treatment  inadvisable. 

Dififuse  flbroma  ia  a  variety  of  fibroma  mollua- 
cum  in  which  the  tunaours  are  large  and  attached  by 
broad  bases.  As  they  are  usually  multiple,  they 
overlap  each  other,  forming  large  folds  of  loose  skin 
with  dilated  sebaceous  orifices.  The  condition  must 
be  distinguished  from  elastic  skin,  which  is  an 
anatomical  peculiarity. 

Von  Reckling-hausen's  disease  (Fig.  40).— A 

special  type  of  multiple  fibroma  of  the  skin,  described 
by  Von  ReckhnghaUBcn  and  known  by  his  name,  is 
characterised  by  coffee- coloured  pigmentation  on  and 
around  the  nodular  tumours,  which  are  irregularly 
distributed.  In  association  with  the  growtlis  there 
ia  perceptible  thickening  of  the  nerves  of  the  arms. 
The  distinctive  feature  of  fibroma  of  the  Von  Reck- 
linghausen type  ia  that  whereas  ordinary  fibroma  is 
composed  of  fibrous  tissue,  it  is  made  up  of  fibrous 
and  nervous  tissue.*  A  case  has  been  recorded  by 
Preble    and    Hektoen  f    in    which    multiple  neuro- 

•  For  au  exhauBtivo  study  of  tbi«  uHpeliuii  uv  work  by  Alexib 
ThcnnBOii,  Edinburgh. 

t  Amtr.  Jaimi.  Mfd.  Sei.,  Juuuarr,  I9(li  ;  ubatrBttcd  iu  Bril. 
Jmini.  Dtrm.,  ISOI.  p,  Ha. 


552  HEXiaN    NEW    OROWTBS.         [chap.  » 

fibromata  of  the  aldn  were  aBsociated  with  arthritU' 
deforniftus. 

Hard  fibromata  and  neuro  fibromata  yaxj 

size  from  a  pin's  head  to  very  large  dimensioiu. 
They  tiauiiUy  arise  in  the  corium,  but  may  start  in  the 
tend  on -sheaths  or  the  sheatha  ot  the  nerve  tihres. 
In  the  latter  case  they  a.19  called  neuro-fibromata; 

■&&  lie  as  a  rule  in  the  subcutaneous  taesne,  but  il 

e  oases  have  been  found  in  the  skin.  Seveni 
tumours  may  coalesce  into  a  single  lobulated  taaa 
(Schwimmer).  They  occur  on  the  trunk  and  at 
tremities,  and  are  usually  isolated.  N euro-fibroma tl 
are  usually  multiple,  and  are  movable  in  the 
cutaneous  tissue.  The  tumours  tend  to  enla 
slowly,  but  sometimes  calcificatioa  or  fatty  degent 
tion  takes  place.  Thus  blood-vessels  may  becomt 
dilated  into  blood  cysts ,  (telangiectatic  form).  Tha 
neuro- fibromata,  owing  to  the  nerve-fibres  stretched 
over  or  included  in  them,  are  often  extremely  seni^itivfl 
to  pressure.  The  other  forma  are  not  sensitive.  On 
section,  hard  fibromata  resemble  tendon  tissue. 

Nothing  is  known  as  to  the  etiology  <rf  theM 
growths.  Like  the  soft  fibromata,  they  may  becoma 
developed  very  early  in  life,  The  diagnosis  is  usualljr 
easy.  Neuro-fibromata  may  be  mistaken  for  rhen-* 
matic  nodules.  The  latter,  however,  occur  chiefly  IB 
the  region  of  the  elbows  and  about  the  scalp, 
there  is  a  history  of  rheumtttism. 

The  treatment  is  the  name  as  that  of  soft  fibri»r 
mata.  Neuro-fibroma  may  be  successfully  dealt  widi 
by  excising  a  portion  of  the  nervous  cords  Bupplyini 
tile  tumours. 

Myoma  cutis  occurs  either  as  a  superficial  growtk 
or  as  a  tumour  originating  from  the  suhcutancnuft 
musi'ular  structures.  Of  the  former  kind  Crocker  • 
collected  ten  cases  recorded  in  medical  literature,  and 

■  a,:l.  J-wi.  Ihr-a.,  Kubniary,  1897. 


KiG,  41.— MviiMA  Curm 


IL]  MYO-MA     CUTIS.  553 

added  one  of  his  own.  Later  Leslie  Roberts  * 
collected  five  further  cases,  aad  added  one  of  his  own. 
Another  case  was  pnbhahed  by  Marschalko.t  The 
author  has  recently  had  two  caseB  under  observation, 
the  patients  being  father  and  daughter.  The  former, 
aged  fifty-four,  a  nervona  subject,  was  troubled  with 
"  rlieumatic  "  pains  about  the  ankle-joints  at  the  age 
of  twenty,  when  the  tumours  were  first  noticed. 
These  are  situated  on  the  left  side  of  the  chest,  and 
the  man's  attention  was  first  called  to  them  by  pain 
described  as  being  "  Uke  the  cutting  of  a  knife,"  and 
greatly  aggravated  by  cold.  The  daughter,  who  had 
suffered  feom  neuralgia,  sufiers  from  similar  tumours 
in  various  parts  of  the  body.  They  began  as  hard  red 
pimples  on  the  leg  (Fig.  41), which  caused  "  cramp," 
aggravated  by  cold.  Similar  growths  appeared  later 
on  the  right  hypochondriac  region  and  on  the  arm  ;  as 
a  rule,  several  appear  at  once  and  at  some  distance 
from  each  other  ;  occasionally  they  coalesce.  They 
are  not  painful  for  four  or  five  years  after  their  first 
appearance,  but  aa  they  grow  larger  they  become 
tender,  and  are  the  seats  of  frequent  attacks  of 
neuralgic  pains. 

Superficial  myoma  generally  occurs  in  the  form  of 
nodular  tumours  on  the  arms,  back,  chest,  and  cheek. 
The  deeper  land  occurs  as  a  soUtary  tumour, 
cbiefly  on  the  breasts  and  genitals.  The  distinctive 
clinical  feature  of  myoma  cutis  is  that  it  con- 
tracts under  the  influence  of  cold.  It  grows 
slowly,  and  generally  causes  no  pain.  In  one  of  my 
cases,  however,  the  pain  caused  by  exposure  to  cold 
was  so  severe  that  the  patient  came  to  the  hospital 
to  have  the  growth  removed.  It  is  principally  made 
up  of  unstriped  muscular  fibre,  with  which  may  be 


I 


554  BENiay    NEW    GROWTHS.        [chat,  xmff 

mixed  a  greater  or  lesser  amount  ol  fibrous  tissue. 
constituting  flbro-myoma ;   or  the  structure  mav 
be  largely  erectile  {ang"io-inyoma);  or  tlie  Ij-mphatiw    , 
may  be  involved  (lymphangio-myoma). 

A  rare  class  of  muscuiai  tumours  has  been  deaif ,  I 
nated  by  Besnier  leiODiyoniata  (smooth 
tumours).  These  growths,  which  are  geDcralNj 
multiple,  are  soft,  elastic,  and  olten  painful.  ~ 
are  Bometiraea  sessile,  sometimes  pedunculat«d. 
do  not  as  a  rule  attain  a  very  large  size.  The 
is  the  commouest  site,  but  they  may  ocour  on  1 
scrotum,  the  nipple,  and  in  other  parts. 
develop  very  slowly,  and  often  start  in  an 
motic  spot.  The  skin  over  them  is  generally  red.  but 
may  be  natural  in  colour.  Sometimes  they  undergo 
involution,  but  as  a  rule  they  slowly  increase  in  siir 
and  also  in  number,  oft«n  coming  out  in  crope.  .K» 
they  develop  they  become  more  painful.  The  rliag- 
nosis  can  be  made  only  by  exclusion.* 

These  growths  may  arise  from  (1)  the  vgmcI 
walls,  (2)  the  arrectorca  pilorum,  (.3)  the  deep  layer 
of  unstriped  muscle  in  the  nipple.  ecTotum,  etc. 

The  only  treatment  for  myomata,  of  whateva 
kind,  is  to  remove  tliem  by  surreal  methods  when 
inconvenient  from  their  size  or  seriously  painful. 

Neuroma,  no  far  as  it  affecte  the  skin,  has  bpm 
(IcMcribcd  under  the  head  of  ueuro- fibroma. 

Myxoma,  when  it  arises  in  the  skin,  usually 
forma  rounded  pedunculated  translucent  tmuoura.  It 
is  commonest  in  the  loose  skin  of  the  scnttiim  and  thr 
labia,  but  it  may  ove\a  in  any  part.  The  grun-ths  uv 
usually  multiple.  They  tend  to  enlarge  slowly.  The 
gelatinous  appearance  of  the  tumour  ia  charact«risli>*. 
The  absence  of  a  central  depression  distinguishes  tben 


iltiplex  of  the  : 
■.b.,?.  I,  18 


CHAP,  xxni.]  TELANOIECTASIS.  556 

from  moUuscum  contagiosum.  They  are  made  up  oi 
lax  tissue,  cluefly  fibrous,  with  wide  interatices  filled 
with  mucilaginous  matter  containing  mucin.  The 
treatment  in  to  remove  the  growths  by  ordinary 
surgical  methods. 

MyxoBdema  may  be  regarded  as  diffuse  myxoma. 
The  condition  belongs  more  to  the  province  of  general 
medicine  than  to  that  of  dermatology. 

The  skin  may  be  the  seat  oi  a  variety  ol  condi- 
tions, congenital  and  acquired,  in  which  permanent 
dilatation  of  blood  -  vessels,  sometimes  with  formation 
of  new  vessels,  is  the  most  prominent  anatomical 
feature. 

Telang'iectasiS  is  an  acquired  condition  in  which 
the  capilkrieH  are  considerably  dilated  over  a  larger 
or  smaller  area  of  skin.  They  are  often  stellate  in 
shape,  a  number  of  vessels  radiating  from  a  raised 
central  dot  which  is  the  enlarged  loop  of  an  arteriole. 
These  lesions  are  generally  seen  in  persons  with  a 
delicate  skin  ;  occasionally  they  follow  injury,  and  in 
a  person  who  has  been  struck  by  lightning  the  vessels 
of  the  skin  can  sometimes  be  seen  clearly  marked  out 
as  if  they  had  been  injected.  Telangiectasis  also 
occurs  in  the  upper  part  of  the  body,  and  on  the  face 
and  neck,  particularly  in  elderly  people,  in  the  form 
of  small  spots  constituted  by  small  tufts  of  dilated 
capillaries.  Clinically,  telangiectasis  resembles  the 
slighter  forms  of  vascular  ruevus.  The  condition  is 
most  common  on  the  face,  especially  in  persons  much 
exposed  to  the  weather,  and  is  oft-ew  associated  with 
inflammatory  and  otlier  morbid  processes  (rosacea, 
adenoma  sebaceum,  etc,).  If  treatment  is  required, 
the  dilated  vessels  should  be  obliterated  by  elec- 
trolysis or  gal vuo -cautery. 

Nebvus  vascularis,  or  cutaneous  angioma,  is  a 
congenital    condition    characterised    by    the    over- 


550  BENWN    NEW    GROWTHS^.        [chap,  i 

development  of  tlie  vascular  tissue  in  the  ; 
Frequently  at  first  cutaneous  n£evi  resemble  6el 
bites  ;  by  the  formation  of  new  capillary  ■ 
they  cover  a  wider  area,  and  constitute  the  ' 
wine  mark."  If  they  remain  smaller,  with  dilata 
vessels  at  the  outer  pait,  the  spider-Uke  nievtu  i 
fonned.  With  or  without  a  growth  of  new  capillariw 
in  the  corium  there  may  be  a  new  formation  ol  veins 
in  the  subcutaneous  tissue,  thus  constituting  the 
capillary  venous  or  the  venous  nsevus,  soft,  com- 
presaible,  slightly  lobulated  tumours  of  greater  or 
less  extent,  and  either  bright  red  or  purple  in  colour 
according  as  the  corium  is  or  is  not  aSected.  Some- 
times II  venous  ntevus  contains  a  considerable  amount 
of  fat,  constituting  the  noevus  hpomatodea.  which  has 
the  combined  oharacters  of  a  venous  naevue  and  a 
lipoma. 

Capillary  nsevi  occur  most  frequently  on  the  face. 
head,  and  neck,  but  they  are  met  with  in  other  part». 
Venous  nievi  are  met  with  on  any  part  of  tlie  bodv, 
not  unfrequently  on  the  hps  and  tongue.  The  sago- 
grain  tongue  is  regarded  as  a  form  of  n«evus.  Nnivi 
may  be  fully  formed  at  birth  and  remain  stationary 
throughout  life.  Frequently,  however,  they  are 
small  at  birth  and  extend  slowly  for  some  years,  alt«- 
which  they  remain  stationary.  Very  many  nsevi 
which  are  preeent  at  birth  disappear  within  a  lew 
months.  Slight  injuries  to  venous  n«evi  frequently 
cause  hsemorrhage,  or  result  in  inflnmmatiun  wliirli 
may  lead  to  extensive  ulceration,  or  to  apontanrMiv 
cure  by  thrombosis  or  sloughing.  Cyst«  may  form 
from  obliteration  of  vessels. 

The  microscope  shows  the  growth  to  coneiet  almost 
entirely  of  blood-vessels-  In  the  case  ol  tlie  naevua 
lipomatosus  there  is  also  a  good  deal  of  nen -formed 
iat.  Of  the  causation  of  the  condition  nothing  if 
known.    The  newly-formed  vessels  arise  from  pn- 


OttiP.  xxm.]       S^VVS    PIGME'STOSDS.  557 

existing  vessels  in  the  corium  or  aubcutaneoue  tissue, 
la  very  slight  cases  there  is  always  a  chance  that  the 
condition  may  disappear  spontaneously  ;  compres- 
sion of  the  dilated  vessels,  aa  by  the  application  of 
collodion,  may  help  to  bring  this  about.  Very  large 
nrevi  are  best  left  alone.  In  ordinary  cases  various 
methods  have  been  found  successful.  Inflammation 
induced  in  the  nffivus  will  sometimea  effect  a  cure. 
Foe  this  purpose  vaccination  or  the  injection  of 
irritants  and  astringents,  such  as  tinctuTe  of  iodine, 
percMoride  of  iron,  or  tannin,  may  be  found  of 
service.  Electrolysis  has  also  given  good  results. 
The  needle  must  be  passed  entirely  through  the 
tumour  in  several  directions.  Multiple  puncture 
with  the  gal vano- cautery  has  also  proved  satisfactory 
in  some  cases.  Caustics,  such  as  fuming  nitric  add 
and  add  nitrate  of  mercury,  have  their  advocates. 
In  choosing  a  method  the  practitioner  must  be  guided 
by  the  size  and  structure  of  the  nrovus,  and  the 
nature  of  the  scar  that  is  likely  to  be  left.  For  large 
projecting  mevi  the  best  treatment  is  excision. 

Navua  pig-mentOSUS,  or  mole^  has  no  patho- 
logical or  clinical  relation  with  the  true  mevus  that  has 
just  been  described.  The  lesions  consist  of  pig- 
mentary macules,  or  shghtiy  raised  pigmented  patches, 
with  or  without  an  excessive  growth  of  hair.  In  the 
latter  case  the  condition  la  sometimes  termed  navus 
spitm.  The  pigmentation  may  be  slight  or  absent 
(white  moles  ;  Hutohinaon).  Sometimes  moles  are 
more  distinctly  raised,  and  contain  a  quantity  of  fat. 
Another  variety  conaista  of  pigmented  papillomata, 
which  may  have  a  wide  extent.  These  moles,  which 
are  not  hairy,  are  called  vermcose  mevi. 

Moles  are  commonest  on  the  face,  neck,  and  trunk, 
but  they  are  also  met  with  on  the  hmbs.  Usually 
small,  they  may  occupy  extensive  surfaces,  as  in 
Fig,  42,    They  are  often  single,  but  frequently  occur 


w 


660  BENIGN    NSW    GROWTHS.      [cHiP.  xsin. 

Though   all    of   them    Kufiered    from    chilMaius,    nu 

telangiectases   developed   on  the   parts   affected   by 

chilblains.     The  essential  feature  of  the  process  is 

telangiectases    resulting    from    repeated    tempoia 

dilatation  of  the  small  blood-vessels.     The  hyperkev 


tinisation  which  gives  the  hiUy- developed  Ivsioj 
their  warty  appearance  is  a  secondary  chw 
Angiokeratoma  can  hardly  be  mistaken  for  anyl* 
else.  The  lesions  show  no  tendency  to  spontaiiM 
involution,  and  fresh  ones  usually  come  into  existf 
every  winter. 


CHAP,  xxni.]        INFECTIVE   ANGIOMA.  B61 

The  best  treatment  is  electrolysis,  which  has 
been  successfully  used  by  Priugle.  A  fine  steel 
needle  connected  with  the  negative  pole  is  inserted 
into  the  telangiectaais,  the  positive  pole  being 
held  in  the  other  hand,  and  a,  current  of  two  to 
three  milli amperes  allowed  to  pass  for  thirty  Beconds. 
The  procedure  causes  some  pain,  but  Js  not  followed 
by  Bcarcing.  The  genera!  measures  for  the  improve- 
ment of  the  circulation  in  peiBona  subject  to  chil- 
blains are  also  indicated  * 

Infective  angioma.  —  Under  this  name 
Hutchinson  has  described  an  affection  characterised 
by  minute  red  points  "  hke  grains  of  cayenne  pepper  " 
embedded  in  the  sldn.  The  lesions  are  arranged  in 
groups  which  spread  out  peripherally  while  clearing 
up  in  the  centre,  thus  forming  rings.  Outside  these, 
fresh  points  or  "  infective  satellites  "  arise,  and  by  the 
meeting  of  adjacent  rings  large  areas  of  sldn  become 
affected,  the  lesions  having  the  gyrate  serpiginous 
outline  common  in  such  circumstances.  Moat  of 
the  little  points  can  be  obliterated  by  pressure,  but 
some,  larger  than  the  others,  cannot.  The  limbs  are 
generally  the  seat  of  the  affection,  which  has  also 
been  seen  on  the  face  and  trunk.  The  disease  spreads 
slowly,  with  intervals  of  remission.  It  begins  in  early 
life,  vascular  mevus  appearing  sometimes  to  be  a 
predisposing  factor  ;  indeed,  Jamieson  thinks  the  con- 
dition itself  is  simply  that  of  a  superficial  ntevus,  and 
in  this  view  I  agree  with  liim.  Hutchinson,  on  the  other 
hand,  looks  upon  it  as  a  kind  of  lupus  and  allied  to 
lymphangiectodes.  The  fact  of  the  development 
after  birth  and  the  serpiginous  character  of  the 
telangiectases  will  suffice  to  identify  the  affection. 

*  An  eicelleut  ucconnt  of  aJiKiokeratorna  (with  colaured  illuB- 
tnlioiiB),  embodj'inK  umrly  all  the  litomture  of  llie  subjwl,  was 
(riven  bv  PrinKle  in  the  Bril,  Jitiiru.  Derm.  forAugust.  Septfinher, 
and  Oi'tober,  19(11. 


HEXIOX    XEW    GHOWTUS. 


[CKAF.  T-Xfl^l 


The  only  treatment  that  aeems  likely  to  be  successful 
is  electrolysis. 

Lymphangioma  circumscriptum  cutis 
(Fig.  44}  is  an  affection  characterised  by  the  forma- 
tion of  vesicles  connected  with  the  lymphatica  in  cir- 
cumscribed areaa  of  the  skin.  Patches  of  greater 
or  leas  extent  are  formed,  covered  with  cluaters  of 
small  vesicles.  These  are  deep-seated  and  have  thick 
walls,  and  sometimes  have  a  superhcial  resemblance 
to  warts.  They  have  been  met  with  on  the  limbs, 
the  face,  the  neck,  and  the  shoulders.  They  are 
pale  or  straw-coloured,  sometimes  marked  with 
red  striee,  and  contain  clear  alkahne  fluid  in  which 
a  few  lymph  corpuscles  are  found.  The  condition 
is  very  chronic,  spreading  slowly  at  the  circum- 
ference, where  freah  vesicles  develop.  The  affec- 
tion is  probably  congenital,  but  is  generally  first 
noticed  in  early  cliildhood.  The  sexes  appear 
be  equally  liable  to  the  affection.  The  tB» 
features  of  the  condition  are  overgrowth 
dilatation  of  the  lymphatic  vcaels.  Some 
the  patches  are  partly  fibro-cavemoua  in  structure, 
and  the  occasional  astiociation  of  the  lesion.s  with 
venous  naevi  suggests  that  the  blood-vessels  are.  at 
least  in  some  cases,  concerned  in  the  process.  Bn 
and  Bernard  *  liold  that  the  disease  is  primarily 
of  the  lymphatics,  and  that  the  appearance  of  bli 
ia  due  either  to  the  rupture  of  capillaries 
the  lymphatic  dilatation,  in  which  case  the  fluid 
the  vesicle  is  pinkish,  or  to  the  rapture  of  capil 
into  the  floor  of  the  vesicles  but  not  into  the  ovil 
this  form  giving  rise  to  the  appearance  of  a  dark 
in  the  centaj  of  the  vesicle. 

In  one  recorded  case.f  that  of  a  bov  aged  nine, 
dilatation    of    the    lymphatics    occurred    after    two 
H.  dt  Derm,  tl  A  Sypi..  M&rch,  iUVS. 


brst 


t  Hoggnu,  J 


.■«.  ,/ J«« 


OHiP.  KSHL]  LYMPHANGIOMA. 

attacks  of  iuflammatory  cliaracter  in  two  a 
years.  The  dilated  vessels  filled  and  became  tense 
wliDQ  the  patient  stood  up,  and  coUapaed,  leaving 
only  indefiiute  traoea^  when  he  lay  down.  Micro- 
soopic  examination  showed  plexiiorm  dilatation  of 
lymphatics,  the  walls  of  which,  aa  well  as  the  sur- 
rounding tissues,  were  normal.  For  this  condition 
A.  G.  Francis  *  has  proposed  the  term  "  lymphoma 

Under  the  name  of  lymphangioma  tuberosum 
multiplex,  Kaposi  f  described  a  condition  met  with 
on  the  trunk  and  neck  of  a  woman  aged  thirty-two  ; 
it  had  been  noticed  during  childhood,  but  had  ex- 
tended in  the  few  years  previous  to  her  coming  under 
observation.  The  lesions  consisted  of  close- set 
vesicles,  the  size  of  lentils  and  smaller.  Microscopic 
examination  showed  small  lymphatic  dilatations 
throughout  the  corium,  Besnier  and  Doyon  consider 
that  such  cases  may  be  examples  of  cystic  adenomata 
developed  in  the  sweat  glands.  After  reviewing 
all  the  cases  reported,  Francis  concludes  that  they 
are  examples  of  lymphangioma,  and  suggests  the 
term    first    proposed    by    Torok,     "  lymphangioma 


Under  the  head  of  Aiemaio-^ywipSawyiomfi,  Francis 
has  classed  several  groups  of  cases  : — One  group 
contains  the  modification  of  ordinary  angiomata 
(nsei-i)  of  the  akin  and  mucous  membranes,  termed 
"  warty  degeneration,"  the  best  known  example  of 
which  is  the  "  sago  tongue,"  The  white  wart-like 
prominences  contain  cystic  spaces  filled  with  clear 

*  S'e  ' '  LyinpliBngioma  Circumicritituni  Cutis,"  Brit.  Joiira. 
Ih'riii.,  Feb.  and  Muicli,  1803,  where  a  compreliBnave  accouat  of 
the  wiiale  Hubject  ii  giron;  nieo  "  Fire  Cassi  of  LTmphoneioma," 
Lealie  Roberta,  Bril.  Jmini.  flmn.,  tdI.  viii.,  p.  308:  "Lymni- 
anniooii  Circunncriptuiu  a.  CystaideR  Cutis,"  M!ix  Freftdweirar, 
Areh./,  Deimat.  ii.  %/jA.,  Bd,  lU.,  H.  3,  p.  3-23. 
f  Kaposi,  op,  oit.,  vol.  II. 


684  BENiaN   NEW   OROWTBS.         [cihap.  ixifl 

fluid.  Most  observers  in  England  regard  them  as 
dilated  lympliaticB  ;  others^ — for  exftmple,  Eesnipr  and 
Doy on— consider  them  to  lie  the  result  rf  the  occiiiaion 
of  blood-vessels,  and  hold  that  the  condition  is  allind 
to  angiokeratoma. 

In  another  group  the  primary  condition  is  a  welt- 
marked  angioma,  upon  which  a  condition  of  Ivm^ 
angioma  afterwards  develops.  The  first  i 
described  by  Tillinry  and  Colcott  Fox,*  A  man  a 
twenty-one,  bom  in  Manritius  of  English  parenti. 
had  two  large  mevi  on  the  left  thigh,  which  tiail 
remained  unchanged.  At  the  age  oi  six  months  thp 
veins  of  the  left  calf  began  to  enlarge.  At  the  age  oC 
two  years  a  number  of  little  "  warty "  grow " 
appeared  on  the  sian  of  the  left  buttock,  the  Ata 
surface  of  the  left  knee,  and  the  left  half  of  (^ 
perinteal  region,  on  areas  quit*  distinct  from  tbop 
occupied  by  the  neevi.  At  the  same  time  he  bad  a 
attack  of  fever,  which  left  liim  very  prostrate  fur  six 
months.  On  each  occasion  the  skin  affection  liccame 
worse,  the  "  warts  "  enlarging  and  becoming  luui 
vesicular  in  appearance. 

-Another  group  of  eases,  included  under  the  s 
heading  by  Francis,  resemble  those  first  described  1 
Hutcliinson.  A  case  has  also  been  recorded  by  t" 
author.-f-  The  patient  was  a  delicate.  fair-cO], 
plexioned  little  girl,  aged  seven.  The  disease  mai 
its  first  appearance  when  she  was  a  few  montha  o' 
as  a  group  of  vesicl  s  in  (he  left  scapular  region  ; 
affection  spread  slowly  and  caused  but  littl«  im 

"here  were  no  attacks  of  hmphnnfiiri^ 


lymil 


I  welt- 

irent^H 
h  bail 

ha  the 
age  oC 


CHAT,  xxm.]  XANTHOMA.  5«5 

Tlie  only  treatment  of  these  conditious  is  de- 
struction hy  dectTolysis  or  removal.  In  either  case  the 
operation  must  be  thorough,  or  recurrence  is  almost 
certain  to  take  place. 

Xanthonia. — This  term  is  appUed  to  a  some- 
what rare  disease,  first  described  by  Addison  and 
Gull,  cliaracteriBed  l)y  the  formation  of  plates 
or  nodosites  of  a  yellow  or  yellowish -whit«  colour 
embedded  in  the  corium.  When  the  lesions  are 
in  the  form  of  plates  (xanlkoma  planum),  they  vary 
in  size  from  that  of  a  pin's  head  to  that  of  a  finger- 
nail ;  the  larger  plates  are  often  composed  of  a  group 
of  smaller  ones.  They  are  flat,  or  have  a  shghtly 
raised  margin ;  they  are  so  soft  as  often  to  be 
imperceptible  to  the  touch  when  the  finger  is  drawn 
over  them.  The  skin  covering  the  plates  presents 
the  normal  plication,  and  is  not  scaly. 

The  nodular  lesions  {xanthoma  tuberosum)  form 
papules,  which  are  sometimes  separate,  sometimes 
clusterod  together  or  arranged  in  lines.  The  papules 
vary  in  size  from  that  of  a  millet  seed  to  that  of  a 
pea,  or  larger.  The  smaller  lesions  are  generally  soft, 
wbile  the  larger  ones  are  firmer  and  more  prominent, 
standing  on  an  inflamed  base,  and  being  painful  on 
pressure.  Beanicr  has  applied  the  term  xanikSme 
en  tumeurs  to  the  condition  in  which  very  large 
lesions  are  formed.  The  distribution  and  course  of 
the  lesions  in  difierent  cases  difier  so  widely  that 
they  must  he  treated  of  separately. 

Xanthoma  planum  is  nearly  always  met 
with  in  tlip  form  of  plates,  very  rarely  of  nodides. 
OccasionaUy  cystic  spaces  form  within  the  lesions. 
Commencing,  as  a  rule,  in  the  upper  eyehd  near  the 
inner  canthus  on  one  side,  it  soon  makes  its  appear- 
ance on  the  other  side,  and,  after  extending  for  a  time, 
remains  stationary  for  the  rest  of  the  patient's  life. 
In  many  cases  the  lower  hds  are  affected  as  well  as 


BENIGN    NEW    GROWTHS.        [chap,  nxiii. 


^^H  the  upper,  find  sometimes  a  zone  of  xanthoma  is 
^^H  jormed,  looking  like  a  circle  of  wash-leather  let  into 
^^H  the  lids.  Xanthoma  planum  has  sko  been  met  witli 
^^H  on  the  ears,  the  nose,  the  mucous  meml>rane  of 
^^H  the  mouth,  the  tongue,  the  palate,  and  other  mucous 
^^^  membraneB.  The  alfection  usually  begins  after 
^^^  forty  ;  when  it  appears  in  childhood  it  ie  generally  a* 
I  part  of  a  xanthoma  multiplex.       The  affection  is 

commoner  in  women  than  in  men  (in  the  proportion 
^^^  of  about  three  to  one).  It  seems  sometimes  to  be 
^^K  hereditary,  and  it  has  been  observed  to  skip  a  genera- 
^^H  tion.  It  has  frequently  been  noticed  in  connection 
^^^r  with  migraine  and  jaundice.  The  diagnosis  can 
^^^  seldom  present  any  difficulty,  the  appearance  of  thi" 
yellow  patches  embedded  in  the  corium,  and  almost 
imperceptible  to  the  touch,  being  absolutely  distint-l- 
ive.  In  severe  cases  excision  is  the  only  treatment. 
Xanthoma  multiplex  is  generally  asaocisUi) 
with  jaimdice,  but.  especially  in  children,  it  may 
exist  independently  of  that  condition.  The  form  of 
multiple  xanthoma  occasionally  met  with  in  diabetes 
melhtus  presents  clinical  pecuharities  which  entitle  it 
to  separate  eonBldoration.  In  xanthoma  multiplex 
the  lesione  are  nearly  alwa^'s  of  the  nodular  form,  but 
the  plane  variety  is  occasionally  met  with.  The 
colour  varies  greatly  ;  a  mixture  of  blackish  pigment 
with  the  yellow  has  been  noticed.  A  case  has  been 
recorded  by  Kobner  in  which  the  lesions  developrd 
in  capillary  mevi  and  had  a  reddish  hue.  The  erup- 
tion has  been  found  associated  with  thickening  of 
tendons  (Hutchinson). 

Linear  grouping  of  lesions  is  often  obeervrd. 
especially  along  the  tines  of  tlexion.  No  part  of  the 
skin  is  exempt.  The  eruption  ia  usually  widespread, 
but  it  may  be  Hmited  to  one  part.  Although  it 
generally  starts  on  the  eyelids,  many  caem  uw 
recorded  in  which  these  were  spared.     The  conditioa 


CHAP.  xxiiL]  XANTHOMA.  567 

has  been  noted  in  the  moutL,  pharynx,  and  ceso- 
phagns,  the  respiratory  passage,  the  aorta,  the  bile- 
duct,  peritonenm,  etc.  The  handa  and  the  penis  are 
often  aJTected,  and  around  the  anus  and  in  the  gluteal 
folds  the  lesions  may  be  present  in  great  numbers, 
and  by  their  aggregation  constitute  small  tumours 
{xanthoma  tttberosum).  Most  cases  are  dependent 
on  hepatic  disease  and  are  associated  with  jaundice, 
but  in  a  considerable  number  there  appears  to  be  no 
such  connection.  Some  cases  are  congenital,  others 
begin  within  the  first  few  years  of  hfe.  In  some  of 
these  early  cases  an  hereditary  disposition  seems  to 
have  existed.  The  disease  usually  progresses  for  a 
time,  and  then  remains  stationary  for  the  rest  of  life. 
Spontaneous  involution  has  been  known  to  occur,  but 
this  is  rare.  The  distinctive  feature  of  the  lesions 
is  that  they  are  embedded  in  the  corium.  Some 
cases  of  multiple  dermoid  tumours  of  the  skin  have 
been  found  indistinguishable  from  xanthoma  multi- 
ples until  microscopic  examination  was  made.  The 
condition  has  also  been  confounded  witli  urticaria 
pigmentosa.  The  latter  affection  is  characterised  by  ■ 
itcliing  and  wheals,  and  can  usually  be  seen  at  some 
stage  in  the  disease,  and  the  skin  is  in  an  urticarial 
state,  so  that  factitious  lesions  can  be  induced. 

The  usual  treatment  is  excision.  Recently 
Mr.  Willmott  Evans  has  suggested  the  use  of  the 
X-rays. 

Xanthoma  of  Balzer.— Tliis  extremely  tare 
affection  is  characterised  by  hypertrophy  and 
deformity  of  the  elastic  tissue  in  limited  areas  of 
the  skin.  The  lesions  have  a  general  similarity  to 
those  of  ordinary  xanthoma.  They  consist  of 
slightly -raised  lenticular  pinkish-yellow  areas,  soft  to 
the  touch,  and  having  no  inSammatory  zone  around 
them.  In  the  only  case  of  this  affection  that  has 
come  under  my  notice  the  patient  was  a  young  lady. 


BENIGN     NEW    GROWTHS. 


[CI 


aged  twenty-one.     The  lesions  wexe  situated  « 
left  aide  of  the  lower  part  of  the  neck,  and  the  should) 
of  the  same  Bide.     They  had  appeared  about  puberty^] 
and  very  slowly  increased  in  size  and  numbers-      ~ 
mi  Close  opic    examination    by    Jackson    Clarke     tlMi4 
elastic  fibres  were  found   greatly  thickened,    fibril-" 
lated,  and  knobbed.    There  was  neither  inflammatoiy   ' 
exudation  nor  fatty  cells.     In  Baker's  case  a  slight 
inflammatory  infiltration   was   present.     The    diag- 
nosis can  be  made  with  certainty  only  by  the  aid  oI_ 

!  microscope.     No  treatment  has  yet  been  fouiu 
successful. 

Xanthoma    diabeticorum.  ~  The    spe^cia 

ieatutea  of  this  variety  consist  in  its  swift  evoIatiM 
its  swift  and  complete  involutioD,  and  its  associatiqd 
with  diabetes  mellitus.  The  author  drew  attendeo 
to  these  peculiarities  in  1S83,*  in  connection  with  thi 
fourth  case  then  on  record.  Since  that  time  severi 
other  cases  have  been  brought  forward,  and  the  affec 
tion  is  now  everywhere  recognised,  though  it  ii 
tremely  rare.  The  lesions  are  distinguished  from  thoi 
of  other  forms  of  xanthoma  by  th^resence  of  »  r  ' 
red  area  around  the  yellow  spots.  This  ffve«  \ 
eruption  the  superficial  aspect  of  common  acne, 
which  it  haa  been  mistaken,  until  the  lesions  1 
been  punctured  and  proved  to  be  sohd.  The  ff 
appeal  first  on  the  extensor  surfaces  of  the  limbt 
next  on  the  lower  part  of  the  back  and  abdomen.  « 
the  buttocks,  and  on  the  penis.  They  have  also  bno 
met  with  on  the  palms  in  several  cases.  In  only  o 
case  did  they  affect  the  eyefid.  They  generally  d 
appear  in  a  few  weeks,  involution  sometimes  bei 
preceded  by  increased  itclung  in  the  patches 
crops  may,  however,  continue  to  come  out  for  g 
time.     The  affection  is  commonest  in  young  ad 


rHAP.xxni.]       HISTOWOy  OF  XANTHOMA.  069 

especially"  in  those  inclined  to  obesity.  It  is  always 
associated  with  glycosuria,  though  when  the  patient 
first  seeks  advice  no  sugar  may  be  lound  in  the  urine. 
Of  tlie  manner  in  which  the  diabetes  produces  the 
akin  lesions  nothing  is  at  present  known.  In  its  early 
stage  xanthoma  diabeticoruna  may  for  a  few  days 
simulate  lichen  or  acne,  but  when  the  lesions  arc 
fully  developed  their  xanthomatous  character  be- 
comes evident. 

In  contrast  with  other  forms  of  xanthoma,  the 
prognoBie  in  this  is  good,  so  far  as  the  skin  eruption  is 
concerned.  Its  significance  must  not,  however,  be 
forgotten  as  an  index  of  a  grave  constitutional  state. 

The  eruption  tends  to  subside  under  the  influence 
of  antJglycoBuric  treatment. 

HistOlog'y  of  Xanthoma.— The  morbid  ana- 
tomy of  all  forma  of  xanthoma,  with  the  exception  of 
xanthoma  etasticum  of  Balzer,  already  described,  is 
essentially  the  same.  It  will  be  convenient  to 
describe  it  under  one  heading.  The  process  consists 
in  the  accumulation  of  large,  often  multinuclear  cells, 
of  connective- tissue  type,  filled  with  fat  drops.  In 
addition  to  this  there  is  a  formation  of  new  and  a 
destruction  of  pre-existing  fibrous  tissue.  The  view 
of  Chambard  is  that  now  generally  received  :  namely, 
that  the  affection  is  essentially  of  inflammatory 
nature,  and  that  the  xanthoma  cells  (wliich  are 
practically  the  same  as  the  cells  met  with  in  atheroma 
of  arteries)  are  developed  partly  from  leucocytes, 
partly  from  connective -tissue  corpuscles.  Krzyszta- 
lowicz,*  from  a  histological  study  of  a  case,  specially 
insists  on  the  hypertrophied  connective- tissue  cells 
with  which  the  collagen  and  the  fat  lying  in  and 
between  them  build  up  the  papule.  The  so-called 
xanthoma   cells    are,    he    says,    merely   the    greatly 


670  BENlOy    NEW    OROWTUS.         ((tbap.  mill- 

enlarged  ordinary  connective -tissuB  celb  filled  witL 
fat.  My  own  obsetvationB,  made  in  conjunction  with 
6.  C.  Henderson  and  Jackson  Clarke,  on  xanthoma 
diabeticorum,  point  distinctly  to  the  process  bein^ 
of  inflammatory  nature.  The  elastic  fibres  remalii 
unaffected.* 

Rhinoscleroma  ia  a  new  growth,  allied  to  the 
granulation  tumours,  which  commences  in  the  nostnis 
and  the  skin  around  them.  The  initial  lesions  are 
nodules  in  the  cutis,  and  deeper  layers  of  the  mucons 
membrane,  which  coalesce  to  form  a  hard  growth 
with  smooth  glistening  surface,  which  spreads  la- 
wards  from  the  lip  and  downwards  to  the  pharynx 
from  the  posterior  nares.  On  the  mucous  membraDe 
the  appearance  is  as  if  the  parts  bad  been  infiltrated 
with  glue,  which  had  set  to  the  solidity  of  stone. 
When  the  growth  is  situated  in  the  skin  the  epidermis 
is  tense  and  often  cracked,  especially  about  the 
comers  of  the  nostrils  and  mouth  ;  from  the  cracks 
a  glutinous  discharge  exudee,  which  dries  into  yellow 
scabs.  Thfe  growth  is  not  painful,  but  aches  on 
pressure.  It  causes  great  deformity  {Fig.  45),  hot 
no  symptoms  except  those  due  to  nasal  obstruotjou  ; 
the  danger  to  Ufe  is  mechanical,  from  blockage  of  the 
larynx.  The  growth  has  also  been  known  to  per- 
forate the  skull  and  extend  into  the  brain  (Kaposi). 
The  growth  does  not  break  down  spontaneously,  but 
is  generally  slowly  but  surely  progressive.  Thi- 
disease  may  last  fifteen  or  twenty  years,  or  even 
longer.  Spontaneous  disappearance  aft«i  acute  fev«n 
has  been  recorded. 

*  A  BUDunary  of  all  tlie  casea  recorded  up  to  that  date,  aaJ  * 
complete  account  of  a  (lecoiid  one  olMerrea  W  iii;h-U.  with  tbf 
reniltB  of  a  bislological  aiomiuution  bj  Jackwiu  Clarke  aiul  * 
ducuuiiMi  of  tho  whole  subject,  will  be  found  in  th*  Itnl.  Jamn. 
TiiTiH.,  Auguiit,  1S92.  For  a  good  iilateniinit  of  our  j-roiHit 
knowledge  on  xanthoma  diabotioonira  trr  Komiau  waUt, 
Jlril.  Jonrn.  Drrm.,  vol.  ii,,  p.  461,  1897. 


"■] 


RHIN03CLER0MA. 


The  condition  is  very  rare,  and,  as  far  as  may  be 
judged  from  the  majority  of  the  caeea  hitherto  re- 
corded, is  chiefly  prevalent  in  Austria.  Keegan  *  has 
reported   four  cases   of  rhinOBcleroma   in   Hindoos. 


/M  Mar  a'Kosjifal— I    siHu  l.y  E«r<Ula, 
hcriuiaim^f  IhcHlii-ilalat.Lomi.P'trii.) 

The  sexes  are  equally  liable,  and,  as  far  as  can  be 
judged  from  the  limited  statistics  at  present  available, 
the  disease  develops  before  the  age  of  forty.  Bacilli 
closely  resembhng  Friedlilnder's  pneumococcns,  but 
distinct  from  it.  have  been  found  by  Frisch,  Comil, 
and    others ;     and    some    investigators,     including 

Oacellc,  Jimaitrf,  1BS9. 


I 


572  HEe^lGN     NEW    GROWTHS.        [puap.  xm 

Unua,  are  inclined  to  think  that  the  growth  is  a 
inflammatory  product,  arising  from  blocking  ot  tl 
lymphatics  by  bacilli. 

The  treatment  can  only  be  paUiative.  Ti 
growth  recurs  almost  immediately  after  removal  OE 
destruction.  All  tliat  can  bo  done  is  to  keep  the  air- 
passages  patent  as  far  as  possible,  and  miuntaiQ  tb< 
patient's  strength  if  necessary.  Salicylic  acid  in- 
jected into  the  growth,  and  applied  to  its  surface  isi 
various  ways,  has  been  found  useful  by  Lang  I 
diminishing  the  bulk  of  the  tumour  in  one  case. 

MoUuscum  contag:iosuTn  is  characterised  bf 
the  formation  of  small  growths  like  tiny  mother-ol^ 
pearl  shirt-buttons  (Hutchinson).  They  are  roundish' 
in  shape  and  generally  flattened  on  Uio  top,  whei 
there  is  usually  a  depression,  in  which  there  is 
small  aperture  leading  into  the  interior  of  the  tumour. 
Through  tliis  hole  a  whitish  material,  or  someliinca 
a  milky  fluid,  can  be  squeezed  out.  The  UuJk 
growths  are  firm  in  consistence.  At  first  they  an 
sessile,  hut  as  they  develop  they  not  unfrequentlj 
acquire  a  pedicle.  They  are  most  commonly  seen  oa 
the  face,  the  eyelids  being  a  favourite  situation.  Thef 
are  also  met  with  on  the  neck,  the  breast,  the  limbs, 
the  genitals,  and  about  the  anua.  They  are  neva 
seen  on  the  palms  or  soles.  They  are  genecallj 
multiple,  sometimes  very  numerous,  and  widel] 
distributed.  After  attaining  a  certain  size  they  mt,f 
remain  stationary  for  an  indefinite  time.  They  c ' 
undergo  involution  or  drop  off  owing  to  strangulatia 
of  the  pedicle.  Sometimes  they  become  inflame) 
and  are  destroyed  by  suppuration. 

Molluscum  contagiosum  is  most  common  in  th 
young,  and  poverty  seems  to  be  a  predisposing  oof 
dition.  The  disease  is  generally  beUeved  in  Englaa 
to  be  contagious,  and  many  cases  are  on  record  i 
which  several  members  of  the  same  family  sufferel 


ni.]      MOI.LUSCUM    CONTAOIO.WM.  573 

from  it  at  the  same  time.  Successful  experimental 
inoculations  have  been  made  by  Vidal  and  by  Pick.* 
ft  ia  clear,  howevex,  that  the  contagion  is  operative 
only  under  certain  exceptional  conditions,  about 
which  nothing  is  definitely  known.  The  disease  has 
been  known  to  develop  after  the  use  of  Turkish 
baths,  probably  aa  the  result  of  infection.  A  few 
summers  ago  at  least  ha)f  a  dozen  cases  came  under 
my  care  within  a  very  aiiort  time  of  each  otlier,  in  all 
of  which  the  disease  appeared  to  have  followed  a 
visit  to  the  same  Turkish  bath.  Pick  concluded 
from  his  experiments  that  there  is  a  pciiod  of  incuba- 
tion lasting  two  months,  and  that  the  inoculated 
disease  requires  from  three  to  four  months  for  its 
complete  evolution.  In  structure  (Pig.  4li)  mollus- 
cum  contagiosum  resembles  a  racemose  gland,  and 
many  authorities  believe  it  to  be  merely  an  enlarged 
and  altered  sebaceous  gland.  This  view  finds  some 
support  in  the  fact  that  the  growth  never  occurs  in 
trie  palms  and  solea,  where  no  sebaceous  glands  exist. 
Virehow,  however,  believed  that  the  hair  foiUcle  is 
the  starting-point  of  the  process.  His  observations 
have  been  confirmed  by  Thin,  Crocker,  and  others. 
Paorosperma,  developing  in  the  epithelial  cells,  are 
considered  by  Neiaseir  and  Mansurof!  to  be  the  real 
etiological  factors  in  the  process,  and  a  micrococcus 
has  been  found  by  Shaw.f  The  cells  of  the  tumonr. 
especially  in  the  more  internal  portions  bordering  on 
the  layers  continuous  with  the  rete  Malpighii,  show 
characteristic  degenerated  forms  which  are  held 
by  Neisser  and  others  to  be  LOLtidia  and  to  be  the 
cause  of  the  tumours  but  this  \Tew, though  plaus- 
ible, has  not  so  far  been  confirmed  J 


BMNION   NEW   OR0WTB8. 


The  appearance. of  the  little  pearly  growths,  with 
the  central  depresfdon  aud  the  hole  leading  into  the 
substanne  of  the  tumour,  is  characteristic^;  Some- 
timea  whun  they  are  very  small  they  resemble 
vesicles,  and  might  suggest  varicella.  The  micro- 
scopic examination  of  the  contents  will  show  the 
nature  of  the  afEection.  A  small  tumour  on  the 
genitals  has  been  mistaken  for  a  hard  chancre,  but 
the  presence  of  similar  growths  elsewhere  and  the 
other  chnical  aspects  of  the  case  wilt  generally  pre- 
vent sucli  an  error. 

Moll  use  um  contagiosum  sometimes  dis&ppeu 
spontaneously.  Touching  with  pure  liquid  c 
acid,  followed  by  brushing  with  flexible  coUodiin 
will  often  get  rid  of  the  tumours.  When  this  faT 
they  should  be  split  from  below  upwards  and  squee 
out,  or  they  may  be  cut  ofE. 

Colloid  milium  is  a  rare  condition,  characterise 
by  small  yellow  translucent,  cyst-hke  formations  il 
the  skin,  cliiefly  on  the  upper  part  of  the  face, 
do  not  contain  fluid,  but  a  gelatinous  material 
Sometimes  they  become  depressed  in  the  centre  a 
are  slowly  absorbed ;  sometimes  they  become  i 
flamed  and  afterwards  dry  up.  The  ufiection  occu 
in  both  sexes,  and  does  not  generally  begin  befor 
puberty.  The  condition  appears  to  be  one  of  colloid 
degeneration  of  the  skin.  Spontaneous  recovery  has 
been  known  to  occur,  but  the  condition  is  refrac- 
tory to  treatment.  Erosion  with  the  sharp  spoon,  orfl 
dectrolysis,  might  be  tried.' 

Epithelioma    adenoides    cysticum. 

growth  was  first  described  by  Jacquet  and  Dai 
in  1887  ,t  under  the  name  of  hydradenoma  MtpUf,  i 

■  The  affection  wna  Urat  deu^ribpd  bf  Wuffner,  ArcM.  d,  Hnl 
Bd.  i-ii.    1866.     TLe  pBthologj  of  tho  pondition  hu " 
by  L.  Philipp»on,  llril.  Jmirn.    I'crm.,    »..!.   iii.,  I 
Beaiiier,  Frencli  tranHlstiou  of  Kupoei,  vol.  li,,  p.  !17 
'     '  iialtfi  dt  IlrriiHilel.  rl  dr  Sgph. 


sxui.]  EPITHELIOMA  ADENOWES  CYSTICUM.    575 

since  then  by  Torok,  Perry,  Quinquaud,  Philippaon, 
Besnier,  Fordyce,  and  others,  each  writer  seeming  to 
make  it  a  point  oi  honour  to  invent  a  new  name 
for  the  tumour.  The  one  used  here  was  proposed 
by  Brooke,*  who  made  a  moat  painstakiiig  investiga- 
tion of  the  disease. 

The  following  brief  description  is  mainly  con- 
densed from  Brooke's,  The  lesions  are  small  tu- 
mours, at  first  of  the  same  colour  as  the  surrounding 
skin,  which  afterwards,  as  they  increase  in  size,  be- 
come shining  and  translucent,  but  hardly  sufficiently 
^o  to  suggest  that  they  contain  fluid.  Nearly  all 
contain  one  or  more  minute  white,  brightly  refract' 
ing,  milium-hke  bodies.  The  httle  growths  are  firm, 
but  not  hard,  and  can  he  felt  to  be  embedded  in  the 
skin.  In  the  four  cases  observed  by  Brooke  the 
most  common  sites  of  the  growths  were  the  space 
between  the  eyebrows,  the  root  of  the  nose,  the 
nostrils,  the  cheeks,  the  upper  hp,  and  to  a  less 
extent  the  chin.  In  these  situations  they  were  so 
thickly  clustered  together  as  to  form  disfiguring 
lumpy  patches.  The  growths  may  occur  on  any 
part  of  the  body  from  the  occiput  to  the  pelvis, 
and  on  the  arms  and  legs.  The  course  of  the  affec- 
tion is  very  slow,  subject,  however,  to  sudden  accel- 
eration, even  after  it  has  lasted  many  years.  It 
begins,  as  a  rule,  between  the  tenth  and  fourteenth 
years. 

Heredity  appears  to  play  some  part  in  its  caufa- 
tion,  three  of  Brooke's  cases  having  occurred  in 
members  of  tlie  same  family  (mother  and  two 
daughters),  and  two  cases  recorded  by  Fordyce  f 
having  been  in  a  mother  and  daughter  respectively. 

*  Brit.  Joarn.  Lrrai,,  1892,  p.  2<J9. 

t  Joum.  of  VulBHfom  and  (iniilo-  Uriii.  I)it.,  Decemlier.  1892. 
The  paper  is  iliustrated  with  an  escelleot  colouied  plate  aud 
miaroKupical  seDtions, 


^ 


BEN[QN    NEW    QHOWTHS.         [rt 


The  lesions  never  attain  any  great  size,  and  i 
remain  unclianged  for  years.     They  are  painless, 
the  only  symptom  to  wliich  they  give  rise  is  slig 
pricking   or   itching.     They    show    no    tendency    ' 
ulceration. 

Clinically  the  growths  seem  to  be  absolute 
benign,  but  histologically  they  are  epitheliomata  i 
the  wider  sense  of  that  term,  denoting  only  a  tumoi 
composed  of  epithelial  elements  and  not  neceesanl 
malignant.  Microscopically  the  growtJis, 
to  Brooke,  consist  of  finger- hke  prolongaiions  i 
epithelium  coiled  on  themselves  so  as  to  form  m&ast 
in  which  are  cysts  filled  either  with  purely  colM 
material  or  with  concentric  layers  of  flattened  1 
cells  round  a  colloid  centre.  Some  believe  tbat  tl 
growth  has  its  starting-point  in  the  sweat-gland 
but  Brooke  holds  that  it  originates  directly  from  tl 
epidermis  and  from  the  epithelium  of  the  hair  aao 
The  new  cells  are  probably  of  embryonic  origin. 

The  only  treatment  is  removal  by  exdnon  i 
destruction  with  the  cautery.  Healing  talies  \ ' 
readily.  Fordyce  succeeded  in  removing  most  ol  t 
larger  tumours  by  meana  of  the  dermal  curette,  soin 
of  the  smaller  ones  being  expressed  with  a  come ' 
extractor. 

Keratosis    folllcularis  (Fig.    47).— Keratfl 
follicularis  is  a  rare  disease,  formerly  termed  by] 
Wilson"  ichthyosis  sebacea  cornea."  The  subject  h 
been  carefully  studied  by  Darier,  from  whose  work 
the  following  account  is  chiefly  derived.     I 
pendently  described  simultaneously  by  J.  C.  White  < 
Boston,  and  Darier  applied  the  teim  "  folliculai 
tating    psorospermosis"    (/worospermose    loUic 
vi'gHanti']  to  the  process.     The  lesions  first  appear  I 
small  brown  or  yellow  cruste,  which  are  rejuovab 

•  ,J.,«.  df  lierm.  el  dt  S</pli..  No.  7.  Julj  25,    18S0. 


Ill 


A 


I 


lu 


IIIMH 


i 
i, 

L 

* 


■l 
I 


CHAP,  sxm.]     KERATOSIS  FOLLICOLARIS.  577 

after  maoeratioa,  but  readily  form  again.  The 
crusts  project  sometimes  as  much  aa  ^  to  t  ram.  above 
the  aurfuce.  They  are  haid,  dry,  and  adhere  firmly 
to  the  underlying  tissue.  When  detached,  as  they 
may  be  by  squeezing  with  the  fingers,  they  are  found 
to  present  on  their  under  surface  a  softish  prolonga- 
tion which  dips  into  a  follicle.  This  soft  part  can  be 
squeezed  out  by  pressing  with  the  finger-nails.  The 
lips  of  the  depression  are  slightly  everted,  and  are 
redder  and  firineT  than  normal.  The  lesions  are  at 
first  discrete,  but  may  become  confluent  by  extension, 
and  the  thickening  of  the  affected  parts  increases  so 
that  nodular  masses  are  formed,  from  which  oozes  an 
offensive  discharge. 

The  eruption  in  Darier's  first  case  (a  woman  aged 
thirty)  began  on  the  epigastrium  and  on  tha  flanks, 
and  rapidly  epread  to  the  sternal  region,  the  face,  and 
the  scalp.  Finally  the  whole  of  the  trunk  was 
aSected,  and  also  the  hmbs  to  a  sUght  extent.  In 
certain  parts — e.g.  the  scalp,  temples,  naso-tahial 
furrows,  asillse,  groins,  and  anal  cleft— the  lesions 
were  confluent  three  years  after  the  commencement 
of  the  disease.  In  a  second  case  recorded  by  the 
same  author  the  eruption  began  over  the  sternum 
when  the  patient  (a  man)  was  thirty-eight.  Seven 
years  later  the  scalp  was  covered  with  yellowish- 
brown  cmsta,  covering  pits  from  which  tufts  of 
hair  projected.  The  face,  ejtcept  the  eyehds  and  the 
circumference  of  the  orbits,  waa  covered  with  papules, 
which  were  confluent  at  the  roots  of  the  hatr  on  the 
eyebrows  and  around  the  mouth.  The  shoulders  and 
the  neck  were  moderately  affected.  The  middle  of 
the  back  part  was  covered  with  a  ma«s  of  lesions 
resembling  large  comedones.  A  similar  condition 
existed  on  the  sternum  and  epigastrium.  On  tiie 
hypogastrium,  about  the  pubes,  and  in  the  groins  the 
lesions  constituted  large  hemiBpherical  bosses,  with 


BENIGN  NEW  GROWTHS. 


[c. 


B  central  pit,  from  whieli  stinking  puriform  matttf 
escaped.  There  were  many  lesions  on  the  outer  and 
posterior  aspects  of  the  loreanoB,  and  some  in  front 
of  the  anua.  The  inner  surfaces  of  the  tlijgha  and 
legs  were  shghtly  afiected.  The  palms  and  sole-s  were 
studded  with  yellow  dots  from  thickening  of  the  lioray 
layer. 

In  all  the  cases  lilthert-o  recorded  the  affection 
has  been  slowly  progressive.  Fresh  areas  may 
become  rapidly  covered  with  papules.  In  ten  of  the 
twelve  cases  the  patients  were  males.  The  affection 
does  not  seem  to  react  to  any  marked  extent  on  thr 
general  health. 

The  lesions  almost  invariably  implicat*  the  hair 
folhcle,  the  outer  part  of  which  is  dilated.  Th* 
granular  layer  of  the  epidermis  is  slightly,  the  mucont 
layer  greatly,  thickened,  and  its  interpapillarjr 
processes  are  enlarged.  Some  of  the  cells  of  tLe»» 
layers  contain  "  round  bodies  "  about  as  large  as  the 
epithelial  cells  themselves,  and  presenting  a  grannlur 
protoplasm  and  a  nucleus  with  a  doubly  contoured 
nuclear  membrane.  The  sebum-like  plug  which  &II1 
the  depression  contains  numerous  round  or  oval 
highly  refracting  "  grains,"  in  which  a  trace  of  a 
nucleus  can  sometimes  be  made  out.  Darier  regards 
the  "  round  bodies  "  and  "  grains  "  as  peorosperms. 
wliich  he  beheves  to  be  the  cause  of  the  disease.  Thi« 
view  has  received  the  eapport  of  Malassez,  Bnlbioni, 
and  some  subsequent  observers.  Torok  and  Tom- 
maaoli,  on  the  other  hand,  on  account  of  tlii'  ri>siii^ 
ance  of  these  bodies  to  mineral  acids  and  alkaliee, 
regard  them  as  product*  of  degeneration.  The 
question  must  therefore  be  considered  for  the  present 

Bowen  *  is  inclined  to  adhere  to  the  view  ori^n* 
ally  enunciated   by   J,  C.  White,    that    the   proocM 

•  Juam.  of  Vul.  and  Gru.-Ur.a.  /*.,„  Juue,  1H96. 


ciiAC.  xxm.]      ACANTHOSIS    NIORWANS.  571! 

is    esseiitially    a    ktiiatoBig    of   the    mouths    of    tlie 
folliclea. 

The  only  treatment  which  offers  any  ciiance  oi 
success  is  that  proposed  hy  Schwimmer,viz,  to  destroy 
the  lesions  as  they  appear  with  the  tkermocawtery. 

Acanthosis  nigricans  (Fig.  48)isapeculia^pig- 
IllentatioE.  ol  the  skin  with  warty  growths,  described  by 
Polhtzer  and  others.  To  the  few  cases  on  record  the 
pigmentation  has  occurred  more  or  leas  suddenly,  the 
face,  neck,  axillae,  upper  Hmba,  groins,  abdomen, 
thighs,  and  genital  regions  being  the  parts  affected. 
The  mucous  membrane  of  the  mouth  also  suffers. 
The  discoloration  varies  from  yellowish-brown  to 
almost  biack.  The  affected  skin  Js  thickened,  the 
natural  lines  of  cleavage  being  deeper  than  normal, 
and  in  some  parts  it  is  covered  with  small  papiUary 
growths.  In  Pollitzer's  case  the  aldn  lesions  dis-  ' 
appeared  after  a  time,  but  the  patient  died  later 
from  what  was  supposed  to  be  internal  cancer.  In 
a  case  under  my  own  care  a  similar  sequence  of  events 
probably  occurred.*  Dariert  has  repotted  two  rases, 
and  proposes  the  name  of  "  dyatrophie  papillaire  et 
pigmentaire  "  for  the  disease.  In  a  case  reported  by 
Gr.  Hiiget  X  the  disease  began  at  the  age  of  three,  and 
the  patient,  a  man  aged  twenty-five,  showed  no  sign 
of  visceral  disease. 

Lentigo  is  the  familiar  condition  known  as 
"  freckles,"  or  small  pigmented  spots,  tbe  colour  of 
which  is  usually  yellow  or  yellowish  brown,  occasion- 
ally sepia.  Their  most  common  situations  are  the 
face,  especially  about  the  nose  and  cheeks,  and  the 
backs  of  the  hands.  Sometimes  they  are  seen  on 
covered  paits,  such  aa  the  urma,  the  hack,  the 
buttocks,  etc,     (lenerally  the  number  of  them  is 

lico-IJhimygieal  Trann.,  vol.  Ixsvii. 
,  ._    1.  (fe  Ihrm.  ct  ih  8<ipl:,  t.  vi 
i  t^nXtaO^iu  Bfil.  Journ.  Ihrm.,  ia99,  p.  21h, 


L  CCEt 


580  BENION  NEfV  GROWTHS.  [chap,  ism 

moderate,  and  they  are  smaU  and  light  in  tint ; 
occasionatly  the  face  is  bo  thickly  covered  with 
them,  and  they  are  so  large  and  dark,  as  to  consti- 
tute a  disfigurement.  Freckles  are  sometimes  con- 
genital, but  generally  first  appear  in  childhood  about 
the  age  of  ten.  A  fair,  deUcate  skin  is  a  prediepoeing 
coodition.  The  exciting  cause  is  sunlight ;  hence 
they  are  always  most  marked  in  summesr,  and  fade 
more  or  less  in  winter.  The  afiectiou  tends  to  dis- 
appeiir  as  age  advances.  In  rare  cases  freckles 
develop  in  adult  hfe  and  in  old  age,  particularly  on 
covered  parts  ;  in  such  circumstances  tlje  condition 
is  probably  connected  with  impairment  of  nutrition 
or  senile  atrophy.  PathologicaUy  freckles  are 
patches  formed  by  the  localised  deposit  of  pigment 
in  the  basal  layer  of  the  epidermis.  If  treatment 
'  be  considered  necessary,  the  indication  is  to  remove 
the  patches  by  inducing  localised  blistering  or 
desquamation.  The  best  remedy  is  a  solution  of 
■perckloride  of  mercury,  two  or  three  grains  to  the 
ounce,  applied  several  times  a  day.  Pure  carbtilk 
acid  apphed  with  a  match  to  each  spot  separately, 
and  aaliGylic  acid  ured  in  the  form  of  Unna's  plabtsr 
mull,  are  also  useful.  In  mast  cases,  however,  the 
cure  is  merely  temporary.  In  view  of  the 
constitutional  results  that  may  possibly  follow  t 
unrestrained  use  of  corrosive  sublimate,  it  shot 
be  employed  only  under  medical  superviMon, 
patients  should  he  warned  to  liave  nothing  to  i 
with  advertised  nostrums. 

Paplllonia  of  the  skin  includes  various  i 
ditions  characterised  by  the  formation  of  papilli 
growths.  These  may  be  of  syphilitic,  tuberi'ulous, 
cancerous,  or  inflammatory  nature  (as  in  syfom. 
ccEema,  etc.),  and  as  such  they  are  treated  of  in 
connection  with  the  process  of  which  they  are  tlw 
result.    .  In    this    section    only    innoceat    jmpillaiy 


CHAP.  JtsuL]  WARTS.  381 

growths  arising  independently  of  any  general  procrss 
— warts,  corns,  and  horny  formations — are  considered. 

Warts  are  ol  several  kinds,  the  differences  being 
in  their  shape,  general  appiaranne,  and  situatjon  ; 
structuially  they  are  all  essentially  the  same.  The 
cominon  wart  {verruca  v^aris)  ia  generally  seen  on 
the  hands,  but  also  on  other  paits,  as  a  small  sessile 
growth  with  a  surface  at  first  smooth,  afterw'ards 
roughened  with  enlarged  papills.  which  can  some- 
times be  seen  projecting  like  coarse  bristles;  occa- 
sionally the  little  masa  is  fissured  here  and  there 
to  its  base.  The  colour  is  at  first  that  of  the  skin, 
but  after  a  time,  owing  to  changes  in  the  keratin, 
and  in  uncleanly  persons  to  griming  with  dirt,  it 
becomes  brown  or  even  black.  They  may  be  single 
or  multiple ;  sometimes  tliey  are  seen  clustered 
together  on  the  fingers.  The  condition  is  most 
common  in  childhood,  and  tends  to  disappear  with 
the  advent  of  puberty.  It  may.  however,  perfiist 
much  longer,  and  may  even  become  developed  in 
adult  life.  Warts  give  rise  to  no  symptoms,  imlesa 
they  are  of  such  a  size  or  in  such  a  situation  as  to 
interfere  with  the  holding  of  a  pen,  etc. 

Plat  wart  (verruca  j^ana)  may  occtir  in  youth, 
but  is  generally  seen  in  old  age.  In  young  persons 
such  warts  are  most  common  on  the  face  (particularly 
the  forehead)  and  on  the  backs  of  the  hands  ;  in  the 
elderly  the  back  and  the  arms  are  the  ordinary 
situations.  The  warts  are,  as  the  distinguishing 
epithet  implies,  flat ;  they  are  smoother,  as  a  rule, 
than  the  common  wart,  and  often  square  in  outUne, 
resembling  the  papules  of  lichen  ruber  planus.  The 
changes  found  on  examination  are  hypertrophy  of 
all  the  layers  of  the  epidermis,  with  elongation  of  the 
papillffi.  In  old  people  they  are  often  large  and 
prominent,  dark  in  colour,  and  associated  with  other 
senile    changes    in    the    skin.     They    are    generally 


BENIGN  NEW    QROWTHS. 


1 


situated  on  the  back,  the  foTearma,  anil  the 
They  often  itch  intensely.  Such  a  wart  may 
the  starting-point  o£  a  malignant  growth. 

Another  form  of  wart  is  characterised  by  ragged- 
nesB  of  surface,  the  overgrown  papilla  being  sepsrat«(! 
and  forming  finger-like  processes  ;  hence  this  kind  of 
wart,  is  known  as  verruca  digiUUa.  They  are 
common  on  the  scalp,  especially  in  women. 
sometimes  cause  inconvenience  in  dressing  the 

A   long   tliread-like   wart    (verrvca   filifortnif) 
aometimea  seen  on  the  neck  and  the  eyelids. 

Verruca  seborrhoelca  (seborrhoeic  wart) 
only  in  adult  life,  and  generally  in  old  age. 
lesions  consist  of  multiple  patches  of  warty  growth 
the  back,  arms,  belly,  sternum,  and  net-k  ;    the  face; 
sometimes,  though  rarely,  attacked.     The  lesions 
generally  more  or  leas  grouped  in  lines  following 
natiu-al  lines  of  cleavage  in  the  skin.     The  patvl 
are  generally  rounded  in  outline,  and  usually  priwi 
varying  degrees  of  pigmentation,  from  brown  to  Wj 
In  connection   with   this  point  it  is   necessary, 
pointed  out  by  Pollitzer,*  to  distinguiah  between 
growth  itself  and  the  crust  with  which  it  is 
It  is  to  the  latter  that  the  colour  is  due,  and  it 
obvious  that  the  depth  of  tone  must  depend  on  tlie 
amount  of  dirt  accumulated  on  the  surface  of  the 
lesion.     In  cleanly  persons  the  patches  are  of  a  pale 
fawn  tint,  and  tile  surface,  which  is  soft  and  greasj 
to  the  touch,  has  a  reticulated  appearance.     In  tfa( 
who-  wash    seldom   and   imperfectly    the   warta 
covered  with  a  dark  crust  of  dirt  which  can  be  scxa] 
off  with  a  knife  ;   a  pinkish-yellow  reticulated 
will  then  come  into  view.     The  only  symptom 
which  the  warts  give  rise  is  itching,  which,  especii 
in  elderly  persons,  may  be  very  troublesome, 
ing  to  Pollitzer,  the  hiatolo^cal  characters  ol  the 

•  Brit.  JoUYH.  lltrm.,  vol,  ii.,  1890,  p.  200. 


ssju.]     SEBORHHmw  AND  YENEltBAL  WARTS.     583 

growth  are  slight  thickening  of  the  horny  layer,  with 
t-dtisiderable  hypertrophy  of  the  Malpighian  layer, 
while  in  the  papillary  and  subpapillary  luyera  there 
are  epithelioid  cells  in  groups  and  lines  separated  by 
bundles  of  connective  tissue  with  a  peculiar  infiltra- 
tion of  fat,  affecting  the  coil-gland  epithelium,  the 
middle  and  papillary  layers  of  the  cutis  and  the 
epithelium  of  the  rete,  and  perhaps  some  atrophy  of 
the,  sebaceous  gliinds  and  hair  follicles.  He  looks 
upon  these  warts  as  benign  growths  developed  out 
of  "  misplaced "  embryonic  colls,  resembling  in 
respect  of  the  presence  and  peculiar  arrangement  of 
the  epithelioid  cbIIb  the  growth  called  by  Von  Reck- 
linghausen "  lymphangi-fibroma,"  The  fatty  infil- 
tration in  the  skin  may  perhaps  be  regarded  as 
evidence  of  a  aeborrhceic  process,  if  Unna's  view  that 
the  coil-gland  glomerulus  not  only  secretes  sweat,  but 
is  the  cliief  source  of  fat  for  the  skin,  be  accepted. 

If  treatment  be  considered  necessary,  the  growths 
may  be  dealt  with  in  the  same  way  as  ordinary  warts. 

Venereal  warts  {verruca  acuminata)  are  papil- 
lary escreseences  usually  seen  about  the  genitals  in 
both  sexes,  and  sometimes  in  the  axillee  and  other 
moist,  warm  ports.  They  are  generally  reddish  in 
colour,  pointed,  tufted,  or  cauliflower  in  shape,  bathed 
in  decomposed  sweat  and  purulent  discharge  ;  some- 
times, especially  about  the  vulva,  they  grow  with  an 
unrestrained  luxuriance  suggestive  of  tropical  vegeta- 
tion. These  warta  are  not  syphilitic,  but  they  are 
most  frequently  gonorrhceal  in  origin,  proliferation 
of  the  papillie  being  due  to  the  irritation  of  the  dis' 
charge.  Somewhat  similar  warts  are  sometimes  seen 
in  pregnant  women  who  have  not  suffered  from  gonor- 
rhtea.  In  such  cases  the  warts  quickly  disappear  after 
delivery,  but  the  gonorrhceal  warts  show  little 
tendency  to  do  so,  and  may  continue  to  grow  for  years; 
They  are  highly  contagious. 


i 


BENIOX  SEW  omWTB.'i.       [on 


Except  aa  regards  the  fotm  last  mentioned,  the 
etiology  of  warts  is  obscure.  The  flat  wart,  as  has 
teen  said,  ia  sometimes  a  result  of  senile  degeueratJon 
of  the  skin  ;  and  Jamieson  says  he  has  in  some  CAsm 
traced  the  origin  of  the  digitate  wart  to  the  use  «f 
rancid  hair-oil  or  pomade.*  The  popular  notion  that 
the  common  wart  ia  inoculable  finds  some  support 
in  facta  observed  by  Payne  f  and  others  ;  and  cocct 
and  bacilli  have  been  found  in  the  little  growths  by 
Comil,  Kiihnemann,  and  others,  but  the  signHicancr 
of  these  micro -organisma  ia  doubtful. 

Treatment. — Ordinary  warts  may  be  successtatly 
dealt  with  by  causing  exfoliation  by  means  of  salieytir 
acid  in  the  form  of  a  plaster,  or  dissolved  in  coUadum 
Cbi  <Ki  SJ).  and  then  applying  chrmnio  acid  to  the  basi? 
of  the  growth.  If  this  fails,  a  strong  caustic,  such  as 
acid  niirale  of  mercury,  should  be  used,  with  precau- 
tions to  hmit  the  range  of  its  destructive  action.  A 
good  method  is  to  moisten  the  wart  with  strong 
acetic  acid,  and  when  damp  to  apply  the  solid  stick 
of  nitrate  of  silver. 

Digitate  warts  should  he  removed  with  the  elastic 
ligature  or  the  knife,  the  base  being  afterwards 
cauterised.  Larger  growths  may  require  the  galvanic 
cautery  loop  or  the  ecraseur.  Gonorrhteal  warta,  if 
very  luxuriant,  should  be  snipped  off  with  scissora 
or  destroyed  with  the  galvano -cautery  ;  if  they  are 
small  they  may  be  got  rid  of  by  applying;  cJiromie 
or  glacial  acetic  add.  An  important  element  in  the 
treatment  of  these  moist  warts  Is  to  keep  tliem  drt' 
and  clean,  and  the  surrounding  parts  protected  from 
infection.  The  conditions  (irritating  discharge,  etc.) 
keeping  up  the  papillary  hypertrophy  must  also  b« 
dealt  with. 

>.  3Ti. 


a.] 


CORNS. 


COPns  are  circumscribed  tluckenings  of  the 
epidermis,  in  the  centre  of  which  a  homy  peg  or  nail 
(hence  the  name,  ciavus)  projects  downwards  among 
the  papillffi  so  that  its  point  rests  on  the  sensitive 
cutis,  causing  sharp  pain  when  driven  inwards  by 
preaaure.  Corns  also  "  shoot  "  spontaneoualy,  especi- 
ally under  the  influence  of  barometric  depression. 
The  most  common  situations  for  corns  are  the  outer 
surfaces  of  the  little  toes,  the  upper  surfaces  of  the 
other  toes,  and  the  sole,  especially  the  part  where  the 
weigiit  of  the  hody  falls  in  walking.  A  softer  but 
not  less  painful  kind  of  corn  oiten  forms  between  the 
toes.  Pressure  and  friction  are  the  causes  chiefly 
reaponaible  for  corns,  but  some  persons  show  a  much 
greater  proclivity  than  others  to  their  production. 
They  may  be  congenital,  or  at  any  rate  may  develop 
in  early  childhood  on  feet  that  have  never  been 
impriaoned  in  tight  or  ill-fitting  boots.  Anatomic- 
ally, the  conditiou  is  hyperplasia  of  the  homy  layers. 
Coma  sometimes  become  inflamed,  and  suppurate  and 
break  down  into  deep  ulcers.  The  treatment  consists 
in  removing  the  corn  by  tlie  application  of  salicylie 
acid  in  a  plaster,  or  in  the  following  form  : — 


Aokit  Sttlioylici    . . 
Extr.  camiahiH  inctici 


prs.  \ 


This  should  be  painted  on  with  a  camel-hair  brush 
or  a  glass  rod  after  the  corn  has  been  soaked  in  hot 
water  and  the  top  shaved  off.  After  a  day  or  two 
the  thickened  epidermis  can  easily  be  picked  off. 
Another  somewhat  similar  formula  is  that  s 
by  Vigier  :— 


gra.  * 


w 

I 
I 

I 


BENIGN  NEW   OBOWTI/S.        [chap.  mB 

A  method  which  I  have  ioimd  most  aucceasful  is  i 
soak  the  com  with  acetic  acid  and  then  rub  i 
thoroughly  with  nitrate  of  sUver.  Cuttdng  corna  i 
not  more  eSectual  than  the  methods  described,  ani 
haa  Bometimes  been  followed,  especially  when  pM 
formed  by  unqualified  "  chiropodista,"  by  seriou 
and  even  fatal  comphcationB.  After  treatment  thi 
part  should  be  protected  from  pressure  by  perforated 
pads  of  felt  plaster  or  am.adou,  and  boots  adapted  b 
the  shape  of  the  foot  should  be  worn.  , 

Callosities  diSer  from  corns  chiefly  in  tha 
absence  of  t.hc  "  nail."  The  thickening  of 
epidermia  may  be  congenital,  but  is  usually  actiuiird. 
It  occurs  on  parts  exposed  to  pressm-e,  as  on  the  lundi 
of  working  men,  the  fingera  of  harpists,  etc.  Calloei' 
ties  may  also  develop  on  the  feet  from  the  pressunf 
of  boots,  or  from  going  barefoot.  The  condition 
seldom  calls  for  treatment,  but  if  any  ia  required  the 
hypertrophied  homy  layer  can  be  got  rid  of  by  me»na 
of  mlicylic  acid  ■plmler,  or  "  emol."  * 

Homy  excrescences,  resembhng  the  homa  a 
animals,  have  in  rare  casee  been  observed  in  humai 
beings ;  they  sprout  generally  from  the  scalp,  tlv 
forehead,  the  temples,  sometimes  from  the  iacv,  tbft 
extremities,  the  genitals,  and  the  trunk.  They  an 
not  painful,  except  when  injured ;  occasionally  tbtj 
are  the  starting-point  of  malignant  disease.  They 
are  rare  under  the  age  of  forty,  but  have  beca 
observed  in  children.  They  are  essentially  ovc^rown 
warts  (Crocker).     In  most  cases  they   origituit«  in 

•  Itifl  sulwtanGB,  whicli  whb  introdnuBil  iuto  dnrautnlneiatl 
tiroctice  by  JamieBOn.  u  s  natuml  prodiict  (oiiuil  uear  Dunnini! 
lu  PertliBhire,  but  ruliuHil  uid  purified,  ll  is  ii  n>ft,  iiu|wln«]il* 
powder,  ol  a  delicate  inak  htie,  niid  iacJiemiOiUj  nllirr]  to  fultor'* 
earth.  It  conbiiDa  steatite  a»  trpll  ns  ulim,  uluminik,  villi  • 
mere  trace  ol  lime,  nacl  .Titmioaon  thinka  it  ia  iinibilil.v  tii  thv  Hnt 
of  those  iugrediontsihnt  llinsii' 
'^  ir  further  detaila  ua  t.  " 
ril.  Mtd.  Journ.  t. 


intsihnt  ihi-siilwlBTiiwinrosits  pveulinr  pronerti 
ila  lU  tu  the  tUurainutic  UKO  of  "  iimo]  "  »  i 


CHAP,  xxin.]     HORNY   EXCRESCENCES.  687 

sebaceous  cysts ;  sometimes  they  arise  in  warts  or 
scars,  or  a  broken-down  molluscous  tumour  of  the 
eyelids  (Jamieson).  The  horn  should  be  removed, 
and  the  base  thoroughly  cauterised. 


N 


CHAPTEK   XXIV. 

NEW   (iROWTHS   {confludtd). 
II. — Malignant, 

The  essential  feature  of  a  malignant  growth  i 
in  its  extension  it  does  not  thrust  aside  the  structurw 
in  whith  it  grows,  but  destroys  them  and  takes  thdr 
place.  A  tumour  may  be  locally  malignant,  that  i*. 
it  may  spread  indefinitely  from  a  given  centre  and 
■  after  removal,  not,  however,  becoming  general' 
ised  in  the  system  ;  oi  it  may  be  malignant  in  thn 
full  sense  of  the  word,  not  only  invading  the  surround- 
ing parts,  but  giving  rise  to  secondary  formations  in 
distant  regions.  Thus  sarcoma  is  often  only  locally 
malignant,  while  carcinoma  is  typically  malignant. 
The  group  of  malignant  growths  afiecting  the  skin 
includes  Paget's  diseaBe,  sarcoma  (of  various  types), 
epithelioma,    mycosis     fungoides,     and     xerodermia 


Facet's  disease.— This  aflection,  the  iudiridu- 
ality  of  which  was  established  by  Paget  •  in  a  pap**! 
based  on  the  study  of  fifteen  cases,  has  since  tliat 
time  been  the  subject  of  many  memoirs,  one  of  tha 
most  important  being  that  of  Wickham.t  The  firsl. 
visible  lesion  is  reddening  of  a  patt-h  of  aVin  on 
around  the  nipple,  which  has  the  appearance  of 
inflammatory  hyperemia,  followed  by  branny 
desquamation.     The  infiltration  soon  deepens,  ; 

■  St.  BarthoIomBn-'B  UoemtHl  Beporta,  IB7«,  1<.  H-t  rt  ^. 
'■  Contribuliou  A  IV-tu?     '  " "  ■  "  ' 

ceitainet  farniec  de  cancer," 


i 


CHiP.  ixiv.]  PAGETR   DISEASE.  5S9 

duf.ing  a  bright  red  granular,  distinctly  indurated 
siirface,  from  wliich  there  usuaUy  oozes  a  eticky 
yellowish  discharge.  This  may  form  crusts  and 
obscure  the  nature  of  the  lesions,  save  at  the  border, 
which  is  characteristic,  being  sharply  defined, 
indurated,  and  sometimes  distinctly  raised.  In  the 
later  stages  of  the  disease  itcliing  and  burning  are 
the  cliief  subjective  symptoms.  The  process  usually 
commences  in  the  nipple  and  areola,  but  undoubted 
instances  have  been  recorded  of  its  attacking  the 
scrotum,*  the  scrotum  and  thigh,  the  penis,f  the  glans, 
the  anus  and  perinieum,  the  abdominal  wall,  and 
otherparts.J  Dubreuilh§  has  recorded  a  case  in  which 
the  vulva  was  the  seat  of  the  disease.  After  a  period, 
which  ie  usually  about  two,  but  has  been  known  to 
be  extended  to  twenty,  years,  deep-seated  parts  may 
become  affected  by  the  cancerous  process.  On  the 
breast  this  shows  itself  by  retraction  and  induration 
of  the  nipple,  and  the  formation  of  a  tumour  in  the 
substance  of  the  gland.  The  liistological  changes 
consist  in  great  proliferation  of  the  deeper  layers  of 
the  epidermis,  and  infiammatory  infiltration  of  the 
corium.  In  the  thickened  epidermis  the  bodies 
described  as  psorosperms  by  Darier,  Wickham,  and 
Jonathan  Hutchinson,  junr.,  abound.  Most  English 
writers  have  looked  upon  the  cancerous  disease  in 
wliich  the  affection  terminates  as  having  no  closer 
connection  with  the  orij^nal  malady  than  as  being  the 
effect  of  prolonged  irritation  ;  Thin,  however,  regards 
the  affection  as  cancerous  throughout,  and  has 
suggested  the  name  "malignant  papillary  derma- 
titis." Wickham  attributes  both  the  affection  of  the 
skin  and  the  cancer  in  which  it  terminateB  to  psoro- 

•  Ccocfcor,  tath.  fhf.  T>-«iii:.  vol.  si,  18S9. 
t  Pick,  IJtfKli.  iwd.  Z-il..  NovBOTber  S,  IMOl. 
'I   Sti  a  caao  reported   b;  MartuiiiliikD   Shield,  Bril.  Jaurii. 
J>(rrm.,  roL  ix,,  1897. 

g  BrU.  Joiirii.  Urn,..,  November,  I'JOl. 


■^ 


MALIGNANT  NEW    GROWTH 8.      [cH4p.  > 

spermia,!   infection.     The    disease    occurs    chiefly  iM 
men  after  the  age  of  forty. 
As    regards    diagnosis,     the  biiglrt    red 
ular     surface    exposed    after    removal     of     cruafBL 
the    induration    especially    marked    at    the     well-9 
defined   edge,   with    the    intractable   tiaturo   of   thaff 
affection,  distinguish  it  from  chronic  eczema,  whicll  ' 
it  most  closely  reaemblea.     The  diagnosis  is  made 
certain  by  the  microscopic  examination  of  scrapings 
in  iodised  serum  (Darier)  or  hquor  potassie  (Hutchin- 
son, junr.).     The  psorosperms  appear  as  bright  oval 
nucleated  bodies,  some  stiil  contained  withiQ  the  huet 
Is,  others  surrounded  by  distinct  capaulea.     Th* 
irse  of  the  disease  is  steadily  progressive,  and  if 
left  untreated  it  terminates  in  death.     The  tFea^J 
nient  should   consist  of  complete  removal  of  1 
whole  breast  or  part  affected  as  soon  as  the  dia^l 
nosis  ia  established.  I 

Cancer  of  the  skin. — The  forms  of  canc«l 

inamencing  in  the  skin  are  squamous  epithelionwa 
and  rodent  ulcer.     Cancer,  secondary  to  malignaill 
disease  of  the  breast,  often  implicates  the  skin,  eithflt 
3,  nodular  or  as  a  diffuse  infiltration  ;  the  former  il 
termed  lenticular,  the  latter  "  cuirass- acirrhufl." 

Cancer   "en   cuirasse."  —  Cancer  en  cvirtu 
may  occur  primarily  in  the  skin  without  previoosl 
mammary  cancer.     I  have  myself  seen  ttiree  caaM,  >Ul 
in  women.     In  one  case  it  commenced  in  the  skin  ova ^ 
the  breast,  and  in  the  other  two  at  some  distance  torn 
thatpart (Fig.  49).  Thefirstvisiblelesionisathicken- 
ing  of  the  skin  somewhat  resembhng  acIerodeniUA. 
After  a  time  nodules  develop,  and  by  causing  pressniv 
on  the  lymphatics  give  rise  to  l}ead-)ike  chains  ovtsj 
the  breast.     The  blocking  of  the  lymphatics  CAUMtl 
c^dema  of  the  arm ;    this  in  one  cose  was  the  liivlJB 
symptom  observed.      It  spread  rapidly,  and  deat&fl 
occurred  within   four  m      '      ta  all   the  ( 


11: 


II] 


l« 


CHAP,  XXIV.]  EPITHELIOMA.  501 

forming  a  sort  of  breastplate,  whicli  compresHed  the 
ribs  and  caused  a  very  painful  form  of  death  by 
gradually  increased  oppression  of  the  breathing.  The 
only  treatment  for  tliis  condition  is  subcutaneous 
injections  of  morphia. 

Melanotic  cancep. — Although  nearly  all  the 
cases  described  as  melanotic  cancer  of  the  skin  have 
doubtless  been  instances  of  melanotic  sarcoma,  yet 
cases  of  undoubted  melanotic  cancer  occur  elsewhere, 
ao  it  is  presumable  that  the  disease  may  now  and  then 
be  met  with  on  the  skin.  The  cases  described  as  such 
have  been  marked  by  the  development  of  dark  areas 
rapidly  changing  to  tumours  along  the  course  of  the 
lymphatics,  with  early  implication  of  glands.* 

Epithelioma  (Fig,  50), — All  cancerous  tumours 
are  chiefly  characterised  by  overgrowth  of  a  certain 
extent  of  epithelium  at  the  expense  of  the  surround- 
ing tissues.  Thus  on  the  skin  cancerous  growths 
usually  begin  aa  slight  papillary  elevations,  but  if  the 
process  begins  in  a  gland  a  nodule  forms  the  starting- 
point.  To  take  the  more  usual  case,  the  papule 
becomes  firmer  and  extends  laterally,  involving  the 
skin  immediately  around  it,  the  infiltration  being 
evidenced  by  the  characteristic  firm  raised  border. 
Extension  in  depth  is  also  efiected  by  continual  growth 
of  the  deeper  layers  of  the  rete  mucosum.  The  rapid 
growth  of  the  epidermis  at  the  sides  and  the  base  of 
the  growth  causes  the  central  and  superficial  part  to 
perish  for  want  of  nutrition,  bo  that  ulceration  occurs 
in  the  middle  while  extension  is  going  on  in  the  depths 
and  at  the  sides  of  the  growth.  If  this  is  of  moderate 
degree,  the  surface  remains  covered  by  a  certain 
thickness  of  epithehum,  and  there  is  no  bleeding  from 
denudation  of  vessels— in  fact,  no  true  idceration, 


•  Ou  pigiDBntution  prKuediuB  malignaQt  growth,  ,-ce  Galloway, 
Brit.  MrH.  JMrn.,  Oot.  2, 1897. 


3  MALIGNANT  NEW  GROWTHS,      [chap,  x 

although  there  is  a  moist  discharge  which' dries 
forms  crusts.     If  the  necrotic  process  extends  to 
vaacular  tissues,  there  is  more  or  leas  htemorrl 
When  the  lateral  growth  predominates,  the 
discoid  epithelioma  is  the  result.     This  is  typii 
seen  in  sweep's  cancer  of  the  scrotum  ;   the  surfaoe 
raised,  with  a  steep  border,  and  bright  red,  with  lins' 
granular  surface.    If  there  is  luxuriant  formation  of 
new  tissue  at  the  margin  and  deep  ulceration  in  the 
centre,  the  crateriform  ulcer  of  Hutchinson  is  the 
result.     If   the   granulations  are   of   large   sJKe, 
cancer  is  said  to  bo   of  the  papillary  form. 
phase  may  be  so  marked  as  to  deserve  the 
"  cauliflower  growth,"  such  as  is  met  with  c 
external  genitals  and  the  oa  uteri.     Frequently 
appearance  of  the  lesions  is  modified  by  some 
existent  morbid  condition.     Thus  epithelioma 
arise  in  a  chronic  ulcer,  simple  or  sypliilitic,  or  from" 
lupus ;  in  a  wart  or  mole,  etc.     All  forins  of  epithi 
lioma  have  the  following  common  charact«r3 
pheral    extension,    infiltration    and    destruction 
neighbouring  parts,    central    ulceration,    and   in 
cases  with  the  exception  of  rodent  ulcer  a  tendi 
to  form  secondary  growths  in  lymphatic  glands, 
the  viscera,  and  elsewhere.     Just  as  a  cancer  of 
tongue  which  has  its  starting-point  at    the  liottam 
of  a  deep  fissure  may  widely    infiltrate   the  or^ui 
before  there  is  any  appreciable  induration  or  ulcera- 
tion   of  the  surface,  so  an  epithelioma  of  the  fIciq 
beginning     in    the     deepest  part    of     .the     gUodi 
may    widely     infiltrate     the      corium      and     »iil»- 
cutaneous  tissues   hclore    the  surface    is  ulc^TntHl. 
These  deep-seated  epitUeliomata  are  the  more  danpv- 
ous  by  reason  of  their  anatomical  connections.     Thi^ 
amount  of  pain  caused  by  cutaneous  cancel  vainta 
according  to  the  structure  involved.     Cancer  of  "'  "" 
skin  lias  a  predilection  for  certtun  sites,  sncli  m 


peri- 


CHAF.  xxn-.]  EPITHELIOMA.  593 

natural  orifices — mouth,  anus,  vulva,  and  eyelids ; 
moist  parts,  as  the  glans  penis  ;  exposed  regions,  as 
the  face  and  hands  ;  parts  exposed  to  shght  injuries, 
such  as  the  feet  from  friction  of  the  boots — but  it  may 
occur  in  any  part.  As  already  said,  a  wart,  a  mole, 
or  an  ulcer  may  be  the  starting-point.  An  ulcerated 
and  everted  aebaceous  cyst  simulates  in  appearance 
a  malignant  growth,  and  also  tends  to  terminate  in 
veritable  epithelioma.  The  malignant  infiltration 
varies  in  rapidity  in  different  cases,  but,  as  with 
cancer  gonerally,  it  may  be  said  that  unless  speedily 
and  thoroughly  removed,  sooner  or  later  tlie  diseatie 
causes  tlie  death  of  the  patient  by  generalisation  of 
the  disease  and  exhaustion. 

Cancers  vary  in  structure  according  to  the  par- 
ticular epithelium  in  which  they  arise.  On  the  skin 
they  are  usually  of  the  stratified  squamous  type,  with 
well-marked  cell-nesta  in  the  central  parts  of  the 
older  iobules.  These  nests  are  due  to  the  older 
comified  cells  becoming  flattened  and  arranged  in 
concentric  layers  as  the  result  of  pressure.  Whefl 
the  process  starts  in  a  tubular  gland,  the 
glandular  tubular  type  of  epithelioma  is  the  result. 
Not  only  is  there  overgrowtli  of  epithelium,  but  the 
connective  tissue  is  altered  by  inflammatory  exuda- 
tion and  by  formation  of  new  vessels. 

L.  C.  Pfeiffer  *  and  other  observera  have  described 
parasitic  sporozoa  in  cutaneouK  as  in  other  epithelio- 
mata.  Malassez  and  some  others  beheve  that  there 
may  be  a  causal  relationship  betneen  these  parasites 
and  the  growth.  The  question  is  still  imsettied. 
Early  and  free  removal  with  the  knife  la  the  only 
safe  treatment  of  cancer  of  the  skin  When  tliis 
is  impossible  the  sharp  spoon  followed  by  the 
actual  cautery  or  chloride  of  ziul  gives  some  hope 
of  a 


594  ilALlQN ANT  NEW  GROWTHS,    [chap.  SMi^l 

Bie   has  published  a  report   of  sixteen  cages  in 
whicli  epithelioma  of  the  skin  was  treated  by 
centrat^d  Ught.     In  seven  the  result  is  described 
a  cure,  which  has  been  maintained  respeutively 
two  and  a  half  years,  eleven  months  (two  casee), 
and  a  half  monthiB,   and  six  montlis  (three  case^ 
Finsen  concludes  trom  the  cases  so  far  treated  " 
tliia  method  that  the  cases  of  epithelioma  which  can 
be  dealt  with  succeBsfully  by  means  of  light  are  snpfr- 
ficial  well-defined  forms  in  accessible  situations. 

Rodent  ulcer. — The  individuality  of  rodi 
ulcer  is  well  explained  in  the  words  of  A.  Jocob,^ 
by  whom  its  claim  to  be  considered  a  distinct  clinii 
entity  was  first  established  ;  "■'  The  characterii 
features  of  this  disease  are  the  extraordinary  slownt 
of  its  projE^ess,  the  pecuhar  condition  of  the  edfies 
surface  of  the  ulcer,  the  comparatively  inconsideral 
suffering  produced  by  it,  its  incurable  nature, 
by  extirpation,  and  its  not  contaminating  the.  nei| 
bouring  lymphatic  glands."  The  affection  is  ; 
of  epithehoma.  The  initial  lesion  is  a  small  c 
scribed  nodule  in  the  sldn,  flat  and  depressed  ii 
centre,  with  unbroken  cuticle,  firm  to  the  touch, 
of  a  dull  brownish-red  colour,  It  often  remains 
Bome  years  without  undergoing  any  perceptil 
change,  but  at  length  the  cuticle  covering  it  is  broki 
and  an  ulcer  with  depressed  granular  centi« 
infiltrated  border  is  formed  (Fig.  51).  The  nil 
becomes  slowly  larger  and  deepex ;  it  infill 
and  destroys  the  subjacent  tisanes,  attacking 
replacing  bones  as  well  as  soft  tissues  (Fig. 
Sometimes  it  spreads  superficially,  with  cic^trisatioD 
of  the  centre,  but  usually  the  destruction  of  the  part* 
beneath  it  is  more  marked  in  the  centre,  so  that  » 
crater-like    form    results.      It    is    remarkable    lliat 

•  DuMin  Hospitiil  RepnrtK,  IS-*",  p.  t 


lU 


CHiP.  xxjv,]  HODENT    ULCEB.  S!)5 

almost  every  case  of  rodent  ulcer  has  its  seat  witliin 
an  area  bounded  by  a  line  drawn  from  the  upper- 
most part  of  the  pinna  to  the  root  of  the  nose,  and 
another  drawn  from  the  lobule  of  the  ear  to  the 
columella  of  the  nose.  Cases  are,  however,  recorded 
in  which  it  has  been  met  with  in  other  parts  — e.ij. 
on  the  back  of  the  hand. 

The  structure  is  that  of  an  epithehoma,  the  cells 
being  smaller  than  those  of  the  ordinary  epithehoma, 
and  only  exceptionally  being  arranged  in  cell  nests 
(Fig.  5S).  Most  histologists  are  agreed  that  it 
begins  in  the  deepest  layers  of  the  rete  niucosum, 
but  others  have  traced  it  variously  to  the  sweat 
glands,  the  sebaceous  glands,  and  the  hair  follicles. 
Norman  Walter  *  maintains  that  there  is  no  con- 
nection between  rodent  ulcer  and  squamous  epithe- 
homa, except  the  fact  that  both  are  largely  composed 
of  epithelial  cells.  He  argues  that  its  type  and 
the  arrangement  of  its  cells  correspond  to  that 
described  as  glandular  or  tubular  carcinoma.  Its 
origin  must  therefore  be  looked  for  in  glands,  and 
as  a  matter  of  fact  he  has  generally  found  that  it 
arose  from  the  sweat  glands.  In  one  case  he  was 
doubtful    whether     it    did    not     originate    in    the 


The  etiology  of  rodent  ulcer,  hke  that  of  cancer  in 
general,  is  not  yet  definitively  settled.  Dubreuilh  and 
Wickham  have  described  psorosperms  in  association 
with  the  process.  Like  cancer  in  general,  rodent  ulcer 
is  a  disease  of  old  age,  but  it  is  not  rare  about  thirty, 
and  its  occurrence  has  been  recorded  in  patients  under 
twenty.  Norman  Walker's  t  statistics  give  the 
average  age  for  the  commencement  of  the  disease 
as  forty.  The  affection  occurs  with  about  equal 
frequency  in  the  two  sexes.  Kodent  ulcer  is  distin- 
guished from  other  cancers  by  the  limited  amount  oi 

•  Snl.  Jmm.  Dfrm.,  Sept.,  1893.  t  J-ie.  cif. 


5'J()  MALiriNANT  NEW  GROWTHS.    [cHiP.  j 

new  growtli,  by  the  slownesa  of  ita  progrees,  and  I 
the  absence  of  glandular  infectioD.  From  liq 
vulgaris  it  is  difierentiated  by  th^  absence  of  app( 
jelly  nodules,  by  the  age  of  the  patient,  and  by  ti" 
mode  in  which  it  begins.  From  tertiary  syphilH 
ulcers  it  is  dietingaished  by  the  granular  base, 
usually  Bohtary  character  of  the  ulcer,  and  the  r 
ance  to  treatment.  The  practitioner  must,  howew 
be  on  his  guard  against  being  misled  by  the  ' 
improvement  that  sometimes  takea  place. 

If  the  growth  be  not  freely  removed  or  destr 
it  will  continue  to  progress  till  it  ends  in  (' 
Hideous  deformity  may  be  produced  by  the  ext 
of  the  ulc«r  ;  and  if  sensitive  parts,  such  as  the  tt 
ball,  are  afEected,  the  pain  may  be  so  great  a 
life  almost  unendurable.  The  treatment  is  I 
excision  wherever  this  is  practicable.  The  i 
, cautery  followed  by  caustics  may  sometimes  «fil. 
a  cure.  Even  where  the  disease  has  been  allowed^ 
progress  so  far  that  neither  of  these  i 
applicable,  the  advance  of  the  disease  may  be  i 
tardod  by  the  application  of  strong  antiseptic  J 
ings.  Finsen's  light  treatment  has  been  sue 
in  several  cases  in  my  hands,  but  in  my  expeaist 
it  is  inferior  to  the  X-rays,  A  considerable  t 
of  cases  cured  by  the  latter  method,  the  ufw  nt  vbl 
for  the  purpose  was  suggested  by  f  teuheck  oi  8to( 
holm,  have  now  been  reported  :  •  it  remains,  bowei 
to  l>e  seen  whether  the  eflert  will  be  jiermanent. 

Sarcoma  of  the  skin.— The  skin,  accordiox  to 
Babes,  is  the  moiit  frequent  source  of  sarcoma  ;  hnl. 
as  Kaposi  points  out,  in  the  majority  of  ca<e.»  tlir 
proeess  in  the  skin  is  secondary  to  gwiwlh.-  •■•■m- 
mencing  in  the  lymphatic  glands  or  thf  il.vp.T 
structures.     A   tumour   which   arises   in    pn!\ii>[ii'lr_ 


011(1  J.  H.  SulUeiRi.  > 


iiidDore,  Bnl.  Mnl.  Ji« 


■ 

1 

r^^~  . 

w. 


SARCOMA   OF   THE    flKIl^. 


formation  of  secondary  growths  in  the  viaeera.  They 
owe  their  peculiarities  to  the  rapidity  of  their  forma- 
tion, wltich  leads  to  hremorrhage  and  determincH 
the  rapid  clinical  course. 

Sarcoma  may  be  taken  as  a  type  of  malignant 
growth.  Its  chief  characters  are  unlimited  local 
extension,  with  infiltration  and  destruction  of 
neighbouring  tissues,  and  (when  situated  on  skin 
and  mucous  membranes)  rapid  ulceration.  Secondary 
deposits  in  sarcoma  are  usually  due  to  the  growth 
invading  and  projecting  into  veins,  in  which  detached 
particles  are  carried  to  the  heart,  lungs,  etc.  Exten- 
sion along  lymphatics  is  also  met  with,  and  the  glands 
may  be  enlarged  throughout  the  body.  Subsidence 
and  scarring  are  very  rare.  Congenital  sarcoma, 
sarcoma  appearing  early  in  life,  and  sarcomatous 
tumours  of  the  melanotic  variety,  are  usually  highly 
malignant. 

A  round-celled  sarcoma  differs  but  little  in  struc- 
ture from  a  mass  of  granulation  tissue.  The  blood- 
vessela  have  thin  walla,  and  active  budding  takes 
place  from  the  cells  which  constitute  their  walls, 
All  sarcomata  are  remarkably  vascular,  and  the  walls 
of  their  vessels  being  thin,  hssmorrhages  are  frequent. 
The  central  parts  of  sarcomata  tend  to  degenerate, 
like  those  of  gummata  and  tuberculous  masses  ;  hence 
anfractuous  cysts  are  common.  Melanotic  sarcomata 
owe  their  special  features  to  pigment  granules  being 
deposited  in  some  of  the  sarcoma  cells.  When  there 
la  a  formation  of  spindle-cells  parallel  to  the  long 
axis  of  the  vessels  of  the  tumour,  while  round  cells 
collect  in  the  spaces  so  formed,  the  "  alveolar  sar' 
coma"  is  constituted.  In  one  variety  (lipomatous) 
the  cells  become  loaded  with  fat.  Until  Virchow 
established  the  difEerential  characters  of  sarcomata  as 
compared  with  epitlieliomata,  these  two  groups  were 
Included  together  as  cancers. 


«)  MALiaSJXT  A'EK"  (SROWTHS.    (c» 

Sarcoma  is  markedly  inlective  in  the  body  whoa  1 
once  established  there.  It  is  commonest  at  and  aftfJ  I 
middle  age,  but  may  occur  ia  childhood.  Ulcerakd  I 
sebaceous  cysts  often  present  the  appearance  of' I 
malignant  growths,  and  indeed,  if  long  aeglevUiL  ' 
may  form  starting-pointe  of  such  tumours. 
prognosis  of  sarcoma  is  extremely  bad, 
being  the  rule,  however  freely  removal  be  carried  ] 
at. 

The  only  treatment  is  complete  removal  st  Uia  ] 
earliest  possibie  moment,  whencYer  this  is  prKctic- 
able.     Lassar,  Kobner,  and  Shattuck  have  repOftMl   { 
good  results  from  sul>cutaneous  injections  of  Fo 
solution,  diluted  with  two  parts  of  distilled  i 
beginning    for   an    adult    with  in^iv,  increased  aius  | 

I   &  time  to  n^T-     Pospelow  *  has  given  oraento  intern- 
ally  in    the    form  of  Asiatic  pills  (s6e  p.  .>0)  witk  1 
good  results.      1  have  also  used  this  method    with  | 
success. 

Mycosis  fulig'oides  (Fige.  55  and  .'>•'>).— To  thift  J 
>w  welt -recognised  disease  various  names  have  b«ei  J 
given,  but  the  one  used  here  was  applied  to  it  I 
Alibert,  as  indicative  of  the  nabed-ey 
and  not  as  a  pathological  descriplion.f     The  Itwioni 

L.  in  the  early  stage  are  dull  red  or  livid  patches,  var)'in{ 
'n  size  from  that  of  the  finger-nail  to  that  of  the  p 
of  the  hand,  with  borders  sometimes  wul!  mvlceii 
sometimes  fading  o'S,  occasionally  flat,  but  more  oftfi; 
raised  or  thickened.  The  patches  are  smooth  i 
dry  at  first ;  later  they  become  scaly,  and  at  last  ti 
may  be  moist  or  covered  with  crusts, 
appearance  of  the  lesions,  Erasmus  Wils( 
affection  "  eciema  tuberculatum."  nod  1 


'  Jrrk.f/ar  IkTul. 


!i„ph.,^A.  1 


■rlclgf  of  Ihis  diwHut,  which  bMio*  1 

lewnl-sd  it,  Hr  PiUi'iipr,  •■  M)fi«fc  1 


riiiP.  xxiv.l  MyOSlJ^  FU.VOOtDKS.  ml 

stage  of  the  disease  French  dermatologists  have 
given  the  name  "  eczema  premycoai forme."  Nevins 
Hyde  and  F.  H.  Montgomery,  who  have  made  a 
special  study  ol  this  stage,*  eonsider  that  it  is  just  as 
much  a  manifestation  of  the  disease  as  that  of  tumoui 
formation,  and  that  the  poison  is  in  operation  as  soon 
as  the  early  pruiiginous  symptoms  are  manifested. 
They  sum  up  as  follows  :  "  The  facts  point  to  a 
systemic  origin  for  mycosis  hmgoides  as  definitely 
and  aa  unmistakably  as  a  glycosuric  xanthoma  points 
to  a  condition  which  by  no  possibility  could  have 
been  explained  by  any  examination  merely  of  its 
cutaneous  lesions."  Dnbreuilhf  has  reported  a  case  in 
which  there  was  no  premycoaic  stages,  the  tumours 
being  the  first  manifestations  of  the  disease.  In  the 
premycosic  stage  the  disease  is  often  mistaken  for 
eczema,  urticaria,  or  eiythema.  These  early  phe- 
nomena may  be  slight  or  absent.  In  a  later  stage 
the  moist  eczematous  surface  becomes  more  and 
more  intiltratcd,  so  that  tumours  project  above  the 
level  of  the  skin.  They  may  be  as  smalt  as  a  pea,  or 
as  large  as  an  apple  {A.  Neisser).  They  are  firm  and 
lobulated,  broader  at  the  free  end  than  at  their 
attacliment  (somewhat  resembling  tomatoet.,  whence 
the  term  "  fungoides ").  Their  surface  may  be 
smooth  and  moist,  or  else  excoriated  and  covered 
with  crusts. 

The  lesions  are  not  arranged  according  to  any 
plan.  Any  part  of  the  body  may  be  affected  The_, 
have  been  observed  on  the  mucous  membranes  of  the 
mouth,  the  uvula,  and  the  soft  palate.  The  eczema- 
toid  stage  may  last  for  many  months  or  even  years 
before  tumour  formation  begins.  This  is  not  always 
regularly  progressive,  for  many  of  the  patches  may 
disappear  whilst  new  ones  are  forming  around  them. 


fi02  MALIGNANT  HSW  OHHWTII& 

Ab  a  rule  '  however    progresaive  thickpning  occare,  I 
papillatedf  ooditiOE  (lichenoid  plaque)  often  l>eiB| 
obBerved^  before    fungation     Freah    tumours    roiy  ■ 
develop  on  the  Bite  of  previous  tumours  that  havf 


disappeared.    On   the   whole,   the   dJe^aM  stm 
progresses  and  wears  out  the  patient,  who  becomi 
emaciated  and  dies  of  pneumonia,  iliarrhtp 
other  complication.     In  one  case,  however  (B 
recovery  is  recorded  tx)  have  taken  plKC«  aft«r  I 
attack  of  erysipelas.    Sometimes  the  fiiat  or  e- 


y.] 


jV  YCOSIS  FUNOOWKS. 


toid  stage  of  the  disease  is  wanting,  and  the  tumoor 
formation  is  the  first  evidence  of  tlie  malady.  The 
duration  of  the  disease  is  usually  from  six  months  to 
as  many  years,  or  even  longer.  In  the  early  stage 
the  symptoms   are  intense  itching,   and  sometimes 


burning  pain,  causing  loss  of  sleep  and  impairment 
of  health.  As  a  rule,  however,  the  general  health 
remains  fairly  good  until  many  tumours  have  formed. 
The  growths  are  devoid  of  sensibility.  The  lymphatic 
glands  may  be  enlarged  throughout  the  body,  as  in 
lymph  adenoma.     In  the  early  stage  the  afiection  may 


MALIOSAST  SEW  OHOWTHS.    fc«*r.  i 


be  indiBtanguishable  from  some  forms  c 
other  ej-uptioue.     In  obstinate  eczematoua  conditioa 
the   possil)ility   of  the    case   being  one   of 
fongoides  should  be  borne  in  mind.     The  tmnoimj 
are  composed  of  small  round  cells,    supported  bfl 
scanty  fibrous  tissue,  thus  resembling  Ivmphadenomi.  J 
Indeed,  some  authors  regard  the  affection  as  a  lymph*-  I 
denoma  of  the  akin  ;  others  look  upon  the 
as    granulation    tissue    formed   by    an   infection  «f  I 
micrococci.     Like  that  of  lymphadenonia.  tlie  dinrt- J 
cause  of  the  afiection  is  unknown.     The  extremre  ol 
age  are  twenty  to  axty  years,  but  it  is  commt 
between  forty  and  fifty.     Males  are  more  frequi 
attacked  than  females.     The  genexai  aspect  of  t 
affection,  like  sarcoma  and  cancer,  suggests  s 
sitic   origin,    but  this   as  yet   has  not  been  f 
Payne  *  showed  that  the  micrococci    described  1 
various  authors  are  probably  accidental. 
working  under  Wernicke,  haa  described  cocddia  b 
the  lesions. J     Except  in  the  one  case  already  ref 
to.  the  affectiou  has  always  ended  in  death, 
time  has  been  as  short  as  njne  weeks  and  as 
as  thirty  years,  as  in  a  case  recorded  by  Dubredlh, 
No  treatment  appears  to  have  any  influence  on  tl 
process.     All  that  can  be  done  is  to  reheve  symptomi 
and  maintain  the  health  as  far  as  possible  by  ge. 
tonic  measures.     In  a  case  under  my  care  the  u 
resorcin    ointment  (gr».  xj^    lo   ^j)  wan  followed  1 
considerable  local  improvement, 

Kaposi's  disease,  or  xerodermia  pigmentoeiu 
is  an  extremely  rare  affection,  wliich  was  first  dMcnbf 

•  ;--M.  &K.   Tiau:.  vol.  ixiTii.  (IHHU),  p.  22 

t  Wernitke.  VrHlralh,  f.  Bail..  Ih'OMnbor 28,  IS92. 

X  For  AD  Bihftiuti*e  studf  at  the  histology  «nij  Imc* 
mjiiisn  fiiDfcoiileB  m  ■  (Wwr  hj  J.  OrIIowu-  mad  J.  U.  H.  1 
k<od.  Bill.  Joam    /ii-i-ni..  Majr  and  Jnnc.  1900       The  rmlbi  d 
tlie  tmcterioliwicaJ  exunmntian  were  mc^lire. 

g  AH',  de  b  pBialiHiipu  it  Banleuiu,  UaTcb,  I8W. 


OHAP.  xsty.l  KAPOarS    DISEASE.  tHIS 

by  Kaposi,  In  England  the  first  cases  deserilied 
were  those  of  Crocker,*  to  whom  I  am  Indebted  for 
permission,  to  reproduce  an  illustration,  of  one  of  them 
(Fig.  57),  which  gives  a  good  idea  o!  the  appearance 
of  the  disease.  It  is  characteriaed  by  the  formation 
of  numerous  tumours,  which,  though  apparently 
benign  in  the  early  stage  of  their  development,  run  a 
malignant  course,  and,  after  extensive  destruction  of 
tissues,  cause  the  death  of  the  patient  by  eshauatiou. 
The  initial  lesions  are  small  pigmented  spots,  resemb- 
hng  freckles,  but  rather  darker,  which  appear  chiefly 
on  the  lace,  neck,  arms,  and  legs,  the  area  of  distribu- 
tion corresponding  pretty  exactly  with  the  parts  of 
the  skin  often  left  uncovered  in  infancy.  Erythe- 
matous patches  or  papules,  like  those  of  the  measles 
eruption,  sometimes  precede  the  "  freckles."  The 
latter  usually  come  and  go  for  a  time,  disappearing  in 
the  winter,  to  return  in  the  summer ;  after  a  time 
they  become  permanent,  and  the  colour  tends  to 
deepen  till  they  are  often  quite  black.  They  are 
irregular  in  outline,  vary  in  size  from  a  pin's  head  to 
a  pea,  and  are  generally  thickly  crowded  together, 
especially  on  the  face.  For  some  time  the  condition 
suggests  nothing  more  than  excessive  freckling,  but 
by-and-by  further  lesions  appear  among  the 
"  freckles  "  in  the  form  of  white  glazed  atrophic 
spots,  which  often  run  togetder,  forming  scar-like 
areas ;  teSangiectaees,  stellate  and  striate ;  and 
superficial  ulcers  discharging  pus  which  is  auto- 
inoculable,  and  which  dries  into  yellow  crusts  under 
which  heahng  takes  place,  followed  by  a  good  deal  of 
cicatricial  contraction.  Lastly,  after  some  years, 
small  warty- looking  growtlis  develop  on  the 
"  freckles,"  This  event  marks  the  entrance  of  the 
disease  on  a  more  formidable  phase  of  its  evolution. 
Tumours    form    and    ulcerate,    producing    fungous 

•   Jlri/.  Chir.  Tram.,  iaS4. 


SfALIQ^'AXT  XEW  GROWTHS,    [cb 

LSiies,  the  procesa  extending  both  widely  and  deepl/,1 
and  destroying  every  tissue  that  comes  in  it«  waV^ 
a  case  recorded  by  M'Call  Anderson  *  the  wbncl 


of  the  face  and  part  of  the  neck  were  eatvn  away,  \Wm 
ulcBiating  process,  starting  from  three  foci  (nose,  lipj 
and  cheek),  having  resulted  in  the  exiavalioa  of  Irl 

Jr".  Jm>n<.  Ihrm..  Decembei',  1892.     Tfae  paper  it  illuilnML  I 


CHAP,  XXIV.]  KAPOSI'S    DISEASE.  607 

huiie  pit,  the  greatest  depth  of  which  in  the  face  was 
about  1^  inches,  in  the  neck  about  f  inch.  "  The 
destruction  involved  the  external  auditory  canal  and 
the  lower  purtion  of  the  temporal  bone,  the  zygoma, 
wliich  had  entirely  disappeared,  the  posterior  half 
of  the  lower  jaw,  includine  the  condyles,  the  palatal, 
and  the  supeiior  maxillary  bonea.  In  the  upper 
part  of  the  floor  of  the  ulcer,  behind  the  right  orbital 
plate,  there  was  an  opening  admitting  the  point  ol 
thv  finger,  into  which  the  probe  passed  easily  1  inch 
upwards  and  3  inches  in  a  backward  direction.  .  .  .  : 
On  the  removal  of  the  brain  the  anterior  part  of  ihe 
under  surface  of  the  temporo -sphenoidal  lohe  was 
found  to  communicate  with  the  floor  of  the  ulcer 
through  the  above  aperture.     Almost  the  entire  floor 

of  the  middle  foasa  was  ulcerated  away The 

gap  in  the  middle  fossa  measured  2  inches  by  IJ 
inuhes.  There  was  also  a  large  gap  in  the  lower  part 
of  the  frontal  bone  menauring  1^  inches  by  1  inch. 
The  anterior  part  of  the  ethmoid  and  of  the  nasal 

bones  was  destroyed There  was  no  lesion  in 

anv  of  the  other  organs."  The  fact  last  mentioned 
agrees  with  what  is  recorded  in  the  majority  of  other 
cases,  general! 3 ali on  of  the  disease  rarely  if  ever 
occurring.  This  accounts  for  the  relatively  slight 
effect  which  it  has  on  the  health  until  near  the  end, 
when  emaciation  (from  difficulty  of  taking  foodj  and 
e,shaustion  supervene,  and  a  slight  h»morrhage  may 
close  the  scene. 

Nothing  is  known  as  to  the  etiolog'y  of  this 
tirriblo  affection,  beyond  the  fact  that  exposure  to 
the  sun  may  be  an  exciting  influence,'  but  it  is  clear 

"  "  by  ElBBnbarg  {Arel'.f.  Urrm.  «.  ,Sy/)A., 
to  the  sun  ou  n  hot  BUinmer'i  dii<r  at  the  uge 
updiately  followed  by  an  aruptdon  of  small 
erytheinntous  patehea  dd  the  face,  neuk,  and  hands.  TIibbb  soon 
became  trensfonned  inCo  "  fret'k1», "  und  tbe  disease  a,fteFwardB 
fallowed  the  line  of  evolutiou  indicated  in  the  text. 


608  MALIGNANT  NEW  GROWTHS,    [chap.  mv. 

that  some  special  predisposition  must  exist.  The 
disease  generally  attacks  two  or  more  meml»er8  of 
the  same  family,  often  selecting  its  victims  exclu- 
sively from  one  or  other  sex.  The  sexes  are  equally 
liable.  It  generally  begins  within  the  first  two 
years  of  life,  but  it  has  been  known  to  commence 
in  middle  age. 

The  pathology  of  the  disease  is  very  obscure. 
Kaposi  beUeves  that  the  change  commences  in  the 
papillary  body  and  epidermis,  extending  thence  to 
the  true  skin.  The  primary  pigmentation  is  due  to 
atrophy.  The  tumours  are  epitheliomatous  in  struc- 
ture, a  fact  which  suggests  that  the  process  is 
analogous  to  the  cancerous  degeneration  that  not 
unfrequently  takes  place  in  pigmented  moles  in  elderly 
persons. 

When  the  disease  is  fully  established  it  tends 
steadily  to  a  fatal  issue.  The  commencement  of 
tumour  formation,  which  may  be  called  the  patient's 
death-warrant,  has,  however,  been  known  to  be 
delayed  for  many  years,  but  this  is  altogether 
exceptional. 

The  treatment  can  only  be  palliative.  Auto- 
inoculation  of  pus  from  the  early  ulcers  should  as  far 
as  possible  be  prevented,  and  the  tumours  should  be 
excised  as  soon  as  thev  are  noticed.  The  earlv  and 
thorough  appUcation  of  this  method  offers  the  only 
chance  of  checking  the  disease. 

The  work  of  Bowles  and  others  on  the  action  of 
lisht.  especially  reflected  light,  on  the  sldn  suggests 
that  possibly  something  might  be  done  in  the  early 
stages  of  the  disease  by  the  appHcation  of  reddish  and 
brown  pigments  (salve  sticks),  and  exclusion  of  the 
sun's  ravs. 


MALFORMATIONS. 

There  remaiu  to  be  conaidered  certain  couditions 
which,  though  clearly  not  belonging  to  any  ol  the 
categories  in  which  the  diseases  already  deiicribed 
have  been  provisionally  grouped,  it  is  difficult  to 
classify  on  the  baaiu  of  any  distinctive  feature  common 
to  them  all.  Inasmuch  as,  though  they  are  not 
always,  strictly  speaMng,  congenital,  they  depend  on 
an  error  of  development  of  some  kind,  I  have  ventured 
to  bring  them  together  under  the  head  of  "  malfonna- 
tions."  This  term  must  not,  however,  be  understood 
as  implying  a  definition  ;  it  is  used  merely  as  a  desig- 
nation, neutral  and  temporary  in  character,  for 
conditions  which  await  the  dawn  of  a  fuller  knowledge 
of  their  pathogenesis  before  they  can  be  finally 
classified.  These  conditions  include  ichthyosis,  with 
its  degrees  and  varieties,  tyloais,  sclerema  neonatorum, 
tedema  neonatorum,  and  albinism. 

Ichthyosis  is  an  affection  characterised  by  dry- 
ness of  the  skin,  wliich  becomes  scaly  (hence  the 
name,  from  i\6i(:,  a  fish)  and  rough,  and  often 
warty.  The  afiection  occurs  in  three  principal  forms, 
distinguished  as  xerodermia,  ichthyosis  simples,  and 
ichthyosis  hystris.  The  two  former,  though  chnic- 
ally  distinct,  are  pathologicaUy  identical,  being  the 
results  of  a  process  which  manifests  itself  in  varying 
degrees  of  intensity,  of  which  they  may  be  takea  as 
the  extremes.  The  third,  thouf^i  belonging  to  the 
same  nosological   genus,   is  a  distinct  species.     All 


MALFlHiMATlONS. 


[cnir.  UT 


■f^*k. 


^^m  oio 

^^H    three  are,  aa  a  rule,  congenital,  though  the  conditiat 
^^H    ia  seldom  noticed  till  some  Uttle  time  after  birth 
^^H     exceptional  cases  it  'm  acquired. 
^^H  Xerodermia,  which  is  the   commonest  bprm 

^^H  ichthyosis,  is  often  nothing  more  than  a  dry 
^^F  condition  of  the  skin  ;  little  or  no 
and  the  hair  follicles,  especiallj' 
aspects,  project  on  the  surface  of  the  skin,  giving 
the  hand,  when  passed  ovej  it,  the  feeling  of  a  nul 
grater  (keiatasis  piloTis).     In  the  more  marked 

I  the  epidermia  is  distinctly  thickened,  and  the  ni 
lines  are  better  defined  than  in  normal  skin. 
Ichthyosis  simplex  is  characterised  bf  nt 
scaliness  of  the  skin,  which  sometimes  appeon 
be  covered  with  a  dense  homy  cuirass,  bke  ihe  ' 
of  a  crocodile.  The  colour  of  the  ecalra  vani 
according  to  their  age  and  portion  from  while  I 
dark  green  and  black.  The  whole  sidn  is  aSecta 
bat  in  widely  different  degrees  of  severity,  ll 
extensor  surfaces,  especially  the  elbows  and  koM 
nearly  always  sudering  most :  occasionally  «rai1 
growths  develop  in  these  situations.  <)n  tho  othi 
hand,  the  flexures  and  the  palms  and  sol«a  an 
paratjveiy  little  affected,  and  the  face  also  is 
or  less  spared.  The  hair  participates  in  the 
dryness,  and  becomes  dull  and  brittle ;  tin 
break  easily.  The  sebaceous  as  well  as  th« 
socretion  is  deficient,  though  neither 
suppressed ;  and  patients  are  usnally  batter 
summer,  when  the  glands  act  more  freely. 

The  m0)«t  marked  subjective  symptoni  is  an 

I   aggerated  ^nsitireness  to  cold,  but  tliere  is  al 

good  deal  of  itching.     The  skin  "  uhajM  "  readily 

I  deeply,  and  is  particular!}'  prone  to  become  tha 

1   of  ecsema.  which  adds  greatly  lo  the  safenag 


I  the  patient. 

Acquired  ichthyi 


I  seldom  geneni,  ■ 


CHiP.  sxv.]         WHTHYOSW    UYSTBIX  nil 

usually  been  seen  in  association  with  neuritis  or 
some  centra!  nerve  disease. 

Ichthyosis  hystrix  (SurpiS,  a  porcupine)  is  a 
rarer  affection  than  those  just  described.  It  is  never 
universal,  but  is  occasionally  seen  in  association  with 
xerodernua.  Its  distribution  often  appears  to  cor- 
respond to  that  of  the  cutaneous  nerves,  the  lesions 
being  arranged  longitudinally  on  the  limbs  and 
transversely  on  the  truak.  Unna,  however,  thinis 
that  it  follows  the  embryonic  lines  of  fissure.  The 
lesions  are  small  papillary  growths  with  horny  tops, 
which  Btud  the  skin  as  with  tiny  nail-heads  ;  these 
may  develop  into  large  warty  masses  or  concretions 
like  limpet  shells,  rising  sometimes  to  a  height  of  half 
an  inch  or  more  above  the  level  of  the  surrounding 
akin.  The  affection  may  be  very  widespread,  and 
in  situations  where  the  warty  projections  are  liable 
to  injury  may  cause  a  good  deal  of  inconvenience, 
but  otherwise  it  gives  rise  to  no  symptoms.  When 
localised  in  the  track  of  a  particular  nerve  it  is 
sometimes  described  under  the  name  of  papilloma 
neuToticum. 

All  varieties  of  ichthyosis  are,  as  a  rule,  congenita], 
tliough  there  is  usually  no  very  obvious  abnormality 
in  the  skin  till  some  little  time  after  birth.  In  some 
cases,  however,  the  skin  is  seen  to  be  peculiarly  smooth 
and  glazed  as  soon  as  the  vernix  caseosa  is  removed  ; 
and  in  others  a  remarkable  condition  has  been 
observed  in  the  skin  of  the  itetus,  which  is  covered 
with  thick  epidermic  plates,  separated  by  vertical  and 
horizontal  fissures  into  square  patches,  like  the  parti- 
coloured garment  of  Harlequin  ("  harlequin  fcetus  "),♦ 
Ichthyosis  is  always  hereditary.  Both  sexes  are 
equally  liable  to  the  affection.  Beyond  the  fact  that 
the  condition  clearly  depends  on  an  error  in  develop- 


r 


MALFORMATIONS. 


meat,  nothing  ia  known  as  to  its  pathogenesis, 
process  appears  to  consist  in  increased  formafel| 
of  epithelial  cells,  which  undergo  rapid  keratinisatii 
TommasoU  *  has  found  lesions  in  the  cutis  as  V 
as  the  epidermis,  as  indicated  by  the  presence  I 
round  or  fusiform  cells,  dilated  veasela,  ai 
numbers  of  oval  or  flattened  nuclei.  He  is  thervlffr 
inclined  to  regard  ichthyosis  as  the  expressioi 
catarrhal  condition  of  the  skin.  Hutchinson  think* 
ichthyosis  "  an  intensified  form  of  psoriasis,  beginning 
at  ft  very  early  period,  and  deriving  peculiaritin 
accordin^y."     With  that  opinion  I  cannot,  however. 

The  disease  can  hardly  Iw  miataken.  There  is  little 
prospect  of  a  cure  being  eflected,  but  treatment 
can  generally  alleviate  the  condition.  The  indication* 
are  to  remove  the  scales  and  keep  the  skin  soft  aud 
flexible.  This  is  best  done  by  the  free  use  of  soh 
soap  with  warm  baths,  alkaUne  or  bran,  and  vigorous 
friction.  Inunction  with  lanolin  or  other  fatty 
material  should  follow  the  cleansing  process.  The 
treatment  must  be  regularly  persevered  with,  othei- 
wise  any  advantage  gained  will  speedily  l>e  liwt.  Tlw 
growths  of  the  hystrix  variety  should  be  removed, 
if  convenient.  Salicylie  acid  will  suffice  for  the 
smaller  ones,  but  the  la^e  growths  must  br  excised 
or  scraped  away. 

Tylosis  is  a  condition,  affecting  the  palmn  and 
soles,  which  consists  in  thickening  of  the  cpidenniaj 
into  a  homy  plate,  generally  dr>'  and  smooth  on  th^j 
surface,  sometimes  worm~eaten.  In  the  ltH>t  unit'  tlufl 
part  that  comes  in  contact  with  the  ground  in  wslLiiofl 
is  affected.  The  condition  is  aa  a  rule  coQgeniU^| 
but  may  be  the  result  of  the  long-imntinDeoH 
administration  of  arsenic,  or  ot  hyperidroais.     In  thjj 

-  Uwn.  lul.  <M^  M»hu»  r>-tr»  f  d,a,  ftlh.  S^  .  !««,■ 
ud  ilauik,  18»t.  ■ 


CHAP.  XXV.]      SCLEREMA   NEONATORUM.  013 

former  case  the  afEection  begins  with  the  formation 
of  papules,  which  develop  into  nodules  aud  hy-and-by 
into  a  uniform  callosity  ;  in  the.  latter  the  thickening 
conunences  round  the  sweat  follicles,  and  the  aflected 
epidermis  is  sodden  as  well  as  thickened.  Both  sexes 
are  equally  liable,  and  the  condition  is  sometimes 
hereditary  (Fig.  58). 

Homy  thickening  of  the  palma  and  soles  may  be 
a  secondary  condition,  due  to  infiammatory  proeeases, 
such  as  eczema,  psoriasis,  syphilis,  etc.  These  forms 
of  tylosis  have  been  referred  to  in  connection  with 
the  several  diseases  of  which  they  are  the  result. 

In  congenital  cases  little  good  can,  as  a  rule,  be 
looked  for  from  treatment,  but  the  persevering  use  of 
salicylic  acid  in  ethereal  solution  (10  per  cent.)  or  in 
a  plaster-mull  has  been  succesaful  in  Unna's  hands. 
The  acquired  condition  may  be  dealt  with  in  the  same 
way.  Ichihyd,  combined  with  salicylic  add  in  an 
ointtnenl,  has  been  found  satisfactory  by  Brooke. 

Sclerema  neonatorum  is  a  peculiar  indura- 
tion of  the  skin  which  is.  generally  congenital,  but 
oecasionally  becomes  developed  within  a  few  days 
after  birth.  The  skin  becomes  waxy  in  appearance, 
hard,  tense,  and  cold,  the  baby  lying  motionless  as 
it  its  face  and  limbs  were  fixed  in  death.  The  body 
can  be  lifted  with  one  hand  as  if  it  were  frozen.  The 
temperature  is  subnormal,  the  breathing  very  slow 
and  feeble.  The  child  cannot  open  its  mouth  to  suck, 
so  that  what  little  flicker  of  life  there  may  be  is 
speedily  extinguished.  The  condition  may  be 
acquired  consecutively  to  acute  wasting  illness 
(diarrhcea,  pneumonia,  etc.),  or  may  be  the  result  of 
malnutrition.  According  to  Parrot,  the  anatomical 
changes  are  desiccation  of  the  skin,  with  thickening  of 
the  layers  and  diminution  of  the  tat,  but  no  true 
sclerosis. 

A  somewhat  .timilar  i-ondition  is  oedema  neona- 


I 

^^^BUbinism.  614 
^^^Aleppo  boil,  394 
Alopocio,  532 

•  ,  Treatment— 

Ijoml,  lanolin,  533  ;  Etima- 


niSEASES   OF    THE    SKIN. 


eury,  3(12; 


g  lotions,  533 
OoniilitiitioKal,         thyroid 
fct'ding,  63i 

aroata,    534 ;     ettologj, 

63B  :   epidenu(9  of,  638 

J  Treatment — 

Loeai,    dirjBacobin,    539  ; 

canthatidis. 


I 

^^^H  oil    of    mnstard,    539 ; 

^^^^B  strong    liquid    carbolic 

^^^^M  acid,      540 ;       Butphut, 

^^H  540 ;       Finaen's      light 

^^f  method,  540 

C'onslitulional,  tonioa,  639 

sjphihtio,  456 

Amboyua  button  (Tnwa),  490 
AntestheBia,  14 
Angiokerfttoma,  559 

,  Treatment— 

Local,  electrolysia,  Sfll 
Angioma,  cutaneous,  555 

,  infectiTB,  561 

,  Treatment- 

Looil,  Q^ectrolyBia,  552 
Angio- myoma,  564 
Angio -neuroses,  55,  77 
Angio-neutotio  a>dema,  80 
Anidrosis,  522 
Anthrax,  383 
Antifobrin,    eruptiana    caused 

by,  225 
Antimony,     cniptions    canaed 
by,  i"- 
iljpruri 
itipyriQ, 
by.  a 
bititoxio  eniptjoim 


Appendages,  epidermic, 

of.  506 
Argenti        iiitras.       ii 

caused  by,  '2St\ 
Ariiioa.   emptions   caiwMl  hf^ 

228  ^ 

AtBenic,  ornptions  cad 

ai7 

,    epitheh'onia   eausn)  I 

piotonged  Dae  of,  :!IB- 

.  keratosia  caused  by,  IT^ 

.  peripheral  neuritiscal' 

by,  21S 

Artificial  cruptioua,  202 

"  Asiatic    gull,"    formols    . 

method  of  adminlstrab 

69 ;  in  lichen  ruber  pJw 

1 7S  ;    in  psoriasis,  3ftl ; 


Ascomycotea    fungi    nod   i 


Bacilli  fouud  in  "  blue 
"  red  "  sweat,   19 

of  rmphyvcmntoUB  tta^ 

greue,  18 

Bacillua  f<£tiduB,  19 
of  aetinotnyMHifl,  IB 

of  anthnuc,  3fi3 

— —  of  diphtheria,  18 
of  ^roay,  17.  401 

of  rhinosoleronia,  19 

oJayphnio.  17 

■ aycnaifMTMi  finlidna,  31 

tubrrciiloais,  41(1 


INDEX. 


617 


Bacteria  on  the  surface  of  the 
skin,  20 

,  pyogenic,  normally  pre- 
sent on  skin,  15 

in  eczema  seborrhoeicum, 

20 

Bacteriology  of  the  skin,  13 

Bacterium  foetidum,  519 

Bakers,  skin  eruptions  in,  204 

Baldness,  532 

,  Treatment — 

Loady  lanolin,  533  ;  stimu- 
lating lotions,  533 

Balsam  of  Peru,  eruptions 
caused  by,  226 

Balsamic  erythema,  220 

Beaded  hair,  530 

Bed-sore,  105,  197 

BeUadonna,  eruptions  caused 
by,  221 

Bilharzia  hsematobia,  8,  313 

Biskra  button,  394 

Blastomycetic  dermatitis,  402 

,  Treatment — 

Constitutionalf     iodide   of 
potassium,  404 

Blebs,  definition,  of,  12 

Bloody  sweat,  521 

Blue  sweat,  521 

"  Bodies,"  cancer,  in  car- 
cinoma, 9 

,  in  Paget's  disease, 

9 

Boil,  Aleppo,  394 

,  Delhi,  394 

Boils,  378  ;  parasites  of,  379  ; 
treatment  of,  380 

Boraeic  acid,  eruptions  caused 
by,  226 

ointment,  61 

Borate  of  sodium,  eruptions 
caused  by,  226 

Bot-fly,  8 

Brain,  its  influence  in  pro- 
duction of  skin  eruptions, 
51  ! 


Bromide  eruptions,  210 
,  Treatment— 

ConstittUional,     arsenic, 
234 ;    salol,  234 
Bromidrosis,  519 

,  Treatment— 

Local,    frequent    washing, 
519,    disinfection    with 
boric  acid,  519  ;  mutton 
suet,  519  ;  chromic  acid, 
520 
Bronzing  of   skin     in     Addi- 
son's disease,  189 
Brooke's    ointment  for  lupus, 

formula  of,  436 
Bug,  lesions  caused  by,  334 

harvest,    lesions    caused 

by,  335 
Bullae,  definition  of,  12 


Cade  oil,  eruptions  caused  by, 

226 
Calamine  lotion,  61 
Calculi,  cutaneous,  515 
Callosities,  586 
"  Cancer  bodies,"  9 
Cancer  of  the  skin,  590 

caused  by  arsenic,  218 

en  cuirasse,"  590 
,  Treatment- 


it 


Constitutional,    morphia 
hypodermieally,  591 
— : —  melanotic,  591 
Cannabis      indica,      eruptions 

caused  by,  226 
Cantharides,  eruptions  caused 

by,  227 
Carate,    394 ;     treatment    of, 

397 
Carbolic  acid,  eruptions  caused 

by,  227 
Carbuncle,      381  ;      diagnosis, 

382  ;       pathology,      382 ; 

etiology,  3S2  ;    prognoflis, 

383 


^m 

^^BfllS                       DISSASBS    OF    THE   AT/A'. 

^^BxWbQQcle.      Treatment— 

if  pain,   cocsioe,  h»lk- 

^^^H         Loral,  free  painting  of  the 

donna,  or  opiom.   S» 

^^^^1             surface    with    glycedno 

ChemistB.    ekjn    eruption,   m. 

^^B             morcuiT-airbolia     pliw- 

204 

^^H             ter-innU.  333  ;  cmdal  in- 

^^^H             ciition,  383  ;  Bornpe  and 

L-higOB.  H  ;   lesions  rau.w.1 1.J. 

^^^B             Hyringe  cavity  witii  car- 

335 

^^H             bnUc   acid,   383;   iodo- 

Chilblain,   »5 

^^M             form,  3S3  ;    ^baeqneot 

-,  tnwtmeiit   of.  IW 

^^^H             tro&tment  on  antia^ptic 

^^^^H             principles.  383 

21» 

^^H             383;  perchlorideofiron 

^^H             and  qainine,  383  ;   mor- 

2-JI 

^^M             phia  if  necessary,  383  ; 

Cholera,  rash  in,  32 

Chromidrosis.  S!iO 

^^Hfiueation.     a     result     of    ■□- 

^^^H          flammRtion  of  the  skin,  4 

by,  227 

^^■"Cauliflower  growth,"  5^ 

^^^^H  CerDbro-apinal  meuingitid,  rash 

cansed  by.  227 

^^V         in,  32 

CicatriBation,   a   mult   of  in- 

^^VObancre,  hnnl,  450 

^^B .  soft,  452 

^^■'t%»rcot'a  bed-sore.  197 

aB8sificatiouofsicii.aflnTtio«,     „ 

21                                                II 

^^H ,  etiology,  141 

^^B ,  life    history    of    vesicle, 

,  AIibejt'8.  ai                 ^H 

^^M              141 

.  Auaeiti's,  23                ^H 

^^^1 ,  Byraptoms,  140 

^^H .Treatment— 

-~,  Bazin-s.  23                   ^M 

^^^^1          Local,    antipniritio   rpmc- 

,  Branson's.  i3             ^H 

^^1              dies. 

,  Fraok-s.  22                   ^H 

— ,  Hebra-s.  33                  ^M 

^^B               quinine.    142;    arsenic. 

-,  Hieronynina        Mm^^H 

alA'*.  21                    ^H 

Cheloid.  548 

.  Flenok'i.  S3               ^H 

,  multiple,  540 

-,  Turner'*.  21              ^^1 

1 ,  soar.  548 

,  Dona's.  34                ^H 

^^H -.  spoiitaiieoue,  548 

^^^' .  Treatment— 

.  WillBD-B.  m               ^M 

-,  Wilson's.  US                ^M 

^^^^1          fjtical,  pr<^8iire  with  elastic 

Cleavage     liiwe.      their     H^H 

^^B               549  :  de^p  ga^liing.  549; 

luionfl.  at                        ^H 

^^H             540;    Blectrolysis,  550; 

Coco  (Yan«).  400                     ^M 

INDEX. 


619 


Cold  cream,  61 
Colloid  milium,  574 
,  Treatment — 

Local,  erasion,  574  ;    elec- 
trolysis, 574 
Coloured  sweat,  521 
Comedones,  386,  515 

,Treatmeiit — 

Squeeze  out,  516 
Local,  wash  with  soft  soap 
and  hot  water,  516 ; 
kaoUn,  516 ;  sulphur, 
516 ;  resorcin,  516 
ConstUvtional,  stimulation 
of  hepatic,  digestive, 
and  menstrual  func- 
tions  if   necessary,  516 

,  grouped,  516 

Concretions  on  hair,  540 
Condyloma,  457 
Conjunctiva, "  essential  shrink- 
ing "  of  in  pemphigus,  145 
Copaiba,  eruptions  caused  by, 

220 
Cord,    spinal,    and    cutaneous 

eruptions,  51 
Corona  seborrhoeica,  253 

veneris,  456 

Corns,  585 

,  Treatment— 

Local,  salicylic  acid,  585  ; 
soak   with    acetic    acid 
then  rub  with  nitrate  of 
silver,  586 
Crab-louse(«cc  Pediculus  pubis) 
Crateriform  ulcer  of  Hutchin- 
son, 592 
Craw- craw,  lesions  caused  by, 

335 
Creams,  279 
"  Creeping  "  rash,  8 
Croton  oil,  eruptions  caused  by, 

227 
CrustsB,  13 

Cubebs,  eruptions  caused    by, 
220 


Cuirass  scirrhus,  590 
Cysticercus  cellulosse  cutis,   8, 

336 
Cysts,  dermoid,  546,  554 
,  sebaceous,  546 


Dandruff,  506 
Darier's  disease,  576 
Dartres,  AUbert's,  22 
"  Dead  fingers,"  191 
Degeneration  of  the  skin,  7 
Delhi  boil,  394 
Demodex  foUiculorum,  387 
Dermatitis,  artificial,  202 

,  blastomycetic,  99,  402 

caused  by  irritants,  4 

gestationis,  136 

herpetiformis,  128 

,  etiology,  132 

,  pathology,  134 

,  symptoms,  129 

,  Treatment— 

Hygienic,  regulated  diet, 
136 ;  no  stimulants  or 
coffee,  136 
Local,  weak  sulphur  oint- 
ment, 135  ;  almond  oil, 
135  ;  carboUc  oil,  135  ; 
olive  oil  with  lime- 
water,  135  ;  saUcin,  135  ; 
thiol,  135  ;  warm  bath- 
ing, 136 
Constitutional,       ichthyol, 

135  ;  antimony,  135  ; 
iron,  136 ;    phosphorus, 

136  ;  nerve  tonics,  136  ; 
phenacetin,  136 ;  anti- 
pyrin,  136 

,  malignant  papillary,  589 

papillaris  eapillitii,  526 

repens,  193 

,  Rontgen  ray,  204 

,  toxic,  202 


"variegata"(Boeck),318 


m 

'm 

^^■020                      DISEASES   OF    THE   SKIH.                       H 

^^K  JleniiBtitia  venenatB,  202 

^^^B   Permatoneuroses,  claasificiitioD 

asmmution  of  junt.  1 

^^r                  40 

^^      "  Dorraographisni,"  78 

''                Dermoid  cysts,  646 

2K 

and  aatlinio,  266 

CPBS,  13;    ifa   analogy    to 

and  aerofulii.  271 

1                        cntan-h   of   mucouH  mom- 

at  puberty,  260 

^H,                     G 

.  definition.  237 

^^B          ^rytLema,"  32 

.  diagnoiU.  237 

^^r  Dever^e'B  disease,  172,  185 

,  distinct    from    wtiSi 

^^"    Diabetic  lantlioma,  568 

dermaUtia,  837 

,  distribution  and  i«e>a 

Diphtheria,  rash  in.  32 

,  etiology.  261 

bBCilluH,infootionof  skiu 

^^B            wounds  by,  18 

,  "  gouty,"  270 

^^■DiBBeotion  woimds,  386 

in  ohildren,  348 

ill  elderly  penons,  iS\ 

in  infants.  248 

^H          fieanceof,28 

,  initial  lesion.  239 

—^  in  middle  life,  26(1 

^^■.Drtig   ecuptiona,   206;   tlieory 

in  the  two  soxre,  248 

,  influence  of  climah',  1 

^^H — .  Treatment— 

intertrigo,  240 

^^^1          ConstiHUional,  disoantiuuo 

,   its   tionsfonnation   ii 

^^B              drug,    234  J      dinretiRS, 

^H              234  ;   saline  purg^,  234 

^^    Duhriiig's  impetigo.  373 

'               Dyers,  akin  eruptions  in,  204 

Dyaidrotiis,  139;  treatment  of. 

— .  neurotie,  267 

1                       '^ 

of  anus,  £47 

uf  fftcp,  625 

of  chin.  £10 

^m    t>yar,>pKir    p<,pm,ire    tl    pig- 
^^M           mcHlaiTc  (l)iin«r).  S7t> 

- —  of  ear,  24fl 

of  tftcc.  246 

of  feet,  24fS 

^r 

—  of  KiHiitals,  !M7 

—  of  (cgB  and  laim,  241 

of  lipa.  240 

EcbinorocciiH  hydnliil  in  skiu. 

of  Doib.  H4C 

335                                          1 

of  nipple.  24(5 

"  Bothynift."  373 

of  ooabril«.  »4a 

^^M^et»m»,  SSfi                               i 

- —  ofBoalp.»*6 

^ ,  fteatArrh»flheakin.237    \ 

r 

m 

JNDEX.                                          6S1        H 

Ees»ma  of  wrists,  2i6 

massage  for  removal  of 

secondarj      thickening. 

283;    moditicatioiiH     of 

remediea    according   to 

——   pmriginosum  of  Eraemua 

Wilflon,  128 

tion   according   to   age. 

,  relation     to     funotiotial 

284 

oencoais,  268 

rimoflum,  216 

HpeoiSc,  276;    in    acute 

rubnim,  244 

caaes    antimony,     iron. 

,  gebonliraic,  253 

and   atHenio    coDtra-in- 

,  special  forma  of,  252 

dicated,  270  ;  antimony. 

276 ;        opium,       27H ; 

,  Hnperatition       as         to 

eUoral,  277  ;  sulphonal. 

"  driTing  in,"  274 

277  ;    phenacetin,  277  ; 

,  Hweat,  256 

when     nervous      Hfmp- 

,  BpiptoinB  of,  230,  257 

,  the  queation  of  ita  para- 

toms       are        present. 

quinine,  arsenic,  strych- 

sitic  origin,  263 

—   tuberouiatum.  000 

ETgot,   277 ;   in  climac- 

 ,  "  ylHOeral         mBnifcsla- 

teric   women,   mtisk   or 

tionB,"  261 

Valerian,    277;      when 

,  Treatment— 

discharge      is     profuse. 

Hygiew,    no    atimolmitB, 
,   27fi;      light      clotliing, 

277  ;  wben  disease  very 

^^       27H,     286;    rest,    276; 

rebeJlioufl,     counter-irri- 

^^^_      lowering     diet    contra- 

centres  of  part,   277 

^H     tber^w   2Se;    aulphur 

,    danger    of    over- 

^^^1     vaten,  286  ;  iudifferent 

^^■l    waters,   286;   sea-bath- 

Erzi-ma  iryeip'tato'de  ticidi-vanl           ^H 

^^H    iug,       2SGi        olimate, 

dee  •iHhriliqvf.i.  270                        H 

^B    366 

prr-mgeoti/iiriiir.  6U1                    ^H 

^^^aecal,   oouditioDB   of  sue. 

^^^^  «GaB,   278;    removal  of 

ElephanHasis     Arabiim,    404;         H 

^^V-  oru«t«.   27B  ;     in   acute 

^^^^.  Btage,  wash  with  weak 

^^B    borado  ooid,  never  with 

Empbyseuiut^ns  gangrene,  18           ^M 

^^K  water,    279 ;     glyci-rine 

Emol,  586                                            ■ 

^^^bjeUy.  281  ;  sulphur,  282  ; 

Enteric  fever,  rash  of,  34                  ^H 

^^■yeBOKdn,  282  ;   ichthyol. 

Eosinophile  «lls  in  dermatitis         H 

^^KteSi;      ti^U>T     moalin. 

herpetifonnis,      133;      in         ^H 

^^^^^VwSS ;     jellow   oxide    of 

^^^^^  mercoTy,  283  ;   BpplicH- 

lous  leprosy,  133                        ■ 

^^^^r-tion  of  ohryBarobiu  for 

fCpidermis,  thickening  of,  7               ^H 

^^^H  ehromio   patohee,   283  ; 

Epidermolysis  bullosa,  143                H 

I 

^^^H  soaking  with,  oaf  bolio  oil, 

^^^H  369 ;      applioatioa      ol 

^^^B  parasitioides,  369 

^^H  Feigned  truptiona,  36,  205 

I 


DII:iEASES    OF    THE    8KI^. 


,  scarlet,  roah  in,  32 
-,  typhoid  {eee  Enteric} 
-,  typliua,  rash  in,  34 


1 

I 


— ;  diffoae,  651 
—  mollusDUQi,  650 
— ,  Treatment— 
ioeul,  removal  by  ligatiiro, 
gftlvatio      oautcry,      or 
knife,  651 
— ,  von      Repklingbausen'a, 

651 
bromato,  hard,  65'2 

— , ,  Treatment — 

Rum  oval,  562 
Hbro-myoma,  654 
FilitriiL   BanguiiiiB   hominia    in 
elephantiosiB  Arabum.iOS 
Finsen's    light    treatment    in 

lupUB,  121 
ITiasures,  13 
"  Flannel  rnsh,"  514 
Flea,  leaiona  caused  by,  334 
"Flush  area,"  43 
FoUioular  vegetating  psoroapor- 

mosis,  576 
follicles,  420 
FoBiculUe  d'pilanle,  626 
ToUioolitis  diwslvana,  526 
■Ibrmalin,  eruptions  cnuBcd  liy, 

■ftiimbcBSia  (Vhwh),  4Wi 

Knoklea,  11,  579,  605 

Frost-bite.  96 

,  — ,  Treatment— 
Loa^,  rubbing  with  snow, 
107; 


galv» 


,  107 
luiioiuil,      ichtliyol, 


Fungi  of  ringworm.  33S 

,  vegetable,    13 

Fungus  foot  of  India,  397 

Furunculosis,   378 

— — ,  Treatment— 
Local,    abort     ' 

cerine  of  U'lladoni 
380;  tinoture  of  i.. 
380;  bornoio  acid,  380 1 
spirit  of  camphcw,  3lW; 
nitrate  of  silver,  380 1 
carbolic  acid,  380;  a 
mere  uric -carbolic  pluUl 
mull,  380  If  abottimi 
impracticable,  infi» 
and  acrapp  out  1  ' 
dress  with  iodofin 
3S1 ;  oarboUo  add,  39jQ 


muU,  381  : 

01  fomentatioiiB,  1 

Conalilulioiiai, 

quinine,  381;  a 

Furunculus,  378  ;  special  fors 

of    in   sweat    coils.   SiS; 

prognosis   of.    380 ; 

iDont  of.  380 

—  orieatoliB,  SM 


Gangrene,  diabitlif,  IU4 
— -,  einpliyscmatoiw,  IS 

,  hysterioal,   196 

■ — ~,  symmetriutil,  of  r: 

iUes.  191 
"  UangrenouB  nrticurla.' 
German  mmsliM  (tee  Kk 

Miay,  pnvi-ntion  n(  M 

feet  in,  610 
LJi'nitalB.  dia^usiii  uf  aflnrlilM 
of,  47  ;   eniption*  of,  iTfl 
ulcerx  of,  4»  . 

Gibert'a  |iit]rriaiusniN*,3IT 

Glands,  MbawouB,  df  

506 


^^^^^^~ 

m 

^^^^^P                                        H 

tilauilH,  aweal,  diHeaaea  of,  517 

local,  black  wash,  1115 

Olaoders,  501  ;   etiology,  503  ; 

diagnoBia.    504;     provan- 

ment  of,  137 

with  mallein,  504 

iris,  101 

■■  Glosay  akin."  195 

,  irritative,  153 

Gnata,  sUnga  of,  335 

labialia,  156 

Green  sweat.  620 

"  Grog-bloaaomB,"  122 

■ ,  Bymptoroatic,  156 

Growths,  benign,  .545 

zoflter,  158 

.  malignant,  588       ' 

lesions.  15fi 

—.  neV544 

,  diagnoaia,  164 

Gnioea-worms,  lesions   cauaed 

,  etiology.  100 

by,  336 

__  -__,     its  relation  to  the 

Gununata,  463 

nervous     ayatem. 

Gunahot   wound,   akin,  lesions 

52 

following,  63 

,  leaiona  in,  104 

H 

162 

— ,  prognoflia.  165 

— ^ ,  Treatment— 

— ~,  Treatment— 

Local,  anti-pruritio  lotions. 

Lotal,   electrolysis   or   rc- 

166;     ointments,    165 1 

movftl,  6S6 

protective  powder,  165; 

menthol,      160  i,      con- 

pedioulosis,  330 

Hair,  diaeaaM  of,  625 

division,  stretching,    or 

— — ,  atropliio  eiaogea  in,  520 

resection  of  the  nerve. 

,  beaded,  530 

160 

,  greyness  of,  531 

Consliliiliiinai,       aubcuta- 

— -, ,  Treatment— 

Constilnlianal,  nerve 

tonica,  631 ;   jaborandi. 

166  ;  quinine,  166  ;  iron. 

160;    Btryolioine,    160; 

pilocarpin   hypodermic - 

araeme,  160;    cod-Kver 

aUy,  531 

oil,  166 

,  oTergrowth  of  [sec  Hir- 

Hicsuties,  627 

snUea),  627 

,  Treatment— 

Hsnds,  diagnoais  of  affoctiona 

Ijoeal,    electrolyaia,   527  i 

i)f.  45 

X-rayain,  538;  depila- 

"  Haripquin  ftetua,"  611 

toriea  not  advisable,  620 

Herpes.  164 

Horoy  escreacencoa,  590 

.  Treatment- 

^^^  facialia,  105 

Removal  and  cauterisa- 

^^^b' genitalis.  166 

tion  of  base.  587 

^^^1          0  0 

^^^H 

^^     028                      IJlSMASES    OP    THE    SKIX.                       ^ 

warm   butlia.  «13: 

of.  fi93 

Hyiiatid  eohiuococcuB.  8.  335 

612;  BalicyUc«U.< 
excision  of  larve  zcow 

^H            puraHva   (PoUitMr),   379, 

812 

^m 

IchthyoalB  simplex,  610 

^^H  Hji^rad^iiome  /ruplit.  S7R 

^^^B  Hydroa  leBtlTale  of  Hutahin- 

^^m          Boa.  132 

hf.  376        ' 

^^m    lierpetiforme   of  Tilbur; 

,  Treatment— 

^H                Fox,   123 

Load,  remoTsI  of  soabt 

^^B pueronim,  131 

soaking  in  oarboliwil 

^^^B      vaccmiforme    of    Bazin, 

\\                         128    -4 

HydwwiB  oleoea.  253 

ointment    or     snllA 

HrpcrEestUeaia,  63 

378 

•,               HyperchromaBia.  11 

Contia<aioiKd.  cod-Urer 

and  iron,  375 

^^B  ,  Treatment— 

,  Duhring'a,  373 

^^m           r^cal,  inunction  of  bella- 

- —  herpetiformlB,  137 

^^H                 donna    ointmrnt,    518; 

,  Treatment— 

^^^^               powder    Htockinge    and 

Local,    contlnnous    UtI 

^^M               boots  with   borio  acid. 

and  cooling  applicaUa 

^^M              518 

139 

^^B            Conailvlional,  tonics,  518  ; 

^^T               bcUadoona,   518;   atro- 

strength,  139 

^^                pift,  618  ;  anlphur,  518  ; 

vulgaris  of  Dana,  374 

'                          diuretica.  618 

Indian    hemp    («m    Csnnabfa 

Hyporplasia.   a   aequel   of   in- 

Indica) 

.                      flatnmation  of  the  akin,  3 

^^^    Hypertrophy,  a  sequel  of  in- 

nature  of  process,  2 ;  froa^ 

Abnormal     vaseuUr    M^H 

^^Hfl^tsria,  akin  lesions  in,  55 
^^m  "  Hyat«rical  (cdema,"  B6,  201 

ditiona,  6;  from  applla|^^| 

tjoD  of  irritaiite,  4  ;   (r«^H 

~ 

disordered    norre   octii^H 

Q  ;  from  infection  by  PT^^H 

genie  organisms,  G :  IrOH^I 

Ichthyol  olntmenla,  (12 

retention  of  M»»«tJoi).  G^H 

varnisb,  292 

results  of,  7                     ^H 

Ichthyosifonn    erythrodcrmia. 

Inflaeoca,  rash  in,  32                ^H 

congenital,  188 

Intoning  toe-nail.  543          ^M 

Ichthyosis,  noe 

Injuries   to   the    nnvM,   '^^^1 

cornea.  57ft 

disMs««  following,  a  ^H 

hystriK,  611 

to  the  skin.   llmbUltv  t^H 

1^^ ,  Treatment— 

iutecliou,  I                     ^M 

^^k          Local,     soft     soap     with 

InucnUble  diseasfs,  gcwmil.  1^1 

^^^^^^^ 

m 

^^^^^H                                                                            K7        H 

rnoculftblo  diseases,    diagnosia 

Keratosis  pilaris,  610 

of,  37 

Kerion,  353 

.  Iocs],  38  321 

Koch's  postulates,  14 

,      caused      by 

animal   para- 

Bitea,  321 

L 

— ,  diftgiioais  of. 

39 

Inoculation  reaties,  229 

Intertrigo,  92  ;    treatment  of, 

recommendations     as    to 

106 

Iodic  eruptions,  213 

tion,  235 

Iodoform,  eraptiona  eaused  by, 

LarviB,  eruption  caused  by,  33S 

217 

Lassar's  paste.  280 

Iris,  erythema,  100 

Lead  (acetate  and  carbonate). 

,  herpes,  101 

eruptioQH  caused  hy,  227 

lotions.  61 

ImtBtion,  effeofa  of,  on  skin.  4 

Leiomyomata  (smooth  musolu 

Itch  mite.  326 

tumours),  554 

Itubing,  a  characteristic  foat- 

— — ,  Treatment- 

ure  of  inflammation  of  the 

Removal,  564 

Lentigo,  679 

^^  treatment  of,  67 

,  Treatment— 

Load,     blistering,     680; 

Ir 

perchloride  of  mercury. 

^m 

680;  pure  carbolic  acid, 

Jftcob'B  ulcer,  594 

680  ;  sahcylic  acid,  580 

JiBg«t,  8 

Leontiasis,  481 

Joint  affections  associated  with 

r*pothrii,  540 

"  Lepra,"  a  form  of  psoriasiB, 

paoriaaiB.  2B3 

290 

K 

L'W«v(fi%e(geeSclerodermia) 

Leprosy,  198,  477 

Kaposi's  disnwe,  604;  etiology 

,  ansssthetJc.  479 

807 ;   pathology,  (108 

bacillus.  491 

- — ;  Treatment— 

,  diagnosis  of,  490 

Locai.  excision  of  tumoura, 

.  etiology  of,  489 

,  mised,  479,  488 

dish    and    brown    pig- 

,  nerve,  479,  484 

mente,   G08  ;    exclusion 

,  nodulat,  470 

of  the  Sim's  rays.  808 

,  patholoay  of,  492 

,  prognosis  of,  494 

,  akin,  479 

KecatOBis  follicularis,  670 

— ,  Treatment— 

^^^. -,  Treatment— 

Loaa,    gurjnn    oil.   495; 

^^^B     Thermocautery,  571) 

oiiaulmoogra,     498; 

^H^  eZS                    DIBBASBS   Ot 

THE  SKIN.                      ^1 

^^H              nerve   stretohiug,   495; 

Lichen  ruber  planus,  diagixwd 

^^H              sulpliur,  495 

176                                 — •« 

^ ,  etiology,  ITT^ 

^^H              oil,  490  :    araEnic,  495  ; 

— ,    Treatment—  ■ 

^^^^P               guTJunoil,  496;  qumiiie. 

Load,  anti-prudtio   reme- 

^H              495  ;    cod-Uver  oU,  496 

dies,  179;  oorrosivo  Hub- 

limftta,     179 ;     carbolic 

^^^m  Leaions,  aaymmetrioa),  28 

^^^  ,  due  to  couBtitational  dis- 

acid.     179;     mercatU   J 

^^H             tnrbance,  2S 

179        '          '          ^* 

^^H  ,  evolution  of,  29 

Conttitulional,         aneatti 

^^^^1 -,  nervD   disoider  depend- 

178;     antipjrin.    !?& 

^H               ent  on,  6 

^^B  .  primary,  11 

Licheniaation.  75 

^^^^V  ,  secondary,  13 

^^m    - — .  symmetrical.  28 

Lial«r,     Lord,     treatment    « 

1               Leucodermi*,  190 

lupus,  441 

,  Treatment— 

Lotiona,  cooling,  61 

Louae,  body,  832 

or   peroxide   of   liydro- 

,  trab,  333 

gen.  191 

,  head,  331 

Uukoplakia,  401 

Lupoma,  423 

Ln^,  dias-miiaW  foUicuLMV 

lieUen.  172 

391 

agrins,  172 

■  — ,  (oUowed    bj    (I 

annubiriB,  179 

seminatua.  111 

eyratns,  513 

Bypertrophiona,  172 

,  etiology  of,  lit 

^  — .  pathology  of.  IM 

^^B        sorofulosorum,  413 

,  pointa   of    distinc. 

^^h      aimplei,  172 

tioQ    from    lupiu 

^^B     stropbulosus.  172 

vulgaris.    114 

^^m     tropious.  172 

— ,  relation   to  tuber- 

ouloaia,  in              - 

^^B ,  uw  of  term,  172 

UOangiertic.  Ill       J 

^^^B    Toriegatua  (Crookei),  183 

_,  tranaformatioii  l»-H 

^^^  termcoBua,  175 

to  lupnt  Tulg«itA 

^ —  ruber  planus,  172 

119                     T 

- — ,  Trealmenl— 

^^■m^ 

Local,  evaporating  lotion^ 

INDEX. 


629 


120 ;     calamine    lotion, 

120  ;    lotio  carbonis  de- 

.  tergens,   120  ;    resorcin, 

120  ;  salicylic  acid,  120  ; 
pyrogallic  acid,  120 ; 
chemical  caimticB,  121  ; 
Finson's  light  treatment, 

121  ;  iodoform,  121 
Constitutional,         general 

tonicH,     121  ;  ichthyol, 
121 ;  arsenic,  121 ;  phos- 
phorus, 121  ;  quinine,  121 
Lupus  disseminatus,  423 

exedens,  42.3 

hypertrophicus,  425 

non-exedens,  423 

papillomatosus,  425,  427 

serpiginosus,  425 

verrucosus,  419 

vulgaris,  423 

,  course,  425 

,  development        of 

epithelioma       on, 
434 

,  development       on 

vaccination   scars, 
431 

,  diagnosis,  432 

,  distribution  of 

lesions,  425 

,  etiology,  429 

,  inoculation,  431 

,  pathology,  434 

" ,  points  of  distinc- 
tion from  lupus 
erythematosus,  432 

,  prognosis,  434 

,  pseudo  -  elephanti- 
asis caused  by,  427 
,   pulmonary   phthi- 
sis associated  with, 
427 

,  relation  to  general 

health,  427 

,  secondary     cfTects 

of,  420 


I 


Lupus,  spontaneous     cure   of, 
420 

vulgaris,   tubercular    in- 
fection from,  427 

,  Treatment — 

Oeneral  Principles^  re- 
moval or  destruction  of 
diseased  tissue,  435 ; 
choice  of  method,  444 
Local,  salicylic  acid,  436  ; 
Brooke's  ointment,  436  ; 
parasiticide  applica- 
tions, 437 ;  mercurial 
plasters,  437  ;  corrosive 
sublimate,  437 ;  impreg- 
nation of  affected  tissues 
with  sulphurous  acid  in 
the  nascent  state,  437  ; 
hyposulphite  of  soda, 
437  ;  Harrison's  method, 
437  ;  chemical  caustics, 
438 ;  nitrate  of  silver, 
438 ;  acid  nitrate  of 
mercury,  438 ;  lactic 
acid,  438 ;  arsenical 
paste,  438 ;  chloride  of 
zinc,  439 ;  pyrogallic 
acid,  439  ;  salicylic  acid, 
439 ;  excision,  440 ; 
erasion,  440 ;  Lister's 
method,  441  ;  scari- 
fication, 441  ;  cauterisa- 
tion with  Paquelin's 
cautery,  442  ;  galvano- 
cautery,  442 ;  Finsen's 
concentrated  light 
treatment,  443 ;  X-rays, 
443 
Constitutional,  no  internal 
remedy  a  specific,  445 ; 
arsenic,  445  ;  iodoform, 
445 ;  iodide  of  potas- 
sium, 445 ;  cod-liver  oil, 
445  ;  tuberculin,  445  ; 
TR.,  440  ;  thyroid  feed- 
ing,   440  ;    urea,    440 ; 


^H»0                      DISHASEa   OF 

THE   SKIf/. 

^^B            thiosinamJii,  446  ;  dog's 

Milium,  38U,  514 

^H          »en.in.,446 

Milium,  coUoid,  574 

,  Treatment— 

^^m    lis 

trolysis,  574 

Mole,  667 

^■r           503 

MoUiiscum  bodiea.  9 

^^m DirciimBnr>pt»mcutk,002 

oontagioflum,  572 

^ ,  Treatment- 

^^Kl^mpkoma  simplex,  563 

Pure  liquid  carboUc-  mM 

^—.^ 

574  :   flexible  coUodin 

^m 

574 

Monilethrix,  530 

Macule,  definition  of,  11 

MorphiDo,  170 

Macula  cteruka!.  333 

,  Treatment  — 

Madara  foot,  397 

Load,    electrolysis,     171 

MftlfocmationB,  COB 

massage.   171 

^^■QtUignaDt    pustule,    18,    3B3 ; 

MoFvau's  disease,  Ii)8                      | 

^H{       patholog;,  3S3 
^ ~,  Treatment— 

Mosquitoes,  sliiiKR  of,  335 
Muoous  patch,  467 

^^^r        Excieioii  of  initial  lesion. 

—  tuburele,  457                            | 

^^™              386 ;  free  soraping,  385 

Meaales  roah,  33 

597 

,  German    {ne    ESthelu) 

Mycetoma.  397 

Myooais  fungoides.  000 
,  TFeatment— 

^^^  Melanotic  cancer,  591 

^^^^lerourial  plasters  in  lupus,  437 

^^^^Bbicur;,  eruptions  caused  by. 

flyraptonm.  «<M 

Myoma  cotia.  562 

^^^nCiorococoi  in  pus,  16 

MyitDdema.  565 

Myxoma,  554 

-^~.  Treatment- 

Removal,  filM 

'               Miliaria,  522 

N 

alba.  623 

papulosa,  C-24 

Na-vi,  capillary,  55(1 

,  Treatm^t- 

,  TrcHtmeni— 

^^H           Load,  soothing  or  evapor- 
^^L            ating  lotions,  ^6  ;  Jka- 

^^H            Une    baths.    626;    noii- 

tincture  of  iodine  M 

perchlorideofiroiwH 

^^^P         Caiuilitiaionai.  acetate  aixl 

tanniu.     567  (    electl 

^^H^              mtrate  of  potash,  624 

^^B. riibm,  r>23 

]><mctun  with  galna 

m 

^^^^^^r                                          631    ^M 

cauteryrsST;   oauatica, 

ointment,    61  ;    boracic 

657  ;  BxcUon.  657 

a«id  ointment,  61 ;  anti- 

,  verrnooae,  5S7 

Hepsis      of      secondary 

lesiona,  62 

,  TTeatment— 

changes  in  eczema,  266 

If       noossaary       rejnnve, 

Nervous  diseases  of  skin,  gen- 

5S9 ;  no  caiutjcn.  650 

eral    cbaractera    of,    39 : 

Bpilna,  557 

general  principles  of  treat- 

ment, 57 

Neuralgia  of  the  skin,  63 

47 

Neurasthonia  and  akin   affec- 

 ,  diseases  of,  542 

tions,  55 

,  ringworm  of,  303 

Neuro-fibromata,  562 

Nerve  disorder,  akin  affoctions 

Neuroma,  654 

,  lesions    depeiideut 

55 

-,  Henaory,  of  the  akin.  63 

.  Treatment— 

New  growths,  7,  39,  544 

Hygienic.        physiological 

,  benign,  545 

^^^       roBt,     67 ;     chnnge     of 

,  malifcnaat,  588 

Nux  vomica,  eniptioria  cauat-d 

^^^     maasage,   58;   dothing. 

by,  2-28 

^m     69:         non-alimukting 

^^F  diet,  se 

^^^'Conslitylionai.  chloral  and 

O 

bromide    of    poUBdium 

contra-indicated,       58 ; 

opiam,     68 ;     paralde- 

199 i  treatmCDt  of,  200 

hyde.    58  !    phenaaetiu. 

,  hysterical,      55,      201  ; 

treatment  of,  201 

nabis  indioa,  58  ;  seda- 

tives to  be  given  at  dia- 

,  Treatment— 

'  orBtioD,  58,  153  ;   nerve 

Raise     temperature     and 

^^_      tonics,  5S  ;  quinine  oom- 

improve  nutrition,  614 ; 

^^L    billed  with  heUadonnn. 

wrap  in  cotton  wool  and 

^^^^■k  oiaenio,  and  valerian,  58 

keep  in  an    incubator, 

^^^■iwal,  oidde  of  sine  pow- 

614                               ^ 

^^■^    ders,  eOi  sahcylic  aoid 

,  malignant,     caused     by 

1                  powders,     60;     Unna's 

baoilU,  18 

powder-bags,  00  ;  aeda- 

(Edime  bUa  dea  haathiques,  201 

tivB  astringent  lotionH, 

BO;  DBlamiae,  01;  lead 

Onyohttusifl.  543 

^^^^_^  lotions,       G I ;       cooUng 

Onychia,  542 

^^^L.  ointments,      61  :      :-old 

maUgna,  542 

^^^Bereams,     lil  ;     idithyol 

OnyphogryplioHiB,  543 

w 

•m 

^^n32               nisEAaEs  of  the  skin.                  ^M 

^^^■bjchomycoaia,  33S.  363 

Parasitic  affecUons,  8 

^^K-,  Treatment— 

Pomnyohia.  5*3 

^^^B     Loml,  ecrapo  the  nail  tlio- 

Pastes.  280 

^^^B          rougblyanil  apply  ehrj-B- 

Pathology  of  the  skiu,  1 

^H         arabiu    or   some    cither 

leaiou  of.  330 

^^V         aon'a      method.      3(13  ; 

PedJcuhiB   PipitiH,   (IwcripliO^ 

^^■-          Fournier'B   method.  384 

of,  321. 

0]tiiim.   eruptions  oauscd   by, 

.  Treatmeiit- 

223  ;  pruritus  caused  by, 

/*cat    white    precipitaH 

223 

Orthofomi,    feruptionB    cAiiaed 

add,    332;    ether    M 

by,  217 

oleate  of  mercury.  332 

Oxide  of  line  powdor,  00 

corporis,   de«eripUon   a 

P 

329 
,  Treatment— 

Local,  bake  clothw.  333 

Paget's  (liseaae,  fi88 

alkaline  balhs.  333 

— -.  Treatment— 

iMccd,  complete  reraQval  ol 

Treatment- 

part  nffei-ted,  600 

Loral,    as    for    pedicall 

Palm,  dry  acaly  eruptioua  of.  40 

capitis  1    white  pneifi 

I'aper-hivngera,  skin  eruptions 

tale  ointment,  334 

in,  204 

Pel'ide  (alopei-'ia  an*UJ,  SM 

Papule,  definition  of.  11;  how 

meut  of,  110 

PollnBra,  124 

- — -,  Treatment- 

amination  of,  4 

Paqiieliu'a    cnutecy   in   hipus. 

quinine,    127  :   ealum« 

442 

127  :  nraenic,  127 

Pemphigus.  142 

Parakeratoaes,  181 

Parsnghi  (Yaws),  "4BG 

of  Uio  hands,  IM 

Parasites,  ammat,  in  loeal  in- 

— ^.  eoiuphcatiwia.  Iftf 

oculable  diBoaaes,  321 

infesting  akin,  8 

lU 

,  Treatment— 

- — -.  etiology.  US 

Lofol.  eau  de  coloene.  335  ; 

~ — -.  foliaceoua.  143,  147 

toilet  Tineaar,  335 ;  lead 

—  — ,  Treatment- 

lotion,    335;    napbthol. 

LmoI,    emollient    alkaUn* 

33fi;  mercurial  oinlnipnt. 

or   BulpbuKttod    poU*- 

335 

uum  baths.  IM 

'   vcyelabl...  337 

neonatorum,  14Q 

^^^^^^^ 

V 

^^^^^P                                                                          fl33       V 

Pempbigufl,  points  of    distiuo- 

etiology,    319  ;    diagnosis, 

tiDn  from  ayphili^,  15^ 

319;  prognosis,  320 

— — ,  prognoBia,  153 

Pityriasis  rosea.  Treatment— 

pruriginoBua,  128 

Local,  liquor  carbon  is  de- 

vegettiQS,  148,  152 

vuTgarifl,  143 

tergeos,  320  ;  antipruri- 

tic   appUeations,    320; 

,  Treatment— 

tepid   bran   or   alkaline 

Local,   r^ooling  ointmeata, 

baths.  320 

154 ;    prick  bullie  -witf, 

Pityriasis  rubra,  309 

-.  contagious     form. 

312 

tonios,      163 ;      araenic, 

,  diagnoflia,  315 

163;  phoaphorus,    154. 

,  etiology,  313 

ichthyol,      164 ;      bello- 

.  in  new-born  infanta. 

donna,  154 

312 

PerlicU,  302 

~  ,  its  relation  to  other 

,  Treatment— 

akin        affectiona. 

Local,   cauterisation   «ntb 

310 

sulphate  of  copper  or  ni- 

trate of  silver,  followed 

-,  Mthology,  314 

by   application   of  pro 

;-,  Treatment— 

Hygienic,              protect]  ow 

Pernio  {set.  Chilblain) 

agajnat  cold,   31S ;    no 

sUmulanU,   316 

Lotai,  antimony  in  acute 

Phogocytoeia,  3 

oaaea,    316:    areenic   in 

Phenacetin,    eruptions   caused 

chronic      caaea,      310; 

by,  228  ■ 

316:      tepid     bran     or 

Piedra.  641 

alialine      baths,      318; 

Pigmentation  of  the  skin,  how 

tarrv  preparations,  310  ; 

caiued,  3  ;  a  aeqael  of  in- 

carLolised      oil,       316; 

flammation,  3  ;   a  marked 

swathing  in  sub-acetate 

feature        in        syphilitic 

of     lead     lotion,     317 1 

mercurial    preparations- 

of,  189 

contra-indicated,     317 ; 

Pinta,  337,  304 

protective          powdere. 

,  Treatment— 

317 

Load,  washing   with  soft 

Conalilutioiui!,       cod -liver 

aoap  and   warm  water. 

oil,  316 

371;  iodine,    371;  by- 

pilaris.   184 

poBulpliiteof  soda,  371; 

,  diagnosis.  187 

BulpliucouB  acid.  371 

— .  distribution    of 

"  Pitytiaais  "  not  a  disease  but 

lesions.  187 

a  symptom.  308 

,  patholi^y,  188 

Pityriasis     toaea,    3<ia,     317  ; 

.  symptoms,   J87 

0  O* 

^^^H 

^^V«M                      DISEASES    OF    THE    .SKIS.                         ^^ 

Pityriasis  rubm  pilaria,  Treat- 

Pmritiia, Treatment— 

ment— 

Bvgienie.  removnl  of  anr 

Bygitaic,  violent  eserciae. 

iScal    source    of    irriu. 

188 

tion,  67  ;  diet,  68 

1                      Local,  oUof  cadp,  188;pjTO- 

Internal,  aalicylnte  of  «od* 

gallio  acid,  188  ;  Hooth- 

iu  gouty   patients.   Iit>; 

sulphur  waters,  68 ;  in- 

^^^—        Conalitulional,  arsenic  coa- 

different       wat«is      in 

^^L           tra-indicat«d.   188  i    ar- 

senile  cases.  68  ;  carbolic 

^^H           fleaiate    of   soda,    188; 

acid,   68  i   cannabis  in- 

^^^^H            pilocarpine,  188  ;  jabor- 

^^T            audi.  188 

69;    nas    vomica.    BV; 

Bimples,  308 

digitalis,  69:  ergot.  69; 

antipyrin.      60 ;      BOb- 

Pix  liquids,   eraptiona   caused 

by,  228 

pilocarpin,  89 

Flioapolonica,  331 

Loeal,    menthol,    67 ;   co- 

PodophylliQ, eniptiona  caused 

caine,     67  ;     Paquelin's 

by.  228 

thermo- cautery.  67  ;  no 

PoM-mortem  wart,  418 

alcobol.     as ;     TurkM 

woands,  3BB 

PoBtalates,  Koeh's.  14 

alkaline  baths.  6ft ;  hoi 

'■  Port-wine  •'  mark,  6S6 

lotions,      70 ;      alkaline 

PowdM.bogg,  t'nna'B,  00 

lotions,     70;      oarbolie        ,, 

Powders,  protective,  00 

"  Prickly  heat."  172,524 

Protozoa  and  skin  diseaae,  9 

71  J   chloral,  72 ;  hy^aH 

Prurigo,  74 

cyaDJa         acid,         ^^^^1 

feroj,  74 

aalicyUc  acid,  72  ;  nvl^l 

mitis,  74 

ourial   applioaUon.   7»i^ 
naphthor,   73;  tM.  7S;        " 

Pniritna,  64;  defiiutioa  of,  84; 

nitrate     of     aUfer     in 

diet  in,  68  ;  axberaal  reme- 

solution.   73 ;    benioiD.        ,, 

dies  in.  60  ;  internal  modi- 

73  ;  ichthyol.  73  ;  acon-^J 

cation  in,  38;  local  varis- 

ile,      73 ;      ungUMtDai^l 

tieBof,66 

aconitinn,  73                 ^M 

aai.  66 

"  Pseudo-lupus  vulguis,"  tOS.^H 

hiecaalis.  65 

Psoriasis.  288                              ^M 

palmanim  et  plantarum, 

.  clinical  types.  294            ^ 

66 

.  conise  and  duration,  2B3 

scrotd,  66 

,  diagnosis  of,  298 

senilis,  65  ;  treatment  of. 

,  distribution    of    lesions.        ,, 

1                          68 

290                                     J 

-.  etiology  of.  294          ^^H 

folloving  vaccination,  33^H 

^^^^^^^ 

1 

^^^^^B                                                                   1 

pHOriasia,  "  gouty,"  294 

feeding,   303;   in   coBea 

guttata,  289 

asaociated     with    rheu- 

 ,  inooukbility  of,  298 

matoid  arthritia,  araenio. 

,  internal  remediea  in,  301 

and  eicluBive  meal  diet 

— ^  inveterata,  289 

and  hot  water.  303 

,  joint  affectionB  in,  263 

Paorosyermoee  foUicvlaire  v(ge- 

linauEe,  461 

tanU,  576 

Pulex  penetrans,  335 

,  palmar,  4111 

Purpura,  108 

— ,  Treatment— 

,  ptognosia,  300 

Hygienic,     reat    in     hori- 

zontal    poaitioD.     110; 

mpioidea,  289 

liberal  diet.  110 

.  aubjective  aymptoma  in. 

292 

110;   iron.  110 

,  Byphilitic,  468 

urticans,  81 

,  Treatment— 

Pub,  nature  of,  3 

Hygietiif,    clothing,    301  ; 

Pnatule.      definition      of,      12; 

avoidance  of  cUU,  301  j 

secondary     infection     by. 

warm  climate.  301  ;  sea- 

16 

batWng,  303 

,  malignant.  383  ;  etiology 

Loud,   deal   with   patches 

aeparately      and      tho- 

384 !  prognosis  of,  381 ; 

roughly,    304;    aaUeyho 

add  in  spirit,  304  ;  alka- 

Puatulea, how  formed,  6 

line   batha.    304;    mer- 

 ,  umbiliofttion  of.  5 

curial     oiotmenta.  304; 

Pyococci,  infection  by,  16 

tac,  306 1  resoroin,  305  ; 

isogenic     bacteria     normally 

ohrysorobin,  305  :   trau- 

present  on  the  skin,  IS 

1 maticin,  306 ;  pyrogaUio 

Pyoais,  16 

^^^     aoid,  306 ;  cauatica,  306  ; 

^^^H,    massage   of  skin.   308 ; 

Q 

^^B   aolphur  hatha.  306 

Quinine,  eruptions  cauaed  by, 
223 

^^"      Bhionio      easea.      301; 

II.                  Afliatio  pillB.  301  ;  anti- 

R 

mony   in    acute    casea. 

Bash    of    scarlatina.    32;    in 

302;  phoaphoms,   302; 

diphtheria,     32;     in     in- 

salicylate    of     Bodium. 

fluenza,    32;    of    measlBB, 

?DS ;    bromide   of   pot- 

33;    of   rotheln,    33;     of 

BBBium.  302  i  bFomide  of 

enteric     fever.     34;      of 

BOdinm.     302 ;     hydro- 

typhus,  34  ;  of  smaUpoi. 

biomale      of     quinine. 

34;   of   chioken-poi,    35; 

^^—      302  ;  eoUeiu.  303  ;  large 

"flannei,"  614 

^^^    d0M8  of  iodide  of  pot- 

^^H    Bwinm,     303:     thyroid 

after  vaccination,  231 

^^Bse                      DISEASES    OF 

THE    SKIS. 

Raynaud'a  disease,  191 

chrysarobiii,  359 ;  olnu 

,  Treatment— 

of    copper.    359 ;    olwt* 

Lotal,    oonstanl    current. 

of   mercury.    358;   mb- 

^^-          192  ;  maasage,  193 

limed  sulphur.  35» 

^^h      Constitiitional;       i-MVxyoX. 

Ringworm  of  hair! ess  parte,  354 

^^B          193;       araamc,       163; 

of  liairy  parts  of  face,  Sfll 

^^P           qumiDB.  193 

of  nails,  363                               , 

^^■"  Red  gum."  524 

of      palms      and       aoln.   ^A 

Bweat,  520 

mi                      ML 

*■  Remindera  "  in  Bypliilis,  461 

Tokehiu.  304                      M 

RluigadEfl,  13 

of  the  scalp,  349              ^H 

Rheumatoid      arthritia       and 

— .  Treatment—  ^H 

psoriaaU,  293 

Rhinophyma,  123 

off  d(i6rMwith  spirit  and         ' 

Rhinoscleroma,  570 

ether   lotion,     not   with 

.  Treatment— 

water,  359  ;  apply  anti- 

Lo«d, BslicjUc  aeid,  572 

septic  lotion,  360 ;  nli- 

Bbua,    skin   fruptiona    caiwed 

by,  203 

Rhyncoprion  peoetnuiH.  8 

clironic   eases   powerful 

Ringworm,    337 ;    queetion   of 

remedies  are  req  uiied  to 

immimitj,  355  i  summarj' 

set   up   a    curatiye  d»  H 

o£  etiology,  3J8;     kerion 

matitis.  360;  chrysailN^I 

as  a  oomplioatioii,  353 

Inn,  360  ;  Coat«r's  pMt^^H 

,  bald,  362 

360  ;  Btrong  xulpbur  a«^H 

merourial        ointmnit*^  ^B 

360;   oleate  of  coppt*.         i 

^^B           researches,  336  j  aathor'a 

360  :carboUc  acid.  360  i 

^^H            researobea.  342 ;  autlior's 

croton     oil,     361;     de- 

^^K           method  of  staimag,  343 ; 

fltruction   of  fungus  bj        h 

^^^K             geographical       diatribu- 

deprivaUon  of  air.  3ftl  {  M 

^^H            tioa,    344;    tbe    amall- 

propbylaxia  in  scboola,  Ht^H 

^^^^B            spared     parasite,    345 ; 

Rodent  ulcer,  44,  594  ;  rtiolng|^H 

^^^V              the     lorge-spored    para- 

l^l 

^^              Bite,   345;   size   of    the 

,  Treatment-      H 

1                         spores,    346;     cnlturex. 

lorat.    exoiBion.    5M;     ^H 

346  ;   the  fungi  in  rela- 

cautery.   596;    PloMal^H 

tion    to    clinical    facta. 

light    treatment,    SW^H 

1                         347  ;  relation  of  certain 

X-raya.  596                   ^H 

^^H                forms  of.  to  favua,  348 

B5ateMiray(so-:Xr>.v)           ^M 

^ .  Treatment— 

dematitia.  SM        ^H 

BouoM,  121                              ■ 

^^^1            layers  of  epidermia    by 

Hygi€ni^     recuUtion     <^| 

diet.  124;  no  akoboM^H 

^m — 

1 

^^^^^r                       637  1 

^^K-load,    SB    for    acne    yul- 

aublini.   and   lard,  328  ; 

^^m      gariB  ;  Bcarilication,  124  ; 

Vlemingkx'a  lotion,  32Bi 

^■^       FaqueUn'a  oautory.  124  ; 

sulphur       precipitate 

electrolysis,  124 

328;    weak   balsam   of 

124;  iolitUyol,   124 

RoBWift,  464 

apphcations   sbould    be 

Rotheln,  rasli  of,  33 

vigorouB    but  not  vio- 

RiipiB, 45^ 

lent,  328 

Scales,  formation  of,  13 

S 

Scalp,  diagnoaia  of  affections,  4 1 
Scarlatina  rash,  32 

Sabotiraud'a      researiihfs      nn 

Scars.  13 

ringworm,  338 

Soirrhus,  cuiiasfl.  500 

"  Sago  tongue,"  fi63 

Sclerodactylia,  193 

eaoaed  by,  224 

Stleroilermia,  167 

Salicylic        a«(l,        eniptionB 

causeil  by,  224 

Local,     galvaniam,     170; 

___  __  powder,  60 

niuasage,  170 

Salve  muaUna,  281 

Bticka.  280 

oil,   170;   arseuiP,   170; 

Sarcoma,  alveolar,  509 

thyroid  feeding,  170 

Scrofula,     general     charact«r- 

,  nielRiiotic,  B97.  590 

istica  of,  409 ;  relation  to 

.  multiple  pigmented,  597 

tubercle,   400;    definition 

of  the  flkin,  690 

of  term,  410 

— ,  Treatment— 

Scrofuloderniia,  413 

Local,  removal,  600 

,  Treatment— 

Conatiljitional,     aub-cuta- 

Surairal,  410 

neooa      .injections      of 

Con^litutiowl,       cod-liver 

Fowler's  Bolution,  600 

oil,  416  ;    iron,  416 

8aTcopt4m  Bcabiei,  322 

Scrofulous    abBcess,    subcuta- 

Scab, formatiDn  of,  13 

neous,  416 

Scabies,        322 ;        secondnry 

Sebafooua  cysts,  54ii 

InioiiB  in,  324  i  action  of 

Seborrhoia,  263,    50S  ;   patlio- 

acaruB,    322 ;    pathology. 

\agj,  600  ;  diagnoaiB,  510 

326 ;      (liagnoBifl,       326  i 

corporis,  512 

descriptioQ  of  acarus,  326  ; 

,  Treatment— 

As  for  aebonhceic  eczema. 

,  Treatment— 

oleosa,  505 

Pointa   to    be   aimed   at, 

■ papnloaa,  612 

327 

—  siccu.  505 

^^^mJ«Ctll,   sulphur   ointTuent, 

-,  Treatment— 

Loral,  wash  with  soap  and 

water,  then  apply  pnrn- 

^^^B  eiticldea,   510;  snJpliur, 

^^H  510;      roaarcin.      012; 

^^^^B  corrosiTe         sublimate, 

^^^^P  B12;  yellow  precipitAt«, 

^^^K  613 ;      oalamel.      512 ; 

^^^H  nsphthol,    612;    tnnnio 

^^V  anid,  512 

^^^    SeliQrrfai^u  wart,  582 
I  Sensory  neuroses  of  akin,  133 

Sliingles,  153 
Skin.  bocteriB  on,  20 

glandfl.  diaeaaea  of,  505 

,  mouldB  anil  bacterin  in. 


DISEASES    OF    THE   SKtX. 


P 

r 


554 


Smallpox  eniptt 
Smootb  muBole 
Snuffles,  464 

Sodium    salicylate,    oiniptli 
oaused  by,  224 


parasitic    in 
epithelioma,  5S 
Spatted  aickneas  (sa 


— ftlbuB,  15 

■- citreuB,  15 

Stramonium,  eruptions  ( 


kj.  1 


pyogenes,  15 
Strcptothrix  infection,  400 
StraphuloB,  524 
Strumous  ulcers,  415 
StryRhniB,  eniptinns  caused  by, 

228 
Sudaminik,  522 
SnI  phonal,     eruptions     CBused 

by,  22^ 


Sunburn,  !ll 

Suppiiration.  iwtunt],  IS 
Sweat,  bloody,  SSI 

,  oolourod.  620 

,  foul-amelling,  GtS 

,  green,  520 

,  phosphorcaccinl,  CSI 

- — ~.  led,  520 

Sycosis,  338,  3T5  ;  pattt^h*  ii 
376; 


376 
,  Treatment— 

Iioeai,  remove  cnn 
epilat«,  377  ;  o 
mercury,  377  ; 
ointment,  377  ; 
paate,  377  ;  Unni 
bolic  mercury 
muU,  378 

frauibiBsifonDis,  ESS 

,  lupo'de  o(  Brocq.  878 

papilliHiuiteuM,  S20 

Syiimielrical   gan^^ren)*  of  • 

tromity,  191 
Symmetry,    a      chararln 

Sypliilide,  mamlar,  456 
-^ — -.  maculo-papular,  40 

,  papular,  4M 

Syphilis,  447 

.  a    specific    exta 

toils  (l^ve^.  448 
-,  Bhoraoter   o(   sm 

eruption,  4511 

,  coarse.  502 

,  diagnosis  of,  4U 


',  duration   ol   inCrctlTfi 
401 


INDEX. 


639 


Syphilis,  modes   of     transmis- 
sion, 448 

,  pathology  of,  470 

,  primary  lesion  in,  449 

,  probably  parasitic,  17 

,  prognosis  of,  470 

,  secondary  lesions  in,  453 

,  stages  in,  448 

,  tertiary  lesions  in,  463  ; 

,  transmitted   by   vaccin- 
ation, 231 

,  Treatment- 
General  principles,  476 
Local,  mercury  in  vapour 
bath,  474 ;  applications 
of  mercury,  474  ;  am- 
monio-chloride,  474 ; 
calomel,  474 ;  in  ter- 
tiary lesions  iodide  of 
potassium,  475 
Constitutional,  mercury, 
471;  blue  pill,  471; 
mercury — how  long  ad- 
ministration of  drug 
should  be  continued, 
473 ;  iodide  of  sodium, 
475 

Syphilitic  lesions,  general  char- 
acters of,  37 

psorisisis,  468 

Sjrringomyelia,  199 


TR  in  lupus,  446 

Tar,     eruptions     caused     by, 

228 
Tanners,    skin    eruptions     in, 

204 
Teignes,  Alibert's,  22  ^ 
Telangiectasis,  555 
Terebene,  eruptions  caused  by, 

229 
Tetanus  antitoxin,  233 
Thapsia  juice,   skin   eruptions 

caused  by,  206 


Thickening  of  the  skin,  13 
Tinea  barbae,  361 

ciroinata,  356 

decalvans,  352 

imbricata,  364 

marginata,  338 

nodosa,  541 

palpebralis,  338 

sycosis,  338,  361 

*-,  etiology,  362 

,  diagnosis,  362 

,  pathology,  363 

,  prognosis,  363 

,  Treatment— 

Local,  epilation,  363  ;  ap- 
plication of  parasiticides, 
363  ;  chrysarobin,  363  ; 
sulphur,  363  ;  oleate  of 
copper,  363 ;  prophy- 
laxis, 363 

tonsurans,  337,  349 

-^ —  versicolor,  370 ;  conta- 
gious, 370 ;  diagno- 
sis of,  371 

,  Treatment — 

Local,  washing  with  soft 
soap  and  warm  water, 
371 ;  iodine,  371  ; 
hyposulphite  of  soda, 
371;  sulphurous  acid,  371 
Tokelau  ringworm,  364 

,  Treatment — 

Local,  Linimentum     iodi, 
365  ;  sulphur  ointment, 
365 
Hygienic,    disinfection    of 
clothes,    365 
Trade  eruptions,  204 
Traumaticin,    preparation    of, 

305 
Trichoph3rton  ectothrix,  339 

endothrix,  339 

raegalosporon,  339 

,  Sabouraud's     researches 

on,  339 
tonsurans,  338 


640 


DISEASES  OF  THE  SKIN. 


Trichorrhexis  nodosa,  629 
,  Treatment— 

it«-.E/,  freijiieiit  aiinviiig, 
riHd ;  epilHtioii,  530 ; 
Eiiitiacptit  lotion,  S30 

Tubercle  aa  an  elementary 
leaion,  12  i  its  relation  to 
scrofula.  409  {  aDatomicat 
element  of,  411;  bacillus 
of.  411 

Tuberculides,  420 

Tiibereuliii  eruption,  233 

Tuberculosis,  411.  412 

and  Taecmation,  232 

verrucosa  cutia.  419 

Tuberouloua  ulcers,  417 
Tumour,  definition  of.  12 
Turpentine,   eruptious   caused 

by.  229 
Tyloais,  613 
,  Treatment— 

Loriil,  salicylic  acid,  61? ; 
icbthyol,  G13 
Typhoid     fever    {see    Enteric 

Typhus  fever,  rash  of,  34 


Ulcer,  i 


riforni  of  Hutchin- 


,  rodent,  594 

I'Icera.  l.t 

—  of  the  face,  43 

of  the  gonilals.  47 

of  foot(  perforating.  197 

,  strumous,  415 

,  trophip,  107 

-,  luwrculouB.  417 

Ulerythema  centrifuguui  (lupus 

crylheinatoaua).  110 
Unibihi-ation,  primary,  5 
Uridrosis,  522 
I'rticnrin,  77 


UHJcaria  bullosa,  81 

foctitia,  79 

fugai,  78 

,  gangrenous,  65 

gigaa,  80 

,  hsBmorrhagic,  81 

mdematosa,  80 

of  mucous  membrsiMs,  78 

— ,  palud^  81 
■ papulosa,  79 

,  Treatment — 

Wj,9ifr<.f.prfv,.iitchill,8«i 


Constilvtional,  calcium 
chloride,  86 ;  quinine, 
86;  food  of  a  D<m- 
stimulating     character, 

86  ;  sulphate  of  atropia, 
86 ;  ichthyol,  87 

—  pigmcntoBa.  81,  (t3 

,  Treatment— 

Conatituiionai,  belladonna. 

87  ;  atropine  in  hypoder- 
mic iojectioos,  87 


Vaccination  eruptions,  229 

follDn-e<J  by  psoriaaiH,  233 

,  Lancet  Special  Commis- 
sion, rocommciidaliaas 
tta  to  prrcAutioiis  in,  235 

"  Vagabond's  skin,"  330 

Varicella  (me  Chic  ken- poi) 

Variola  {ate  Smallpox) 

Vasomotor  disturbance  and 
skin  lesions,  55 

Venereal  warts,  457,  583 


INDEX. 


641 


Verruca    necrogenica  or    'post- 
mortem wart,  418 

— ,  Treatment — 

Localy  salicylic  acid,  419  ; 
caustics,  419 ;  electric 
cautery,  419 

plana,  681 

seborrhoeica,  682 

vulgaris,  581 

Vesicle,  definition  of,  12 
Vesicles,  how  formed,  5 

,  umbilication  of,  6 

Vibices,  11 

VitiUgo,  190 

Vlemingkx's  lotion,  328 

Von  Recklinghausen's  disease, 

661 
Vulnerability     of     the     skin, 

causes  influencing,  6 


W 

Wart,  post-mortem,  418 

,  seborrhoeic,  582     - 

Warts,  681 

,  Treatment— 

Local,  salicylic  acid,  584  ; 

chromic  acid,  584 ;  acid 

nitrate  of  mercury,  584  ; 

acetic  acid,  584 

,  digitate,  584 

,  Treatment — 

Local,  removal  with  elastic 

ligature  or  knife,   584 ; 

galvanic   cautery,   584  ; 

6craseur,  584 

,  gonorrhoeal,  584 

, ,  Treatment— 

Local,    galvano  -  cautery, 

584  ;  chromic  acid,  584  ; 

glacial  acid,  584 


Washerwomen,  skin  eruptions 

in,  204 
Wheal,  definition  of,  12 
Whitlow,  543 


(( 


— ,  venereal,  457,  583 
Warty  degeneration,"  563 


X-rays  in  lupus,  121  ;  in  hir- 
suties,  528  ;  in  xanthoma 
multiplex,  567  ;  in  rodent 
ulcer,  596 

Xanthoma,  565 

diabeticorum,  568 

,  Treatment— 

Constitutional,     antiglyco- 
suric,  569 

elasticum,  569 

,  histology  of,  569 

multiplex,  666 

'■ — ,  Treatment — 

Local,       excision,       667 ; 
X-i^ys,  567 

of  Balzer,  667 

planum,  566 

— : ,  Treatment — 

In  severe  cases,  excision, 
666 

tuberosum,  566 

Xanthome  en  tumeurs,  628 

Xerodermia,  610 

Xerodermia  pigmentosum,  604 


Yaws,  496 ;  etiology  of,  499  ; 
pathology  of,  500  ;  diagno- 
sis of,  500 ;  prognosis  of, 
500 

,  Treatment — 

Local,    black    wash,    501  ; 

perchloride  of  mercury, 

601  ;     iodoform,     601  ; 

sulphur      baths,      501  ; 

calomel  fumigations,  601 


642 


DISEASES   OF   THE  SKIN. 


Conatitutional,  quinine, 
501 ;  the  salicylates, 
501 ;  ammonium  car- 
bonate, 501  ;  iron,  501  ; 
cod-liver  oil,  501 ;  mer- 
cury, 501 ;  iodide  of 
potassium,  501 


Zona,  158 

Zymotic  fevers,  rasheu  of,  36 


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I  Manuals  for  atndeuba  of  Medicine  [(onlimicd). 

Manual  of  Military  Ophthalmolog:y. 

-      ■     ■•     ofMtdLcil  Officers  or  iho  Homt,  Indian,  !iDd  Colonbl 
lyB.  T.Yarr,_F.R.0.8.I.,  Major  RoyilArtnirMediciil 


The  Student's  Handbook  of  Surgical 

Operations.     By  air  Fredsrlak  Treves,  Bart..  S.C.T.O,, 

C.B.,  F.RCS.    Wilh9tlUnslr»'ion»-    Efa/imlh  Tkoutand .    7».  8<l. 


Clinical  Papers  on  Surgical  Subjects. 

By  Herbert    T.   Page,  M-A.,  BI;C.  Cantab.,  F.R.C.8.  Ellg.. 


The  Cerebro-Spinal  Fluid:  i„  spoman™. 

EaODe  rrom  the  Na^e.    By  StClalr  TbomsOQ,  M.D.,  etc.    Sk. 

A  Guide   to   the    Instruments  and 

Appliances  Required  in  Various  Operations. 

By  A.  W.  Mayo  Robson,  F.K.C.S,     (».  iid  ,  ur  posi  fi«,  la,  7rf, 

Medical  Handbook  of  Life  Assurance. 


I    Incompatibility    and    Some    of    its 

^^^^    Lessons.       By  Valter  a.  Smith,  U  J>.,  Ex-President  Royal 
^^^^^alJeEei>rPhF<ii:laiis,Ir<ilind,  &c.    It. 


■h  Afoxthly  P, 


-t  9».  ml,  of  lilt 


Annals  of  Surgery,    a  Monthly  R^i^w  qf  surgi^i 

Science    and    Praclice.      EJiKd   hi  W.    H.   A.    JaCObson,   M.OlL 

(or  UondonKL.  B.  PilcHer,  A.H.,  U.D.  M  Hmolclyn,  USA.): 

inUlsjnUacEffen,  H.D.  (ofGra^owj ;  J.  Willi&m  WUte,  M.D. 

I  ^FhlUdclptaUL  U.S.A.).    A  lubscriplion  of  U^.,  paid  in  advnn^e, 

■•rill  lacurB  the  Jounul  bemg  sent  poat  frH  for  odd  yebr. 


w 


HannalE  for  Students  of  Hcdicliie  {icntifnti!). 

The  Tale  of  a   Field  Hospital. 

Sir  Fredenck  Treves.  Bart,.  KC.y.O..  C.B.,  F.R.O.B, 

Cookery  for  Common  Ailments. 

A  Fellow  of  the  BorU  CMiUsee  or  FbrBldBna,  ud  t 
Brow&D.   UiDp  cloU}-    In. 

Handbook  of  Nursing  f^  >he  uom< 


The  Practical  Nursing   of   Infantd 

and  Children.    By  FtuUe  Cole  Madden,  U.B..  B.&  Heui.il 

F.E.C.B.     =B6pp.,  ^rqwDovo.     3.,  «d.  | 

Advice  to  Women  on  the  Care  of 

their   Health,    Before,  During,  and    After 
Confinement,     cy  Florence  Stacpoole,   DipioDifr  of 

the    London    Obsletiical  Socitij,   ac  ac.     Ant-  and  fn.Wrjn/ 


...■;ii.7S=".sr.i." 

'.■xs.'arssEii'ciSsisi""' 

Our  Sick  and  How  to  Take  Care  of 

Them ;   or,  pbin  T< 

«chme  on  Sick  NuBins  «  Horn..    B»L 

FevrIA  Sitilin.    Flpu  conn,  J&j  iJE 

^ 


An  Address  in  School   Hygiene. 

Clement  Dnbea,  BLD.    i; 

Cassell   &   COMrANY's  COMPLETE  CATALOGUE.  . 
faim'iig  paTHculari  of  itpaiards  ef  Ont  lAomand  faiumti, 
ineluding  Bibla   and  Jftbgieui     Werki,    UimitrattJ   amd 
Fine    Art     VBlumes,     Ckildren's     Batiki,     Diilivitarifs, 
EduealioHat   Werks,  Hiitory,  Natural  Hulory,  HtttStMd  _ 
and   Domestic    Trtatiai,    Scimte,    Travtii,     ' 
with    a    Synafiis    of   Iktir    numerous    IL 
Fublitalion!,  stHl  fiat  fret  on  appUcMinm. 


LANE  MEDICAL  UBRARY 


To  avoid  fine,  this  book  should  be  returned  on 
or  before  the  date  last  stamped  below. 


■ 

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M87         Diseases  of  the  skin.  ■ 
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